Άσκηση και καρδιαγγειακές εκβάσεις: μόνο τα δεδομένα. Ανδρέας Πιτταράς
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1 Άσκηση και καρδιαγγειακές εκβάσεις: μόνο τα δεδομένα Ανδρέας Πιτταράς Καρδιολόγος Clinical HTN Specialist ESH Ass. Prof. George Washington University USA Ασκληπιείο Βούλας - MEDITON HCS CONGRESS ATHENS, GREECE
2 Disclosure of Relationships Over the past 12 months A. Pittaras No relationships to disclose
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4 ΔΙΑΒΗΤΗΣ ΔΥΣΛΙΠΙΔΑΙΜΙΑ ΑΣΚΗΣΗ ΠΑΧΥΣΑΡΚΙΑ ΣΤΕΦΑΝΙΑΙΑ ΝΟΣΟΣ ΥΠΕΡΤΑΣΗ
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8 Effects of Exercise/Physical Activity Antihypertensive Weight Control Anti-atherogenic Anti-arrhythmic Lipid Metabolism CHO Metabolism LVH Regression Cardiac Function Endothelial Function Bone Density Reduces Stress Increases Energy Induces Deep Sleep Improves Brain Function Free & Safe No Side-effects
9 Health Benefits Reported by Exercise or Fitness Kokkinos P. and Myers J. Circulation 2010; 122: Randomized-Controlled Studies Lowers Blood Pressure Lowers Exercise BP at Relative and Absolute workloads LV mass Regression Improves Insulin and Normalizes Blood Glucose Levels Insulin-Independent stimulus for Increased Glucose Uptake Increases Lean body weight and Reduces Body Fat Inhibits Inflammation/Thrombosis Favorable Changes on Lipids /Lipoproteins Epidemiologic Studies Attenuated Progression to HTN Lower Mortality rates in HTN and Pre-HTN Attenuated increases in LV mass and progression to LVH Attenuated progression to Type 2 DM Lower Mortality Rates in Diabetics Lower Mortality Rates in Obese and Overweight Protection against CHD
10 Survival of the Fittest In the last 15 years, many studies have shown an unequivocal and robust relationship of fitness, physical activity, and exercise to reduce overall and CVD mortality. These health benefits are realized at relatively low fitness levels and increase with increased physical activity patterns in a dose-response fashion. Balady JG, New Engl J Med 2002;346 (11):852-53
11 Physical Activity and Mortality: The Finish Twin Cohort Kujala UM., et al. JAMA 1998;279: * * P< No Activity 0,8 0,67 0,56 0,6 0,4 Some Activity 30 min walk 6 times/month 0,2
12 Exercise Capacity and CVD Death in Men Blair et al. JAMA 1989; 262: N=10, < METs
13 All-Cause Mortality and Exercise Capacity Kokkinos, Pittaras et al. Circulation 2008; 117: * * P<0.001 n=15, ,8 0,8 0,6 0,51 0,4 0,31 <5 METs 5-7 METs METs >10 METs 0,2
14 All-Cause Mortality and Exercise Capacity (n=15,660) Kokkinos P, Pittaras A. et al. Circulation 2008; 117: Years of Follow-up
15 All-Cause Mortality and Exercise Capacity For Different Age-Groups Kokkinos, Pittaras et al. Circulation 2008; 117: ,8 0,78 0,82 0,74 0,6 0,51 0,54 0,41 0,46 0,4 0,29 0,31 0,2 <50 yrs yrs >70 yrs
16 Exercise Capacity: The stronger predictor of mortality Increase in exercise capacity for 1 ΜΕΤ 16% Mortality Risk hazard ratio=0.86 CI: ; p <0.001
17 Schematic Representation of Fitness and Mortality Relationship 100% Most of us are Here! Fitness levels METs Highly Active >18-24 METs Athletes/ Marathoner, etc Threshold 3-5 times/wk min/session Moderate Intensity (Brisk Walk) Death Rate
18 % Schematic Representation of Exercise- Related Health Benefits Plateau Most of these health benefits are realized at relatively low levels of physical activity METs Highly Active >16-22 METs Athletes/ Marathoner, etc Threshold < METS
19 Threshold for Exercise Capacity and Mortality Relative Risk Kokkinos, Pittaras et al. Circulation 2008; 117: * P<0.001 n=15,660 0,8 0,8 0,6 0,57 0,46 0,4 0,29 0,33 0,27 0,2 2 METs >14
20 Change in Fitness Status and Mortality Kokkinos P, Manolis A, Pittaras A. Doumas M. Circulation 2010 Relative Risk * p< % -41% 0,8 0,65 0,59-61% 0,6 0,39 0,4 0,2 UNFIT- TO- UNFIT UNFIT- TO- FIT FIT- TO- UNFIT FIT-TO-FIT 0
21 Mora S, et al. Circulation 2007; 116:
22 Reverse Causality Is Physical Inactivity the Cause of High Mortality Rates or Physical Inactivity and Higher Mortality are both the Outcome of Pre-Existing Disease?
23 Sedentary Lifestyle/ Low fitness Diseased Population Increases Mortality Rate
24 Putting the Reverse Causality Theory to Test Kokkinos P. Pittaras A, et al. Circulation 2010;122: Removed from analysis those who: Died within the initial 2 years of FU. BMI<20 in the lowest fit category. Not on b-blockers, but did not achieve 85% of age-predicted MHR. Those who met all three conditions.
25 ΔΙΑΒΗΤΗΣ ΔΥΣΛΙΠΙΔΑΙΜΙΑ ΑΣΚΗΣΗ ΠΑΧΥΣΑΡΚΙΑ ΣΤΕΦΑΝΙΑΙΑ ΝΟΣΟΣ ΥΠΕΡΤΑΣΗ
26 ESH/ESC 2007, 2009, 2013 Guidelines: Lifestyle Measures Physical exercise Weight (and stabilization) Excessive alcohol intake Smoking cessation Salt intake Fruit / vegetable intake Evidence Class Level I A Saturated / total fat intake
27 BP Changes with Exercise in Individuals with Stage 2 Hypertension Kokkinos P, Pittaras A., et al. New Eng J Med 1995;333: Controls Controls 2 0 Exercise Exercise % in meds SBP DBP -8 P< weeks 32 weeks
28 LVMI at Baseline and 16 Weeks Kokkinos P.,..Pittaras A., et al. NEJM 1995;333: * p< * Baseline 16 weeks 135
29 Exercise/PA and Hypertension Reduction of BP Reduction in mortality risk Exercise BP and its clinical significance Prevention of hypertension
30 Relative Risk of All-Cause Death and Exercise Capacity in Hypertensive Patients RR of Death Myers J. et al., N Engl J Med 1002;346: ,2 2 1,7 1,2 1,3 1 0,7 0,2 <5 MET 5-8 MET >8
31 Exercise Capacity & Mortality in Hypertensive men with & without risk factors High-Fit N=3.673 Moderate-Fit F-U: 22y ( ) Years of Follow-up Low-Fit P.Kokkinos, M. Doumas, A.Pittaras, A. Manolis et. Al. Hypertension 2009
32 Exercise Capacity: The stronger predictor of mortality in HTNsives ± risk factors Increase in exercise capacity for 1 ΜΕΤ 14% Mortality Risk hazard ratio=0.86 CI: ; p <0.001
33 Exercise Capacity and Mortality in Hypertensives Kokkinos P, Pittaras A. et al., Hypertension, 2009;53: * p< ,8 * 0,66 0,6 * 0,41 0,4 0,29 0,2 <=5 METs 5-7 METs METs >10 METs 0
34 Mortality Risk Mortality Risk within each fitness category for hypertensive with and without additional risk factors Kokkinos P. Pittaras A et al., Hypertension, 2009;53: ,5 * 1,47 * p<0.007 p=0.016 Risk Factors No Risk Factors 1 1 0,97 * 0,5 Referent 0,66 * 0,56 * 0,48 * 0,37 * 0, METs METs METs >10 METs * Different from the Very-Low-Fit with no risk factors (Referent) Different from the Low-Fit with Risk Factor
35 Adjusted Death Rates and Exercise Capacity in HTN Veterans (n=4,631) ,1 3, , , <5 MET MET MET 0 HTN HTN+1 HTN+2 HTN+3 >10 MET
36 ESH Scientific Newsletter: Update on HTN management Exercise and Hypertension A. Manolis, A. Pittaras, C. Tsioufis, P. Kokkinos 2011; 12; No 23 revised version
37 Hypertensive patients should be advised to participate in at least 30 min of moderateintensity dynamic aerobic exercise (walking, jogging, cycling or swimming) on 5 7 days per week. Isometric exercises are not recommended, since data from only a few studies are available. ESH 2013
38 Exercise Capacity and Mortality in Hypertensive, Obese Individuals with Type 2 Diabetes Mellitus A. Pittaras, M. Doumas, C. Faselis, A. Manolis, K. Kyfnidis, T. Zamfir, E. Hamodraka, O. Diakoumakou, M. Papavasiliou, N. Kouremenos, D. Lovic, A. Tsimploulis, & P.F. Kokkinos. Veterans Affairs Medical Center, Washington, USA Mediton Medical Center, Athens, Greece Asclepeion Voulas Hospital, Athens, Greece ESH-ISH 2014, Athens, Greece
39 Relative Risk Adjusted Mortality Risk According to Fitness Categories 1,34 1,2 1 0,92 1, * * 0,8 0,64 0,7 0,69 0,56 0,48 0,48 0,4 0 HTN HTN + DM2 HTN+DM2+ OBESITY
40 SAME BENEFITS IN ELDERLY?
41 Exercise Capacity: A strong predictor of mortality in Hypertensive Men >70 yo. Increase in exercise capacity for 1 ΜΕΤ 8% Mortality Risk hazard ratio=0.92 CI: p <0.001 Faselis C., Doumas M, Pittaras A, Kokkinos P. Hypertension 2014
42 Relative Risk Relative Risk for Death According to Fitness Status Faselis C., Doumas M, Pittaras A, Kokkinos P. Hypertension * p= ,9 0,85 0,8 * 0,7 0,6 15% * 37% 0,63 0,5 Low- Fit Moderate- Fit High- Fit
43 ? -Pre-HTN -High Normal BP
44 Exercise Capacity and all-cause mortality in pre-hypertensive men. N=4735 (56±12 yo) F-U: 9 ±6 years PRE-HTN Years of Follow-up P.Kokkinos, M. Doumas,A. Pittaras, Α. Manolis Am. J. of Hypertension 2009
45 Exercise Capacity: the strongest predictor of mortality in Pre-HTN For every 1-MET increase in exercise capacity 15% reduction in the risk for mortality for entire cohort hazard ratio=0.85 CI: ; p <0.001
46 A graded association of exercise capacity and allcause mortality in males with high-normal BP. P. Kokkinos, M. Doumas, A. Pittaras, A. Manolis, Blood Pressure 2009 >12 METs Ηigh-normal BP N=1727 F-U: years Follow-up in years METs METs METs <4 METs
47 Exercise Capacity: the strongest predictor of mortality For every 1-MET increase in exercise capacity 13% reduction in the risk for mortality for High-normal BP hazard ratio=0.87 CI: ; p <0.001
48 Fitness and Mortality in Diabetics
49 Relative Risk of All-Cause Death and Exercise Capacity in Diabetics RR of Death Myers J et al. 2002;346: ,5 2,35 2 1,5 1 0,5 1 1,3 >8 MET 5-8 MET <5 MET
50 Exercise Capacity and Mortality in Diabetics Kokkinos P, Pittaras A et al. Diabetes Care : * p<0.001 n=2, ,8 * 0,63 0,6 * 0,41 0,4 0,2 <=5 METs 5-8 METs >8 METs 0
51 Fitness and Mortality in Diabetics Kokkinos P. Pittaras A. et al. Diabetes Care : METs (n=934) METs (n=1452) 5 METs (n=762) Years of Follow-up
52 Exercise Capacity and Mortality in Elderly Diabetics ( 60 yrs) * p< ,8 0,6 * 0,59 * 0,45 0,4 0,2 <=5 METs 5-8 METs >8 METs 0
53 Body Weight / Obesity
54 Relative Risk for Physical Activity & BMI, Adjusted For Risk Factors in Women 1 1 Mason JE, et al. NEJM: 99;341:650-8 N=72,488 >29 <29 0,88 RR 0,8 0,79 0,71 0,82 0,65 0,65 0,64 0,69 0,6 0,54 0, Physical Activity Quintiles
55 Relative Risk Cardiorespiratory Fitness & CVD Mortality in Men (N=25,714) Wei M, et al.jama: 99;282(16); ,5 Fit Unfit 4,5 5 3,5 3,1 2,5 1,5 1 1,5 1,6 0,5 BMI<25 BMI BMI 30+ (Normal) (Over WT) (Obese)
56 Relative Risk CVD Mortality Predictors in Normal WT Men (BMI ) Wei M, et al.jama: 99;282(16); ,6 3,1 2 2,1 2,2 1,4 1 TC Smoke DM HTN Low Fit
57 CVD Mortality Predictors in Overweight Men (BMI ) Wei M, et al.jama: 99;282(16); ,5 4 3,9 3,3 3,4 3 2,8 2 TC Smoke HTN DM LOW-FIT
58 CVD Mortality Predictors in Obese Men (BMI >30) Wei M, et al.jama: 99;282(16); ,9 5 4,7 4,5 4,4 4,5 4 3,5 SMOKE HTN TC DM LOW-FIT
59 RR of Death Exercise Capacity and Mortality in Obese Pts (VAMC Data) 4 3, , >9 METs METs 5-7 METs <5 METs
60 Hazard Ratio Risk of All-Cause Mortality by BMI and Fitness for 15,660 Men in the VETS, * P< * 1.29 * 0.84 <20 1 [Reference] ) 0.67 * < >10.0
61 ΔΙΑΒΗΤΗΣ ΔΥΣΛΙΠΙΔΑΙΜΙΑ ΑΣΚΗΣΗ ΠΑΧΥΣΑΡΚΙΑ ΣΤΕΦΑΝΙΑΙΑ ΝΟΣΟΣ ΥΠΕΡΤΑΣΗ
62 Relative Risk of All-Cause Death and Exercise Capacity Myers J et al. 2002;346: RR of Death 5 4,5 4 4,2 NO CVD CVD 3 2 2,4 3 1,7 2,2 1,7 1 1, <6 METS METS METS METS >13 METS Quintiles of Exercise Capacity
63 Exercise capacity and mortality in patients with ischemic left ventricular dysfunction randomized to coronary artery bypass graft surgery or medical therapy: an analysis from the STICH trial (Surgical Treatment for Ischemic Heart Failure). JACC Aug 2014 Exercise capacity and mortality HIGH PP LOW PP 60D LOW PP 5Y 3, ,77 0,95 MED CABG These observations suggest that patients with ischemic left ventricular dysfunction and poor exercise capacity have increased early risk and similar 5-year mortality with CABG compared with medical therapy, whereas those with better exercise capacity have improved survival with CABG.
64 Exercise Capacity and of All-Cause Mortality in Individuals with CVD Relative Risk 1 1 Kokkinos, Pittaras et al. Circulation 2008; 117: N=5,210 0,8 0,81 0,6 0,5 0,42 0,4 0,2 <5 METs 5-7 METs METs >10 METs
65 Γιατί Πέθανε ο Φειδιπίδης? Ήταν τα μέτρα...πιθανά όχι!
66 Cardiac Arrest during Long-Distance Running Races New Eng J Med 2012; 366: Incidence Rate: 1/259,000 participants Significantly Higher during marathon vs half marathon Higher in Men vs Women Most common cause: Hypertrophic Cardiomyopathy
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68 Relative Risk Risk of Onset of MI with Physical Activity 107 Mittleman et al. NEJM ' , /wk 3-4/wk >5/wk
69 Relative Risk Exertion-Related Acute MI According to Fitness Levels Giri S, et al., JAMA 1999;282: , , NS 5 0 2,9 1,2 1 <2 METs 2-4 METs 4-6 METs >6 METs No Exertion
70 ΔΙΑΒΗΤΗΣ ΔΥΣΛΙΠΙΔΑΙΜΙΑ ΑΣΚΗΣΗ ΠΑΧΥΣΑΡΚΙΑ ΣΤΕΦΑΝΙΑΙΑ ΝΟΣΟΣ ΥΠΕΡΤΑΣΗ
71 Relative Risk of All-Cause Death and Exercise Capacity Myers J et al. 2002;346: ,8 1,5 1,5 1 1 >8 MET 5-8 MET <5 MET 0,5 TC>220 mg/dl
72 Exercise Capacity and Mortality in Pts with Dyslipidemia (VAMC Data) RR of Death 2 2,4 2, > 9 METs METs 5-7 METs <5 METs
73 Statin Therapy, Fitness and Mortality in General population & Hypertensive Individuals Kokkinos P, Doumas M, Pittaras et al Lancet 2012 Am J Hypert 2014
74 Mortality risk in hypertensive individuals according to Statin Treatment No Statins (n=5,673) 34% Statins (n=4,529) Years of Follow-up
75 Relative Risk Mortality Risk According to Fitness Categories * p< ,8 0,6 * 0,68 * 0,48 * 0,75 * 0,58 0,4 * 0,27 * 0,33 0,2 0 Statins No Statins
76 Mortality risk in hypertensive individuals according to fitness categories Statin No Statin High-Fit (n=950) Mod-Fit (n=1,510) Low-Fit (n=1,146) Least-Fit (n=923) High-Fit (n=751) Mod-Fit (n=1,828) Low-Fit (n=1,343) Least-Fit (n=1,751) Years of Follow-up Years of Follow-up
77 Relative Risk Synergistic Effects of Fitness and Statins on Mortality Risk 1,4 * 1,33 Statins No Statins 1,2 * p< ,8 0,6 0,4 1 Referent * 0,69 0,99 * 0,47 * 0,79 * * 0,45 0,2 0,25 0 Least Fit ( 5 METs) Low-Fit ( METs) Moderate-Fit ( METs) High-Fit ( 8.5 METs)
78 Conclusions Both statin treatment and fitness lower mortality risk independently in hypertensive individuals. Risk reduction for Statins only: 34% Risk reduction for Fitness only: 25% - 67% (Graded) Statins/No Statins 1 1 0,75 Fitness/No Statins 34% 0,8 0,58 0,6 0,4 0,33 0,2 0 Least Fit High-Fit
79 Synergistic Effects of Fitness and Statins on Mortality Risk 1,4 1,2 1 0,8 0,6 0,4 0,2 0 1 Referent * 1,33 Least-Fit ( 5 METs) 0,69 * 0,99 Low-Fit ( METs) 0,47 0,79 * * * Moderate-Fit ( METs) 0,25 * High-Fit ( 8.5 METs) 0,45 The combination of fitness and statins is more effective than either therapy alone yielding an additional 20-30% risk reduction, with statins being more effective in the lower fitness categories. High fitness alone is more effective in lowering risk than the combination of Low fitness & statins and just as effective as Moderate fitness &statins!
80 Resting Heart Rate, Exercise Capacity and Mortality Risk A. Pittaras, C. Faselis, M. Doumas P. Kokkinos et al Am J Cardiol., 112;10; , November 2013
81 Adjusted Hazards Ratios for Mortality Risk According to Resting Heart Rate Categories - Not Adjusted for METs Resting HR (bpm) Coefficient (β) S E Wald χ 2 H R * C I p < < < < <0.001
82 Adjusted Hazards Ratios for Mortality Risk According to Resting Heart Rate Categories - Adjusted for METs Resting HR Coefficient (β) S E Wald χ 2 HR * C I p < < < < <0.001
83 Adjusted Hazard ratios for Mortality Risk According to Resting Heart Rate Categories for Subjects Treated with b-blockers - Not Adjusted for METs Resting Coefficient S E Wald H R C I p H R (β) χ² < >
84 Adjusted Hazard ratios for Mortality Risk According to Resting Heart Rate Categories for Subjects Treated with b-blockers - Adjusted for METs Resting Coefficient S E Wald H R C I p HR (β) χ² < >
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86 Exercise Prescription
87 How Much Physical Activity? Some is Better than None! Choose an activity you enjoy Start Low & Progress Slowly Start as low as 10 min/week Split duration (AM/PM) if needed Increase duration by 1-2 min/wk Goal: minutes/week Be Consistent (2-6 times/week)
88 Exercise Recommendations for BP Control American College of Sports Medicine: Position Stand: 2004 F: Frequency: 4-6 times/wk I: Intensity: Moderate (Brisk walk) 60-80% of MHR or 8-10 min/km T: Time: min/session. Aim for min/wk T: Type: Type of Exercise : Aerobic
89 AHA/ACSM Guidelines for Aerobic Exercise Haskell WL, et al. Circulation 2007; 116:
90 Exercise Intensity Based on HR Heart Rate Reserve (HRR) Method [Max HR- Resting HR) * %] + Resting HR) For a 50 yr-old with a RHR of 70 bpm [170-70=100] * 0.50 = = 120 bpm - Lower [170-70=100] * 0.70 = = 140 bpm - Upper Max HR = (age)= 170 bpm 170 * 0.70 = 119 bpm - Lower level 170 * 0.85 = 144 bpm - Upper Level
91 A Challenge for All There 1440 minutes in each day. Spend 30 of these minutes doing something that is physically challenging!
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Value of cardiac rehabilitation Prof. Dr. L Vanhees
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