Characterizing differences in mortality at the low end of the fitness spectrum in individuals with cardiovascular disease

Background A graded but nonlinear relationship exists between fitness and mortality, with the greatest mortality differences occurring between the least-fit (first, Q1) and the next-least-fit (second, Q2) quintiles of fitness. The purpose of this study was to compare clinical characteristics, exercise test responses, and physical activity (PA) patterns in Q1 versus Q2 in patients with cardiovascular disease (CVD). Design Observational retrospective study. Methods A total of 5101 patients with a history of CVD underwent clinical treadmill testing and were followed up for 9.1 +/- 5.5 years. Patients were classified into quintiles of exercise capacity measured in metabolic equivalents. Clinical characteristics, treadmill test results, and recreational PA patterns were compared between Q1 (n = 923) and Q2 (n = 929). Results Q1 had a nearly two-fold increase in age-adjusted relative risk of cardiovascular mortality compared with Q2 (hazard ratio: 3.79 vs. 2.04, P < 0.05; reference: fittest quintile). Q1 patients were older, had more extensive use of medications, and were more likely to have a history of typical angina (35 vs. 28%), myocardial infarction (30 vs. 24%), chronic heart failure (25 vs. 14%), claudication (15 vs. 9%) and stroke (9 vs. 6%) compared with Q2 (all comparisons: P < 0.05). Recent and lifetime recreational PA was not different between the two groups. Conclusion Greater severity of disease in the least-fit versus the next-least-fit quintile likely contributes to but cannot fully explain marked differences in mortality rates in CVD patients. To achieve potential survival benefits, our results suggest that unfit CVD patients should engage in exercise programs of sufficient volume and intensity to improve fitness. Eur J Cardiovasc Prev Rehabil 17:289-295 (C) 2010 The European Society of Cardiology