(Circulation. 2000;102:1358.)
© 2000 American Heart Association, Inc.
Clinical Investigation and Reports |
Physical Activity and Mortality in Older Men With Diagnosed Coronary Heart Disease
From the Department of Primary Care and Population Sciences, Royal Free and University College Medical School, London.
Correspondence to Goya Wannamethee, Department of Primary Care and Population Sciences, Royal Free and University College Medical School, Rowland Hill St, London NW3 2PF, UK. E-mail goya{at}rfhsm.ac.uk
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Abstract |
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Background—We have studied the relations between physical activity, types of physical activity, and changes in physical activity and all-cause mortality in men with established coronary heart disease (CHD).
Methods and Results—In 1992, 12 to 14 years after the initial
screening (Q1) of 7735 men 40 to 59 years of age from general practices
in 24 British towns, 5934 (91% of available survivors, mean age 63
years) provided further information on physical activity (Q92) and were
followed up for 5 years; 963 had a physician’s diagnosis of CHD
(myocardial infarction or angina). After exclusions, there were 772 men
with established CHD, 131 of whom died of all causes. The lowest risks
for all-cause and cardiovascular mortality were seen in
light and moderate activity groups (adjusted relative risk compared
with inactive/occasionally active: light, 0.42 (0.25, 0.71); moderate,
0.47 (0.24, 0.92); and moderately vigorous/vigorous, 0.63 (0.39, 1.03).
Recreational activity of 
4 hours per weekend, moderate or heavy
gardening, and regular walking (>40 min/d) were all associated with a
significant reduction in all-cause mortality. Nonsporting activity was
more beneficial than sporting activities. Men sedentary at Q1 who began
at least light activity by Q92 showed lower mortality rates on
follow-up than those who remained sedentary ( relative risk 0.58, 95%
CI 0.33 to 1.03; P=0.06).
Conclusions—Light or moderate activity in men with established CHD is associated with a significantly lower risk of all-cause mortality. Regular walking and moderate or heavy gardening were sufficient to achieve this benefit.
Key Words: exercise • coronary disease • mortality
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Introduction |
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Leisure-time physical activity is associated with lower all-cause mortality and with lower morbidity and mortality rates from cardiovascular disease in middle-aged and older men.1 2 3 4 5 6 Maintaining or increasing physical level in late middle age has been shown to be associated with a reduction in mortality rates,3 7 and light activities are sufficient to produce this benefit in older men.3 4 The role of physical activity and the types of physical activity required to achieve benefit in men with established coronary heart disease (CHD) are less well established. Meta-analyses of cardiac rehabilitation programs suggest a significant reduction in mortality rates in patients participating in an exercise program compared with a control group. The independent effects of physical activity are difficult to separate from other aspects of these programs,8 9 10 and patients >65 years of age are usually excluded. The number of "exercise only" trials is small, and most have failed to reach statistical significance.9 In the majority of cardiovascular studies in populations, men with diagnosed CHD are excluded or are included in the large group of subjects with preexisting disease.3 The British Regional Heart Study has previously reported on the effects of physical activity and changes in physical activity on 4-year mortality rates in men with and without a wide range of preexisting cardiovascular disease.3 The beneficial effect of physical activity was seen in both groups. The specific effect of physical activity in men with established CHD was not examined. We examined the relation between physical activity and changes in physical activity over 5 years of follow-up in older men with established CHD and assessed the effects of the common types of physical activity (walking, gardening, and sport) on mortality rates.
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Methods |
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The British Regional Heart Study is a large prospective study of cardiovascular disease involving 7735 men 40 to 59 years of age at screening selected from the age-sex registers of 1 group general practice in each of 24 towns in England, Wales, and Scotland.11 During 1978 to 1980, research nurses administered to each man a standard questionnaire including questions on smoking, alcohol, physical activity, and medical history (Q1). In 1992, 12 to 14 years after screening, a similar but more comprehensive questionnaire (Q92) was posted to surviving participants, now 52 to 73 years of age (average 63 years). In addition to questions on current illness and medication, detailed information was collected on changes in smoking and drinking and in leisure-time physical activity. Of the 6528 surviving and available participants, 5934 (91%) completed the Q92 questionnaire.
Men With Physician-Diagnosed CHD
At Q92 (but not at Q1), the men were asked to describe their
present health status: "excellent, good, fair, or poor." They
were asked whether a doctor had ever told them that they had angina or
myocardial infarction (heart attack, coronary thrombosis),
stroke, "other heart trouble," and a number of other disorders. Men
with physician-diagnosed CHD consisted of men with a recall of a
physician diagnosis of CHD (heart attack or angina) at Q92 and those
who had had a major nonfatal myocardial infarction event before Q92,
based on the regular surveillance of general
practitioner’s records (n=963). Since men reporting
"poor health" have exceptionally high mortality
rates12 and are likely to have limitations in their
physical activities, we have excluded them from the analyses
(n=116). This report is primarily concerned with men with
physician-diagnosed CHD at Q92 who did not report "poor health"
(n=847), of whom a further 75 men were excluded for incomplete
information on physical activity, leaving 772 men.
Physical Activity
At initial screening (Q1) and 12 to 14 years later (Q92), the
men were asked to indicate their usual pattern of physical activity
under the headings of regular walking or cycling, recreational
activity, and sporting (vigorous) activity. Regular walking and cycling
related to weekday journeys that included travel to and from work.
Recreational activity included gardening, pleasure walking, and
do-it-yourself jobs. Sporting activity included running, golf,
swimming, tennis, sailing, and digging. A physical activity (exercise)
score was derived for each man on the basis of frequency and type
(intensity) of the physical activity. Scores were assigned for each
type of activity and duration on the basis of the intensity and energy
demands of the activities reported.6 13 14 The total score
for each man is not a measure of total time spent in physical activity
but is a relative measure of how much physical activity has been
carried out. At Q92, the subjects were asked additional questions on
how the hours of gardening were spent: light gardening, moderate
gardening, and heavy digging. The men were grouped into 4 mutually
exclusive groups on the basis of their highest category of intensity of
gardening: no gardening, light gardening only, moderate gardening, and
heavy gardening (digging).
Physical Activity Index
At both Q1 and Q92, the men were initially grouped into 6 broad
categories on the basis of their total score: 1, inactive, score 0 to 2
(n=85); 2, occasional, score 3 to 5 (n=238), regular walking or
recreational activity only; 3, light, score 6 to 8 (n=181), more
frequent recreational activities, sporting exercise less than once per
week, or regular walking plus some recreational activity; 4, moderate,
score 9 to 12 (n=100), cycling or very frequent weekend recreational
activities plus regular walking or sporting activity once per week; 5,
moderately vigorous, score 13 to 20 (n=82), sporting activity at least
once per week or frequent cycling plus frequent recreational activities
or walking or frequent sporting activities only; 6, vigorous, score
21 (n=86), very frequent sporting exercise or frequent sporting
exercise plus other recreational activities.
The use of the physical activity score has been validated at baseline in men free of preexisting CHD. Mean heart rate and FEV1 decreased significantly with increasing levels of physical activity even after adjusting for potential confounders.6 We have excluded 75 men not providing complete data on physical activity at Q92 and thus our report is based on 772 men. A further 13 men did not provide information on physical activity at screening and thus our analysis of changes in physical activity from Q1 to Q92 is based on 759 men.
Cardiovascular Risk Factors
Smoking
From the combined information at screening and at Q92, the men
were classified at Q92 as those who had never smoked, ex-smokers, and
current smokers.
Social Class
The longest-held occupation of each man was recorded at
screening, and the men were grouped into 1 of 6 social classes I, II,
III nonmanual, and III manual, IV and V. Those whose longest occupation
was in the Armed Forces formed a separate group.
Body Mass Index
Body mass index (BMI) (weight/height2 in
kg/m2) was calculated for each man on the basis
of reported weight at Q92 and on height measured at screening. Obesity
is defined as BMI 28 kg/m2, the upper fifth of
the distribution of BMI in all men at screening.
Indicators of Ill Health at Q92
Chest Pain on Exertion
With the use of the WHO (Rose) chest pain questionnaire for
angina or possible myocardial infarction, both possible and definite
angina are referred to as "chest pain on
exertion."15
Cardiovascular Surgery
This includes angioplasty, coronary artery bypass
operation, and other heart surgery.
Breathlessness
The men were asked 3 questions regarding breathlessness: (1) Do
you get short of breath walking with people your own age on level
ground? (2) On walking up hills or stairs, do you get more breathless
than people your own age? (3) Do you ever have to stop walking because
of breathlessness? Those who answered positive to any of these
questions were regarded as having breathlessness and those who answered
positive to all 3 questions were regarded as having severe
breathlessness.
Calf Pain on Walking
The men were asked whether they ever got pain in the calf muscle
when (1) walking at an ordinary pace on level ground and (2)
walking uphill or hurrying. Calf pain on walking was defined as an
affirmative answer to either question. Those who answered yes to
question 1 were regarded as having severe calf pain.
Locomotor Disability
This included men reporting difficulty carrying out any 1 of the
6 following activities on their own as a result of a long-term health
problem: (1) going up or down stairs, (2) bending down, (3)
straightening up, (4) keeping balance, (5) going out of the house, or
(6) walking 400 yards.
Follow-Up
All men were followed up for all-cause mortality and for
cardiovascular morbidity.16 All deaths in
the period to December 1997 have been recorded, and follow-up has
been achieved for 99% of the cohort. However, this present report
is concerned only with the men who completed the Q92 questionnaire and
thus mortality follow-up since Q92 is presented (a follow-up
period of 5 years for each man). Information on death was collected
through the established "tagging" procedures provided by the
National Health Service registers in Southport (England and Wales) and
Edinburgh (Scotland).
Statistical Methods
Cox’s proportional hazards model was used to assess the
relation between (1) reported physical activity at Q92 and 5-year
mortality on follow-up and (2) changes in physical activity from Q1 to
Q92 and 5-year mortality and to obtain relative risks adjusting for
potential confounders.17 Adjustments for confounding
factors and symptoms indicating ill health were based on information
obtained at Q92. In the adjustment, smoking (never-smokers, long-term
ex-smokers, recent ex-smokers, and current smokers), social class (7
groups), obesity (yes/no), disability (yes/no), diabetes (yes/no),
stroke (yes/no), breathlessness (none, mild, severe), chest pain on
exertion (yes/no), and calf pain on walking (none, mild, severe) were
fitted as categoric variables.
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Results |
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TopAbstractIntroductionMethodsResultsDiscussionReferences |
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Of the 772 men with diagnosed CHD who did not report "poor health," 284 (36.8%) had diagnosed angina only, 225 (29.1%) had diagnosed myocardial infarction only, and 263 men (34.1%) had a diagnosis of both myocardial infarction and angina. During the mean follow-up of 5 years, there were 131 deaths from all causes (35.0/1000 person-years), 94 attributed to cardiovascular causes. The mortality rates per 1000 person-years were 29.5 for those with diagnosed angina only, 33.5 for those with myocardial infarction, and 42.6 for those with both.
Because of the small numbers in some categories, we have combined the
inactive and occasionally active and also combined the men who did
moderately vigorous and vigorous exercise. The
Figure
shows the age-adjusted rates per
1000 person-years for the 4 physical activity groups, and Table 1 shows the age-adjusted relative
risks of death, with the inactive/occasionally active group as
reference. The reference group had by far the highest mortality rate.
Light and moderately active men showed similar low rates of mortality.
Risk increased slightly beyond moderate levels, but these men still
showed significantly lower risk than the reference group. Light and
moderate levels of activity were associated with a significant
reduction in risk of total and cardiovascular mortality
even after adjustment for age, social class, smoking, obesity, history
of myocardial infarction, diabetes, stroke, and self-rated health
status (Table 1). History of myocardial infarction was included
in the adjustment because these subjects had a higher risk of death
than those with angina only.
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The inverse relation between physical activity and mortality rates was
seen in men <65 years (n=356; 40 deaths) and in men 65 years (n=416;
91 deaths). Adjusted relative risks for the 4 physical activity groups
were 1.00, 0.52, 0.84, and 0.59 in men <65 years of age and 1.00,
0.38, 0.35, and 0.65 in men 65 years of age.
Assessing Severity: Adjustments for Symptoms
There was little difference between the 4 activity groups in
reporting of surgical procedures (eg, angioplasty, CABG, and other
heart surgery). However, inactive/occasionally active men showed the
highest prevalence of breathlessness on exertion, chest pain on
exertion, calf pain on walking, and disability (Table 2). Further adjustment for these factors
made little difference in the relations seen. The adjusted relative
risk (95% CI) for the 4 physical activity groups were 1.00, 0.44 (0.26
to 0.75), 0.48 (0.24 to 0.96), and 0.67 (0.41, 1.10) for total
mortality and 1.00, 0.40 (0.21 to 0.76), 0.51 (0.24, 1.10), and 0.64
(0.36, 1.16) for cardiovascular mortality.
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The benefit of light and moderate activity was seen in men with chest pain on exertion or severe breathlessness on exertion (n=450; 94 deaths) and in men without either symptom (n=322; 37 deaths). In men with chest pain, moderately vigorous/vigorous levels conferred only a small benefit. The adjusted relative risks for the four physical activity groups were 1.00, 0.17, 0.54, and 0.48 in men without chest pain or severe breathlessness and 1.00, 0.62, 0.36, and 0.80 in men with chest pain or severe breathlessness.
Types of Physical Activity
We examined the effects of specific types of activity at Q92 on
all-cause and cardiovascular mortality rates, adjusting
for age, social class, smoking status, obesity, self-rated health
status, recall of physician diagnosis of myocardial infarction, stroke,
and diabetes (Table 3).
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Recreational
Recreational activity during weekends of 4-hour duration
(cumulative) was associated with a significant reduction in both total
and cardiovascular mortality rates.
Walking
The men were divided into 3 categories of walking (none, 
40
min/d, and >40 min/d). Regular walking for >40 min/d was associated
with a significant reduction in total and
cardiovascular mortality rates.
Gardening
The number of men engaged in heavy gardening (digging) was small,
but they showed mortality rates similar to those engaged in moderate
gardening, and the two groups were combined. Moderate or
heavy-intensity gardening but not light gardening was associated with a
significant reduction in total and cardiovascular
mortality rates.
Sport
Men who reported >1 sporting activity per month showed a small
but nonsignificant reduction in total and
cardiovascular mortality rates compared with those who
reported none or 1 per month.
Since these types of activity are not mutually exclusive, further
adjustments were made for each of the other activities. This made only
minor differences to the relations seen in Table 3
.
The benefits of recreational activity, regular walking >40 minutes, and moderate or heavy gardening were seen in those with and without chest pain or severe breathlessness on exertion. Sporting activity was beneficial in those with no chest pain or severe breathlessness but not in those with chest pain or severe breathlessness.
Changes in Physical Activity
To assess the effects of changes in physical activity over
the 12 to 14 years between Q1 and Q92 on mortality rates during 5 years
of follow-up, the men were grouped into 4 groups on the basis of their
physical activity patterns at Q1 and Q92: (A) inactive/occasionally
active at Q1 and Q92, (B) at least lightly active at Q1 but
inactive/occasionally active at Q92, (C) inactive/occasionally active
at Q1 but at least lightly active at Q92, and (D) at least lightly
active at Q1 and Q92. Men who became inactive/occasionally active
(group B) had the highest mortality rates (Table 4). Compared with those who remained
inactive (A), those who became at least lightly active (C) and those
who remained lightly active (D) showed a significantly lower mortality
risk, and this was of marginal significance after adjustment
(P=0.06 and P=0.09, respectively). The same
pattern of mortality risk were seen for cardiovascular
mortality, although the differences from group A were not statistically
significant. Men who remained inactive (A) and men who became inactive
(B) showed similar prevalence of symptoms, for example,
exertion-related breathlessness, calf pain and chest pain, and
reporting of disability and fair health status, and both groups showed
higher prevalence rates of symptoms than those who became or remained
active (Table 2). However, the benefit of taking up physical
activity was seen even when men with chest pain or severe
breathlessness were excluded.
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Discussion |
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TopAbstractIntroductionMethodsResultsDiscussionReferences |
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Cardiac rehabilitation programs have provided evidence for the wide acceptance of physical activity as an important factor in the treatment of subjects with established CHD.18 19 Physical training usually is part of a comprehensive cardiac rehabilitation program, including risk factor management and counseling, and it is difficult to identify the relative importance of each preventive measure.8 9 10 The physical training usually involves supervision in a hospital or other specialized center. Few studies have examined the effects of leisure-time physical activity and the type of activity on mortality in subjects with established CHD in a general population.
Benefits of Light or Moderate Physical Activity
In this study of older men with established CHD, light and
moderate levels of physical activity, even when taken up later in life,
were associated with a significant reduction in risk of all-cause and
cardiovascular mortality rates. The benefit was seen in
men <65 and in men 65 years of age. Benefit was achieved by light
forms of physical activity (eg, walking, gardening, and recreational
activity). Even those with chest pain or severe breathlessness achieved
significant benefit from these lighter activities. Although sporting
activity was beneficial in those with no reported chest pain, it
conferred little benefit in those with chest pain in whom lighter
nonsporting activity was more beneficial.
Potential Bias
Some of the benefit seen may be due to severity of disease
in those who are inactive, but we have excluded all men who reported
"poor health." Statistical adjustment for symptoms and disability
status made minor differences to the relations. The benefit was most
clearly seen in those with no chest pain or breathlessness on exertion,
and optimal benefit was seen in those undertaking light or moderate
activity. More vigorous levels conferred no additional benefit, and
these men were less likely to have chest pain or severe breathlessness
than the lighter activity group. In men with chest pain or severe
breathlessness, more vigorous activity appeared to confer little
benefit. It is unlikely that the benefit seen with light or moderate
activity is simply due to severity of disease in the inactive
subjects.
Previous Studies
Most trials on the effectiveness of physical training and risk
factor management in myocardial infarction survivors have not shown a
significant effect on mortality and morbidity, although many have shown
an improvement in exercise tolerance,20 risk factor
profile,21 and psychosocial status.22
Meta-analyses have indicated a trend toward a significant
reduction in overall mortality and in cardiac mortality rates in
patients undergoing physical training.8 9 However, the
relatively small number of exercise-only trials and the fact that
rehabilitation programs include other interventions do not allow a
definitive conclusion to be reached about the independent effects of
the physical exercise component.9
Few population-based prospective studies have examined the effects of physical activity in men with established CHD, but most suggest a beneficial effect. In a small Japanese study of 80 male myocardial infarction survivors who had been treated in a hospital coronary care unit but not educated about their lifestyle, higher daily physical activity was associated with a significantly lower risk of cardiac death.23 In a study of 782 Harvard alumni 35 to 74 years of age with reported history of CHD, those who exercised <2000 kcal/wk were at greater risk of CHD death than those more active.24
Conclusions
There is a need for every hospital to have facilities and
staff for cardiac rehabilitation after discharge, but it is unlikely
that such facilities will ever be able to deal with the ongoing needs
of all those with established CHD. The level and type of physical
activity carried out as part of everyday activities can be of
considerable benefit to patients with established CHD. Vigorous or
"sporting" activity is not required, and regular leisure activities
such as walking and gardening appear to be sufficient to achieve
significant benefit. In formal, medically supervised exercise programs,
the risk of untoward events taking place is remarkably small, and this
risk is likely to be even smaller in home-based leisure physical
activity.25 26 Regular light or moderate physical activity
should be actively encouraged in all those with established CHD without
pressure to achieve the vigorous exercise previously regarded as
necessary for benefit.
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Acknowledgments |
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The British Regional Heart Study is a British Heart Foundation Research Group and receives support from the UK Department of Health.
Received December 21, 1999; accepted April 20, 2000.
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