Many cohort studies within the past few decades have shown the protective effect of leisure-time physical activity on cardiovascular mortality. To summarise the evidence from prospective cohort studies on the relationship between the amount of leisure-time physical activity and the risk of cardiovascular mortality, a dose–response meta-analysis was conducted in this study.
Methods and results
Electronic databases, including PubMed and Embase databases, Scopus and Cochrane Library, were systemically retrieved by two investigators from inception to 14 June 2018 for related studies. The maximum adjusted hazard ratios (HRs) and 95% confidence intervals (CIs) were extracted, and a dose–response analysis was conducted using the restricted cubic splines. Finally, a total of 44 studies comprising 1,584,181 participants was enrolled into this meta-analysis. The HRs of cardiovascular mortality for moderate and high leisure-time physical activity were 0.77 (95% CI 0.74–0.81) and 0.73 (95% CI 0.69–0.77), respectively. Among these 44 studies, 19 were eligible for the dose–response meta-analysis, which suggested a linear negative correlation of leisure-time physical activity with cardiovascular mortality, regardless of age, gender and the presence of underlying cardiovascular disease or not.
Conclusions
Leisure-time physical activity shows a linear negative correlation with the risk of cardiovascular mortality regardless of age, gender and the presence of cardiovascular disease or not. However, the cardiovascular benefits of leisure-time physical activity is decreased for those aged over 65 years or those with a history of cardiovascular disease. Moreover, leisure-time physical activity displays more cardiovascular benefits to people followed up for over 10 years than to those followed up for less than 10 years. Besides, high-intensity leisure-time physical activity has more obvious cardiovascular benefits than those of moderate-intensity leisure-time physical activity.
HsuBMeromDBlythFMet al.Total physical activity, exercise intensity, and walking speed as predictors of all-cause and cause-specific mortality over 7 years in older men: the Concord Health and Aging in Men Project. J Am Med Directors Assoc2018; 19: 216–222.
2.
ZetheliusBGudbjörnsdottirSEliassonBet al.Level of physical activity associated with risk of cardiovascular diseases and mortality in patients with type-2 diabetes: report from the Swedish National Diabetes Register. Eur J Prev Cardiol2014; 21: 244–251.
3.
WilliamsEDStamatakisEChandolaTet al.Physical activity behaviour and coronary heart disease mortality among South Asian people in the UK: an observational longitudinal study. Heart2011; 97: 655–659.
4.
PowellKEBlairSN. The public health burdens of sedentary living habits: theoretical but realistic estimates. Med Sci Sports Exerc1994; 26: 851–856.
5.
LeitzmannMFParkYBlairAet al.Physical activity recommendations and decreased risk of mortality. Arch Intern Med2007; 167: 2453–2460.
6.
LeeIMSkerrettPJ. Physical activity and all-cause mortality: what is the dose–response relation?Med Sci Sports Exerc2001; 33: S459–S471.
7.
KokkinosPSheriffHKheirbekR. Physical inactivity and mortality risk. Cardiol Res Pract2011; 2011: 924945–924945.
8.
StamatakisEHillsdonMPrimatestaP. Domestic physical activity in relationship to multiple CVD risk factors. Am J Prev Med2007; 32: 320–327.
9.
HaskellWLLeeIMPateRRet al.Physical activity and public health: updated recommendation for adults from the American College of Sports Medicine and the American Heart Association. Circulation2007; 116: 1081–1093.
10.
SjöströmMOjaPHagströmerMet al.Health-enhancing physical activity across European Union countries: the Eurobarometer study. J Public Health2006; 14: 291–300.
11.
NoconMHiemannTMüller-RiemenschneiderFet al.Association of physical activity with all-cause and cardiovascular mortality: a systematic review and meta-analysis. Eur J Cardiovasc Prev Rehabil2008; 15: 239–246.
12.
WarburtonDENicolCWBredinSS. Health benefits of physical activity: the evidence. CMAJ2006; 174: 801–809.
13.
StroupDFBerlinJAMortonSCet al.Meta-analysis of observational studies in epidemiology: a proposal for reporting. Meta-analysis of Observational Studies in Epidemiology (MOOSE) group. JAMA2000; 283: 2008–2012.
HigginsJPThompsonSGDeeksJJet al.Measuring inconsistency in meta-analyses. BMJ2003; 327: 557–560.
16.
HigginsJPThompsonSG. Controlling the risk of spurious findings from meta-regression. Stat Med2004; 23: 1663–1682.
17.
BeggCBMazumdarM. Operating characteristics of a rank correlation test for publication bias. Biometrics1994; 50: 1088–1101.
18.
OrsiniNBelloccoRGreenlandS. Generalized least squares for trend estimationof summarized dose–response data. Stata J2006; 6: 40–57.
19.
OrsiniNLiRWolkAet al.Meta-analysis for linear and nonlinear dose-response relations: examples, an evaluation of approximations and software. Am J Epidemiol2012; 175: 66–73.
20.
BekkeringGEHarrisRJThomasSet al.How much of the data published in observational studies of the association between diet and prostate or bladder cancer is usable for meta-analysis?Am J Epidemiol2008; 167: 1017–1026.
21.
AinsworthBEHaskellWLWhittMCet al.Compendium of physical activities: an update of activity codes and MET intensities. Med Sci Sports Exerc2000; 32(9 Suppl.): S498–S504.
22.
AinsworthBEHaskellWLHerrmannSDet al.2011 Compendium of physical activities: a second update of codes and MET values. Med Sci Sports Exerc2011; 43: 1575–1581.
23.
StewartRHeldCBrownRet al.Physical activity in patients with stable coronary heart disease: an international perspective. Eur Heart J2013; 34: 3286–3293.
24.
SchnohrPO’KeefeJHLangePet al.Impact of persistence and non-persistence in leisure time physical activity on coronary heart disease and all-cause mortality: the Copenhagen City Heart Study. Eur J Prev Cardiol2017; 24: 1615–1623.
25.
ApullanFJBourassaMGTardifJCet al.Usefulness of self-reported leisure-time physical activity to predict long-term survival in patients with coronary heart disease. Am J Cardiol2008; 102: 375–379.
26.
AremHMooreSCPatelAet al.Leisure time physical activity and mortality: a detailed pooled analysis of the dose–response relationship. JAMA Intern Med2015; 175: 959–967.
27.
BarengoNCHuGLakkaTAet al.Low physical activity as a predictor for total and cardiovascular disease mortality in middle-aged men and women in Finland. Eur Heart J2004; 25: 2204–2211.
28.
CheungYKMoonYPKulickERet al.Leisure-time physical activity and cardiovascular mortality in an elderly population in northern Manhattan: a prospective cohort study. J Gen Intern Med2017; 32: 168–174.
29.
LiuYShuXOWenWet al.Association of leisure-time physical activity with total and cause-specific mortality: a pooled analysis of nearly a half million adults in the Asia Cohort Consortium. Am J Respir Crit Care Med2018; 47: 771–779.
30.
HuGJousilahtiPAntikainenRet al.Occupational, commuting, and leisure-time physical activity in relation to cardiovascular mortality among Finnish subjects with hypertension. Am J Hypertens2007; 20: 1242–1250.
31.
LeeDPateRRLavieCJet al.Leisure-time running reduces all-cause and cardiovascular mortality risk. J Am Coll Cardiol2014; 64: 472–481.
32.
LiuYWenWGaoYTet al.Level of moderate-intensity leisure-time physical activity and reduced mortality in middle-aged and elderly Chinese. J Epidemiol Commun Health2018; 72: 13–20.
33.
UeshimaKIshikawa-TakataKYorifujiTet al.Physical activity and mortality risk in the Japanese elderly. Am J Prev Med2010; 38: 410–418.
34.
WannametheeSGShaperAGWalkerM. Physical activity and mortality in older men with diagnosed coronary heart disease. Circulation2000; 102: 1358–1363.
35.
AutenriethCSBaumertJBaumeisterSEet al.Association between domains of physical activity and all-cause, cardiovascular and cancer mortality. Eur J Epidemiol2011; 26: 91–99.
36.
StewartRAHHeldCHadziosmanovicNet al.Physical activity and mortality in patients with stable coronary heart disease. J Am Coll Cardiol2017; 70: 1689–1700.
37.
FanMYuCGuoYet al.Effect of total, domain-specific, and intensity-specific physical activity on all-cause and cardiovascular mortality among hypertensive adults in China. J Hypertens2018; 36: 793–800.
38.
PatelKSuiXZhangYet al.Prevention of heart failure in older adults may require higher levels of physical activity than needed for other cardiovascular events. Int J Cardiol2013; 168: 1905–1909.
39.
BarengoNCAntikainenRBorodulinKet al.Leisure-time physical activity reduces total and cardiovascular mortality and cardiovascular disease incidence in older adults. J Am Geriatr Soc2017; 65: 504–510.
40.
BossHMKappelleLJVanYDGet al.Physical activity and vascular events and mortality in patients with vascular disease. Med Sci Sports Exerc2015; 47: 2359–2365.
41.
JefferisBJWhincupPHLennonLTet al.Physical activity in older men: longitudinal associations with inflammatory and hemostatic biomarkers, N-terminal pro-brain natriuretic peptide, and onset of coronary heart disease and mortality. J Am Geriatr Soc2014; 62: 599–606.
42.
BacevičienėMLukšienėDBernotienėGet al.Estimation of all-cause and cardiovascular mortality risk in relation to leisure-time physical activity: a cohort study. Medicina2012; 48: 632–639.
43.
BessonHEkelundUBrageSet al.Relationship between subdomains of total physical activity and mortality. Med Sci Sports Exerc2008; 40: 1909–1915.
44.
FangJWylie-RosettJCohenHWet al.Exercise, body mass index, caloric intake, and cardiovascular mortality. Am J Prev Med2003; 25: 283–289.
45.
EvensonKRWenFHerringAH. Associations of accelerometry-assessed and self-reported physical activity and sedentary behavior with all-cause and cardiovascular mortality among US adults. Am J Epidemiol2016; 184: 621–632.
46.
HamerMStamatakisE. Physical activity and mortality in men and women with diagnosed cardiovascular disease. Eur J Cardiovasc Prev Rehabil2009; 16: 156–160.
47.
HolmeIAnderssenSA. Increases in physical activity is as important as smoking cessation for reduction in total mortality in elderly men: 12 years of follow-up of the Oslo II study. Br J Sports Med2015; 49: 743–748.
48.
HuGErikssonJBarengoNCet al.Occupational, commuting, and leisure-time physical activity in relation to total and cardiovascular mortality among Finnish subjects with type 2 diabetes. Circulation2004; 110: 666–673.
49.
MoeBAugestadLBNilsenTIL. Diabetes severity and the role of leisure time physical exercise on cardiovascular mortality: the Nord-Trøndelag Health study (HUNT), Norway. Cardiovasc Diabetol2013; 12: 83–83.
50.
MoholdtTWisløffUNilsenTILet al.Physical activity and mortality in men and women with coronary heart disease: a prospective population-based cohort study in Norway (the HUNT study). Eur J Cardiovasc Prev Rehabil2008; 15: 639–645.
51.
PatelAVBernsteinLDekaAet al.Leisure time spent sitting in relation to total mortality in a prospective cohort of US adults. Am J Epidemiol2010; 172: 419–429.
52.
MoholdtTLavieCJNaumanJ. Interaction of physical activity and body mass index on mortality in coronary heart disease: data from the Nord-Trøndelag Health Study. Am J Med2017; 130: 949–957.
53.
SavelaSKoistinenPTilvisRSet al.Leisure-time physical activity, cardiovascular risk factors and mortality during a 34-year follow-up in men. Eur J Epidemiol2010; 25: 619–625.
54.
WannerMTarnutzerSMartinBWet al.Impact of different domains of physical activity on cause-specific mortality: a longitudinal study. Prev Med2014; 62: 89–95.
55.
HoltermannAMortensenOSBurrHet al.The interplay between physical activity at work and during leisure time-risk of ischemic heart disease and all-cause mortality in middle-aged Caucasian men. Scand J Work, Environ Health2009; 35: 466–474.
56.
ZetheliusBGudbjörnsdottirSEliassonBet al.Level of physical activity associated with risk of cardiovascular diseases and mortality in patients with type-2 diabetes: report from the Swedish National Diabetes Register. Eur J Prev Cardiol2014; 21: 244–251.
57.
ZhaoGLiCFordESet al.Leisure-time aerobic physical activity, muscle-strengthening activity and mortality risks among US adults: the NHANES linked mortality study. Br J Sports Med2014; 48: 244–249.
58.
BattyGDShipleyMJMarmotMet al.Leisure time physical activity and coronary heart disease mortality in men symptomatic or asymptomatic for ischaemia: evidence from the Whitehall study. J Public Health2003; 25: 190–196.
59.
HuertaJMChirlaqueMDTormoMJet al.Work, household, and leisure-time physical activity and risk of mortality in the EPIC-Spain cohor]. Prev Med2016; 85: 106–112.
60.
O’DonovanGHamerMStamatakisE. Relationships between exercise, smoking habit and mortality in more than 100,000 adults. Int J Cancer2017; 140: 1819–1827.
61.
ShiromaEJSessoHDMoorthyMVet al.Do moderate-intensity and vigorous-intensity physical activities reduce mortality rates to the same extent?J Am Heart Assoc2014; 3: e000802–e000802.
62.
LahtinenMToukolaTJunttilaMJet al.Effect of changes in physical activity on risk for cardiac death in patients with coronary artery disease. Am J Cardiol2018; 121: 143–148.
63.
O’DonovanGLeeIMHamerMet al.Association of “weekend warrior” and other leisure time physical activity patterns with risks for all-cause, cardiovascular disease, and cancer mortality. JAMA Intern Med2017; 177: 335–342.
64.
DonneyongMMTaylorKCKerberRAet al.Is outdoor recreational activity an independent predictor of cardiovascular disease mortality – NHANES III?Nutr, Metab Cardiovasc Dis2016; 26: 735–742.
65.
HamerMStamatakisE. Low-dose physical activity attenuates cardiovascular disease mortality in men and women with clustered metabolic risk factors. Circulation: Cardiovasc Quality Outcomes2012; 5: 494–499.
66.
WangNZhangXXiangYBet al.Associations of Tai Chi, walking, and jogging with mortality in Chinese men. Am J Epidemiol2013; 178: 791–796.
67.
GunnellASKnuimanMWDivitiniMLet al.Leisure time physical activity and long-term cardiovascular and cancer outcomes: the Busselton Health Study. Eur J Epidemiol2014; 29: 851–857.
RognmoØHetlandEHelgerudJet al.High intensity aerobic interval exercise is superior to moderate intensity exercise for increasing aerobic capacity in patients with coronary artery disease. Eur J Cardiovasc Prev Rehabil2004; 11: 216–222.
70.
RossiADikarevaABaconSLet al.The impact of physical activity on mortality in patients with high blood pressure: a systematic review. J Hypertens2012; 30: 1277–1288.
71.
ThijssenDHMaioranaAJO’DriscollGet al.Impact of inactivity and exercise on the vasculature in humans. Eur J Appl Physiol2010; 108: 845–875.
72.
MoynaNMThompsonPD. The effect of physical activity on endothelial function in man. Acta Physiol Scand2004; 180: 113–123.
73.
BowlesDKLaughlinMH. Mechanism of beneficial effects of physical activity on atherosclerosis and coronary heart disease. J Appl Physiol2011; 111: 308–310.
74.
ChastinSFMDe CraemerMDe CockerKet al.How does light-intensity physical activity associate with adult cardiometabolic health and mortality? Systematic review with meta-analysis of experimental and observational studies. Br J Sports Med2018; doi: 10.1136/bjsports-2017-097563.
75.
SchmidDLeitzmannMF. Association between physical activity and mortality among breast cancer and colorectal cancer survivors: a systematic review and meta-analysis. Ann Oncol2014; 25: 1293–1311.
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