This Article  • Full text  • PDF  • Send to a friend  • Save in My Folder  • Save to citation manager  • Permissions  Citing Articles  • Citation map  • Citing articles on HighWire  • Citing articles on ISI (85)  • Contact me when this article is cited  Related Content  • Related letters  • Similar articles in JAMA  Topic Collections  • Women's Health, Other  • Prognosis/ Outcomes  • Cardiac Diagnostic Tests  • Alert me on articles by topic

A 20-Year Follow-up of the Lipid Research Clinics Prevalence Study

Samia Mora, MD, MHS; Rita F. Redberg, MD, MSc; Yadong Cui, MD, PhD; Maura K. Whiteman, PhD; Jodi A. Flaws, PhD; A. Richey Sharrett, MD, DrPH; Roger S. Blumenthal, MD

JAMA. 2003;290:1600-1607.

Context  The value of exercise testing in women has been questioned.

Objective  To determine the prognostic value of exercise testing in a population-based cohort of asymptomatic women followed up for 20 years.

Design and Setting  Near-maximal Bruce-protocol treadmill test data from the Lipid Research Clinics Prevalence Study (1972-1976) with follow-up through 1995.

Participants  A total of 2994 asymptomatic North American women, aged 30 to 80 years, without known cardiovascular disease.

Main Outcome Measures  Cardiovascular and all-cause mortality.

Results  There were 427 (14%) deaths during 20 years of follow-up, of which 147 were due to cardiovascular causes. Low exercise capacity, low heart rate recovery (HRR), and not achieving target heart rate were independently associated with increased all-cause and cardiovascular mortality. There was no increased cardiovascular death risk for exercise-induced ST-segment depression (age-adjusted hazard ratio, 1.02; 95% confidence interval [CI], 0.57-1.80; P = .96). The age-adjusted hazard ratio for cardiovascular death for every metabolic equivalent (MET) decrement in exercise capacity was 1.20 (95% CI, 1.18-1.30; P<.001); for every 10 beats per minute decrement in HRR, the hazard ratio was 1.36 (95% CI, 1.19-1.55; P<.001). After adjusting for multiple other risk factors, women who were below the median for both exercise capacity and HRR had a 3.5-fold increased risk of cardiovascular death (95% CI, 1.57-7.86; P = .002) compared with those above the median for both variables. Among women with low risk Framingham scores, those with below median levels of both exercise capacity and HRR had significantly increased risk compared with women who had above median levels of these 2 exercise variables, 44.5 and 3.5 cardiovascular deaths per 10 000 person-years, respectively (hazard ratio for cardiovascular death, 12.93; 95% CI, 5.62-29.73; P<.001).

Conclusion  The prognostic value of exercise testing in asymptomatic women derives not from electrocardiographic ischemia but from fitness-related variables.

Author Affiliations: Ciccarone Preventive Cardiology Center, Department of Medicine, Johns Hopkins Medical Institutions, Baltimore, Md (Drs Mora and Blumenthal); Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Md (Drs Mora and Sharrett); Division of Cardiology, Department of Medicine, University of California, San Francisco (Dr Redberg); and Department of Epidemiology and Preventive Medicine, School of Medicine, University of Maryland, Baltimore (Drs Cui, Whiteman, and Flaws). Dr Cui is now with the Department of Global Safety Surveillance and Epidemiology, Wyeth Research, Collegeville, Pa.

RELATED LETTERS

Level of Exercise and Risk of Cardiovascular Disease
Lorraine L. Tosiello and Nallu Reddy
JAMA. 2004;291(2):183.
EXTRACT | FULL TEXT  

Level of Exercise and Risk of Cardiovascular Disease—Reply
Samia Mora, Rita F. Redberg, A. Richey Sharrett, and Roger S. Blumenthal
JAMA. 2004;291(2):183-184.
EXTRACT | FULL TEXT  

THIS ARTICLE HAS BEEN CITED BY OTHER ARTICLES

Association between muscular strength and mortality in men: prospective cohort study
Ruiz et al.
BMJ 2008;337:a439-a439.
ABSTRACT | FULL TEXT  

The Hurdles of Translating a Single-Center Observation Into Practice--Reply
Peterson and Masoudi
Arch Intern Med 2008;168:1720-1720.
FULL TEXT  

The exercise treadmill test: Estimating cardiovascular prognosis
LAUER and MILLER
Cleveland Clinic Journal of Medicine 2008;75:424-430.
ABSTRACT | FULL TEXT  

Lifestyle and Risk of Cardiovascular Disease and Type 2 Diabetes in Women: A Review of the Epidemiologic Evidence
Bassuk and Manson
AMERICAN JOURNAL OF LIFESTYLE MEDICINE 2008;2:191-213.
ABSTRACT  

Inverse Correlation Between Heart Rate Recovery and Metabolic Risks in Healthy Children and Adolescents: Insight from the National Health and Nutrition Examination Survey 1999-2002
Lin et al.
Diabetes Care 2008;31:1015-1020.
ABSTRACT | FULL TEXT  

Exercise Capacity and Mortality in Black and White Men
Kokkinos et al.
Circulation 2008;117:614-622.
ABSTRACT | FULL TEXT  

Association of Exercise Capacity on Treadmill With Future Cardiac Events in Patients Referred for Exercise Testing
Peterson et al.
Arch Intern Med 2008;168:174-179.
ABSTRACT | FULL TEXT  

Ventricular Arrhythmias During Clinical Treadmill Testing and Prognosis
Dewey et al.
Arch Intern Med 2008;168:225-234.
ABSTRACT | FULL TEXT  

External Prognostic Validations and Comparisons of Age- and Gender-Adjusted Exercise Capacity Predictions
Kim et al.
J Am Coll Cardiol 2007;50:1867-1875.
ABSTRACT | FULL TEXT  

Exercise Stress Testing in Patients With Type 2 Diabetes: When Are Asymptomatic Patients Screened?
Harris and White
Clin. Diabetes 2007;25:126-130.
ABSTRACT | FULL TEXT  

Exercise Capacity and Cardiovascular/Metabolic Characteristics of Overweight and Obese Individuals With Type 2 Diabetes: The Look AHEAD clinical trial
Ribisl et al.
Diabetes Care 2007;30:2679-2684.
ABSTRACT | FULL TEXT  

Cardiovascular Reserve and Risk Profile of Postmenopausal Women After Chemoendocrine Therapy for Hormone Receptor Positive Operable Breast Cancer
Jones et al.
The Oncologist 2007;12:1156-1164.
ABSTRACT | FULL TEXT  

Assessment of Functional Capacity in Clinical and Research Settings: A Scientific Statement From the American Heart Association Committee on Exercise, Rehabilitation, and Prevention of the Council on Clinical Cardiology and the Council on Cardiovascular Nursing
Arena et al.
Circulation 2007;116:329-343.
FULL TEXT  

A 52-Year-Old Woman With Hypertension and Diabetes Who Presents With Chest Pain
Harris
Clin. Diabetes 2007;25:115-118.
FULL TEXT  

Cardiorespiratory Fitness as a Predictor of Nonfatal Cardiovascular Events in Asymptomatic Women and Men
Sui et al.
Am J Epidemiol 2007;165:1413-1423.
ABSTRACT | FULL TEXT  

Heritability, Linkage, and Genetic Associations of Exercise Treadmill Test Responses
Ingelsson et al.
Circulation 2007;115:2917-2924.
ABSTRACT | FULL TEXT  

Effects of Different Doses of Physical Activity on Cardiorespiratory Fitness Among Sedentary, Overweight or Obese Postmenopausal Women With Elevated Blood Pressure: A Randomized Controlled Trial
Church et al.
JAMA 2007;297:2081-2091.
ABSTRACT | FULL TEXT  

A comprehensive view of sex-specific issues related to cardiovascular disease
Pilote et al.
CMAJ 2007;176:S1-S44.
ABSTRACT | FULL TEXT  

The Prognostic Value of Normal Exercise Myocardial Perfusion Imaging and Exercise Echocardiography: A Meta-Analysis
Metz et al.
J Am Coll Cardiol 2007;49:227-237.
ABSTRACT | FULL TEXT  

Effect of endurance exercise training on heart rate onset and heart rate recovery responses to submaximal exercise in animals susceptible to ventricular fibrillation
Billman and Kukielka
J. Appl. Physiol. 2007;102:231-240.
ABSTRACT | FULL TEXT  

Plaque stability and plaque regression: new insights
Tschoepe and Stratmann
Eur Heart J Suppl 2006;8:F34-F39.
ABSTRACT | FULL TEXT  

Relations of total physical activity and intensity to fitness and fatness in children: the European Youth Heart Study.
Ruiz et al.
Am. J. Clin. Nutr. 2006;84:299-303.
ABSTRACT | FULL TEXT  

Association of Long-Distance Corridor Walk Performance With Mortality, Cardiovascular Disease, Mobility Limitation, and Disability
Newman et al.
JAMA 2006;295:2018-2026.
ABSTRACT | FULL TEXT  

Insights From the NHLBI-Sponsored Women's Ischemia Syndrome Evaluation (WISE) Study: Part I: Gender Differences in Traditional and Novel Risk Factors, Symptom Evaluation, and Gender-Optimized Diagnostic Strategies
Shaw et al.
J Am Coll Cardiol 2006;47:S4-S20.
ABSTRACT | FULL TEXT  

The Value of Estimated Functional Capacity in Estimating Outcome: Results From the NHBLI-Sponsored Women's Ischemia Syndrome Evaluation (WISE) Study
Shaw et al.
J Am Coll Cardiol 2006;47:S36-S43.
ABSTRACT | FULL TEXT  

Impaired Coronary Vascular Reactivity and Functional Capacity in Women: Results From the NHLBI Women's Ischemia Syndrome Evaluation (WISE) Study
Handberg et al.
J Am Coll Cardiol 2006;47:S44-S49.
ABSTRACT | FULL TEXT  

Enhanced Risk Assessment in Asymptomatic Individuals With Exercise Testing and Framingham Risk Scores
Mora et al.
Circulation 2005;112:1566-1572.
ABSTRACT | FULL TEXT  

The Prognostic Value of a Nomogram for Exercise Capacity in Women
Gulati et al.
NEJM 2005;353:468-475.
ABSTRACT | FULL TEXT  

Exercise Testing in Asymptomatic Adults: A Statement for Professionals From the American Heart Association Council on Clinical Cardiology, Subcommittee on Exercise, Cardiac Rehabilitation, and Prevention
Lauer et al.
Circulation 2005;112:771-776.
ABSTRACT | FULL TEXT  

Determinants of Exercise Capacity in Patients With Type 2 Diabetes
Fang et al.
Diabetes Care 2005;28:1643-1648.
ABSTRACT | FULL TEXT  

The Vascular Surgeon's Role in Risk Factor Modification: Results of a Survey
Leon et al.
PERSPECT VASC SURG ENDOVASC THER 2005;17:145-153.
ABSTRACT  

Heart rate recovery after exercise: a predictor of ventricular fibrillation susceptibility after myocardial infarction
Smith et al.
Am. J. Physiol. Heart Circ. Physiol. 2005;288:H1763-H1769.
ABSTRACT | FULL TEXT  

Role of Noninvasive Testing in the Clinical Evaluation of Women With Suspected Coronary Artery Disease: Consensus Statement From the Cardiac Imaging Committee, Council on Clinical Cardiology, and the Cardiovascular Imaging and Intervention Committee, Council on Cardiovascular Radiology and Intervention, American Heart Association
Mieres et al.
Circulation 2005;111:682-696.
ABSTRACT | FULL TEXT  

Heart Rate Recovery: Predictor of Risk Today and Target of Therapy Tomorrow?
Morise
Circulation 2004;110:2778-2780.
FULL TEXT  

Usefulness of Exercise Testing in the Prediction of Coronary Disease Risk Among Asymptomatic Persons as a Function of the Framingham Risk Score
Balady et al.
Circulation 2004;110:1920-1925.
ABSTRACT | FULL TEXT  

Global Risk Scores and Exercise Testing for Predicting All-Cause Mortality in a Preventive Medicine Program
Aktas et al.
JAMA 2004;292:1462-1468.
ABSTRACT | FULL TEXT  

Relationship of Physical Fitness vs Body Mass Index With Coronary Artery Disease and Cardiovascular Events in Women
Wessel et al.
JAMA 2004;292:1179-1187.
ABSTRACT | FULL TEXT  

The predictive value of cardiorespiratory fitness for cardiovascular events in men with various risk profiles: a prospective population-based cohort study
Laukkanen et al.
Eur Heart J 2004;25:1428-1437.
ABSTRACT | FULL TEXT  

Exercise-Induced Premature Ventricular Beats: Should We Do Anything Differently?
Selzman and Gettes
Circulation 2004;109:2374-2375.
FULL TEXT  

Clinical Correlates and Prognostic Significance of Exercise-Induced Ventricular Premature Beats in the Community: The Framingham Heart Study
Morshedi-Meibodi et al.
Circulation 2004;109:2417-2422.
ABSTRACT | FULL TEXT  

Additional articles abstracted in ACP Journal Club
Evid. Based Med. 2004;9:67-67.
FULL TEXT  

Other articles noted: 14 Nov 2003 to 30 Jan 2004
Evid. Based Nurs. 2004;7:e2-e2.
FULL TEXT  

Exercise Tolerance Testing To Screen for Coronary Heart Disease: A Systematic Review for the Technical Support for the U.S. Preventive Services Task Force
Fowler-Brown et al.
ANN INTERN MED 2004;0:6052004040601-24.
ABSTRACT | FULL TEXT  

ABSTRACTS
Obstet Gynecol 2004;103:397-399.
FULL TEXT  

Level of Exercise and Risk of Cardiovascular Disease
Tosiello and Reddy
JAMA 2004;291:183-183.
FULL TEXT  

Cardiorespiratory Fitness in Young Adulthood and the Development of Cardiovascular Disease Risk Factors
Carnethon et al.
JAMA 2003;290:3092-3100.
ABSTRACT | FULL TEXT  

Exercise Testing Results Predict Mortality in Women
JWatch Women's Health 2003;2003:4-4.
FULL TEXT  

JournalScan
Malik
Heart 2003;89:1467-1468.
FULL TEXT  

Exercise Capacity and Heart-Rate Recovery Predict Death in Asymptomatic Women
Journal Watch Cardiology 2003;2003:2-2.
FULL TEXT  

Exercise Tolerance Testing To Screen for Coronary Heart Disease: A Systematic Review for the Technical Support for the U.S. Preventive Services Task Force
Fowler-Brown et al.
ANN INTERN MED 2004;140:W-9-W-24.
ABSTRACT | FULL TEXT