Impact of Physical Inactivity on Mortality in Patients With Heart Failure

Abstract

The impact of physical inactivity on heart failure (HF) mortality is unclear. We analyzed data from the HF Adherence and Retention Trial (HART) which enrolled 902 patients with New York Heart Association class II/III HF, with preserved or reduced ejection fraction, who were followed for 36 months. On the basis of mean self-reported weekly exercise duration, patients were classified into inactive (0 min/week) and active (≥1 min/week) groups and then propensity score matched according to 34 baseline covariates in 1:2 ratio. Sedentary activity was determined according to self-reported daily television screen time (<2, 2 to 4, >4 h/day). The primary outcome was all-cause death. Secondary outcomes were cardiac death and HF hospitalization. There were 196 inactive patients, of whom 171 were propensity matched to 342 active patients. Physical inactivity was associated with greater risk of all-cause death (hazard ratio [HR] 2.01, confidence interval [CI] 1.47 to 3.00; p <0.001) and cardiac death (HR 2.01, CI 1.28 to 3.17; p = 0.002) but no significant difference in HF hospitalization (p = 0.548). Modest exercise (1 to 89 min/week) was associated with a significant reduction in the rate of death (p = 0.003) and cardiac death (p = 0.050). Independent of exercise duration and baseline covariates, television screen time (>4 vs <2 h/day) was associated with all-cause death (HR 1.65, CI 1.10 to 2.48; p = 0.016; incremental chi-square = 6.05; p = 0.049). In conclusion, in patients with symptomatic chronic HF, physical inactivity is associated with higher all-cause and cardiac mortality. Failure to exercise and television screen time are additive in their effects on mortality. Even modest exercise was associated with survival benefit.

Trial registration: ClinicalTrials.gov NCT00018005.

Figure 1

Absolute Standardized Differences in Baseline Covariates between Physically Inactive and Physically Active Patients Pre and Post Propensity Score Matching HFrEF, heart failure with reduced ejection fraction; SF-36, 36-item short-form questionnaire of the medical outcome study; NYHA, New York Heart Association; ACEi, angiotensin-converting enzyme inhibitor; ARB, angiotensin receptor blocker; HART, Heart Failure Adherence and Retention Trial

Figure 2

Impact of Physical Inactivity on Heart Failure Outcomes in the Propensity-Matched Cohort HR, hazard ratio; CI, 95% confidence interval; Adj HR, hazard ratio adjusted for covariates with >10% post-matching absolute standardized difference (3^rd heart sounds and loop diuretic dose).

Figure 3

Impact of Various Level of Physical Inactivity on Heart Failure Outcomes Survival plots derived from inverse probability weighted Cox regression models fitted in the entire cohort. HR, hazard ratio; CI, 95% confidence interval

Figure 4

Impact of Physical Inactivity on All-Cause Death by Subgroups of the Propensity-Matched Cohort HR, hazard ratio; CI, 95% confidence interval; NYHA, New Your Heart Association classification; HFrEF, heart failure with reduced ejection fraction; HFpEF, heart failure with preserved ejection fraction; CAD, coronary artery disease; CKD, chronic kidney disease (glomerular filtration rate <60 ml/min/1.73m² or dialysis) * Obesity was defined as body mass index ≥30 kg/m² HR, CI, and P values were derived from multivariate Cox-regression models in the propensity-matched cohort and adjusted for covariates with >10% post-matching absolute standardized difference (3^rd heart sounds and loop diuretic dose).

Figure 5. Impact of Sedentary Television Screen Time on All-Cause Mortality

Survival plots derived from inverse probability weighted Cox regression models fitted in the entire cohort. HR, hazard ratio; CI, 95% confidence interval