Relationship Between Physical Activity, Body Mass Index, and Risk of Heart Failure

Abstract

Background: Lower leisure-time physical activity (LTPA) and higher body mass index (BMI) are independently associated with risk of heart failure (HF). However, it is unclear if this relationship is consistent for both heart failure with preserved ejection fraction (HFpEF) and heart failure with reduced ejection fraction (HFrEF).

Objectives: This study sought to quantify dose-response associations between LTPA, BMI, and the risk of different HF subtypes.

Methods: Individual-level data from 3 cohort studies (WHI [Women's Health Initiative], MESA [Multi-Ethnic Study of Atherosclerosis], and CHS [Cardiovascular Health Study]) were pooled and participants were stratified into guideline-recommended categories of LTPA and BMI. Associations between LTPA, BMI, and risk of overall HF, HFpEF (ejection fraction ≥45%), and HFrEF (ejection fraction <45%) were assessed by using multivariable adjusted Cox models and restricted cubic splines.

Results: The study included 51,451 participants with 3,180 HF events (1,252 HFpEF, 914 HFrEF, and 1,014 unclassified HF). In the adjusted analysis, there was a dose-dependent association between higher LTPA levels, lower BMI, and overall HF risk. Among HF subtypes, LTPA in any dose range was not associated with HFrEF risk. In contrast, lower levels of LTPA (<500 MET-min/week) were not associated with HFpEF risk, and dose-dependent associations with lower HFpEF risk were observed at higher levels. Compared with no LTPA, higher than twice the guideline-recommended minimum LTPA levels (>1,000 MET-min/week) were associated with an 19% lower risk of HFpEF (hazard ratio: 0.81; 95% confidence interval: 0.68 to 0.97). The dose-response relationship for BMI with HFpEF risk was also more consistent than with HFrEF risk, such that increasing BMI above the normal range (≥25 kg/m²) was associated with a greater increase in risk of HFpEF than HFrEF.

Conclusions: Our study findings show strong, dose-dependent associations between LTPA levels, BMI, and risk of overall HF. Among HF subtypes, higher LTPA levels and lower BMI were more consistently associated with lower risk of HFpEF compared with HFrEF.

Keywords: body mass index; dose–response relationship; heart failure; physical activity.

FIGURE 1. Cohort Derivation for the Pooled Analysis

The flowchart shows the derivation of the final study population from each of the 3 cohorts: the Women’s Health Initiative (WHI); Multiethnic Study of Atherosclerosis (MESA); and Cardiovascular Health Study (CHS). HF = heart failure; LTPA = leisure time physical activity; MI = myocardial infarction; UNC = University of North Carolina.

FIGURE 2. Risk of HF Subtypes by LTPA and BMI Categories

Kaplan-Meier plots here show the unadjusted cumulative incidence of heart failure with preserved ejection fraction and heart failure with reduced ejection fraction across different LTPA A,B and BMI C,D) groups. BMI = body mass index; HF = heart failure; HFpEF = heart failure with preserved ejection fraction; HFrEF = heart failure with reduced ejection fraction; LTPA = leisure time physical activity; MET = metabolic equivalent.

FIGURE 3. Continuous Association Between LTPA Levels and Risk of HF Subtypes

Restricted cubic splines showing continuous adjusted association between LTPA levels (MET-min/week) and risk of HFrEF (top panel) and HFpEF (bottom panel). The shaded area shows the 95% confidence interval for the hazard ratio point estimates associated with different LTPA levels. MET = metabolic equivalent. Other abbreviations as in Figure 2.

FIGURE 4. Continuous Association Between BMI and Risk of HF Subtypes

Restricted cubic splines showing continuous adjusted association between BMI (kg/m²) and risk of HFrEF (top panel) and HFpEF (bottom panel). The shaded area shows the 95% confidence interval for the hazard ratio point estimates associated with different LTPA levels. Abbreviations as in Figure 2.