Adding Estimated Cardiorespiratory Fitness to the Framingham Risk Score and Mortality Risk in a Korean Population-Based Cohort Study

Estimated pulse wave velocity is associated with all-cause and cardiovascular mortality in individuals with stroke: A national-based prospective cohort study

Extensive evidence underscores the potential of estimated pulse wave velocity (ePWV) as a robust tool for predicting disease prevalence and mortality. However, its comparative effectiveness in forecasting all-cause and cardiovascular disease (CVD) mortality, particularly among stroke populations, remains inadequately characterized in relation to the traditional Framingham Risk Score (FRS) model. This prospective study included 1202 individuals with stroke from the National Health and Nutrition Examination Survey conducted between 1999 and 2014, with comprehensive follow-up data. Survey-weighted Cox regression models were employed to examine the association between ePWV and the risks of all-cause and CVD mortality. Subgroup analyses were performed to evaluate the stability of ePWV in predicting these outcomes. A generalized additive model was utilized to explore the dose-response relationship between ePWV and mortality risk. Receiver operating characteristic curves were then used to assess and compare the prognostic capabilities of ePWV and FRS models for 10-year all-cause and CVD mortality. After adjustment for relevant covariates, each 1 m/s increase in ePWV was associated with a 44% and 65% increase in all-cause and CVD mortality, respectively. ePWV demonstrated consistent prognostic performance across the majority of stroke subpopulations. Notably, ePWV exhibited a nonlinear relationship with all-cause mortality (P for nonlinearity = .045) while maintaining a linear association with CVD mortality (P for nonlinearity = .293). Furthermore, ePWV outperformed the FRS model in predicting 10-year all-cause (Integrated Discrimination Improvement = 0.061, 95% confidence interval: 0.031-0.095, P = .007) and CVD mortality (95% confidence interval: 0.005-0.083, P = .02). ePWV is an independent risk factor for both all-cause and CVD mortality in individuals with stroke, demonstrating superior predictive value compared to the traditional FRS model for forecasting these outcomes.

Comparison of objectively measured and estimated cardiorespiratory fitness to predict all-cause and cardiovascular disease mortality in adults: A systematic review and meta-analysis of 42 studies representing 35 cohorts and 3.8 million observations

BACKGROUND

Cardiorespiratory fitness (CRF) is a powerful health marker recommended by the American Heart Association as a clinical vital sign. Comparing the predictive validity of objectively measured CRF (the "gold standard") and estimated CRF is clinically relevant because estimated CRF is more feasible. Our objective was to meta-analyze cohort studies to compare the associations of objectively measured, exercise-estimated, and non-exercise-estimated CRF with all-cause and cardiovascular disease (CVD) mortality in adults.

METHODS

Systematic searches were conducted in 9 databases (MEDLINE, SPORTDiscus, Embase, Scopus, PsycINFO, Web of Science, PubMed, CINAHL, and the Cochrane Library) up to April 11, 2024. We included full-text refereed cohort studies published in English that quantified the association (using risk estimates with 95% confidence intervals (95%CIs)) of objectively measured, exercise-estimated, and non-exercise-estimated CRF with all-cause and CVD mortality in adults. CRF was expressed as metabolic equivalents (METs) of task. Pooled relative risks (RR) for all-cause and CVD mortality per 1-MET (3.5 mL/kg/min) higher level of CRF were quantified using random-effects models.

RESULTS

Forty-two studies representing 35 cohorts and 3,813,484 observations (81% male) (362,771 all-cause and 56,471 CVD deaths) were included. The pooled RRs for all-cause and CVD mortality per higher MET were 0.86 (95%CI: 0.83-0.88) and 0.84 (95%CI: 0.80-0.87), respectively. For both all-cause and CVD mortality, there were no statistically significant differences in RR per higher MET between objectively measured (RR range: 0.86-0.90) and maximal exercise-estimated (RR range: 0.85-0.86), submaximal exercise-estimated (RR range: 0.91-0.94), and non-exercise-estimated CRF (RR range: 0.81-0.85).

CONCLUSION

Objectively measured and estimated CRF showed similar dose-response associations for all-cause and CVD mortality in adults. Estimated CRF could provide a practical and robust alternative to objectively measured CRF for assessing mortality risk across diverse populations. Our findings underscore the health-related benefits of higher CRF and advocate for its integration into clinical practice to enhance risk stratification.

Estimated Cardiorespiratory Fitness and Metabolic Risks

This review focuses on the emerging evidence for the association between non-exercise fitness testing, estimated cardiorespiratory fitness (eCRF), and metabolic risk factors. Given the challenges associated with directly measuring cardiorespiratory fitness (CRF) in large populations, eCRF presents a practical alternative for predicting metabolic health risks. A literature search identified seven relevant cohort studies from 2020 to 2024 that investigated the association of eCRF with hypertension, hyperglycemia, dyslipidemia, and obesity. This review consistently demonstrates an inverse relationship between higher eCRF and a lower incidence of metabolic risks, which is in line with CRF cohort studies. It highlights the importance of low eCRF as a primordial indicator for metabolic risks and underscores the potential for broader application. Future research directions should include exploring eCRF's predictive ability across diverse populations and health outcomes and testing its real-world applicability in healthcare and public health settings.

Update to the 2016 American Heart Association cardiorespiratory fitness statement

In 2016 the American Heart Association published a scientific statement that summarized a large body of evidence concluding that cardiorespiratory fitness (CRF) was a powerful marker of cardiovascular disease (CVD) and CVD-mortality risk; its association with morbidity and mortality was independent of commonly obtained risk factors, and consequently, that it should be a routine measure in all health care settings. Since 2016 the interest in CRF as a prognostic for human health and performance has increased exponentially. This review will summarize a growing body of evidence that reinforces the notion that the assessment of CRF improves patient/client management. Feasible means of CRF assessment in health care settings is considered, and the expected response of CRF to exercise consistent with consensus recommendations is reviewed. The association between CRF and health care costs is also explored. The evidence reviewed will reinforce the conclusions drawn in 2016; that overwhelming evidence demands that CRF should be a routine assessment in all health care settings - a vital sign.

Updating Framingham CVD risk score using waist circumference and estimated cardiopulmonary function: a cohort study based on a southern Xinjiang population

Purpose

To explore the association between waist circumference (WC), estimated cardiopulmonary function (eCRF), and cardiovascular disease (CVD) risk in southern Xinjiang. Update the Framingham model to make it more suitable for the southern Xinjiang population.

Methods

Data were collected from 7705 subjects aged 30–74 years old in Tumushuke City, the 51st Regiment of Xinjiang Production and Construction Corps. CVD was defined as an individual's first diagnosis of non-fatal acute myocardial infarction, death from coronary heart disease, and fatal or non-fatal stroke. The Cox proportional hazards regression analysis was used to analyze the association between WC, eCRF and CVD risk. Restricted cubic spline plots were drawn to describe the association of the two indicators with CVD risk. We update the model by incorporating the new variables into the Framingham model and re-estimating the coefficients. The discrimination of the model is evaluated using AUC, NRI, and IDI metrics. Model calibration is evaluated using pseudo R² values.

Results

WC was an independent risk factor for CVD (multivariate HR: 1.603 (1.323, 1.942)), eCRF was an independent protective factor for CVD (multivariate HR: 0.499 (0.369, 0.674)). There was a nonlinear relationship between WC and CVD risk (nonlinear χ2 = 12.43, P = 0.002). There was a linear association between eCRF and CVD risk (non-linear χ2 = 0.27, P = 0.6027). In the male, the best risk prediction effect was obtained when WC and eCRF were added to the model (AUC = 0.763((0.734,0.792)); pseudo R² = 0.069). In the female, the best risk prediction effect was obtained by adding eCRF to the model (AUC = 0.757 (0.734,0.779); pseudo R² = 0.107).

Conclusion

In southern Xinjiang, WC is an independent risk factor for CVD. eCRF is an independent protective factor for CVD. We recommended adding WC and eCRF in the male model and only eCRF in the female model for better risk prediction.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-14110-y.