title: A non-exercise testing method for estimating cardiorespiratory fitness: associations with all-cause and cardiovascular mortality in a pooled analysis of eight population-based cohorts.
abstract: OBJECTIVE
  Cardiorespiratory fitness (CRF) is a key predictor of chronic disease, particularly cardiovascular disease (CVD), but its assessment usually requires exercise testing which is impractical and costly in most health-care settings. Non-exercise testing cardiorespiratory fitness (NET-F)-estimating methods are a less resource-demanding alternative, but their predictive capacity for CVD and total mortality has yet to be tested. The objective of this study is to examine the association of a validated NET-F algorithm with all-cause and CVD mortality.
  
  
  RESULTS
  The participants were 32,319 adults (14,650 men) aged 35-70 years who took part in eight Health Survey for England and Scottish Health Survey studies between 1994 and 2003. Non-exercise testing cardiorespiratory fitness (a metabolic equivalent of VO2max) was calculated using age, sex, body mass index (BMI), resting heart rate, and self-reported physical activity. We followed participants for mortality until 2008. Two thousand one hundred and sixty-five participants died (460 cardiovascular deaths) during a mean 9.0 [standard deviation (SD) = 3.6] year follow-up. After adjusting for potential confounders including diabetes, hypertension, smoking, social class, alcohol, and depression, a higher fitness score according to the NET-F was associated with a lower risk of mortality from all-causes (hazard ratio per SD increase in NET-F 0.85, 95% confidence interval: 0.78-0.93 in men; 0.88, 0.80-0.98 in women) and CVD (men: 0.75, 0.63-0.90; women: 0.73, 0.60-0.92). Non-exercise testing cardiorespiratory fitness had a better discriminative ability than any of its components (CVD mortality c-statistic: NET-F = 0.70-0.74; BMI = 0.45-0.59; physical activity = 0.60-0.64; resting heart rate = 0.57-0.61). The sensitivity of the NET-F algorithm to predict events occurring in the highest risk quintile was better for CVD (0.49 in both sexes) than all-cause mortality (0.44 and 0.40 for men and women, respectively). The specificity for all-cause and CVD mortality ranged between 0.80 and 0.82. The net reclassification improvement of CVD mortality risk (vs. a standardized aggregate score of the modifiable components of NET-F) was 27.2 and 21.0% for men and women, respectively.
  
  
  CONCLUSIONS
  The CRF-estimating method NET-F that does not involve exercise testing showed consistent associations with all-cause and cardiovascular mortality, and it had good discrimination and excellent risk reclassification improvement. As such, it merits further attention as a practical and potentially and useful risk prediction tool.
authors.affiliation: Department of Epidemiology and Public Health, University College London, 1-19 Torrington Place, London WC1E 6BT, UK. e.stamatakis@ucl.ac.uk
authors.forename: Emmanuel
authors.initials: E
authors.lastname: Stamatakis
authors.forename: Mark
authors.initials: M
authors.lastname: Hamer
authors.forename: Gary
authors.initials: G
authors.lastname: O'Donovan
authors.forename: George David
authors.initials: GD
authors.lastname: Batty
authors.forename: Mika
authors.initials: M
authors.lastname: Kivimaki
mesh_terms: D000328:Adult; D000368:Aged; D000465:Algorithms; D015992:Body Mass Index; D002318:Cardiovascular Diseases / Q000401:mortality* / Q000503:physiopathology; D015444:Exercise / Q000502:physiology; D005260:Female; D005500:Follow-Up Studies; D006339:Heart Rate / Q000502:physiology; D006801:Humans; D008297:Male; D008875:Middle Aged; D010101:Oxygen Consumption / Q000502:physiology; D010809:Physical Fitness / Q000502:physiology*; D012737:Sex Factors