title: Cardiorespiratory Fitness and Incidence of Major Adverse Cardiovascular Events in US Veterans: A Cohort Study.
abstract: OBJECTIVE
  To assess the association between exercise capacity and the risk of major adverse cardiovascular events (MACEs).
  
  
  METHODS
  A symptom-limited exercise tolerance test was performed to assess exercise capacity in 20,590 US veterans (12,975 blacks and 7615 whites; mean ± SD age, 58.2±11.0 years) from the Veterans Affairs medical centers in Washington, District of Columbia, and Palo Alto, California. None had a history of MACE or evidence of ischemia at the time of or before their exercise tolerance test. We established quintiles of cardiorespiratory fitness (CRF) categories based on age-specific peak metabolic equivalents (METs) achieved. We also defined the age-specific MET level associated with no risk for MACE (hazard ratio [HR], 1.0) and formed 4 additional CRF categories based on METs achieved below (least fit and low fit) and above (moderately fit and highly fit) that level. Multivariate Cox models were used to estimate HR and 95% CIs for mortality across fitness categories.
  
  
  RESULTS
  During follow-up (median, 11.3 years; range, 0.3-33.0 years), 2846 individuals experienced MACEs. The CRF-MACE association was inverse and graded. The risk for MACE declined precipitously for those with a CRF level of 6.0 METs or higher. When considering CFR categories based on the age-specific MET threshold, the risk increased for those in the 2 CFR categories below that threshold (HR, 1.95; 95% CI, 1.73-2.21 and HR, 1.41; 95% CI, 1.27-1.56 for the least-fit and low-fit individuals, respectively) and decreased for those above it (HR, 0.77; 95% CI, 0.68-0.87 and HR, 0.57; 95% CI, 0.48-0.67 for moderately fit and highly fit, respectively).
  
  
  CONCLUSIONS
  Increased CRF is inversely and independently associated with the risk for MACE. When an age-specific MET threshold was defined, the risk for MACE increased significantly for those below that threshold and decreased for those above it (P<.001).
authors.affiliation: Cardiology Division, Veterans Affairs Medical Center, Washington, DC; Georgetown University School of Medicine, Washington, DC; Department of Exercise Science, Arnold School of Public Health, University of South Carolina, Columbia, SC. Electronic address: peter.kokkinos@va.gov.
authors.forename: Peter F
authors.initials: PF
authors.lastname: Kokkinos
authors.affiliation: Cardiology Division, Veterans Affairs Medical Center, Washington, DC; George Washington University School of Medicine and Health Sciences, Washington, DC.
authors.forename: Charles
authors.initials: C
authors.lastname: Faselis
authors.affiliation: Cardiology Division, VA Palo Alto Health Care System, Palo Alto, CA; Stanford University, Stanford, CA.
authors.forename: Jonathan
authors.initials: J
authors.lastname: Myers
authors.affiliation: Cardiology Division, Veterans Affairs Medical Center, Washington, DC.
authors.forename: Puneet
authors.initials: P
authors.lastname: Narayan
authors.affiliation: Department of Exercise Science, Arnold School of Public Health, University of South Carolina, Columbia, SC.
authors.forename: Xuemei
authors.initials: X
authors.lastname: Sui
authors.affiliation: Department of Epidemiology and Biostatistics, Arnold School of Public Health, University of South Carolina, Columbia, SC.
authors.forename: Jiajia
authors.initials: J
authors.lastname: Zhang
authors.affiliation: Department of Cardiovascular Diseases, John Ochsner Heart and Vascular Institute, Ochsner Clinical School, University of Queensland School of Medicine, New Orleans, LA.
authors.forename: Carl J
authors.initials: CJ
authors.lastname: Lavie
authors.affiliation: Cardiology Division, Veterans Affairs Medical Center, Washington, DC; Georgetown University School of Medicine, Washington, DC.
authors.forename: Hans
authors.initials: H
authors.lastname: Moore
authors.affiliation: Cardiology Division, Veterans Affairs Medical Center, Washington, DC; Georgetown University School of Medicine, Washington, DC; George Washington University School of Medicine and Health Sciences, Washington, DC.
authors.forename: Pamela
authors.initials: P
authors.lastname: Karasik
authors.affiliation: Cardiology Division, Veterans Affairs Medical Center, Washington, DC; Georgetown University School of Medicine, Washington, DC.
authors.forename: Ross
authors.initials: R
authors.lastname: Fletcher
mesh_terms: D000368:Aged; D015992:Body Mass Index; D000072599:Cardiorespiratory Fitness; D002318:Cardiovascular Diseases / Q000453:epidemiology* / Q000517:prevention & control; D005080:Exercise Test; D005260:Female; D006801:Humans; D015994:Incidence; D008297:Male; D008875:Middle Aged; D016016:Proportional Hazards Models; D011446:Prospective Studies; D018570:Risk Assessment; D014481:United States / Q000453:epidemiology; D058014:Veterans Health / Q000706:statistics & numerical data*