Meeting of the Balkan Excellent Centers “Exercise Capacity and New Onset of Atrial Fibrillation ” Andreas Pittaras Cardiologist – Clinical HTN Specialist ESH Ass. Prof. George Washington University Asclepeion Hospital Athens, MEDITON Για την διαχρονικά σταθερή στηριξή του

Abstract Objective was to assess the association between exercise capacity and the risk of developing atrial fibrillation (AF). A symptom-limited exercise tolerance test was conducted to assess exercise capacity in 5962 veterans (mean age, 56.8+/-11.0 years) from the Veterans Affairs Medical Center, Washington, DC. None had evidence of AF or ischemia at the time of or before undergoing their exercise tolerance test. We established 4 fitness categories based on age-stratified quartiles of peak metabolic equivalent task (MET) achieved: least fit (4.9+/-1.10 METs; n=1446); moderately fit (6.7+/-1.0 METs; n=1490); fit (7.9+/- 1.0 METs; n=1585), and highly fit (9.3+/-1.2 METs; n=1441). Multivariable Cox proportional hazards regression models were used to compare the AF-exercise capacity association between fitness categories. Results: During a median follow-up period of 8.3 years, 722 (12.1%) individuals developed AF (14.5 per 1000 person-years; 95% CI, 13.9-15.9 per 1000 person-years). Exercise capacity was inversely related to AF incidence. The risk was 21% lower (hazard ratio, 0.79; 95% CI, 0.76-0.82) for each 1-MET increase in exercise capacity. Compared with the least fit individuals, hazard ratios were 0.80 (95% CI, 0.67-0.97) for moderately fit individuals, 0.55 (95% CI, 0.45-0.68) for fit individuals, and 0.37 (95% CI, 0.29-0.47) for highly fit individuals. Similar trends were observed in those younger than 65 years and those 65 years or older. Conclusion: Increased fitness is inversely and independently associated with the reduced risk of developing AF. The decrease in risk was graded and precipitous with only modest increases in exercise capacity. These findings counter previous suggestions that even moderate increases in physical activity, as recommended by national and international guidelines, increase the risk of AF, with marked protection against AF noted with increasing levels of fitness.

INTRODUCTION AF is associated with increased mortality risk. The risk for AF increases for individuals with HTN and DM2 Little is known about the association between fitness and AF in HTNsive DM & General population. The aim our study was to explore this association.

Prevalence of Hypertension in AF Trials AF populations 90 90 86.6 86.3 86 80 80 71 68 63 64.4 62.6 55 60 51 51.8 51 49 Patients with hypertension, % 40 20 PIAF STAF RELY RACE AFFIRM Predomin. AFFIRM overall CHARM ACTIVE I ATHENA ROCKET HOT CAFÉ RECORD AF Heart Survey AVERROES

Mayo Clin Proc 2016

Methods From 1986 to 2012, a total of 6,390 men (4,401 blacks & 1,989 whites) including 3,811 HTN, & 1787 Diabetics with normal sinus rhythm ( 57.2 ± 11.0, 60±10 for HTN & 58±9 for DM ), underwent a routine ETT at VAMC Washington DC. During a mean follow-up of 8.3±4.6 years 838 13.1% developed AF (8.6% for HTN & 7.2% DM).

Methods (ALL) Least-Fit: 4.9±1.13 METs; n=1,578 , To assess the role of fitness status in the development of AF, we formed the following four fitness categories based on peak workload achieved (metabolic equivalents; METs): Least-Fit: 4.9±1.13 METs; n=1,578 , Low-Fit: 6.7±1.0; n=1,613, Moderate-Fit: 7.9±1.0 METs; n=1,683 & High-Fit: 9.3±1.2 METs n=1,516).

Demographic and Clinical Characteristics According to Fitness Categories

Results The association between exercise capacity and the risk for developing Atrial Fibrillation was inverse and graded.

Adjusted risk of developing atrial fibrillation according to fitness categories.

Adjusted risk of developing atrial fibrillation according to age and fitness categories

For every 1-MET increase in exercise capacity Cardiorespiratory Fitness Lowers the Risk for Atrial Fibrillation in ALL Men For every 1-MET increase in exercise capacity 21% reduction in AF-risk HR: 0.79, 95% CI, 0.76-0.82, p<0.001 Οι μελέτες έχουν δείξει ότι η μείωση της ΑΠ μπορεί να οδηγήσει σε ταχεία μείωση του κινδύνου καρδιαγγειακής νόσου. Πράγματι, ακόμη και μια μείωση κατά 2 mmHg στη συστολική ΑΠ οδηγεί σε περίπου 7% χαμηλότερη θνητότητα από ισχαιμική καρδιακή νόσο και 10% χαμηλότερη θνητότητα από εγκεφαλικό επεισόδιο. Αναφορά Lewington S, et al. Age-specific relevance of usual blood pressure to vascular mortality: a meta-analysis of individual data for one million adults in 61 prospective studies. Lancet 2002;360:1903–13.

For every 1-MET increase in exercise capacity Cardiorespiratory Fitness Lowers the Risk for Atrial Fibrillation in Hypertensive Men For every 1-MET increase in exercise capacity 30% reduction in AF-risk hazard ratio=0.70 CI: 0.66-0.74; p <0.001 Οι μελέτες έχουν δείξει ότι η μείωση της ΑΠ μπορεί να οδηγήσει σε ταχεία μείωση του κινδύνου καρδιαγγειακής νόσου. Πράγματι, ακόμη και μια μείωση κατά 2 mmHg στη συστολική ΑΠ οδηγεί σε περίπου 7% χαμηλότερη θνητότητα από ισχαιμική καρδιακή νόσο και 10% χαμηλότερη θνητότητα από εγκεφαλικό επεισόδιο. Αναφορά Lewington S, et al. Age-specific relevance of usual blood pressure to vascular mortality: a meta-analysis of individual data for one million adults in 61 prospective studies. Lancet 2002;360:1903–13.

For every 1-MET increase in exercise capacity Cardiorespiratory Fitness Lowers the Risk for Atrial Fibrillation in Men with T2 DM 33% reduction in AF-risk HR=0.67; CI: 0.60-0.75; p<0.001. For every 1-MET increase in exercise capacity Οι μελέτες έχουν δείξει ότι η μείωση της ΑΠ μπορεί να οδηγήσει σε ταχεία μείωση του κινδύνου καρδιαγγειακής νόσου. Πράγματι, ακόμη και μια μείωση κατά 2 mmHg στη συστολική ΑΠ οδηγεί σε περίπου 7% χαμηλότερη θνητότητα από ισχαιμική καρδιακή νόσο και 10% χαμηλότερη θνητότητα από εγκεφαλικό επεισόδιο. Αναφορά Lewington S, et al. Age-specific relevance of usual blood pressure to vascular mortality: a meta-analysis of individual data for one million adults in 61 prospective studies. Lancet 2002;360:1903–13.

Conclusion Aerobic fitness is associated with lower risk for AF in general population, HTNsives & DM. The AF risk was 21%(all), 30%(HTN) & 33%(DM) lower for 1-MET increase in exercise capacity. When compared to the Least-Fit category, the risk was 18%- 72% lower in Low-Fit, Moderate-Fit; and High-Fit individuals.