ArticlesInteractive effects of fitness and statin treatment on mortality risk in veterans with dyslipidaemia: a cohort study
Introduction
Results of several clinical trials have shown that statin treatment substantially reduces morbidity and mortality of individuals with coronary heart disease.1, 2, 3 On the basis on these findings, the Adult Treatment Panel 3 and other expert panels have issued guidelines4 for statin treatment of patients with established coronary heart disease.5 Trials also suggest that statin treatment provides health benefits for individuals with high risk of cardiovascular disease who do not have coronary heart disease.6, 7, 8, 9
Expert panels on management of lipids have also emphasised the importance of lifestyle changes for reduction of cardiovascular risk.4, 5 These recommendations are based on evidence from large epidemiological studies. Data from these studies show inverse, graded, independent, and robust associations between physical activity (fitness) and mortality risk in apparently healthy participants10, 11, 12, 13, 14, 15, 16 and in patients with cardiovascular disease, irrespective of age, sex, or comorbidities.14, 17, 18, 19, 20 Mortality risk is highest for patients with low fitness; risk decreases as fitness increases irrespective of sex, presence of other risk factors, or age.14, 15, 17, 19, 20, 21
Although a healthy lifestyle—including physical activity and fitness—is promoted as an essential component for prevention and management of coronary heart disease, little data are available regarding the combined health benefits of fitness and statin treatment. Furthermore, for dyslipidaemic patients who cannot take statins, whether increased mortality risk can be abated by increased fitness is unclear. We assessed the separate and combined effects of statin treatment and exercise capacity on all-cause mortality risk in veterans with dyslipidaemia.
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Study design and patients
This prospective cohort study included patients from the Veterans Affairs Medical Centers in Washington, DC, USA and Palo Alto, CA, USA. The cohort was taken from a database of more than 20 000 veterans who had dyslipidaemia (defined by the International Classification of Diseases) and who had a symptom-limited exercise tolerance test between 1986, and 2011. The test was administered either as part of a routine assessment or to assess exercise-induced ischaemia. This information, along with the
Results
We assessed 20 023 people for eligibility. We enrolled 10 043 veterans (9700 men and 343 women). 5192 were African-American (mean age 57·8 years, SD 10·7), 4425 were white (mean age 59·5 years, SD 10·9), and 426 were other (mean age 57·6 years, SD 11). Median follow-up was 10·0 years (IQR 6·0–14·2); providing 105 334 person-years. 2318 (23·1%) patients died (no data were missing), with an average yearly mortality of 22 deaths per 1000 person-years (95% CI 13–31). Patients not treated with
Discussion
Our findings support the notion that both statin treatment and increased fitness lower mortality significantly and independently from other clinical characteristics. Our findings accord with previous reports regarding statin treatment for primary or secondary prevention of premature mortality in individuals at high risk of cardiovascular mortality.1, 2, 3, 4 Previous studies have also shown an inverse and graded association between fitness and mortality risk in apparently healthy individuals10,
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