The relationship of cardiorespiratory fitness, physical activity, and coronary artery calcification to cardiovascular disease events in CARDIA participants

Aims Moderate-to-vigorous-intensity physical activity (MVPA), cardiorespiratory fitness (CRF), and coronary artery calcification (CAC) are associated with cardiovascular disease (CVD) risk. While a U-shaped relationship between CRF or MVPA and CAC has been reported, the presence of CAC among highly fit individuals might be benign. We examined interactive associations of CRF or MVPA and CAC with outcomes and evaluated the relationship of CRF and MVPA to CAC incidence.Methods and results CARDIA participants with CAC assessed in 2005-06 were included (n = 3,141, mean age 45). MVPA was assessed by self-report and accelerometer. CRF was estimated with a maximal graded exercise test. Adjudicated CVD events and mortality data were obtained through 2019. CAC was reassessed in 2010-11. Cox models were constructed to assess hazard ratios (HRs) for CVD, coronary heart disease (CHD), and mortality in groups defined by CAC presence/absence and lower/higher CRF or MVPA levels. Logistic models were constructed to assess associations with CAC incidence. Adjustment was made for sociodemographic and CVD risk factors. Relative to participants with no CAC and higher CRF, the adjusted HRs for CVD were 4.68 for CAC and higher CRF, 2.22 for no CAC and lower CRF, and 3.72 for CAC and lower CRF. For CHD, the respective HRs were 9.98, 2.28, and 5.52. For mortality, the HRs were 1.15, 1.58, and 3.14, respectively. Similar findings were observed when MVPA measured either by self-report or accelerometer was substituted for CRF. A robust inverse association of CRF and accelerometer-derived MVPA with CAC incidence was partly accounted for by adjusting for CVD risk factors.Conclusion In middle-aged adults, CRF and MVPA demonstrated an inverse association with CAC incidence, but did not mitigate the increased cardiovascular risk associated with CAC, indicating that CAC is not benign in individuals with higher CRF or MVPA levels. This study explored the relationship between physical fitness, physical activity, and coronary artery calcification (CAC) in predicting heart disease risk. CAC is the build-up of calcium deposits in the coronary arteries, indicating the presence of atherosclerosis. Involving approximately 3000 adults with an average age of 45, the study measured physical activity through self-report and accelerometer, fitness via treadmill tests, and CAC at two time points, 5 years apart. Being fit and active was associated with a lower chance of developing new CAC. Similarly, higher fitness and physical activity levels were associated with a lower risk of experiencing heart disease events and death over 13 years of follow-up. In contrast, the presence of CAC strongly predicted elevated heart disease risk and death. Furthermore, having CAC eliminated the heart health benefits of being physically active or fit. The study concludes that while being fit and active is beneficial, CAC remains a serious risk factor for heart disease, even in individuals with higher fitness and physical activity levels. In middle-aged adults, being aerobically fit and physically active is associated with an overall benefit regarding heart disease events and mortality.Despite this, having CAC significantly increases the risk of heart disease events, even for those who are fit and active. Graphical Abstract