Fitness Boosts Effects of Statins

November 28, 2012

WASHINGTON DC — Combining treatment with statins with better physical fitness can boost survival in patients with dyslipidemia, a new prospective cohort study illustrates [1].

Following a group of veterans with dyslipidemia for an average of 10 years, Dr Peter F Kokkinos (Veterans Affairs Medical Center, Washington DC) and colleagues show that both statin therapy and increased fitness lower mortality significantly and independently of other clinical characteristics. The study is the first to look at this issue and "offers some unique and clinically relevant information," they say. "The combination of statin treatment and an exercise capacity of more than 5 [peak metabolic equivalents] METs lowers mortality risk substantially more than either alone."

 
Better fitness improves survival significantly and is a valuable additional treatment or an alternative when statins cannot be taken.
 

In an accompanying editorial [2], Dr Pedro C Hallal (Federal University of Pelotas, Brazil) and Dr I-Min Lee (Brigham and Women's Hospital, Boston, MA) say Kokkinos and colleagues "add to the large body of work on the benefits of physical activity or fitness for health. Irrespective of whether patients were prescribed statins, the physically fittest participants had a 60% to 70% reduction in all-cause mortality rates during follow-up, compared with the least fit."

They call for much more emphasis to be put on physical activity: not only should prescribing exercise become routine clinical practice, but "concerted efforts" to promote fitness are needed from the medical profession, society, and governments, they assert. Kokkinos agrees: "While treatment with statins is important, better fitness improves survival significantly and is a valuable additional treatment or an alternative when statins cannot be taken," he says in a statement [3].

Highly Fit on Statins Had 70% Reduction in Mortality Compared With Unfit

Kokkinos and colleagues assessed 10 043 veterans with dyslipidemia (mean age 58.8 years) from VA medical centers in Palo Alto, CA and Washington DC who had an exercise tolerance test between 1986 and 2011.

Individuals were assigned to one of four fitness categories based on METs achieved during exercise testing and eight categories based on fitness status and statin treatment. The primary end point was all-cause mortality adjusted for age, body-mass index, ethnic origin, sex, history of cardiovascular disease, cardiovascular drugs, and cardiovascular risk factors. They ascertained mortality from VA records on December 31, 2011.

During a median follow-up of 10 years, 2318 participants died. Mortality risk was 18.5% (935/5046) in people taking statins vs 27.7% (1386/4997) in those not taking statins (p<0.0001).

In patients who took statins, risk of death decreased as fitness increased; for highly fit individuals (>9 METs; n=694), the hazard ratio was 0.30 (p<0.0001) compared with the least fit (<5 METs; HR=1.00, n=1060).

Highly Fit Not on Statins Had 50% Lower Mortality Than Unfit on Statins

For those not treated with statins, the HR for least fit participants (n=1024) was 1.35 (p<0.0001), and this progressively decreased to 0.53 (p<0.0001) for those in the highest fitness category (n=1498) compared with the least-fit group treated with statins.

"Strikingly, patients not prescribed statins but who were highly fit still had a significantly lower risk of mortality than those taking statins . . . who were unfit," note Hallal and Lee.

They go on to lament the "undervaluation of physical activity in clinical practice." For example, a survey in Brazil showed that 71% of patients had never been prescribed physical activity in a medical consultation. "If clear and equivalent health benefits can be achieved through being physically active or fit, prescription of physical activity should be placed on a par with drug prescription," they note. Plus, the cost of becoming physically active is "probably lower" than that of buying drugs, and there are few side effects associated with becoming fit, they note.

 
If clear and equivalent health benefits can be achieved through being physically active or fit, prescription of physical activity should be placed on a par with drug prescription.
 

And not all patients with dyslipidemia will be prescribed statins, nor will all those who are prescribed statins take them, the editorialists add.

Kokkinos agrees, noting that the exercise capacity necessary to achieve protection that is much the same as or even greater than that achieved by statin treatment in unfit individuals "is feasible for many middle-aged and older adults through moderate-intensity physical activity such as walking, gardening, and gym classes."

The authors and editorialists have no conflicts of interest.

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