Hypertension Journal

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Move over Blood Pressure: Make Room forCardiorespiratory Fitness as a Vital Sign
Move over Blood Pressure: Make Room for
Cardiorespiratory Fitness as a Vital Sign
Nina Radford
Clinical Cardiologist
Cooper Clinic, Dallas, Texas, USA
Correspondence Author: Nina Radford, Clinical CardiologistCooper Clinic, Dallas, Texas, USA
Phone: +9725602741
e-mail: nbradford@cooper-clinic.com
Cardiorespiratory fitness (CRF) describes the ability of anindividual to perform physical exercise, an activity that relieson the cardiovascular system's capacity to facilitate oxygendelivery to working muscles and the pulmonary system's abilityto clear carbon dioxide from the blood. Ideally, CRF is measuredusing cardiopulmonary stress testing (exercise with analysis ofgas exchange). To enhance the feasibility of assessing CRFin large populations, prediction equations using only exercisevariables were developed to provide measures of estimatedCRF. More recently, nonexercise methods of assessing CRFhave been developed. Using exercise (objective) methodsof measuring CRF, a robust evidence base has developeddescribing the inverse association of CRF with total mortality,nonfatal cardiovascular events, incident cancer, cancer survival,chronic conditions, and dementia; CRF has also beenshown to be inversely related to development of cardiac riskfactors including hypertension. Because CRF provides a strong,graded inverse association with cardiovascular and all-causemortality, recent American Heart Association scientific statementshave vigorously promoted the concept of CRF as a vitalsign: All adults should have an estimation of CRF included intheir annual health care visits along with resting blood pressure(BP), heart rate, and body mass index (BMI). The additionof CRF as a vital sign provides enhanced risk prediction thatcan improve patient care and encourage the incorporation ofphysical activity (PA) programs into treatments plans aimed atimproved health outcomes.
Keywords: Cardiorespiratory fitness, Cardiovascular disease,Hypertension, Physical activity, Prevention.
How to cite this article: Radford N. Move over BloodPressure: Make Room for Cardiorespiratory Fitness as a VitalSign. Hypertens J 2017;3(2):51-57.
Source of support: Nil
Conflict of interest: None


Over the last 30 years, a vast literature has developeddescribing the inverse association of CRF and numeroushealth outcomes including total mortality, nonfatal cardiovascularevents, incident cancer, cancer survival, chronic conditions, and dementia; CRF has also been shown tobe inversely related to development of individual andclustered cardiovascular risk factors; these associationshave been demonstrated in the young and old, healthyand unhealthy, men and women, and in different racial/ethnic groups.1-16 Because CRF provides a strong, gradedinverse association with cardiovascular and all-causemortality, recent American Heart Association scientificstatements have vigorously promoted the concept of CRFas a vital sign.17-19 In clinical practice, all adults wouldhave an estimation of CRF included in their annual healthcare examinations much like measurements of restingBP, heart rate, and BMI. To enhance the feasibility of thisrecommendation, both exercise- and nonexercise-basedmethods are available to estimate CRF. In this context, thegoals of this paper are: (1) To define CRF and its relationshipto PA, (2) to review the role of CRF in preventinghypertension and modifying cardiovascular risk in thesetting of established hypertension, and (3) to describeCRF assessment and utilization in clinical practice.


The CRF describes the ability of an individual toperform physical exercise, an activity that relies on thecardiovascular system's capacity to facilitate increasedoxygen uptake needed by working muscles and thepulmonary system's ability to clear carbon dioxide fromthe blood (diffusion) and disperse into the atmosphere(ventilation). The gold standard for measuring CRF iscardiopulmonary exercise testing because it providesthe most accurate and standardized quantification ofCRF.20 Typically, exercise is performed on a motorizedtreadmill; a stationary cycle ergometer can also be usedif the individual has an unsteady gate or orthopediclimitations to walking, but leg fatigue may drive terminationof exercise at a submaximal effort in deconditionedindividuals.21 A mouthpiece and nose clip or facemaskare worn throughout exercise and are connected to a gasanalyzer. Cardiopulmonary exercise testing combinesconventional exercise stress-testing variables (electrocardiographychanges, heart rate and BP responses, heartrhythm abnormalities, and exercise-related symptoms)with ventilatory expired gas analysis (providing measuresof oxygen uptake (VO2), carbon dioxide output, andminute ventilation).
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Nina Radford

Cardiopulmonary exercise testing generates a numberof variables that have characteristic patterns in the settingof health and in specific disease states.19 A key measureprovided by this test is maximal oxygen uptake (VO2maxor VO2peak); this value defines maximal aerobic capacity ingenerally healthy individuals or peak exercise capacity inindividuals with cardiac or pulmonary disease. The VO2maxis usually expressed in milliliters of O2 per kilogram ofbody weight per minute (to allow comparisons amongindividuals with different body weights); values can rangefrom 80 mL O2/kg/minute in a young, elite athlete to 40mL O2/kg/minute in a sedentary 35-year-old to < 10 mLO2/kg/minute in a patient with end-stage lung disease.20,21

The VO2max (measured CRF) is influenced by age, sex,genetics, PA, lifestyle choices (diet, smoking), physiologicalfactors (fat, muscle mass), exercise training, and thepresence of clinical or subclinical (cardiac, pulmonary,and skeletal muscle) disease.18,20-23 In a study of 473 sedentaryadults, from 99 families enrolled in the Health, RiskFactors, Exercise Training, and Genetics (HERITAGE)Family Study, participants exposed to a standardized20-week exercise program gained increases in VO2max of15 to 25%; using a panel of 21 single nucleotide polymorphisms,investigators were able to estimate that almosthalf of the gain in CRF could be attributed to favorablegenetic inheritance.22

Cardiopulmonary exercise testing with its requisiteventilatory expired gas analysis require specializedequipment and higher levels of staff training; it may bea burdensome procedure for some individuals undergoingtesting and cardiopulmonary exercise testing facilitiesmay not be broadly available. Historically, from anepidemiological point of view, obtaining measured CRFdata from large populations was difficult, if not impossible.To solve this problem, prediction equations weredeveloped so that estimated CRF could be derived fromtreadmill variables alone. Exercise-based estimates ofCRF are obtained using common treadmill protocols(Bruce, Balke, Modified Balke) or cycle ergometer exercisewithout the complexity of measuring expired gases. TheCRF is estimated from the work rate achieved duringexercise and is commonly expressed in units of metabolicequivalents (METs). One MET is defined as the energyexpenditure required for sitting quietly (approximately3.5 mL O2/kg/minute mL for an average adult). To putthis in a clinical context, moderate-intensity activitiesare those that result in an energy expenditure three tosix times the energy rquired to sit quietly or 3 to 6 METS.

These prediction equations are less accurate if thepatient is allowed to hold onto the treadmill handrails(because this decreases workload and increases exerciseduration) or if there is patient-protocol mismatch.The patient's fitness should be matched with treadmill protocol (e.g., choosing a slower belt speed and rate ofincline for an unfit patient). These caveats are importantto keep in mind as we consider adding measured CRFas a vital sign.17,18,20

Estimated CRF derived from the peak work rate is thetypical measure of CRF in most epidemiological studiesinvolving large populations. Almost 30 years ago, Blairet al7 published a landmark study assessing estimatedCRF obtained using maximal treadmill exercise testingand risk of all-cause and cause-specific mortality in 10,224men and 3,120 women enrolled in the Aerobics CenterLongitudinal Study (ACLS). With an average follow-upof more than 8 years, adjusted all-cause mortality ratesdeclined across CRF quintiles from the least fit to the mostfit. Lower mortality rates in higher fitness categories alsowere seen for cardiovascular disease and cancer.

Cardiorespiratory fitness
VS physical activity

Because CRF can be modified through changes in routinePA, it is regarded as a surrogate for habitual PA. Why notadd PA as a vital sign rather than CRF? This seems likea much easier variable to collect. Furthermore, clinicalrecommendations aimed at improving health are madein terms of PA with the goal of improving CRF.

First, as a clinical variable, PA can be difficult toquantify in an accurate and reproducible way.24,25 Historically,much of the epidemiological data evaluating theassociation of PA with health outcomes have quantifiedPA using self-report questionnaires. These assessmentscan be subjective regarding the duration, intensity, andfrequency of PA. To obtain more objective measuresof PA, investigators are now using accelerometers torecord PA throughout the day. However, little researchhas been published on how PA assessed by accelerometerswill perform in predicting health outcomes comparedwith data collected by PA questionnaire.

Most importantly, CRF has many determinants ofwhich PA is just one. An individual may engage in regularPA and still have low CRF (unfit) because of poor lifestylechoices (smoking) or the presence of subclinical or clinicaldisease (emphysema); quitting smoking may be the bestroute to improved CRF in this individual.

A number of studies have evaluated the relationshipbetween PA, CRF, and mortality. Lee et al26 examined thecombined associations and relative contributions of PAand CRF to all-cause mortality in 31,818 male and 10,555female participants in the ACLS with PA assessed by selfreportedquestionnaire and CRF assessed by maximaltreadmill test. In this generally healthy population, CRFwas more strongly associated with all-cause mortalitythan PA. Myers et al27 reported all-cause mortality with 5 years of follow-up in a subgroup of 842 less healthymale veterans from Palo Alto, California with estimatedCRF from clinically indicated treadmill tests (for chestpain, dyspnea, and so on) and habitual PA obtained byself-report questionnaire. In this high risk group of men,CRF was also a stronger predictor of mortality than PA.Davidson et al28 evaluated a larger cohort (8,171) of maleveterans from Washington, DC with similar methods estimatingCRF and PA, who were followed for 8.7 years, forall-cause mortality. The PA was a significant predictor ofmortality after controlling for clinical variables; however,the association was eliminated after further adjustingfor CRF. Conversely, CRF remained a strong predictor ofmortality, independent of PA status and established CVrisk factors. These findings support the concept that CRFmediates the association between PA and mortality. Thus,the recommendation that CRF, a better marker of risk thanPA, ought to be included as a vital sign.

Move over Blood Pressure: Make Room for Cardiorespiratory Fitness as a Vital Sign

Given that the process of atherosclerosis begins inyouth, continues for decades, culminating in clinical cardiovascularevents, it is reasonable to suggest that bothCRF and PA play important roles in primordial prevention(CRF preventing the development of CV risk factors) andprimary prevention (PA interventions designed to modifylow CRF with the goal of preventing an initial CVD event).This concept is well illustrated in the case of hypertension.


The presence of an age-related increase in BP is welldocumented. Data from 2,000 enrollees in the FraminghamHeart Study demonstrated that in normotensive anduntreated hypertensive subjects, systolic BP increasedlinearly from age 30 through age 84 with a current risein diastolic BP until age 50 to 60 after which time it.29Furthermore, the age-related progressive increase in BPis accompanied by an incremental increase in cardiovascularrisk evident beyond BP levels of 115/75 mm Hg.30Whether the age-related increase in BP is inevitable is amatter of debate. It is likely the result of a combinationof innate biological aging, genetic underpinning, andlifestyle choices.31,32 Some of the age-related increasesin hypertension can be attenuated through lifestylemodifications that focus on dietary salt restriction, highconsumption of fruits and vegetables, increased intakeof fish, reduced intake of saturated fat, maintainingan ideal body weight, engaging in regular PA, and notsmoking.33,34

A number of large prospective cohort studies haveexamined the cross-sectional and/or longitudinal relationshipsbetween CRF and the risk of developing hypertensionin a variety of populations: generally healthy white men and women, men and women with a family historyof hypertension, young black and white men and womenwith long term follow-up, and older black and white menand women at high risk for CVD events. Barlow et al35evaluated almost 5,000 normotensive, generally healthywomen followed in the ACLS; the cumulative incidenceof hypertension was 3.2% with an average follow-up of5 years. High-fit women had one-third the risk of developinghypertension compared with low-fit women. Liuet al36 studied 13,953 generally healthy normotensive menfollowed in the ACLS. High-fit men had lower systolic BPduring the follow-up period compared with moderateandlow-fit men. Shook et al37 evaluated the joint associationof CRF and family history of hypertension onincident hypertension in more than 6,000 normotensivemen and women in the ACLS. Thirty-three percentreported a parent with hypertension. Low-fit individualswith parental hypertension had a 70% higher risk fordeveloping hypertension and high-fit individuals withparental history had only a 16% increased risk of developinghypertension (using high-fit individuals with noparental hypertension as the referent group).

Carnethon et al38 evaluated 4,681 black and whitemen and women enrolled in The Coronary Artery RiskDevelopment in Young Adults (CARDIA) Study (averageage 25), who were followed for over 20 years. Acrossrace-sex groups, there was an inverse, graded associationbetween CRF and the development of hypertension. Theestimated proportion of hypertension cases that couldbe prevented if participants moved to a higher fitnesscategory (i.e., preventive fraction) was 34%. Jurascheket al39 examined the association of fitness with prevalentand incident hypertension in 57,284 less healthy black andwhite men and women from The Henry Ford ExerciseTesting (FIT) Project (1991-2009). Fitness was measuredusing a clinician-referred treadmill stress test (withindications such as chest pain, "rule out" ischemia, andshortness of breath). In this group at high risk for CVDevents (more than 40% current smokers and about halfwith a family history of heart disease), higher CRF wassignificantly associated with lower rates of hypertensionat baseline.

Prehypertension, affecting 25 to 50% of adults worldwide,increases the risk of incident hypertension bytwo- to three-fold and is an independent risk factor forcardiovascular disease. The optimal treatment strategiesfor prehypertension are controversial.40 Drug therapyhas been shown to reduce cardiovascular events amongindividuals with prehypertension who have clinicalcardiovascular disease with or without diabetes; thisrisk reduction needs to be weighed against drug-relatedadverse events including hyperkalemia, renal failure,and hypotension as well as the cost associated with drug treatment in this patient population.41,42 Treatment strategiesare uncertain in generally healthy individuals withprehypertension.

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Clinical variables associated with progression fromprehypertension to hypertension include black ethnicity,older age, higher BMI, diabetes, chronic kidney disease,and low CRF.40 In the case of CRF, the impact of highfitness on progression is substantial. Faselis et al43 evaluated2,303 male veterans with prehypertension followedfor 9.2 years; CRF was a strong and independent predictorof the rate of progression. Compared with the high-fitindividuals (10.0 METs), the adjusted risk for developingHTN was 72% higher for the least-fit individuals. Othersignificant predictors of progression were age, restingsystolic BP and type II diabetes mellitus.

Finally, the impact of change in CRF (e.g., low-fit tohigh-fit over time) on the risk of developing hypertensionhas been evaluated in the few longitudinal studies withrepeated measures of CRF. Three studies are presentedhere with approximately 5, 10, and 20-year follow-up. Suiet al44 reported on 4,932 men and women in the ACLSwho had at least four preventive medicine evaluationsand were free of hypertension during the first threeexaminations with almost 11 years of follow-up. Among4,932 participants, 1,954 developed hypertension. Therewere five patterns of changing CRF over time: Decreasing,increasing, bell-shaped, U-shaped, and inconsistent.A pattern of increasing CRF provided the lowest risk ofhypertension. Jae et al45 evaluated 3,831 men withoutCVD, hypertension, or diabetes, who were seen at theSamsung Medical Center in Seoul, South Korea, for twohealth examinations. The CRF was directly measured bypeak oxygen uptake using expired gas analysis duringa standard treadmill test. During an average follow-upof 5 years, 373 (9.7%) subjects developed hypertension.The incidence of hypertension was inversely associatedwith baseline CRF quartiles. In a study with much longerfollow-up time, Jae et al46 evaluated Finnish 431 menwithout hypertension enrolled in the Kuopio IschemicHeart Disease Study with measures of CRF at baselineand 11 years later with follow-up for hypertension 10years after that. Men who demonstrated the largestdecline in CRF had more than a four-fold risk of incidenthypertension compared with men with the smallestdecrease or improvement in CRF. Collectively, thesestudies underscore the potential importance of CRF toprevent the aging-related progressive rise in BP as well asthe development of prehypertension and hypertension.

In addition to its inverse association with incidenthypertension, several large epidemiological studies havedemonstrated an inverse and independent association ofCRF and mortality risk in individuals with establishedhypertension. Myers et al47 studied a total of 6,213 male veterans in Palo Alto, California, who referred fortreadmill exercise testing for clinical reasons and werefollowed for 6 years; 3,679 had an abnormal exercisetestresult or a history of cardiovascular disease, orboth, and 2,534 had a normal exercise-test result and nohistory of cardiovascular disease. They found that CRFwas a more powerful predictor of mortality than otherestablished risk factors for cardiovascular disease. In allsubgroups defined according to risk factors (includingthe subgroup of hypertensives), the risk of death fromany cause in low-fit men (< 5 METs) was roughly doublethat of moderate-fit men >8 METs. Faselis et al48 studieda group of 4,183 hypertensive veterans from WashingtonDC referred for treadmill exercise testing for clinicalindications to evaluate the interaction between fitness,fatness, and mortality risk in hypertensive individuals.They found that increased CRF was associated withlower mortality risk in hypertensive males regardless ofBMI. Finally, in a study that included men and women,Evenson et al49 evaluated the effect of CRF on mortalityamong hypertensive and normotensive women (2,712)and men (3,000) followed up for more than 20 years in theLipids Research Clinics Prevalence Study. Comparing thelowest with the highest quintile of fitness, the adjustedall-cause mortality among hypertensive women was 1.7and among hypertensive men was 2.0.
How improved CRF reduces the risk of all-causemortality in a number of clinical settings, includinghypertension, is not fully understood. From a clinical perspective,higher levels of CRF are associated with reducedlevels of traditional cardiovascular risk factors, such ashypertension, type II diabetes, metabolic syndrome, lipidprofiles, fasting blood glucose, and anthropometric measures.Each of these effects is mediated through multipledownstream modifications; e.g., increasing CRF anddecreasing BP are mechanistically linked to alterations invascular mechanics. Improvements in metabolic factorswith increasing CRF are likely related to CRF-mediatedincreases in insulin sensitivity and reduced levels ofinflammation and oxidative stress. Improvements incardiovascular risk may also be mediated by changes invascular health mediated through nitric oxide functionand or changes in autonomic nervous system activity.Because CRF relies on the integrated function of multiplephysiological systems, it reflects the global health statusof an individual, and as such serves as an importantvital sign.50-54


In clinical practice, an estimation of CFR could providean additional tool for risk stratification when making clinical decisions. In situations where there is an intermediatedetermination of risk, the presence of low CRF maylend support for a decision to initiate drug treatment ofhypertension or dyslipidemia for example. An annual estimationof CRF could also be a means to assess the impactof a PA program. Experts suggest that measurement of CRFin clinical settings is feasible and no more difficult thanmeasuring BP.18 They recommend that at a minimum, alladults should have CRF estimated each year using a nonexercisealgorithm (although they caution that this shouldnot be viewed as replacement for an objective measure ofCRF). Ideally, all adults (age range yet to be determined)should have CRF estimated using a maximal exercise teston a regular basis (follow-up interval yet to be determined)similar to other preventative services like mammographyor colonoscopy. Finally, adults with chronic disease shouldhave CRF measured with a peak or symptom-limited cardiopulmonarystress test on a regular basis.

Move over Blood Pressure: Make Room for Cardiorespiratory Fitness as a Vital Sign

Numerous nonexercise equations to estimate CRFhave been developed over the last 10 to 15 years usingcross-sectional data from generally healthy cohorts over arange of ages and cohort sizes (as few as 100 and as manyas 46,000) using variables of age, sex, body weight (or BMI,percentage of body fat, waist circumference), PA/exercise/training (self-reported or measured), smoking, restingHR and/or perceived functional ability.18 In a recentstudy designed to determine the validity of nonexerciseestimatedCRF on mortality, Nauman et al55 assessed thepredictive value of estimated CRF (eCRF) in healthy men(N = 18,721) and women (N = 19,759) aged 30 to 74 years,who were enrolled in a large health survey in Norway(Nord-Trondelag Health Study [HUNT]), with medianfollow-up of 16 years. They found that low eCRF was independentlyassociated with CVD and all-cause mortality.The inclusion of traditional clinical CVD risk factors addedlittle to risk discrimination and did not improve the classificationof risk beyond this simple eCRF measurement.

Their nonexercise algorithm-estimated eCRF usedthe following algorithms:

Women: 78.00 - (0.297 × Age) - (0.270 × WC) - (0.110 - rHR)
+ (2.674 × PA)

Men: 105.91 - (0.334 × Age) - (0.402 × WC) - (0.144 × rHR)
+ (3.102 × PA)

The WC is waist circumference. The rHR is restingheart rate. The PA variable is assigned a value of 1, ifthey were meeting recommended levels of PA: Vigorousintensityexercise training for ≥20 minutes per day on ≥3days per week for a total of ≥75 minutes per week and/or moderate-intensity exercise training for ≥30 minutesper day on ≥5 days per week for a total of ≥150 minutesper week. The PA is assigned a value of 0, if they are notmeeting recommended levels of PA.
The overarching goal of measuring or estimatingCRF is to identify the lowest CRF or least-fit individualbecause the greatest reduction in total mortality occursbetween the least-fit (< 5 METs) and the next least-fitlevels of CRF (5 to 7 METs). Getting out of the lowestcategory of fitness has a much greater impact on healthoutcomes than moving from good (10-12 METs) to better(>13 METs) fitness categories. high-fit individuals (thosewith CRF > 13 METS), increases in CRF have less impacton improving mortality and more impact on improvingperformance.

A PA plan for a low-fit individual needs to deliver a sufficientdose of exercise to increase CRF 1 or 2 METs; this isassociated with 10% to 30% lower cardiovascular risk. Whenperformed frequently over weeks or months, a wide varietyof PA programs produce this level of CRF improvementin most adults. The PA programs need to include exerciseactivities that involve major muscle groups working in acontinuous and rhythmic nature, such as brisk walking,jogging, running, cycling, swimming, and so on. Standingat the net for most of a doubles tennis game is not sufficientexercise intensity to advance fitness. Light-to-moderateintensity activity is recommended for deconditioned orthe elderly while moderate and/or vigorous intensityactivity is recommended for most generally healthy adults.Advancing exercise intensity, rather than frequency orduration, is more likely to increase CRF. Individuals oughtto accumulate 150 minutes per week of light-to-moderateor moderate-intensity exercise and 75 minutes per week ofvigorous-intensity exercise (or some combination of both;exercise sessions can be as short as 10 minutes.56

In conclusion, there are many compelling indicationsto measure CRF as a vital sign. That being said,the integration of estimates of CRF into routine clinicalpractice may be challenging. Referring this testing tocardiovascular subspecialists, especially in generallyhealthy individuals, may not be an appropriate utilizationof subspecialty expertise. Understandably, primarycare providers outside of academic centers may be resistantto perform treadmill testing to estimate CRF citinglack of time, training, equipment, and reimbursements.Specialty teams of exercise physiologists or other healthcare providers may be needed to fill this function. In themeantime, familiarizing primary care providers withnonexercise algorithms to estimate CRF (on a smartphoneapp or embedded in an electronic medical record) maybe an important first step in adding CRF as a vital sign.

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Move over Blood Pressure: Make Room for Cardiorespiratory Fitness as a Vital Sign

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