Kunutsor, Setor K

Kurl, Sudhir

Lakka, Timo A.

Laukkanen, Jari

Ogunjesa, Babatope A.

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                          Laukkanen, J., Lakka, T. A., Ogunjesa, B. A., Kurl, S., & Kunutsor, S. K.(2019). Cross-country skiing and the risk of acute myocardial infarction: aprospective cohort study. European Journal of Preventive Cardiology, 1-4.https://doi.org/10.1177%2F2047487319869696Peer reviewed versionLicense (if available):OtherLink to published version (if available):10.1177%2F2047487319869696Link to publication record in Explore Bristol ResearchPDF-documentThis is the accepted author manuscript (AAM). The final published version (version of record) is available onlinevia Sage at https://doi.org/10.1177%2F2047487319869696 . Please refer to any applicable terms of use of thepublisher.University of Bristol - Explore Bristol ResearchGeneral rightsThis document is made available in accordance with publisher policies. Please cite only the publishedversion using the reference above. Full terms of use are available:http://www.bristol.ac.uk/pure/about/ebr-terms 1  Cross-country skiing and the risk of acute myocardial infarction: a prospective cohort study Jari A. Laukkanen1,2, Timo A. Lakka3,4,5, Babatope A. Ogunjesa6, Sudhir Kurl1, Setor K. Kunutsor7,8    1Institute of Public Health and Clinical Nutrition, University of Eastern Finland, Kuopio, Finland 2Faculty of Sport and Health Sciences, University of Jyväskylä, Jyväskylä and Central Finland Health Care District Hospital District, Jyväskylä, Finland 3Institute of Biomedicine, School of Medicine, University of Eastern Finland, Kuopio Campus, Finland 4Department of Clinical Physiology and Nuclear Medicine, Kuopio University Hospital, Kuopio, Finland 5Foundation for Research in Health Exercise and Nutrition, Kuopio Research Institute of Exercise Medicine, Kuopio, Finland   6Faculty of Medicine, Department of Biostatistics, Near East University, Cyprus 7National Institute for Health Research Bristol Biomedical Research Centre, University Hospitals Bristol NHS Foundation Trust and University of Bristol, Bristol, UK 8Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Learning & Research Building (Level 1), Southmead Hospital, Bristol, BS10 5NB, UK  Source of Funding: The authors acknowledge the Finnish Foundation for Cardiovascular Research, Helsinki, Finland, for supporting the Kuopio Ischemic Heart Disease Study. SKK acknowledges support from the NIHR Biomedical Research Centre at University Hospitals Bristol NHS Foundation Trust and the University of Bristol. The views expressed in this publication are those of the authors and not necessarily those of the NHS, the National Institute for Health Research or the Department of Health and Social Care. These sources had no role in design and conduct of the study; collection, management, analysis, and interpretation of the data; and preparation, review, or approval of the manuscript.      2  Corresponding author Jari A. Laukkanen: Faculty of Sport and Health Sciences, University of Jyväskylä, Jyväskylä, Finland P.O. Box 35, 40014 Jyväskylä, Finland, tel:+358408053478, E-mail: jari.a.laukkanen@jyu.fi  Word count, text only [1201] References [13] Table [1] Figure [1]      3  Compared with moderate-intensity physical activity (PA) (energy expenditure of 3.0-6.0 METs), vigorous- or high-intensity (HIPA) (energy expenditure of >6.0 METS) has more pronounced health benefits on adverse vascular and non-vascular outcomes.1 Cross-country skiing, a seasonal HIPA commonly undertaken during the winter months, is considered to be one of the most demanding of aerobic endurance activities that requires both upper and lower-body work to different extents. It is also associated with the highest recorded levels of cardiorespiratory fitness,2 which is established to be inversely and independently associated with CVD and mortality.3 Cross-country skiing can be undertaken as a leisure-time activity or long-term endurance competitive sport and evidence suggests both types of activity are associated with reduction in the risk of hypertension, cardiovascular disease (CVD) outcomes, as well as all-cause mortality.4-6 Although several HIPAs, if regularly performed, have been demonstrated to be associated with a reduced risk of acute myocardial infarction (AMI),7 evidence on the role of cross-country skiing in reducing the risk of AMI is limited and uncertain. Using a large general population-based sample of middle-aged Finnish men, we examined the associations of the total volume and duration of leisure-time cross-country skiing with the risk of incident AMI.  The data used in this study were derived from the Kuopio Ischemic Heart Disease Risk Factor (KIHD) study, which is a long-term prospective follow-up study on risk factors for CVD and other health outcomes in a population sample of middle-aged men from eastern Finland.8 Full details of recruitment methods and measurements of risk markers have been described previously.8 Briefly, baseline assessments and examinations were performed between March 20, 1984 and December 5, 1989. Cross-country skiing activity habits as well as total PA were assessed using a 12-month PA questionnaire modified from the Minnesota Leisure-Time PA Questionnaire. We included all incident cases of AMI that occurred from study entry until the end of 2014. There were no losses to follow-up. The diagnostic classification of AMI was based on symptoms of coronary heart disease, electrocardiographic findings, cardiac enzyme elevations, and autopsy outcomes.9  The KIHD study received the approval of the Research Ethics Committee of the University of Kuopio, Kuopio, Finland in line with the Helsinki Declaration. Written informed consents were provided by all participants. The final cohort for the present  4  analysis is based on 2,589 men with no missing data on cross-country skiing activity habits, total PA, relevant covariates, and AMI. Cox proportional hazard models were used to calculate hazard ratios (HRs) with 95% confidence intervals (CIs). All statistical analyses were conducted using Stata version 15 (Stata Corp, College Station, Texas, USA). The overall mean (standard deviation, SD) age and body mass index of participants at baseline was 53 (5) years and 26.9 (3.6) kg/m2 respectively. The baseline median [interquartile, (IQR); minimum-maximum] total volume and duration of cross-country skiing was 40.0 (0.0-190.0; 0-3,375) MET hours per year and 60 (60-90; 0-480) minutes per week respectively. A total of 808 AMI events were recorded during a median (IQR) follow-up of 23.6 (12.3-27.2) years. The high incidence of AMI reflects the high prevalence and incidence of atherosclerotic vascular disease in Finland.10 A restricted cubic spline curve suggested there may be a trend for a linear relationship between total volume of cross-country skiing and AMI risk (p-value for nonlinearity=0.295) (Figure); but given the wide 95% CIs, further work is required to characterize the shape that better describes the relationship. Compared to men with no cross-country skiing activity, the age-adjusted HRs (95% CIs) for AMI were 0.77 (0.66-0.90) and 0.58 (0.48-0.70) for men who did 1-200 and > 200 MET hours per year of cross-country skiing respectively (Table). Following further adjustment for body mass index, systolic blood pressure, smoking status, history of diabetes, history of coronary heart disease, total cholesterol, high-density lipoprotein cholesterol, alcohol consumption, and total PA, the corresponding HRs (95% CIs) were attenuated to 0.96 (0.81-1.12) and 0.81 (0.66-0.98) for 1-200 and > 200 MET hours per year of cross-country skiing respectively.  In analysis that adjusted for age, compared to men with no cross-country skiing activity, the HRs (95% CIs) of AMI were 0.73 (0.63-0.86) and 0.63 (0.52-0.76) for men who did 1-60 and > 60 mins per week of cross-country skiing (Table). The corresponding HRs (95% CIs) were 0.93 (0.79-1.10) and 0.84 (0.69-1.02) following further adjustment for several confounders.  In this prospective cohort study evaluating the associations of leisure-time cross-country skiing habits with the risk of AMI in middle-aged Finnish men, total volume of cross-country skiing was inversely associated with risk of AMI and this was independent of several established and emerging coronary risk  5  factors. The association of average duration of cross-country skiing with risk of AMI was however modest. There is established evidence that HIPAs are associated with reduced risk of AMI7 and there is emerging evidence that cross-country skiing may be protective of CVD outcomes as well as all-cause mortality.4-6 There is however limited evidence on whether cross-country skiing may play a role in reducing the risk of AMI. When a large cohort of cross-country skiers with a first MI were compared with their non-skier counterparts, the skiers had a 24% reduced risk of recurrent MI in analysis adjusted for several confounders.11 In this first population-based cohort study, we have shown that higher volumes of leisure-time cross-country skiing (>200 MET hours/year) may reduce the risk of a first MI in a middle-aged population. Compared to common aerobic activities, such as walking, running, and cycling, cross-country skiing places greater metabolic demands on the cardiovascular and respiratory systems. Just like other HIPAs, cross-country skiing may reduce the risk of AMI via multiple pathways described previously,5, 12 such as (i) improvements in cardiovascular risk factors including body weight, blood pressure, glucose tolerance, endothelial function, and lipid profile and (ii) anti-inflammatory effects. The inability to demonstrate an association of average duration of cross-country skiing with the risk of AMI, may reflect the fact that the total volume of PA is a more important determinant of health benefits than the intensity, duration, or frequency.13 An appropriate intensity, frequency, and duration, which comprise the volume, is essential to maximally benefit from PA. These novel findings add to the growing evidence that leisure-time cross country skiing has beneficial effects on adverse vascular outcomes. Other highlighted strengths of our study include the representative population-based sample of men with long-term follow-up with no losses to follow-up. However, there are some weaknesses of the study that deserve consideration, such as (i) the non-inclusion of women; (ii) the specific age range of the participants; (iii) the assessment of cross-country skiing habits using self-reported questionnaires; (iv) inability to demonstrate if cross-country skiing could provoke AMI due to lack of relevant data; and (v) the inability to infer a cause-and-effect relationship given the observational design. There is a possibility that since cross-country skiing is just a seasonal HIPA, its protective effect  6  on AMI may reflect the high level of PA over the years and superior lifestyle of cross-country skiers. However, our analyses accounted for total PA. In conclusion, total volume but not duration of leisure-time cross-country skiing is inversely associated with the risk of AMI in a middle-aged male Caucasian population. Further is required to demonstrate the optimal cross-country skiing intensity, frequency, and duration needed for AMI prevention.  Author contribution  JAL, TAL, BAO, SK, and SKK contributed to the conception and design of the work. All authors contributed to the acquisition, analysis, or interpretation of data for the work. JAL, BAO, and SKK drafted the manuscript. All authors critically revised the manuscript. All authors gave final approval and agree to be accountable for all aspects of the work ensuring integrity and accuracy.  Acknowledgments Our gratitude is extended to the team of the of the Kuopio Research Institute of Exercise Medicine and the Research Institute of Public Health and University of Kuopio, Finland, for the collection and provision of the data for this study.   Declaration of conflicting interests  The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.     7  References   1. Chomistek AK, Cook NR, Flint AJ, et al. Vigorous-intensity leisure-time physical activity and risk of major chronic disease in men. Med Sci Sports Exerc 2012; 44: 1898-1905. DOI: 10.1249/MSS.0b013e31825a68f3. 2. Haugen T, Paulsen G, Seiler S, et al. New Records in Human Power. Int J Sports Physiol Perform 2018; 13: 678-686. 2017/09/06. DOI: 10.1123/ijspp.2017-0441. 3. Ozemek C, Laddu DR, Lavie CJ, et al. An Update on the Role of Cardiorespiratory Fitness, Structured Exercise and Lifestyle Physical Activity in Preventing Cardiovascular Disease and Health Risk. Prog Cardiovasc Dis 2018; 61: 484-490. 2018/11/18. DOI: 10.1016/j.pcad.2018.11.005. 4. Hallmarker U, Lindback J, Michaelsson K, et al. Survival and incidence of cardiovascular diseases in participants in a long-distance ski race (Vasaloppet, Sweden) compared with the background population. Eur Heart J Qual Care Clin Outcomes 2018; 4: 91-97. 2018/02/02. DOI: 10.1093/ehjqcco/qcy005. 5. Laukkanen JA, Laukkanen T and Kunutsor SK. Cross-country skiing is associated with lower all-cause mortality: A population-based follow-up study. Scand J Med Sci Sports 2018; 28: 1064-1072. 2017/09/19. DOI: 10.1111/sms.12980. 6. Kunutsor SK, Makikallio TH, Kauhanen J, et al. Leisure-time cross-country skiing is associated with lower incidence of hypertension: a prospective cohort study. J Hypertens 2019 2019/04/18. DOI: 10.1097/HJH.0000000000002110. 7. Cheng X, Li W, Guo J, et al. Physical activity levels, sport activities, and risk of acute myocardial infarction: results of the INTERHEART study in China. Angiology 2014; 65: 113-121. 2013/01/18. DOI: 10.1177/0003319712470559. 8. Laukkanen JA, Araujo CGS, Kurl S, et al. Relative peak exercise oxygen pulse is related to sudden cardiac death, cardiovascular and all-cause mortality in middle-aged men. Eur J Prev Cardiol 2018; 25: 772-782. 2018/03/01. DOI: 10.1177/2047487318761679. 9. Laukkanen JA, Kurl S, Lakka TA, et al. Exercise-induced silent myocardial ischemia and coronary morbidity and mortality in middle-aged men. J Am Coll Cardiol 2001; 38: 72-79. Research Support, Non-U.S. Gov't 2001/07/14. 10. Conroy RM, Pyorala K, Fitzgerald AP, et al. Estimation of ten-year risk of fatal cardiovascular disease in Europe: the SCORE project. Eur Heart J 2003; 24: 987-1003. 11. Hallmarker U, Michaelsson K, Arnlov J, et al. Risk of recurrent ischaemic events after myocardial infarction in long-distance ski race participants. Eur J Prev Cardiol 2016; 23: 282-290. 2015/04/02. DOI: 10.1177/2047487315578664. 12. Fletcher GF, Landolfo C, Niebauer J, et al. Promoting Physical Activity and Exercise: JACC Health Promotion Series. J Am Coll Cardiol 2018; 72: 1622-1639. 2018/09/29. DOI: 10.1016/j.jacc.2018.08.2141. 13. 2018 Physical Activity Guidelines Advisory Committee. 2018 Physical Activity Guidelines  8  Advisory Committee Scientific Report. Washington, DC: U.S. Department of Health and Human Services, 2018. .  Table. Associations of total volume and duration of leisure-time cross-country skiing with acute myocar-dial infarction  Cross-country skiing exposure Events/ Total Model 1  Model 2    HR (95% CI) P-value HR (95% CI) P-value Total volume (MET hours/year)      0 382 / 1,067 ref  ref  1-200 271 / 897 0.77 (0.66 to 0.90) 0.001 0.96 (0.81 to 1.12) 0.59 > 200 155 / 625 0.58 (0.48 to 0.70) < 0.001 0.81 (0.66 to 0.98) 0.03 P-value for trend   < 0.001  0.04 Duration (mins/week)      0 382 / 1,067 ref  ref  1-60 268 / 914 0.73 (0.63 to 0.86) < 0.001 0.93 (0.79 to 1.10) 0.41 > 60 158 / 608 0.63 (0.52 to 0.76) < 0.001 0.84 (0.69 to 1.02) 0.07 P-value for trend   < 0.001  0.07  Model 1: Adjusted for age Model 2: Model 1 plus body mass index, systolic blood pressure, smoking status, history of diabetes, history of coronary heart disease, total cholesterol, high-density lipoprotein cholesterol, alcohol consumption, and total physical activity     9  Figure Legend Figure Restricted cubic spline of the hazard ratios of acute myocardial infarction with total volume of lei-sure-time cross-country skiing 0.20.61.01.41.82.2Hazar dratioforAMI0 500 1000 1500 2000 2500 3000 3500Volume of skiing (MET hrs/year) Models were adjusted for age, body mass index, systolic blood pressure, smoking status, history of diabe-tes, history of coronary heart disease, total cholesterol, high-density lipoprotein cholesterol, alcohol con-sumption, and total physical activity; AMI, acute myocardial infarction Broken lines represent 95% confidence intervals     

Cross-country skiing and the risk of acute myocardial infarction:a prospective cohort study

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Cross-country skiing and the risk of acute myocardial infarction:a prospective cohort study

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