Fitness and strength in young adulthood and protection from future heart failure

We are in the midst of a heart failure (HF) pandemic with wide-ranging implications for aging populations, physicians, and healthcare delivery systems (1). The major epidemiologic determinants for HF have been traditionally viewed as hypertension, coronary artery disease, valvular disease, and more recently obesity, diabetes, and kidney disease (2,3). Among those with HF, approximately half have HF with reduced ejection fraction (HFrEF) and the other half with preserved ejection fraction (HFpEF). In this issue of the European Journal of Preventive Cardiology, Lindgren and co-workers report on a ray of hope in HF epidemiology (4). They describe a protective relationship between cardiopulmonary fitness as well as muscle strength and the development of HF at a relatively young age in all categories in which it can be accounted for using automated sources of data. This report is a major advance in the cardiopulmonary fitness literature, which has had a global interest in “survival of the fittest” which was a way of explaining the relationship between fitness and mortality (5). In brief, cardiopulmonary fitness has been associated with reduced mortality not only because of improved risk factors, and modest reductions in atherosclerotic events such as myocardial infarction, but because it markedly improves the survival of potentially fatal events such as critical illness.