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Arnett et al 2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease

September 10, 2019 Circulation. 2019;140:e596–e646. DOI: 10.1161/CIR.0000000000000678 e608

CLINICAL STATEMENTS AND GUIDELINES

amounts.S3.2-5,S3.2-6,S3.2-12 All adults should engage in at least 150 minutes per week of accumulated moderate-intensity aerobic physical activity or 75 minutes per week of vigorous-intensity aerobic physical activity (or an equivalent combination of moderate and vigorous activity) to lower ASCVD risk (Table 4). These recommendations are in line with those of other health organizations.S3.2-26 Shorter durations of exercise seem to be as beneficial as longer ones (eg, ≥10-minute bouts),S3.2- 27,S3.2-28 and thus the focus of physical activity counseling should be on the total accumulated amount. Additional reduction in ASCVD risk is seen in those achieving higher amounts of aerobic physical activity (>300 minutes per week of moderate-intensity aerobic physical activity or 150 minutes per week of vigorous-intensity aerobic physical activity).S3.2-5,S3.2-6,S3.2-12,S3.2-14 There is a continued but diminishing additive benefit of further increasing physical activity to very high levels.S3.2-5,S3.2-6,S3.2-12 Specific exercise recommendations for the prevention of heart failure may differ slightly because the dose–response relationship with increasing physical activity levels may be linear.S3.2-29

3 There is likely no lower limit on the quantity of

moderate-to-vigorous physical activity at which benefits for ASCVD risk start to accrue.S3.2-6 All efforts should be made to promote achievement of the minimum recommended amount of physical activity by all adults. However, for individuals unable to achieve this minimum, encouraging at least some moderate-to-vigorous physical activity among those who are inactive (ie, no moderateto-vigorous physical activity) or increasing the amount in those who are insufficiently active is still likely beneficial to reduce ASCVD risk.S3.2-6 Strategies to further increase physical activity in those achieving less than targeted amounts should be implemented. 4 Despite the focus on moderate- and vigorous-

intensity physical activity, such activity accounts for a small proportion of individuals’ daily time as compared with other forms of activity. Other activity states that comprise a 24-hour period for an average individual include sleep, light-intensity physical activity, and sedentary behavior (Figure 1). Sedentary behavior refers to waking behavior with an energy expenditure of ≤1.5 metabolic equivalents while in a sitting or reclining posture (Table 4).S3.2-30 Increased sedentary behavior is associated with worse health parameters, including cardiometabolic risk factors.S3.2-3,S3.2-9–S3.2-11 Sedentary behavior may be most deleterious to ASCVD risk for individuals who engage in the least amount of moderate to vigorous physical activity.S3.2-3,S3.2-10,S3.2-12 Thus, strategies to reduce sedentary behavior, particularly in those not achieving current recommended physical activity levels, may be beneficial for lowering ASCVD risk. However, data on the value of reducing or modifying sedentary behavior over time to reduce ASCVD risk are sparse, and whether replacing sedentary behavior with light-intensity activity (eg, slow walking, light work) is beneficial for ASCVD prevention is unclear.S3.2-31 The strength and specificity of the recommendation to reduce sedentary behavior are limited by uncertainty about the appropriate limits of and optimal approach to modifying sedentary behavior.S3.2-30

Figure 1. Hours per day spent in various states of activity. US adults spend >7 h/d on average in sedentary activities. Replacing sedentary time with other physical activity involves increasing either moderate- to vigorous-intensity physical activity or light-intensity physical activity. Data modified from Young et al.S3.2-30

Table 4.  Definitions and Examples of Different Intensities of Physical Activity

Intensity METs Examples Sedentary behavior* 1–1.5 Sitting, reclining, or lying; watching

television

Light 1.6–2.9 Walking slowly, cooking, light housework Moderate 3.0–5.9 Brisk walking (2.4–4 mph), biking (5–9 mph),

ballroom dancing, active yoga, recreational

swimming

Vigorous ≥6 Jogging/running, biking (≥10 mph), singles

tennis, swimming laps

*Sedentary behavior is defined as any waking behavior characterized by an energy expenditure ≤1.5 METs while in a sitting, reclining, or lying posture. Standing is a sedentary activity in that it involves ≤1.5 METs, but it is not considered a component of sedentary behavior.

MET indicates metabolic equivalent; and mph, miles per hour.

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