IJCS | Volume 32, Nº4, July/August 2019

321 Araújo et al. Exercise/sport & cardiovascular health: an update Int J Cardiovasc Sci. 2019;32(4):319-325 Viewpoint to transport blood from the heart to meet the oxygen requirements, the ability of muscle cells to use the oxygen and other essential nutrients delivered by the blood. Indeed, the efficiency of this system is only partly related to aging. 6 When evaluating existing knowledge in exercise medicine, we need to know the difference in findings derived from observational studies as compared with possible effects of exercise interventions on death, myocardial infarction and stroke. 6 An important question is how physicians should deal with individuals who have low CRF level. Should we carry out diagnostic examinations to find out the possibly underlying early disease stages reducing fitness or shouldwe just prescribe exercise training to improve CRF and possibly reduce the risk of death? When comparing the prognosis of physically active versus inactive individuals to prevent serious adverse events, we should understand that many measurable or immeasurable factors are associated with physical activity level even before the intervention or follow-up was started. CRF is related to reduced health costs Jonathan Myers Q: It is widely recognized that a high cardiorespiratory (aerobic) fitness in middle-aged and older men and women is strongly related to many important health outcomes. A substantial amount of years of life and life to years is gained with regular exercise and, as a natural consequence, CRF is improved. Additionally, healthier people tend to use less regular medication and to have lower chances to be hospitalized for chronic diseases. In a time of growing interest in reducing and controlling medical expenses, what is already known about the relationship between CRF and health costs? A: It is correct that there is a growing body of research on the impact of CRF and health outcomes, and it makes intuitive sense that a fitter individual would have lower healthcare costs. While there has been quite a bit research performed on the impact of physical activity patterns (or more often, corporate wellness programs) on healthcare costs, surprisingly few data are available regarding the association between fitness and healthcare costs. In an era in which there is increasing focus on reducing healthcare costs, it is also surprising that there has been so little attention paid to the potential impact of fitness on costs, given that it so powerfully influences health outcomes. The effect of fitness onhealthcare costs has recentlybeen documented by the Cooper Institute 9 and the Veterans Exercise Testing Study (VETS). 10,11 After controlling for age and the presence of co-morbidities, these studies demonstrate that fitter subjects have markedly lower health care costs compared to those who are less fit. Both groups observed that each 1-MET higher fitness level was associated with approximately 5-7% lower annual costs over lengthy follow-up periods; in the VETS cohort, this represented ≈$1,600 USD lower annual health care costs per higher MET. 11 Much like cardiovascular and all-cause mortality, a small improvement in fitness has a considerable effect on costs. In addition to its effect on health outcomes, improving fitness through regular physical activity should be encouraged for its potential to lower health care costs. Cardiovascular diseases and indication for exercise training Claudio Gil Araújo Q: According to several institutional guidelines, exercise training has been recommended as part of the treatment of patients with coronary artery disease and heart failure. Notwithstanding, it is possible that patients with several other cardiovascular disorders could benefit from exercise training programs. Is it time to extend exercise training prescription as an important therapeutic strategy to cardiovascular disorders other than ischemic heart disease and heart failure? A: This is 100% true. While there is a large body of evidence showing many relevant benefits of different modalities of exercise training (either alone or in combination with other lifestyle and/or behavioral interventions) for patients with coronary artery disease or heart failure, there are also recent observational studies showing that patients with other cardiovascular diseases – including valve or vascular patients 12 – could also benefit from exercise training. So, for a given patient with a specific cardiovascular disorder, the question would be how to prescribe the most appropriate, individualized exercise program, with a high benefit-risk ratio based on functional assessment results. Competent expertise and knowledge of exercise sciences are basic requirements to prescribe the best, most viable and individually tailored exercise regimen. Indeed, in the clinical scenario, it is very rare to find a patient to whom all types of exercises would be formally prohibited or contraindicated. Complete avoidance of