Highlight
- Moderate to vigorous physical activity (MVPA) declines steadily from young adulthood into midlife, plateauing thereafter, as shown by CARDIA data.
- Individuals who experienced cardiovascular disease (CVD) events had a sharper pre-event decline in MVPA, especially in the 12 years leading up to their event, with a further steep drop in the last 2 years before CVD onset.
- Post-CVD, MVPA levels remain persistently lower compared to matched controls, with Black women facing the steepest declines and highest risk for sustained low activity.
- Findings underscore the urgent need for tailored strategies to promote lifelong activity and reduce disparities in CVD outcomes.
Background
Cardiovascular disease remains the leading cause of morbidity and mortality globally, with modifiable lifestyle factors such as physical activity playing a pivotal role in both primary and secondary prevention. Despite well-established guidelines recommending at least 150 minutes per week of moderate to vigorous physical activity (MVPA), many adults fail to meet these targets, and adherence often further declines with age and following CVD events. Understanding how MVPA patterns evolve across the lifespan and particularly around CVD events is critical for informing effective, equitable intervention strategies. Previous studies have primarily relied on cross-sectional or short-term data, leaving a gap in knowledge regarding the long-term trajectories of physical activity and their relationship to CVD incidence and recovery, especially across demographic subgroups.
Study Overview and Methodological Design
The study by Gerber and colleagues leveraged data from the Coronary Artery Risk Development in Young Adults (CARDIA) study, a prospective, multisite cohort initiated in 1985-1986. CARDIA enrolled a balanced population of Black and White men and women, aged 18-30 years at baseline, drawn from four US cities, and followed participants for up to 37 years with repeated assessments of MVPA and cardiovascular outcomes.
A total of 3,068 participants were included in the cohort analysis, with up to 10 MVPA assessments per participant through 2020-2022. MVPA was self-reported using a validated questionnaire, with exercise units (EU) as the metric (300 EU ≈ 150 min/week of MVPA). Incident CVD events (coronary heart disease, stroke, heart failure) were centrally adjudicated. A nested case-control design matched 236 incident CVD cases 1:1 to controls by age, sex, and race, allowing for detailed pre- and post-event analysis. The primary endpoint was the trajectory of MVPA relative to CVD onset, with secondary analyses exploring subgroup differences and associations with post-CVD low MVPA (defined as <300 EU). Statistical analysis employed smoothed regression models and generalized estimating equations for odds ratios.
Key Findings
The study revealed several important and clinically relevant patterns:
1. Overall MVPA Trajectories: MVPA declined steadily from young adulthood through midlife, with a plateau in older age. On average, participants did not meet MVPA guidelines by midlife.
2. Racial and Sex Disparities: Black women exhibited the lowest MVPA levels throughout adulthood, with Black men showing a more persistent decline over time. White men and women had higher and more stable MVPA trajectories.
3. Pre-CVD Decline: Among those who developed CVD, MVPA began to drop approximately 12 years before the event, with an accelerated decline in the 2 years preceding the event. This steep pre-event drop was particularly notable in heart failure cases.
4. Post-CVD Plateau and Gap: After a CVD event, MVPA did not recover to pre-event levels and remained consistently lower than in matched controls, with the most pronounced gap seen in Black women (post-CVD low MVPA OR 4.52, 95% CI 2.29-8.89).
5. Persistent Risk: Adjusted odds of low MVPA post-CVD were 1.78-fold higher in cases versus controls (95% CI 1.26-2.50), suggesting a durable impact of CVD events on physical activity behaviors.
| Group | Mean MVPA Decline (EU) Pre-CVD | Odds Ratio for Low MVPA Post-CVD (95% CI) |
|---|---|---|
| All CVD Cases | Steep, especially 2 years pre-event | 1.78 (1.26-2.50) |
| Black Women | Lowest baseline; steepest decline | 4.52 (2.29-8.89) |
| Heart Failure Cases | Most pronounced decline | Consistently low post-event |
Mechanistic Insights and Pathophysiological Context
The progressive decline in MVPA leading up to CVD events likely reflects the interplay of subclinical disease burden, emerging symptoms, and lifestyle adaptation. Prodromal symptoms—such as dyspnea, fatigue, or chest discomfort—may prompt activity avoidance well before overt clinical events. Sedentary behavior can exacerbate metabolic dysfunction, inflammation, and endothelial impairment, reinforcing a vicious cycle of risk. The particularly steep pre-event decline in heart failure cases aligns with the insidious onset of heart failure symptoms and reduced exercise tolerance. Demographic disparities may be influenced by social determinants of health, including access to safe exercise environments, chronic stress, and comorbidities.
Clinical Implications
These findings have significant implications for preventive cardiology and secondary prevention programs. First, MVPA promotion should begin in early adulthood and be sustained throughout life, with particular attention to at-risk groups such as Black women. Second, the preclinical decline in MVPA may serve as an early warning sign, arguing for routine activity assessment as part of cardiovascular risk screening. Third, rehabilitation and recovery strategies after CVD events must address persistent barriers to physical activity, including physical limitations, psychosocial factors, and systemic inequities. Tailored interventions, community programs, and culturally competent counseling may help bridge the persistent activity gap.
Limitations and Controversies
Key limitations include reliance on self-reported MVPA, which is susceptible to recall and social desirability bias. The CARDIA cohort, while diverse, included only Black and White participants, limiting generalizability to other racial/ethnic groups. Residual confounding by unmeasured variables (e.g., socioeconomic status changes, comorbidity accrual, or environmental factors) may influence trajectories. The observational design precludes causal inference regarding the impact of pre- or post-CVD MVPA on outcomes. Additionally, the relatively small number of heart failure events limits granular analysis in this subgroup. Despite these caveats, the longitudinal design and robust adjudication of CVD outcomes provide strong evidence for the observed patterns.
Expert Commentary or Guideline Positioning
Current guidelines from the American Heart Association and the U.S. Preventive Services Task Force continue to endorse at least 150 minutes per week of moderate-intensity aerobic activity, with additional recommendations for individualized support post-CVD. The persistent MVPA gap after CVD—particularly among Black women—raises questions about the adequacy of current rehabilitation outreach and the need for community-embedded strategies. As Dr. Mercedes Carnethon, a co-author and preventive cardiologist, has previously noted, “Addressing disparities in physical activity is not just a matter of individual motivation; it requires structural change and culturally tailored approaches.”
Conclusion
The CARDIA study provides compelling longitudinal evidence that MVPA declines well before and remains low after CVD events, with substantial disparities by sex and race. These findings highlight an urgent need for proactive, tailored interventions spanning the life course and recovery phases—especially for Black women, who face the greatest burden of low activity and CVD risk. Future research should expand to more diverse populations, employ objective activity monitoring, and test multilevel interventions aimed at sustaining MVPA and improving cardiovascular outcomes.
References
1. Gerber Y, Pettee Gabriel K, Jacobs DR Jr, et al. Trajectories of Physical Activity Before and After Cardiovascular Disease Events in CARDIA Participants. JAMA Cardiol. 2025 Jul 23:e252282. doi: 10.1001/jamacardio.2025.2282 IF: 14.1 Q1 .
2. Piercy KL, Troiano RP, Ballard RM, et al. The Physical Activity Guidelines for Americans. JAMA. 2018;320(19):2020-2028. doi:10.1001/jama.2018.14854 IF: 55.0 Q1 .
3. Benjamin EJ, Muntner P, Alonso A, et al. Heart Disease and Stroke Statistics—2019 Update: A Report From the American Heart Association. Circulation. 2019;139(10):e56-e528.
4. Franklin BA, Brinks J, Berra K, et al. Using the “Life’s Simple 7” Metrics to Improve Secondary Prevention of Cardiovascular Disease. Am J Cardiol. 2020;135:53-60.
