Importance of Assessing Cardiorespiratory Fitness in Clinical Practice: A Case for Fitness as a Clinical Vital Sign: A Scientific Statement From the American Heart Association
Open accessAbstract
Mounting evidence has firmly established that low levels of cardiorespiratory fitness (CRF) are associated with a high risk of cardiovascular disease, all-cause mortality, and mortality rates attributable to various cancers. A growing body of epidemiological and clinical evidence demonstrates not only that CRF is a potentially stronger predictor of mortality than established risk factors such as smoking, hypertension, high cholesterol, and type 2 diabetes mellitus, but that the addition of CRF to traditional risk factors significantly improves the reclassification of risk for adverse outcomes. The purpose of this statement is to review current knowledge related to the association between CRF and health outcomes, increase awareness of the added value of CRF to improve risk prediction, and suggest future directions in research. Although the statement is not intended to be a comprehensive review, critical references that address important advances in the field are highlighted. The underlying premise of this statement is that the addition of CRF for risk classification presents health professionals with unique opportunities to improve patient management and to encourage lifestyle-based strategies designed to reduce cardiovascular risk. These opportunities must be realized to optimize the prevention and treatment of cardiovascular disease and hence meet the American Heart Association’s 2020 goals.
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Higher levels of physical activity and/or cardiorespiratory fitness before hospitalization for acute coronary syndromes and elective or emergent surgical procedures appear to yield more favorable short-term outcomes.
“Higher levels of PA and/or CRF before hospitalization for acute coronary syndromes and elective or emergent surgical procedures also appear to yield more favorable short-term outcomes [2] .”
From Physical activity, cardiorespiratory fitness, and cardiovascular health: A clinical practice statement of the American Society for Preventive Cardiology Part II: Physical activity, cardiorespiratory fitness, minimum and goal intensities for exercise training, prescriptive methods, and special patient populations (2022) · cites this paper as [2]
The section “CRF as a Preoperative Predictor of Surgical Risk” (p. 6) says preoperative fitness predicts complications and short-term outcomes across several types of surgery. Our copy does not establish the corresponding claim for physical activity or fitness before hospitalization for acute coronary syndromes (searched: acute coronary syndromes, before hospitalization, and related terms). (LLM, conf=0.84)
Experimental — accuracy not yet measuredNumerous epidemiologic analyses combined with evidence of biologic plausibility support a cause-and-effect relationship between increased physical activity and/or cardiorespiratory fitness levels and reduced cardiovascular disease mortality.
“Numerous epidemiologic analyses combined with evidence of biologic plausibility support a cause-and-effect relationship between increased PA and/or CRF levels and reduced CVD mortality.”
From Physical activity, cardiorespiratory fitness, and cardiovascular health: A clinical practice statement of the American Society for Preventive Cardiology Part II: Physical activity, cardiorespiratory fitness, minimum and goal intensities for exercise training, prescriptive methods, and special patient populations (2022) · cites this paper as [2]
The Overview of CRF and Health Outcomes (p. 3) describes numerous studies linking fitness with lower cardiovascular mortality, and Association Between CRF and Health Outcomes (p. 4) discusses plausible biological mechanisms. But the paper calls the mortality relationship an association and says its reasons are not fully understood; it does not establish the claimed cause-and-effect relationship. (LLM, conf=0.87)
Experimental — accuracy not yet measuredIncreased cardiorespiratory fitness at the observed magnitude has been associated with a decreased risk of cardiovascular disease and decreased all-cause mortality.
“at a magnitude that has been associated with a decreased risk of cardiovascular disease and decreased all-cause mortality, 34”
From Healthy Weight Loss Maintenance with Exercise, Liraglutide, or Both Combined (2021) · cites this paper as [34]
The statement’s Serial Changes in CRF and Risk Prediction section (p. 10) associates a 1-MET fitness increase with lower CVD mortality, and its Associations Between Nonexercise Estimated CRF and CVD section (p. 16) reports lower all-cause mortality and nonfatal CVD risk per MET. The citing excerpt does not specify the observed magnitude, so our copy cannot establish that the reported associations apply to that particular change. (LLM, conf=0.82)
Experimental — accuracy not yet measuredCardiorespiratory fitness (peak or maximal oxygen uptake) is now regarded as a clinical vital sign.
“Cardiorespiratory fitness (peak or maximal oxygen uptake) is now regarded as a clinical vital sign,47”
From Effect of exercise training for five years on all cause mortality in older adults—the Generation 100 study: randomised controlled trial (2020) · cites this paper as [47]
The title (p. 1) makes a case for fitness as a clinical vital sign, and the Conclusions and Recommendations (p. 5) say CRF assessment should become a standard part of clinical encounters. The paper thus supports treating CRF as a proposed vital sign, but not the stronger implication that it is already accepted as one. It also identifies peak or maximal oxygen uptake as a measure of CRF (p. 11). (LLM, conf=0.82)
Experimental — accuracy not yet measuredLow levels of cardiorespiratory fitness have been designated as a clinical vital sign, a risk factor for cardiovascular disease, and a strong prognostic indicator in exercise-based cardiac rehabilitation.
“Consequently, low levels of CRF have now been designated as a clinical vital sign, risk factor for CVD [1] , [2] , [3] , and as a strong prognostic indicator in exercise-based cardiac rehabilitation (CR) [ 4 , 5 ].”
From Physical activity, cardiorespiratory fitness, and cardiovascular health: A clinical practice statement of the American Society for Preventive Cardiology Part II: Physical activity, cardiorespiratory fitness, minimum and goal intensities for exercise training, prescriptive methods, and special patient populations (2022) · cites this paper as [2]
Low cardiorespiratory fitness is a leading risk factor for CVD morbidity and mortality, and higher fitness is cardioprotective.
“Low cardiorespiratory fitness is a leading risk factor for CVD morbidity and mortality (33), with higher levels of fitness universally considered cardioprotective (34) and an important ' vital sign ' of cardiovascular health (35).”
From Cardiorespiratory Fitness, Workload, and the Blood Pressure Response to Exercise Testing (2022) · cites this paper as [35]
Cardiorespiratory fitness is a stronger predictor of mortality risk than traditional risk factors such as smoking, hypertension, high cholesterol, or type 2 diabetes.
“cardiorespiratory fitness (CRF) is a stronger predictor of mortality risk than traditional risk factors such as smoking, hypertension, high cholesterol, or T2D”
From Global consensus on optimal exercise recommendations for enhancing healthy longevity in older adults (ICFSR) (2025) · cites this paper as [44]
Adding cardiorespiratory fitness to conventional risk assessment significantly enhances the accuracy of risk stratification for adverse outcomes.
“Adding CRF to conventional risk assessment significantly enhances the accuracy of risk stratification for adverse outcomes [44]”
From Global consensus on optimal exercise recommendations for enhancing healthy longevity in older adults (ICFSR) (2025) · cites this paper as [44]
The risk reduction per 1 MET increase in measured cardiorespiratory fitness is associated with a 10-30% reduction in adverse cardiovascular events.
“the risk reduction per 1 MET increase in measured CRF is associated with a 10–30% reduction in adverse cardiovascular events [37,48,49]”
From Global consensus on optimal exercise recommendations for enhancing healthy longevity in older adults (ICFSR) (2025) · cites this paper as [49]
Cardiorespiratory fitness (CRF) is a stronger predictor of mortality risk than traditional risk factors such as smoking, hypertension, high cholesterol, or T2D.
“However, epidemiological data increasingly demonstrate that cardiorespiratory fitness (CRF) is a stronger predictor of mortality risk than traditional risk factors such as smoking, hypertension, high cholesterol, or T2D.”
From Global consensus on optimal exercise recommendations for enhancing healthy longevity in older adults (ICFSR) (2025) · cites this paper as [44]
Adding CRF to conventional risk assessment significantly enhances the accuracy of risk stratification for adverse outcomes.
“Adding CRF to conventional risk assessment significantly enhances the accuracy of risk stratification for adverse outcomes [44].”
From Global consensus on optimal exercise recommendations for enhancing healthy longevity in older adults (ICFSR) (2025) · cites this paper as [44]
Proof-of-concept trials have shown that very small doses of exercise-based intermittent VPA can have rapid and measurable effects on cardiorespiratory fitness, a key causal determinant of CVD.
“Proof-of-concept trials39 have shown that very small doses of exercise-based intermittent VPA can have rapid and measurable effects on cardiorespiratory fitness, a key causal determinant of CVD14.”
From Association of wearable device-measured vigorous intermittent lifestyle physical activity with mortality (2022) · cites this paper as [14]
High-intensity interval training and studies of intermittent stair climbing have shown that VPA bursts lasting 20 s to a few minutes, performed three to five times a day, can result in substantial improvements in cardiorespiratory fitness in previously inactive adults within a few weeks.
“High-intensity interval training40 and studies of intermittent stair climbing39 have shown that VPA bursts lasting 20 s to a few minutes, performed three to five times a day, can result in substantial improvements in cardiorespiratory fitness in previously inactive adults within a few weeks, providing a plausible physiological basis14 for the associations we observed.”
From Association of wearable device-measured vigorous intermittent lifestyle physical activity with mortality (2022) · cites this paper as [14]
CRF is frequently used in sports as an indicator of endurance capacity, having strong predictive value for other sport-related performance traits.
“Beyond its implications in medicine, CRF is frequently used in sports as an indicator of endurance capacity, having strong predictive value for other sport-related performance traits [148].”
From Human-centred artificial intelligence for mobile health sensing: challenges and opportunities (2023) · cites this paper as [148]
Clinical evidence shows that CRF is potentially a stronger predictor of mortality than well-established risk factors like hypertension, type 2 diabetes, high cholesterol or smoking.
“Clinical evidence shows that CRF is not only potentially a stronger predictor of mortality than well-established risk factors like hypertension, type 2 diabetes, high cholesterol or smoking, but that using CRF to complement these traditional risk factors significantly improves the precision of risk prediction models for adverse CVD health outcomes [148].”
From Human-centred artificial intelligence for mobile health sensing: challenges and opportunities (2023) · cites this paper as [148]
Using CRF to complement traditional risk factors significantly improves the precision of risk prediction models for adverse CVD health outcomes.
“using CRF to complement these traditional risk factors significantly improves the precision of risk prediction models for adverse CVD health outcomes [148].”
From Human-centred artificial intelligence for mobile health sensing: challenges and opportunities (2023) · cites this paper as [148]
Many studies have demonstrated numerous strong benefits from physical activity, especially among those who suffer from a variety of chronic diseases.
“However, many studies have demonstrated numerous strong benefits from PA, especially among those who suffer from a variety of chronic diseases. 25-28”
From Physical inactivity is associated with a higher risk for severe COVID-19 outcomes: a study in 48 440 adult patients (2021) · cites this paper as [26]
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Cardiorespiratory fitness and health outcomes: a call to standardize fitness categories.
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Self-citationEffects of two years of calorie restriction on aerobic capacity and muscle strength
RACETTE, S. B., ROCHON, J., UHRICH, M. L., VILLAREAL, D. T., DAS, S. K., FONTANA, L., BHAPKAR, M., MARTIN, C. K., REDMAN, L. M., FUSS, P. J., et al. (2017) · Medicine & Science in Sports & Exercise · doi:10.1249/mss.0000000000001353 · Cited by 58 · see citing works
Six-Year Changes in Physical Activity and the Risk of Incident Heart Failure: ARIC Study
Florido, R., Kwak, L., Lazo, M., Nambi, V., Ahmed, H. M., Hegde, S. M., Gerstenblith, G., Blumenthal, R. S., Ballantyne, C. M., Selvin, E., et al. (2018) · Circulation · doi:10.1161/circulationaha.117.030226 · Cited by 56 · see citing works
Cardiorespiratory Reference Data in Older Adults: The Generation 100 Study
STENSVOLD, D., BUCHER SANDBAKK, S., VIKEN, H., ZISKO, N., REITLO, L. S., NAUMAN, J., GAUSTAD, S. E., HASSEL, E., MOUFACK, M., BRØNSTAD, E., et al. (2017) · Medicine & Science in Sports & Exercise · doi:10.1249/mss.0000000000001343 · Cited by 46 · see citing works
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Self-citationSeverin, R., Sabbahi, A., Albarrati, A., Phillips, S. A., & Arena, S. (2020) · Physical Therapy · doi:10.1093/ptj/pzaa034 · Cited by 43 · see citing works
Cardiorespiratory Fitness, Workload, and the Blood Pressure Response to Exercise Testing
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Human-centred artificial intelligence for mobile health sensing: challenges and opportunities
Dang, T., Spathis, D., Ghosh, A., & Mascolo, C. (2023) · Royal Society Open Science · doi:10.1098/rsos.230806 · Cited by 30 · see citing works
Personal activity intelligence and mortality in patients with cardiovascular disease: the HUNT study
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Healthy Vascular Aging Is Associated With Higher Cardiorespiratory Fitness
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Economic burden of low cardiorespiratory fitness in Canada
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“…with reduced all-cause and cardiovascular mortality and prevention of age-related declines [2, 33, 34] and were considered realistic to detect [7, 26], and they were therefore chosen as the minimum clinically relevant differences (see the statistical analysis plan in the ESM for details).”
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- Authors
- Ross, R., Blair, S. N., Arena, R., Church, T. S., Després, J.-P., Franklin, B. A., Haskell, W. L., Kaminsky, L. A., Levine, B. D., Lavie, C. J., Myers, J., Niebauer, J., Sallis, R., Sawada, S. S., Sui, X., & Wisløff, U.
- ORCID
- Venue
- Circulation
- Published
- 2016-12-13
- Volume
- 134
- Issue
- 24
- Pages
- e653-e699
- ISSN
- 0009-7322 (ISSN-L)
- 1524-4539
- OpenAlex
- W2555189237
- Semantic Scholar
- 88871f3a128b0217f4058ab714e636cae4b88b8f
- Cited by
- 2,486
- References
- 308
- Citations by year
- 2026: 298 · 2025: 294 · 2024: 344 · 2023: 302 · 2022: 289 · 2021: 282 · 2020: 229 · 2019: 202 · 2018: 164 · 2017: 74 · 2016: 4 · 2015: 1 · 2014: 1
- FWCI
- 304.38
- Type
- journal article
- Language
- en
- Open access
- hybrid
- doi.org
- Licence
- other-oa
- Locations
- Circulation (publishedVersion, other-oa)
- PubMed (publishedVersion)
- Funders
- U.S. Department of Veterans Affairs (I01 RX000344, IK6 RX002477)
- Topics
- Health Sciences › Medicine › Complementary and alternative medicine › Cardiovascular and exercise physiology
- Health Sciences › Medicine › Physiology › Physical Activity and Health
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Cardiovascular Health and Risk Factors
- Keywords
- cardiorespiratory fitness, cardiovascular risk prediction, mortality risk, cardiovascular disease prevention, risk reclassification, all-cause mortality, cancer mortality, cardiovascular risk management
- MeSH terms
- Cardiorespiratory Fitness, Cardiovascular Diseases, Humans, Metabolic Diseases, Oxygen Consumption, Risk Factors, Exercise, Metabolic Equivalent
About these checks
Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.
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