Brisker Walking Tied to Lower Heart Failure Risk

Batya Swift Yasgur, MA, LSW

January 28, 2022

A faster walking pace is associated with a lower risk of developing heart failure (HF), suggests a new observational study in postmenopausal women.

Investigators followed over 25,000 women between the ages of 50 and 70 years for a median of almost 17 years. Compared with women who walked at a casual pace, those who walked at an average or fast pace had a 27% and 34% lower risk of HF, respectively.

Moreover, even a short duration of fast walking — less than 1 hour per week — was associated with the same amount of HF risk reduction as twice that amount of average or casual walking.

"Walking is an effective, inexpensive form of exercise that likely can prevent multiple chronic diseases, such as coronary heart disease, cancers, and heart failure," senior author Charles Eaton, MD, professor, Department of Family Medicine and Epidemiology, Alpert Medical School, Brown University, Rhode Island, told | Medscape Cardiology.

"You can get the same or better benefit by walking at a fast pace, which you can accomplish in a shorter time frame, than walking slower for a longer period of time," said Eaton, who is also the director of the Center for Primary Care and Prevention of Brown University at Memorial Hospital of Rhode Island.

The study was published online January 20 in the Journal of the American Geriatric Society.

Does Energy Expenditure Matter?

Physical activity (PA) has been shown to be associated with a lower risk of HF, but the "role of specific types of PA remains to be elucidated," the authors write. Walking is the "most common type of PA," they note, especially for women and older adults.

"Our study was motivated by the fact that previous studies have shown that the volume of PA and walking, as calculated as energy expenditures — MET [metabolic equivalent intensity] hours per week — was associated with a reduced risk of heart failure," Eaton said. "But relatively few studies have evaluated whether the frequency, duration, or pace (energy expenditure per bout) made any difference."

To investigate the question, the researchers looked at a subset of postmenopausal women who enrolled in the Women's Health Initiative (WHI) cohort between 1993 and 1998 (N = 25,183, mean [SD] age 62.6 [7.2] years, 56% White, 28% Black, 14% Hispanic) with no history of HF or cancer.

At baseline, participants completed self-administered questionnaires providing information about personal and family health history, recreational PA, smoking, diet, and other behavioral and lifestyle factors. In addition, their height, weight, waist and hip circumference, and blood pressure were measured.

Questions about PA included separate assessment of walking, including specific questions about the frequency of walks outside the home for > 10 minutes without stopping; the average duration of each walk; and the usual walking pace.

Walking pace was categorized as casual, average, or fast (Table 1).

Table 1. Walking Pace and Energy Expenditure

Type of Walk Speed METs
Casual < 2 miles/hour 2
Average 2-3 miles/hour 3
Fast > 3 miles/hour 4.5


Walking volume was summarized as MET-hours/week of walking activity.

HF with preserved ejection fraction (HFpEF) was defined as an EF of ≥ 45%, while HF with reduced ejection fraction (HFrEF) was defined by an EF of < 45%.

Women who reported walking at a fast pace tended to be younger and were more frequently White. In addition, they had lower BMI, higher physical functioning scores, and higher total recreational PA.

They differed in medical history as well, having a lower history of hysterectomy and a lower prevalence of diabetes, hypertension, hypercholesterolemia, and family history of myocardial infarction.

Training Effect

Patients were followed for a median of 16.9 years (IQR, 11.7 years), during which time there were 1455 newly diagnosed acute decompensated HF hospitalizations. Most of these cases were HFpEF, followed by cases of HFrEF and unknown EF (n = 811, 429, and 215, respectively).

A "strong inverse association" was found between walking pace and overall risk of HF, as well as both HF subtypes, the authors report.

Table 2. Walking Pace and Heart Failure Risk

Walking Pace
Overall HF
HR (95% CI)
HR (95% CI)
HR (95% CI)
Average vs casual 0.73 (0.65 - 0.83) 0.73 (0.62 - 0.86) 0.72 (0.57 - 0.91)
Fast vs casual 0.66 (0.56 - 0.78) 0.63 (0.50 - 0.80) 0.74 (0.54 - 0.99)

The HF risk associated with fast walking for < 1 hour per week was "comparable" to the risk of HF among casual and average walkers with > 2 hours per week of walking duration, they note.

The researchers conducted several sensitivity analyses in which they accounted for vigorous-intensity PA other than fast walking, as well as potential confounding by diabetes, hypertension, and dyslipidemia, "which could be on the causal pathway between walking pace and HF."

They found that walking pace continued to be significantly associated with the risk of incident acute hospitalized overall HF as well as HFpEF "in an adverse and graded fashion, similar to what was observed in the primary analysis."

Additional sensitivity analyses excluded participants with low physical functioning score and those who developed HF during the first 3 years of follow up, to reduce the likelihood of reverse causality. The findings remained the same.

"We did not study the mechanism by which walking pace impacts heart failure risk; but the likely mechanism, based on other studies, is that by walking fast, you improve cardiovascular fitness through a training effect that allows you to extract oxygen in your muscles more efficiently, improves the balance in the autonomic nervous system between the sympathetic and parasympathetic systems, and improves risk factors for HF, such as elevated blood pressure and insulin resistance," Eaton commented.

He added that future research that actually "manipulates walking" can answer the question of whether women who walk at a fast pace already have greater cardiovascular fitness, which protects them from HF.

Walking Intensity Matters

Commenting for | Medscape Cardiology, Mary Norine Walsh, MD, medical director of heart failure and cardiac transplantation, Ascension St. Vincent Heart Center, Indianapolis, Indiana, called the study "an important contribution with regard to a specific endpoint in cardiovascular disease — heart failure — showing that walking speed matters."

Walsh, who is a past president of the American College of Cardiology and was not involved with the study, said the take-home message is "that walking intensity and speed really matter lifelong in order to avoid cardiovascular events, particularly heart failure."

Clinicians should consider "looking at those who have slower walking pace more carefully, and look at their individual risk of heart failure," Walsh suggested. "It is something to add to our counseling of patients, to encourage them to adopt a more active lifestyle. We talk to patients about how many steps they take, but how fast they take those steps appears to matter as well."

This research is supported by the National Institutes of Health. The WHI program is funded by the National Heart, Lung, and Blood Institute, National Institutes of Health, and US Department of Health and Human Services. Eaton and coauthors and Walsh disclose no relevant financial relationships.

J Am Geriatr Soc. Published online January 20, 2022. Abstract

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