The Association of Walking Pace and Incident Heart Failure and Subtypes Among Postmenopausal Women

Moafi-Madani Miremad MD, MS; Xiaochen Lin PhD; Somwail Rasla MD; Amr El Meligy MD; Mary B. Roberts MS; Deepika Laddu PhD; Matthew Allison MD, MPH; Lisa W. Martin MD; Aladdin H. Shadyab PhD; Jo Ann E. Manson MD, DrPH; Rowan Chlebowski MD, PhD; Gurusher Panjrath MD; Michael J. LaMonte PhD; Simin Liu MD, ScD; Charles B. Eaton MD, MS


J Am Geriatr Soc. 2022;70(5):1405-1417. 

In This Article

Abstract and Introduction


Background: To investigate the association between walking pace and the risk of heart failure (HF) and HF sub-types.

Methods: We examined associations of self-reported walking pace with risk of incident HF and HF subtypes of preserved (HFpEF) and reduced (HFrEF) ejection fractions, among 25,183 postmenopausal women, ages 50–79 years. At enrollment into the Women's Health Initiative cohort in 1993–1998, this subset of women was free of HF, cancer, or the inability to walk one block, with self-reported information on walking pace and walking duration. Multivariable Cox regression was used to examine associations of walking pace (casual <2 mph [referent], average 2–3 mph, and fast >3 mph) with incident HF. We also examined the joint association of walking pace and duration with incident HF.

Results: There were 1455 incident adjudicated acute decompensated HF hospitalization cases during a median of 16.9 years of follow-up. There was a strong inverse association between walking pace and overall risk of HF (HR = 0.73, 95% CI [0.65, 0.83] for average vs. casual walking; HR = 0.66, 95%CI [0.56, 0.78] for fast vs. casual walking). There were similar associations of walking pace with HFpEF (HR = 0.73, 95%CI [0.62, 0.86] average vs. casual; HR = 0.63, 95%CI [0.50, 0.80] for fast vs. casual) and with HFrEF (HR = 0.72, 95%CI [0.57, 0.91] for average vs. casual; HR = 0.74, 95%CI [0.54, 0.99] for fast vs. casual). The risk of HF associated with fast walking with less than 1 h/week walking duration was comparable with the risk of HF among casual and average walkers with more than 2 h/week walking duration.

Conclusion: Walking pace was inversely associated with risks of overall HF, HFpEF, and HFrEF in postmenopausal women. Whether interventions to increase the walking pace in older adults will reduce HF risk and whether fast pace will compensate for the short duration of walking warrants further study.


Heart failure (HF) is an increasingly prevalent public health problem, accounting for more than 800,000 hospitalizations in 2016 and 83,000 deaths in 2018 in the United States. Prevalence of HF in the United States is projected to increase by 46% from 2012 to 2030, affecting more than 8 million people. HF predominantly affects older adults; with an approximate prevalence of 4 and 11 percent among 60–80 and older than 80 years' old women, respectively. We still lack data defining the optimal lifestyle interventions to prevent HF in this population especially HF with preserved ejection fraction (HFpEF), which has no effective therapy, and is more common in women, older adults, and those with multiple comorbidities.[1]

Physical activity (PA) has been associated with lower risk of HF,[2] but the role of specific types of PA remains to be elucidated. Walking, which essentially does not require any equipment, is the most common type of PA, especially for women and older adults.[3] Walking volume (MET-hours/week) has been shown to be inversely related to incident coronary heart disease, cardiovascular disease (CVD), and CVD-specific and all-cause mortality in older women.[4] A few studies have evaluated walking pace independent of walking duration and found that those with a faster walking pace had a lower risk of incident CVD, CVD, and all-cause mortality.[5–7] Studies on the specific relationship between walking and the risk of developing HF are extremely limited. We previously published results of a 14-year follow-up on 137,303 multiethnic older women and showed significant inverse associations of walking volume with risks of HF and its sub-types, after controlling extensively for confounding including total PA levels.[8] However, we did not evaluate the unique role of walking pace in this previous study. Postmenopausal women and racial-ethnic minorities are disproportionately affected by the burden of HF[1]and physical inactivity[9]and yet under-represented in most previous studies on PA and HF risk.[2] Lack of time is frequently cited as the primary barrier to meeting current recommendations regarding physical activity.[10] If brisk walking for a shorter duration (frequency × time per bout) provides similar benefit as walking at a slower pace but for a longer duration, then PA recommendations may suggest such a strategy to improve health outcomes. This could be particularly relevant among older adults who often are not capable of safely engaging in other types of activities at higher intensity but who are able to participate in walking and gradually increase their walking pace.[11] Understanding of the potential role of walking pace in the development of HF and its subtypes in later life could provide the opportunity to refine PA recommendations as part of primary HF prevention for older adults. In this prospective study, we examined associations of walking pace with overall HF and its subtypes adjusting for walking duration (hours/week) and nonwalking PA among the Women's Health Initiative (WHI) participants.