Sex differences in the association of wearable accelerometer-derived physical activity with coronary heart disease incidence and mortality

Despite American Heart Association, European Society of Cardiology and World Health Organization (AHA/ESC/WHO) guidelines uniformly recommending 150 min week^-1 of moderate-to-vigorous physical activity (MVPA) for both sexes, a substantial 'gender gap' persists in exercise capacity and guideline adherence, and its impact on coronary heart disease (CHD) development and prognosis remains underexplored. Here we analyzed the accelerometer-measured MVPA of 80,243 CHD-free participants to assess CHD incidence and 5,169 patients with CHD to evaluate all-cause mortality. Compared with non-adherent counterparts, guideline-adherent participants showed a 22% lower CHD risk in female individuals (hereinafter referred to as females) and a 17% lower CHD risk in male individuals (hereinafter referred to as males; (P_interaction = 0.009). Notably, females achieved a CHD risk reduction of 30% (hazard ratio (HR) = 0.70) with 250 min week^-1 of MVPA, whereas males required 530 min week^-1 for comparable benefits. Among patients with CHD, active females experienced greater mortality risk reduction than males (HR = 0.30 versus 0.81; P_interaction = 0.004). Similar sex differences were observed when analyzing guideline-adhering days (P_interaction < 0.05). Our findings underscore the value of sex-specific tailored CHD prevention strategies using wearable devices, which may help bridge the 'gender gap' by motivating females to engage in physical activity.