Sex differences in cardiovascular mortality associated with aerobic and muscle-strengthening activity: A propensity score–matched analysis of National Health Interview Survey (NHIS)-linked mortality data

Background Aerobic and muscle-strengthening activities are recommended for cardiovascular prevention, but whether their associations with mortality differ by sex remains unclear. Methods We analyzed U.S. adults in the National Health Interview Survey (1997–2017) linked to the National Death Index through 2019. We estimated propensity scores for meeting guideline-concordant moderate-to-vigorous physical activity (MVPA ≥150 min/week), any vigorous contribution (vigorous physical activity/MVPA; >0%), muscle-strengthening activity (MSA ≥2 sessions/week), and MVPA + MSA using logistic regression including sex and other baseline covariates, and constructed 1 : 1 matched cohorts. Cause-specific Cox models estimated hazard ratios (HRs) for all-cause and cardiovascular disease (CVD) mortality; robust standard errors were clustered by matched pair. In landmark sensitivity analyses, participants with <2 years of follow-up were excluded. Results In matched cohorts, guideline-concordant MVPA was associated with lower CVD mortality in both sexes, with a stronger association in women (men HR 0.857, 95% CI 0.806–0.912; women HR 0.753, 0.705–0.805; P interaction = 0.005). Similar patterns were observed for any vigorous contribution, MSA, and meeting both MVPA and MSA. In landmark analyses, estimates were directionally consistent (e.g. MVPA: men 0.876, 0.821–0.935; women 0.769, 0.718–0.824; P interaction = 0.007). Conclusion MVPA and MSA were associated with lower mortality in men and women. Relative associations for CVD mortality were generally stronger among women, although absolute differences should be interpreted in the context of lower baseline CVD mortality among women. Findings were robust in landmark analyses excluding the first 2 years of follow-up.