Assessment of Long-Term Engagement in Aerobic Versus Resistance Exercise on 20-Year Cardiovascular Disease Incidence (2002–2024): The ATTICA Epidemiological Cohort Study

Objective: The aim of this study was to assess whether aerobic exercise, as opposed to resistance training or a combination of both, is associated with long-term cardiovascular outcomes. Methods: The ATTICA study is a population-based cohort study with a 20-year follow-up (2002–2022); it was conducted in the Attica region, Greece, and included 3042 adult participants (45 ± 11 years, 1518 females). Physical activity engagement in aerobic, resistance, or combined exercise, and 20-year tracking, together with information regarding atherosclerotic cardiovascular disease (ASCVD) incidence were available for 1988 participants (45 ± 12 years old, 987 males, 1001 females). Physical activity levels were evaluated using the validated International Physical Activity Questionnaire, in all follow-up examinations (2001–2002, 2006, 2012, and 2022). Cox proportional hazard models were applied; the results are presented as hazard ratio (HR) and 95% confidence intervals (CIs). Results: Participants engaged in the combined (aerobic and resistance) physical activity group had 0.41-times [95%CI (0.20, 0.82)] lower ASCVD risk compared to inactive participants; participants in the healthy engaging aerobic physical activity (HEPA) group had 0.54-times [95%CI (0.36, 0.80)] lower ASCVD risk; no significant associations were observed regarding the minimally active aerobic group [HR, 0.81, 95%CI (0.57, 1.17)], or the resistance training only group [HR, 1.17, 95%CI (0.25, 1.52)]. Conclusions: These findings carry a strong public health message, underscoring the importance of incorporating aerobic or combined aerobic–resistance training into physical activity guidelines to enhance cardiovascular health and reduce the long-term risk of CVD.