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Table 12 Studies examining the relationship between physical activity and cardiovascular disease.

From: A systematic review of the evidence for Canada's Physical Activity Guidelines for Adults

Publication Country Study Design Quality Score Objective Population Methods Outcome Comments and Conclusions
Paffenbarger and Hale 1975 [47] To evaluate the role of PA in reducing coronary mortality among longshoreman • n = 6,351 22 years of follow up, or until reached the age of 75 yr RR (95% CI) Sudden death VPA is associated with reduced risk of coronary mortality, particularly sudden cardiac death.
USA   • Sex: Men      • G1 = 1.00 (referent)  
   • Age: 35-74 yr      • G2 = 3.5  
   • Characteristics: Longshoreman PA assessment: Energy and oxygen cost requirements of longshoring jobs    • G3 = 2.8  
Prospective cohort     Delayed death  
        • G1 = 1.00 (referent)  
D & B score = 12        • G2 = 1.4  
    Activity level    • G3 = 1.5  
    G1 = Heavy (5.2-7.5 kcal/min) Unspecified death  
    G2 = Moderate (2.4-5.0 kcal/min)    • G1 = 1.00 (referent)  
    G3 = Light (1.5-2.0 kcal/min)    • G2 = 1.1  
        • G3 = 1.6  
    Outcome measure: Death from CHD   
Manson et al 2002 [56] To compare the roles of walking and vigorous exercise in the prevention of CV events in a large, ethnically diverse cohort of postmenopausal women. • n = 73,743 Enrolment from 1994-98 Clinic visit for baseline screening,    • Number of New Cases: 345 Both walking and VPA are associated with substantial reductions in the incidence of CHD events.
USA   • Sex: Women      • Total Number of CVD events: 1551  
   • Age: 50-79 yr    
   • Characteristics: Healthy, Post Menopausal   Age adjusted RR (95% CI) Total exercise (MET-hr/wk)  
    PA assessment: Questionnaire for: Total exercise (MET- hr/wk)   
Prospective cohort    G1 = 0-2.4    • G1 = 1.00 (referent)  
   • Women's Health Initiative Observational Study G2 = 2.5-7.2    • G2 = 0.73 (0.53-0.99)  
    G3 = 7.3-13.4    • G3 = 0.69 (0.51-0.95)  
D & B score = 12    G4 = 13.5-23.3    • G4 = 0.68 (0.50-0.93)  
    G5 = ≥ 23.4    • G5 = 0.47 (0.33-0.67)  
     p = <0.001  
     Walking (MET-hr/wk)  
    Walking (MET-hr/wk)    • G1 = 1.00 (referent)  
    G1 = None    • G2 = 0.71 (0.53-0.96)  
    G2 = 0.1-2.5    • G3 = 0.60 (0.44-0.83)  
    G3 = 2.6-5.0    • G4 = 0.54 (0.39-0.76)  
    G4 = 5.1-10.0    • G5 = 0.61 (0.44-0.84)  
    G5 > 10 p = 0.004  
    Time for VPA (min) Vigorous exercise  
    G1 = None    • G1 = 1.00 (referent)  
    G2 = 1-60    • G2 = 1.12 (0.79-1.60)  
    G3 = 61-100    • G3 = 0.56 (0.32-0.98)  
    G4 = 101-150    • G4 = 0.73 (0.43-1.25)  
    G5 = >150    • G5 = 0.58 (0.34-0.99)  
     p = 0.008  
    Outcome Measure: Incidence of CVD and CHD   
Wisloff et al 2006 [58] To study the association between the amount and intensity of exercise and CVD mortality. • n = 56,072 (27,143 men; 28,929 women) Length of follow-up: 16 ± 4 yr    • Number of Cases: 1,603 male, 993 female Men and women who exercise to a moderate degree and spend less than the recommended energy (< 1000 kcal/wk) are at lower risk of dying from heart disease than those who never exercise.
Norway   • Sex: Men and women PA assessment: Questionnaire for LTPA, 4 groups Multivariate RR (95% CI)  
Prospective cohort   • Age: ≥ 20 yr   Men  
   • Characteristics: Free form CVD Men    • Q1 = 1.00 (referent)  
    Q1 = None    • Q2 = 0.66 (0.50-0.87)  
D & B score = 12   • HUNT study Q2 = 1/wk >30 min high    • Q3 = 0.83 (0.65-1.06)  
    Q3 = 2-3/wk > 30 min high    • Q4 = 0.77 (0.59-1.01)  
    Q4 = ≥ 4/wk > 30 min high Women  
        • Q1 = 1.00 (referent)  
    Women    • Q2 = 0.63 (0.31-1.29)  
    Q1 = None    • Q3 = 0.66 (0.32-1.34)  
    Q2 = 1/wk ≤ 30 min low    • Q4 = 0.86 (0.45-1.62)  
    Q3 = 1/wk ≤ 30 min high   
    Q4 = 2-3/wk ≤ 30 min low   
    Outcome Measure: Ischaemic heart disease mortality   
    Cox proportional HR   
Lee et al 2001 [59] To examine the relationship between PA (specifically walking) and CHD among women, including those at high risk for CHD. • n = 39,372 Recruitment of Participants: Sept 1992-May 1995    • Number of Cases: 244 Even light to moderate activity is associated with lower CHD rates in women.
USA and Puerto Rico   • Sex: Women    
   • Age: ≥ 45 yr   Multivariate RR (95% CI) Time spent walking  
   • Characteristics: Healthy PA assessment: Questionnaires Divided into 4 or 5 groups:    • G1 = 1.00 (referent)  
   • Women's Health Study      • G2 = 0.86 (0.57-1.29) As little as 1 hour of walking per week predicted lower risk.
Prospective cohort        • G3 = 0.49 (0.28-0.86)  
        • G4 = 0.48 (0.29-0.78)  
     p = <0.001  
D & B score = 12    Time spent walking   
    G1 = No regular walking Walking pace  
    G2 = 1-59 min/wk    • G1 = 1.00 (referent)  
    G3 = 1.0-1.5 h/wk    • G2 = 0.56 (0.32-0.97)  
    G4 = ≥ 2.0 h/wk    • G3 = 0.71 (0.47-1.05)  
    Walking pace (km/h)    • G4 = 0.52 (0.30-0.90)  
    G1 = No regular walking p = 0.02  
    G2 = 3.2   
    G3 = 3.2-4.7   
    G4 = ≥ 4.8 EE (kcal/wk)  
        • Q1 = 1.00 (referent)  
    EE (kcal/wk)    • Q2 = 0.79 (0.56-1.12)  
    G1 = 200    • Q3 = 0.55 (0.37-0.82)  
    G2 = 200-599    • Q4 = 0.75 (0.50-1.12)  
    G3 = 600-1499 and p = 0.03  
    G4 = 1500 or more   
     Energy expended VPA (kcal/wk)  
    Energy expenditure for VPA (kcal/wk)    • G1 = 1.00 (referent)  
    G1 = No vigorous, <200 kcal/wk    • G2 = 0.65 (0.46-0.91)  
    G2 = No vigorous, ≥ 200 kcal/wk    • G3 = 1.18 (0.79-1.78)  
        • G4 = 0.96 (0.60-1.55)  
        • G5 = 0.63 (0.38-1.04)  
    G3 = Vigorous, 1-199 kcal/wk   
    G4 = Vigorous, 200-499 kcal/wk   
    G5 = Vigorous, ≥ 500 kcal/wk   
Paffenbarger et al 1993 [67] To analyze changes in the lifestyle of Harvard Alumni and the associations of these changes to mortality. • n = 10,269 Baseline measure in 1962 or 1967 with a follow up in 1977 Alumni who increased their PA index to 2000 kcal or more per week had a 17% lower risk of death from CHD then those who were sedentary (p = 0.507) Moderately vigorous sports activity was associated with lower rates of death from CHD among middle aged and older men
   • Sex: Men    
   • Age: 45-84 yr    
USA   • Characteristics: Health, Harvard College Alumni    
Prospective cohort    PA assessment: Mailed questionnaires included questions on type, duration, intensity, frequency of PA. Men who took up moderate took up moderately vigorous activity had a 41% lower risk than those who continued not to engage in such activity (p = 0.044)  
D & B score = 13    Outcome Measure: CHD deaths between 1977 and 1985   
    Cox proportional hazards model   
    Poisson regression methods   
    The Mantel extension of the Mantel-Haenszel test   
Haapanen et al 1997 [77] To examine the association between duration and intensity of LTPA and the risk of CHD. • n = 2,840 (1,500 men; 1,340 women) Length of Follow-up: 10 yrs    • Incident Rates (per 1000 person-years) for CHD = 108 for men and 75 for women. Total EE had an inverse and independent association with risk of CHD in middle aged Finnish men but not among women.
Finland   • Sex: Men and women PA assessment: Questionnaire for LTPA EE (kcal/wk) Multivariate RR (95% CI) LTPA and CHD mortality  
Prospective cohort   • Age: 35-63 yr   Men  
   • Characteristics: Healthy Men    • G1 = 1.98  
    G1 = 0-1100    • G2 = 1.33  
D & B score = 13    G2 = 1101-1900    • G3 = 1.00 (referent)  
    G3 = >1900   
     Women  
    Women    • G1 = 1.25  
    G1 = 0-900    • G2 = 0.73  
    G2 = 901-1500    • G3 = 1.00 (referent)  
    G3 = >1500   
    Outcome Measure: CHD mortality   
    Cox proportional HR   
Barengo et al 2004 [164] To investigate whether moderate or high LTPA are associated with a reduced CVD and all-cause mortality, independent of CVD risk factors and other forms of PA in men and women. • n = 31,677 (15,853 men; 16,824 women) 20 year follow-up    • Number of Cases (Men): 1,661 Moderate and high levels of LTPA and OPA are associated with reduced CVD mortality.
    PA assessment: Questionnaire for LTPA and OPA, 3 groups    • Number of Cases (Women): 778  
Finland   • Sex: Men and women   HR (95% CI) LTPA, men  
Prospective cohort   • Age: 30-59 G1 = Low activity    • G1 = 1.00 (referent)  
   • Characteristics: Participant from eastern and south-western Finland G2 = Moderate activity    • G2 = 0.91 (0.82-1.00)  
D & B score = 14    G3 = High activity    • G3 = 0.83 (0.69-0.99)  
     LTPA, women (referent)  
        • G1 = 1.00  
        • G2 = 0.83 (0.71-0.96)  
        • G3 = 0.89 (0.68-1.18)  
     OPA, men  
        • G1 = 1.00 (referent)  
        • G2 = 0.75 (0.64-0.87)  
        • G3 = 0.77 (0.69-0.87)  
     OPA, women  
        • G1 = 1.00 (referent)  
        • G2 = 0.73 (0.60-0.88)  
        • G3 = 0.77 (0.65-0.91)  
Bijnen et al 1998 [166] To describe the association between the PA pattern of elderly men and CHD mortality. • n = 802 Length of Follow-up: 10    • Number of Cases: 90 PA did not show a protective effect on death from CHD.
   • Sex: Men    
   • Age: 64-84 yr PA assessment: Questionnaire, divided into 3 groups RR (95% CI)  
Netherlands   • Characteristics: Free from Serious Illness      • G1 = 1.00 (referent)  
        • G2 = 0.63 (0.38-1.05)  
Prospective cohort    G1 = Lowest    • G3 = 0.85 (0.51-1.44)  
   • Ethnicity: Dutch G2 = Middle   
   • Zutphen Elderly Study G3 = Highest   
D & B score = 13    Outcome Measure: CHD Mortality   
    Cox Proportional HR   
Davey-Smith et al 2000 [174] To examine the association between two measures of physical activity (LTPA and usual walking pace) with cause specific mortality (CHD). • n = 6,702 Length of Follow-up: 25 yrs    • Number of Cases: 955 Inverse associations of both LTPA and walking pace with mortality from CHD were seen.
   • Sex: Men    
   • Age: 40-64 yr   RR (95% CI) by walking pace  
England   • Whitehall Study PA assessment: Questionnaire during examination for walking pace and LTPA    • G1 = 1.45 (0.9-2.2)  
        • G2 = 1.30 (1.1-1.6)  
Prospective cohort        • G3 = 1.00 (referent)  
     p < 0.01  
D & B score = 11    Walking pace Multivariate RR (95% CI) by LTPA level  
    G1 = Slower    • G1 = 1.24 (1.0-1.5)  
    G2 = Same    • G2 = 0.94 (0.8-1.2)  
    G3 = Faster    • G3 = 1.00  
     p < 0.05  
    LTPA   
    G1 = Inactive   
    G2 = Moderate   
    G3 = Active   
    Outcome Measure: CHD Mortality   
    Cox Proportional HR   
Eaton et al 1995 [175] To determine whether self reported PA predicts a decreased risk of CHD. • n = 8,463 (LTPA), 8,418 (OPA) Length of Follow-up: 21 yrs    • Number of Cases: 709 Baseline levels of self reported LTPA predicted a decreased rate of CHD.
     Age adjusted RR (95% CI) by LTPA level  
USA   • Sex: Men PA assessment: Interview    • G1 = 1.00 (referent)  
   • Age: 40 yr      • G2 = 0.79 (0.63-0.99)  
Prospective cohort   • Characteristics: Healthy, free of CHD LTPA    • G3 = 0.73 (0.59-0.89)  
    G1 = Sedentary    • G4 = 0.71 (0.52-0.98)  
    G2 = Light   
D & B score = 11   Ethnicity: Israeli G3 = Light Daily Age adjusted RR (95% CI) by OPA level  
    G4 = Heavy    • G1 = 1.00 (referent)  
        • G2 = 0.99 (0.75-1.18)  
    OPA    • G3 = 0.94 (0.78-1.12)  
    G1 = Sitting    • G4 = 0.87 (0.67-1.10)  
    G3 = Walking   
    G4 = Physical Labour   
    Outcome Measure: CHD Death   
    Cox Proportional HR   
Hillsdon et al 2004 [183] To examine whether a short, easily administered measure of PA is associated with the risk of death from all causes and specific causes. • n = 10,522 (4,929 men; 5,593 women) Length of Follow-up: > 10 yrs    • Number of Cases: 155 Self reported VPA is associated with the risk of future mortality.
     Multivariate RR (95% CI) by PA level  
UK   • Sex: Men and women PA assessment: Questionnaire, 3 groups:    • G1 = 1.00 (referent)  
        • G2 = 0.46 (0.19-1.12)  
Prospective cohort   • Age: 35-64 yr G1 = Never / <1 time/month    • G3 = 0.96 (0.53-1.75)  
   • Characteristics: no history of chest pain    
    G2 = <2 times/wk   
D & B score = 11    G3 = ≥ 2 times/wk   
    Outcome Measure: IHD mortality   
    Cox proportional HR   
Leon et al 1997 [199] To study the relationship of PA to CHD in a well defined population at above average risk for CHD over a 16 yr observation period. • n = 12,138 Follow up for 16 years Age Adjusted RR (95% CI) A relatively small amount (10-36 min/d) of daily moderate intensity LTPA can significantly reduce premature mortality from CHD in middle aged men at high risk for CHD.
USA   • Sex: Men      • G1 = 1.00 (referent)  
   • Age: 35-57 yr PA assessment: Questionnaire at baseline (Minnesota LTPA questionnaire), divided/grouped into deciles of LTPA (min/d)    • G2 = 0.71 (0.56-0.91)  
   • Characteristics: Free of CHD but in the upper 10-15% of a CHD probability risk score      • G3 = 0.75 (0.59-0.96)  
        • G4 = 0.69 (0.54-0.96)  
Prospective cohort     Multivariate adjusted RR (95% CI)  
        • G1 = 1.00 (referent)  
D & B score = 11    G1 = D1: (0-9 min/d)    • G2 = 0.75 (0.54-0.96)  
   Multiple risk factor intervention trial G2 = D2-4: (10-36 min/d)    • G3 = 0.81 (0.64-1.04)  
    G3 = D5-7: (37-75 min/d)    • G4 = 0.75 (0.59-0.96)  
    G4 = D8-10: (76-359 min/d)   
    Outcome Measure: CHD Mortality   
Rosengren et al 1997 [211] To examine the long term effect of OPA and LTPA on the risk of death from CHD. • n = 7,142 Length of Follow-up: 20 yrs Number of Cases: 684 There appears to be a protective effect of LTPA on CHD-related death.
   • Sex: Men    
   • Age: 47-55 yr   Multivariate RR (95% CI) for LTPA  
Sweden   • Characteristics: Swedish men PA assessment: Questionnaire for LTPA, 3 groups    • G1 = 1.00 (referent)  
        • G2 = 0.84 (0.71-1.00)  
Prospective cohort        • G3 = 0.84 (0.73-0.96)  
    G1 = Sedentary   
    G2 = Moderately active   
D & B score = 13    G3 = Regular exercise   
    Outcome Measure: CHD death   
    Proportional HR   
Schnohr et al 2006 [214] To describe the associations between different levels of LTPA and subsequent causes of death. • n = 4,894 (2,136 men; 2,758 women) Participants included in the study were only those whose PA levels did not change over 5 years    • Number of Cases: 292 There was an inverse and significant dose- response association between LTPA and CHD-related mortality.
     Adjusted RR (95% CI) Whole group  
Denmark   • Sex: Men and women      • G1 = 1.00 (referent)  
        • G2 = 0.71 (0.51-0.99)  
Prospective cohort   Age: 20--79 yr PA assessment:    • G3 = 0.56 (0.38-0.82)  
   • Characteristics: Healthy Questionnaire LTPA   
D & B score = 12   • Copenhagen City Heart Study G1 = <4 METS Men  
    G2 = 4-6 METS    • G1 = referent  
    G3 = >6 METS    • G2 = survived 4.9 yrs longer  
        • G3 = survived 6.8 yrs longer  
    Cox proportional HR   
     Women  
        • G1 = referent  
        • G2 = survived 5.5 yrs longer  
        • G3 = survived 6.4 yrs longer  
Weller et al 1998 [220] To examine the relationship between PA and mortality. • n = 6,620 Length of Follow-up: 7 yrs    • Number of Cases: 109 LTPA is inversely associated with risk of fatal MI.
   • Sex: Women    
   • Age: ≥ 30 yr PA assessment: OR (95% CI) by LTPA  
Canada   • Characteristics: Canadian Women Questionnaire, 4 groups for LTPA (kcal/kg/day) and non-LTPA (kcal/kg/day)    • Q1 = 1.00 (referent)  
        • Q2 = 0.61 (0.07-1.19)  
Prospective cohort        • Q3 = 0.84 (0.52-1.37)  
        • Q4 = 0.63 (0.36-1.09)  
D & B score = 9    LTPA (kcal/kg/day) OR (95% CI) by non-LTPA  
    Q1 = ≥ 0    • Q1 = 1.00 (referent)  
    Q2 = ≥ 0.1    • Q2 = 0.71 (0.44-1.16)  
    Q3 = ≥ 0.5    • Q3 = 0.57 (0.33-0.97)  
    Q4 = ≥ 1.6    • Q4 = 0.49 (0.26-0.92)  
    Non-LTPA (kcal/kg/day)   
    Q1 = ≥ 0   
    Q2 = ≥ 2.8   
    Q3 = ≥ 5.9   
    Q4 = ≥ 9.9   
    Outcome Measure: Fatal MI   
    Logistic regression analysis   
Yu et al 2003 [221] To examine the optimal intensity of LTPA to decrease the risk of CHD mortality in middle aged British men. • n = 1,975 10 year follow-up    • Number of Cases: 82 Strong significant inverse relationship between heavy LTPA and CHD mortality.
   • Sex: Men PA assessment: Questionnaire (Minnesota LTPA questionnaire), 3 groups Multivariate adjusted HR (95% CI)  
   • Age: 49-64 yr      • G1 = 1.00 (referent)  
UK   • Characteristics: Healthy, no previous history of CHD      • G2 = 0.74 (0.44-1.25)  
        • G3 = 0.55 (0.31-0.98)  
Prospective cohort     p = 0.039 Relationship was not significant for low- moderate intensity LTPA and OPA.
   • Caerphilly collaborative heart study Total activity level (kcal/day)   
D & B score = 11    G1 = 0.0 - 161.6   
    G2 = 161.8 - 395.3   
    G3 = 395.5 - 2747.2   
    Cox proportional HR   
Altieri et al 2004 [222] To assess the possible protective role of PA on CHD. • n = 985 (507 men; 478 women) PA assessment: Questionnaire for OPA, divided into quartiles Number of Cases: 507 LTPA from 15-19 yrs as well as OPA from 30 - 39 yrs both have a significant inverse relationship with risk of non fatal acute MI.
     OR (95% CI) for CHD and OPA  
Italy   • Sex: Men and women Q1 = lowest    • Q1 = 1.00 (referent)  
    Q2    • Q2 = 0.63 (0.39-1.03)  
Case Control   • Age: < 79 yr Q3    • Q3 = 0.56 (0.35-0.90)  
   • Characteristics: Case: Patients admitted to Hospital with non-fatal Acute MI. Controls: Patients admitted to hospital for acute condition unrelated to known or potential risk factors for acute MI Q4 = highest    • Q4 = 0.57 (0.34-0.95)  
D & B score = 11     p = 0.045  
    Outcome Measure: Non Fatal acute MI   
    Unconditional logistic regression   
Batty et al 2003 [223] To examine the relationship between physical activity and three mortality endpoints in healthy persons. • n = 6,474 Length of Follow-up: 25 yr    • Number of Cases: 837 A suggestion that the symptomatic nature of ischemia appeared to modify the affects of
   • Sex: Men      • Number of Dropouts: 158  
   • Age: 40-64 yr PA assessment: Questionnaire for LTPA, divided into 3 groups:   
UK   • Characteristics: British civil servants who underwent a resting ECG   HR (95% CI) for CHD and LTPA  
        • G1 = 1.14 (0.9-1.4) PA on total and CHD mortality.
Prospective cohort    G1 = Inactive    • G2 = 0.94 (0.8-1.1)  
    G2 = Moderate    • G3 = 1.00 (referent)  
    G3 = Active   
D & B score = 13      
    Outcome Measure: CHD mortality   
    Cox Proportional HR   
Chen and Millar [224] To examine the potential protective effect of LTPA on the incidence of heart disease and depression. • n = 15,670 Length of Follow-up: 2 yrs • 100 cases Regular and at least MPA can be beneficial to heart health.
   • Sex: Men and women    
   • Age: ≥ 20 yr PA assessment: EE from self administered questionnaire, 4 groups (kcal/kg/day) Adjusted OR (95% CI)  
Canada   • Characteristics: Healthy and free from heart disease      • G1 = 5.0 (1.84-13.59)  
        • G2 = 3.7 (1.26-10.67)  
Prospective cohort        • G3 = 1.00 (referent)  
    G1 = Sedentary    • G4 = 1.3 (0.41-3.89)  
    G2 = Light (<1.5)   
D & B score = 11   National Population Health Survey G3 = Moderate (1.5-2.9)   
    G4 = Active (≥ 3)   
    Outcome Measure: CHD incidence   
    Multiple logistic regression   
Conroy et al 2005 [225] To examine the relationship between 1) PA during young adulthood and middle age, and 2) PA during each time period and CHD during middle age and older women. • n = 37,169 Length of Follow-up: 9 yrs    • Number of Cases: 477 PA during middle age predicts lower risk of CHD
   • Sex: Women    
   • Age: ≥ 45 yr   Multivariate RR (95% CI) Baseline PA and incidence of CHD  
US   • Characteristics: Healthy women health professionals PA assessment: Questionnaire for EE (kcal/wk) and months/yr   
   • Women's Health Study      • G1 = 1.00 (referent)  
Cohort study        • G2 = 0.62 (0.48-0.80)  
        • G3 = 0.61 (0.48-0.79)  
D & B score = 11    Baseline PA (kcal/wk)    • G4 = 0.61 (0.46-0.81)  
    G1 = <200 p = <0.001  
    G2 = 200-599   
    G3 = 600-1499 Past PA and incidence of CHD  
    G4 = ≥ 1500    • G1 = 1.00 (referent)  
        • G2 = 0.76 (0.57-1.02)  
    Past PA    • G3 = 0.95 (0.72-1.24)  
    Months per year    • G4 = 1.04 (0.78-1.39)  
    G1 = 0    • G5 = 0.81 (0.58-1.14)  
    G2 = 1-3   
    G3 = 4-6   
    G4 = 7-9   
    G5 = 10-12   
    Outcome Measure: Incidence of CHD   
    Cox proportional hazard regression   
Dorn et al 1999 [226] To examine the long-term relationships between total PA and mortality from all causes and CHD in the general population. • n = 1,461 (698 men; 763 women) Length of Follow-up: 29 years    • Number of Cases: 109 men, 81 women PA favorably influences mortality risks in non- obese men and younger women.
USA   • Sex: Men and women PA assessment: Questionnaire Multivariate RR (95% CI) for PAI in non- obese men  
Prospective cohort   • Age: 15-96 yr      • 0.40 (0.19-0.88) for 1 kcal/kg/h  
   • Characteristics: Outcome Measure: CHD Multivariate RR (95% CI) for PAI in obese men  
   Healthy, free from CHD, diabetes, and Stroke. Mortality    • 1.86 (0.86-4.03) for 1 kcal/kg/h  
D & B score = 11      
    Cox Proportional Hazard   
    Ratio Multivariate RR (95% CI) for PAI in women < 60 yrs  
   • Ethnicity: White.      • 0.42 (0.11-1.52) for 1 kcal/kg/h  
     Multivariate RR (95% CI) for PAI in women > 60 yrs  
        • 1.78 (0.77-4.09) for 1 kcal/kg/h  
Folsom et al 1997 [227] To examine the association of PA at baseline with CHD incidence. • n = 13,999 (6,166 men; 7833 women) Length of Follow-up: 4-7 yrs    • Number of Cases: 223 men, 97 women, No significant relationships.
     Multivariate RR (95% CI) LTPA, men  
USA   • Sex: Men and women PA assessment: Questionnaire during home interview, divided into quartiles of LTPA and sports activity   
        • Q1 = 1.00 (referent)  
Prospective cohort   • Age: 45-64 yr      • Q2 = 1.08 (0.75-1.55)  
   • Characteristics: no CHD at baseline      • Q3 = 0.83 (0.51-1.36)  
        • Q4 = 0.89 (0.59-1.35)  
D & B score = 9    Q1 = Low   
   • Ethnicity: Black and non Black Q2 LTPA, women  
    Q3    • Q1 = 1.00 (referent)  
   • Atherosclerosis Risk in Communities Study Q4 = High    • Q2 = 0.74 (0.42-1.31)  
        • Q3 = 1.07 (0.55-2.09)  
    Outcome Measure: CHD incidence Poisson Regression    • Q4 = 0.64 (0.34-1.24)  
     Multivariate RR (95% CI) Sports, men  
        • Q1 = 1.00 (referent)  
        • Q2 = 1.15 (0.79-1.68)  
        • Q3 = 1.03 (0.68-1.54)  
        • Q4 = 0.83 (0.56-1.23)  
     Sports, women  
        • Q1 = 1.00 (referent)  
        • Q2 = 0.99 (0.58-1.67)  
        • Q3 = 0.64 (0.32-1.27)  
        • Q4 = 0.72 (0.37-1.38)  
Fransson et al 2004 [228] To estimate the influence of LTPA and OPA on acute MI. • n = 4069 (2,742 men; 1,327 women) PA assessment: Questionnaire for LTPA, 5 groups    • Number of Cases: 1,204 men, 550 women Exercise seems to reduce the risk of MI.
Sweden   • Sex: Men and Women G1 = Seldom OR (95% CI)  
    G2 = Sometimes   
Case Control   • Age: 45-70 yr G3 = 1×/wk LTPA, men  
   • Characteristics: Cases: Diagnosed with acute MI G4 = 2-3×/wk    • G1 = 1.00 (referent)  
D & B score = 12    G5 = >3×/wk    • G2 = 0.76 (0.61-0.95)  
        • G3 = 0.67 (0.51-0.88)  
        • G4 = 0.63 (0.49-0.83)  
   • Stockholm Heart Epidemiology Questionnaire for total physical activity, 3 groups    • G5 = 0.53 (0.38-0.73)  
    G1 = Passive   
    G2 = Somewhat active LTPA, women  
    G3 = Active    • G1 = 1.00 (referent)  
    Questionnaire for sitting at work, 3 groups    • G2 = 0.69 (0.49-0.98)  
        • G3 = 0.38 (0.25-0.58)  
    G1 = Less than half the time    • G4 = 0.62 (0.38-1.01)  
    G2 = About half the time    • G5 = 0.31 (0.15-0.66)  
    G3 = More than half the time Total physical activity, men  
        • G1 = 1.00 (referent)  
        • G2 = 0.66 (0.47-0.94)  
    Outcome Measure: Acute MI    • G3 = 0.46 (0.31-0.69)  
     Total physical activity, women  
    Conditional and unconditional logistics regression    • G1 = 1.00 (referent)  
        • G2 = 0.34 (0.22-0.53)  
        • G3 = 0.16 (0.07-0.37)  
     Sitting at work, men  
        • G1 = 1.00 (referent)  
        • G2 = 0.91 (0.73-1.15)  
        • G3 = 0.90 (0.72-1.12)  
     Sitting at work, women  
        • G1 = 1.00 (referent)  
        • G2 = 0.77 (0.51-1.17)  
        • G3 = 0.47 (0.31-0.69)  
Fransson et al 2006 [229] To evaluate whether LTPA compensates for the increased risk of acute MI associated with overweight and obesity. • n = 4069 (2,742 men; 1,327 women) PA Assessment: Questionnaire for LTPA, 3 groups Number of Cases: 1204 men, 550 women Regular LTPA seems to provide protection against MI and non- fatal MI.
     Multivariate OR (95% CI) for acute MI  
Sweden   • Sex: Men and women G1 = Very little /occasional walks LTPA, men  
        • G1 = 1.00 (referent)  
Case Control   • Age: 45-70 yr G2 = Occasional / once per week    • G2 = 0.70 (0.58-0.84)  
   • Characteristics: Cases: had acute MI      • G3 = 0.57 (0.46-0.71)  
D & B score = 12    G3 = Twice per week or more LTPA, women  
        • G1 = 1.00 (referent)  
    Outcome measure: Acute MI    • G2 = 0.52 (0.40-0.68)  
        • G3 = 0.44 (0.30-0.65)  
     Multivariate OR (95% CI) for non-fatal MI  
    Conditional and unconditional logistics regression LTPA, men  
        • G1 = 1.00 (referent)  
        • G2 = 0.79 (0.65-0.96)  
        • G3 = 0.63 (0.50-0.79)  
     LTPA, women  
        • G1 = 1.00 (referent)  
        • G2 = 0.64 (0.48-0.86)  
        • G3 = 0.58 (0.39-0.87)  
Haapanen-Niemi 2000 [230] To investigate the independent associations and the possible interaction of BMI LTPA and perceived physical performance and functional capacity with the risk of mortality. • n = 2,212 (1,090 men; 1,122 women) Length of Follow-up: 16 yrs    • Number of Cases: 208 all cause deaths, 54% of those CVD. 73% of CVD deaths due to CHD Increase perceived PF is associated with a reduced risk of CHD mortality in men.
Finland   • Sex: Men and women PA assessment: Postal Survey   
     Multivariate RR (95% CI)  
Prospective cohort   • Age: 35-63 yr Total LTPA energy expenditure (kcal/wk) Total LTPA EE index and CHD mortality, men  
   • Characteristics: Healthy      • G1 = 1.00 (referent)  
    G1 = High    • G2 = 0.88 (0.44-1.76)  
D & B score = 13   • Ethnicity: Finnish G2 = Moderate    • G3 = 1.70 (0.90-3.21)  
    G3 = Low p = 0.056  
    Perceived physical fitness compared to age-mates Multivariate RR (95% CI) Perceived physical fitness, men  
    G1 = Better    • G1 = 1.00 (referent)  
    G2 = Similar    • G2 = 2.82 (1.06-7.46)  
    G3 = Worse    • G3 = 4.64 (1.56-13.84)  
    Outcome Measure: CHD mortality p = 0.011  
     Total LTPA EE index and CHD mortality, women  
    Cox proportional HR   
        • G1 = 1.00 (referent)  
        • G2 = 0.43 (0.16-1.16)  
        • G3 = 1.17 (0.51-2.68)  
     p = 0.046  
     Multivariate RR (95% CI) Perceived physical fitness, women  
        • G1 = 1.00 (referent)  
        • G2 = 0.82 (0.32-2.16)  
        • G3 = 1.89 (0.57-6.27)  
     p = 0.154  
Kannel et al 1986 [231] To examine the role of low levels of OPA and LTPA in the development of CV morbidity and mortality over the short and long term. • n = 1,166 Length of Follow-up: 24 yrs    • Number of Cases: 220 mortality, 371 morbidity Rate of CHD Mortality and Morbidity decreases with increased level of PA but no association was found with physical demand of work
   • Sex: Men    
   • Age: 45-65 yr    
USA   • Characteristics: PA assessment: Questionnaire during examination Cumulative 24 year age adjusted rate per 1000 people  
Prospective cohort     24 hr PA index for LTPA CHD mortality  
    PA index:    • G1 = 255  
D & B score = 11    G1 = <29    • G2 = 184  
    G2 = 30-34    • G3 = 152  
    G3 = >34 p < 0.01  
    Physical demand of work 24 hr PA index for LTPA CHD incidence  
    G1 = Sedentary    • G1 = 414  
    G2 = Light    • G2 = 353  
    G3 = Medium    • G3 = 311  
    G4 = Heavy   
    Outcome Measure: CHD mortality and Morbidity Physical demand of work and CHD mortality  
        • G1 = 216  
    Cox proportional HR    • G2 = 209  
        • G3 = 169  
        • G4 = 170  
     Physical demand of work and CHD incidence:  
        • G1 = 355  
        • G2 = 405  
        • G3 = 307  
        • G4 = 325  
Kaprio et al 2000 [232] To examine the contribution of genetic and other familial factors to the relationship between LTPA and CHD. • n = 8,205 Length of Follow-up: 18 yrs    • Number of Cases: 723 LTPA compared to being sedentary helps prevent CHD in men.
   • Sex: Men    
   • Age: 25-69 yr   Multivariate RR (95% CI)  
Finland   • Characteristics: Same sex twin pairs, free of CVD PA assessment: Questionnaire for LTPA, 3 groups:    • G1 = 1.00 (referent)  
        • G2 = 0.84 (0.70-1.01)  
Prospective cohort        • G3 = 0.68 (0.50-0.92)  
    G1 = Sedentary p = 0.010  
    G2 = Occasional   
D & B score = 12    Exercisers   
    G3 = Conditioning   
    Exercisers   
    Outcome Measure: Hospitalization or death from CHD   
    Poisson regression   
Lakka et al 1994 [233] To investigate the independent associations of LTPA and maximal oxygen uptake with the risk of acute MI. • n = 1,166 Baseline examination: 1984-1989   Conditioning LTPA and VO2 max had an inverse, graded and independent association with the risk
   • Sex: Men    
   • Age: 42-61 yr   Adjusted RH (95% CI) by conditioning PA level  
Finland   • Characteristics: Healthy with normal ECG PA assessment: Questionnaire for conditioning PA (h/wk), 3 groups (h/wk)   
    G1 = <0.7    • G1 = 1.00 (referent)  
Prospective cohort    G2 = 0.7    • G2 = 1.11 (0.58-2.12)  
   • Kuopio Ischaemic Heart Disease Risk Factor Study G3 = >2.2    • G3 = 0.31(0.12-0.85)  
D & B score = 13     Adjusted RG (95% CI) by VO2 max  
        • G1 = 1.00  
    PF assessment: VO2 max (ml/kg/min)    • G2 = 0.76 (0.38-1.50)  
        • G3 = 0.26 (0.10-0.68)  
    G1 = <28.0   
    G2 = 28.0-33.6   
    G3 = >33.6   
    Outcome event: acute MI   
    Cox proportional HR   
Laukkanen at al 2004 [234] To determine whether VO2peak predicts CVD morbidity and mortality in a sample of men as related to conventional risk factors, medications or underlying chronic disease. • 1,294 healthy; 1,057 unhealthy PF Assessment: VO2 peak (ml/kg/min) measured by exercise test with an electrically braked cycle ergometer, divided into quartiles    • Number of Cases: 204 CV deaths, 323 non-fatal coronary events Dose-response relationship between directly measured PF and CVD death among healthy men at baseline.
Finland   • Sex: Men   Healthy men with low VO2 peak (lowest quartile) had an increased risk  
   • Age: 42-60 yr    
Prospective cohort   • Characteristics: Healthy and not healthy participants    
    Q1 = <27.6 Adjusted RR (95% CI) by PF quartile Fatal MI  
    Q2 = 27.6-32.2   Unfit men with unfavorable risk profiles are the risk group that would benefit the most from preventative measures.
D & B score = 11    Q3 = 32.3-37.1    • 3.29 (0.86-12.90)  
   • Kuopio Ischaemic Heart Disease Risk Factor Study Q4 = >37.2   
     Non-Fatal MI  
    Outcome Measure: Incidence of fatal and non fatal CVD during 13 year follow-up    • 2.16 (1.12-4.18)  
    Cox proportional HR   
Lee at al 2000 [235] To investigate whether different durations of exercise episode are associated with different risk of CHD. • n = 7,307 Baseline survey in 1988    • Number of Cases: 482 Longer durations of PA bouts are not associated with decreased CHD risk compared with shorter bouts, once total EE is taken into account.
   • Sex: Men    
USA   • Age: Mean 66.1 ± 7.5 PA assessment: Survey for EE (kJ/wk), divided into 5 groups and episodes of PA (min), divided into 6 groups Multivariate adjusted RR (95% CI) by EE  
        • G1 = 1.00 (referent)  
   • Characteristics: Healthy      • G2 = 0.80 (0.57-1.12)  
        • G3 = 0.80 (0.55-1.16)  
Prospective cohort   • Harvard Alumni Study      • G4 = 0.74 (0.47-1.17)  
        • G5 = 0.62 (0.41-0.94)  
D & B score = 12    Energy expenditure (kJ/wk)   As long as the total EE is similar, more frequent shorter bouts or longer less frequent bouts have an equivalent reduction in CHD risk.
    G1 = <4,200 Multivariate adjusted RR (95% CI) by duration of PA episode  
    G2 = 4,200-8,399   
    G3 = 8,400-12,599   
    G4 = 12,600-16,799    • G1 = 1.00 (referent)  
    G5 = ≥ 16,800    • G2 = 1.15 (0.70-1.87)  
        • G3 = 1.01 (0.68-1.51)  
        • G4 = 1.11 (0.67-1.84)  
    Duration of PA episode (min)    • G5 = 1.18 (0.77-1.80)  
    G1 = None    • G6 = 1.25 (0.83-1.87)  
    G2 = 1-15   
    G3 = 16-30   
    G4 = 31-45   
    G5 = 46-60   
    G6 = >60   
    Outcome Measure: Fatal and Non Fatal CHD   
    Proportional hazards regression   
Lee et al 2003 [236] To investigate whether moderate- intensity exercise is associated with reduced CHD. • n = 7,337 PA assessment: Survey rating usual level of exertion when exercising, divided into tertiles    • Number of Cases: 551 Inverse association between relative intensity of PA and the risk of CHD.
USA   • Sex: Male   Multivariate adjustment RR (95% CI)  
   • Age: Mean 66.1 yr      • T1 = 1.00 (referent)  
        • T2 = 0.87 (0.70-1.09)  
   • Characteristics: Healthy      • T3 = 0.92 (0.75-1.14)  
Prospective cohort    Energy expenditure (kcal/wk)   
   Harvard Alumni Study    
    T1 = <1000   
D & B score = 13    T2 = 1000-2499   
    T3 = ≥ 2500   
    Cox proportional HR   
Lemaitre et al 1999 [237] To investigate whether regular participation in moderate intensity activity confers overall protection from sudden primary cardiac arrest. • n = 355 cases, 503 controls PA assessment: Interview (with spouses) for LTPA, 7 groups    • 355 cases Participation in moderate intensity LTPA was associated with a decreased risk of primary cardiac arrest.
   • Sex: Men and women   RR (95% CI)  
USA    G1 = No activity    • G1 = 1.00 (referent)  
   • Age: 25-74 yr G2 = Gardening only≤ 60 min/wk    • G2 = 0.52 (0.21-1.28)  
Case control   • Characteristics: Previously healthy prior to primary cardiac arrest. Control Subjects: Individually matched to case patients on age (within 7 years) and sex at a ratio of about 2:1 were randomly selected from community by random-digit dialing G3 = Gardening only > 60 min/wk    • G3 = 0.34 (0.13 0.89)  
    G4 = Walking ≤ 60 min/wk    • G4 = 0.45 (0.17-1.19)  
D & B score = 11    G5 = Walking > 60 min/wk    • G5 = 0.27 (0.11-0.67)  
    G6 = Moderate intensity    • G6 = 0.31 (0.13-0.74)  
    LTPA (not walking or gardening) G7 = 0.34 (0.16-0.75)  
    G7 = High intensity LTPA   
    Logistic regression analysis   
Lemaitre et al 1995 [238] To examine whether LTPA decreases the risk of MI in postmenopausal women. • n = 1,193 PA assessment: Phone interview for LTPA, divided into quartiles of EE (mean kcal/wk)    • Number of Cases: 268 Risk of MI among postmenopausal women is decreased by 50% with modest LT energy expenditures, equivalent to 30-45 min of walking for exercise three times per week
   • Sex: Women    
   • Age: Mean 67 yr   Multivariate RR (95% CI)  
USA        • Q1 = 1.00 (referent)  
   • Characteristics: Postmenopaus al Cases: Diagnosed with non-fatal MI Controls: free from MI Q1 = 71    • Q2 = 0.52 (0.34-0.80)  
Case control    Q2 = 472    • Q3 = 0.40 (0.26-0.63)  
    Q3 = 1183    • Q4 = 0.40 (0.25-0.63)  
D & B score = 11    Q4 = 3576 p = <0.001  
    Outcome Measure: Diagnosed with non-fatal MI   
    Logistic regression analysis   
Li et al 2006 [239] To examine independent and joint associations of PA and adiposity with CHD incidence. • n = 88,393 Length of Follow-up: 20 yrs    • Number of Cases: 2,358 Physical inactivity independently contributes to the development of CHD in women.
   • Sex: Women      • Number of Dropouts: <2% lost to follow-contributes to the development of CHD in women.  
USA   • Age: 34-59 yr   up  
   • Characteristics: Nurses PA assessment: Questionnaire for LTPA (hr/wk), 3 groups   
Prospective cohort     Multivariate HR (95% CI)  
   • Nurses' Health Study      • G1 = 1.00 (referent)  
    G1 = ≥3.5    • G2 = 1.34 (1.18-1.51)  
D & B score = 12    G2 = 1-3.49    • G3 = 1.43 (1.26-1.63)  
    G3 = <1   
    Outcome Measure: CHD incidence   
    Cox proportional HR   
Lemaitre et al 1995 [240] To evaluate the effect of PA on MI occurrence. • n = 1,107 (726 controls, 381 cases) PA assessment: Questionnaire, 3-5 groups depending on variable OR (95% CI), PA level was inversely associated with occurrence of MI in both sexes, although the association presented a significant linear trend only for women; in men it suggested a u-shaped relation.
     Total PA, men  
Portugal   • Sex: Men and women      • G1 = 1.00 (referent)  
    Total PA (MET hr/day), men    • G2 = 0.54 (0.33-0.88)  
Case control   • Age: ≥ 40 yr      • G3 = 0.34 (0.20-0.59)  
   • Characteristics: Case: Admitted to Hospital and diagnosed with first episode of MI Control: Healthy, no history of CHD G1 = 28.3-32.1    • G4 = 0.59 (0.36-0.98)  
D & B score = 12    G2 = 32.2-33.3    • G5 = 0.90 (0.56-1.45)  
    G3 = 33.4-36.5 Trend p = 0.827  
    G4 = 36.6-40.3 Total PA, women  
    G5 = 40.4-83.1    • Q1 = 1.00 (referent)  
    Total PA (MET hr/day), women    • Q2 = 0.39 (0.21-0.73)  
    Q1 = 28.9-32.7    • Q3 = 0.33 (0.17-0.64)  
    Q2 = 32.8-34.1    • Q4 = 0.22 (0.11-0.47)  
    Q3 = 34.2-37.8 p = <0.001  
    Q4 = 37.8-70.6   
     Sport participation, men  
    Sport participation (MET hr/day), men    • G1 = 1.00 (referent)  
    G1 = 0.0    • G2 = 0.36 (0.19-0.69),  
    G2 = 0.1-1.0    • G3 = 0.72 (0.41-1.26),  
    G3 = 1.1-2.0    • G4 = 0.42 (0.23-0.76),  
    G4 = 2.1-3.6    • G5 = 0.31 (0.16-0.62)  
    G5 = 3.7-15.4 p = <0.001  
Lovasi et al 2007 [241] To investigate the shape of the relationship between LTPA and MI risk. • n = 4,094 PA assessment: Telephone interview (Minnesota LTPA Questionnaire)    • Number of Cases: 697 Time engaged in LTPA, even non strenuous LTPA was associated with a lower risk of MI, and the shape of this relationship was non- linear
   • Sex: Men and women   Adjusted OR (95% CI)  
USA   • Age: 64 ± 9 yr   LTPA and non fatal CHD  
   • Characteristics: Group Health Cooperative Members      • G1 = 1.00 (referent)  
Case control    LTPA    • G2 = 0.88 (0.66-1.17)  
    G1 = None    • G3 = 0.62 (0.46-0.83)  
D & B score = 11    G2 = <2    • G4 = 0.61 (0.45-0.82)  
    G3 = 2-5    • G5 = 0.59 (0.44-0.80)  
    G4 = 5-9   
    G5 = >9 h/wk Adjusted RR (95% CI) Strenuous LTPA and non Fatal CHD  
    Strenuous LTPA    • G1 = 1.00 (referent)  
    G1 = None    • G2 = 0.76 (0.59-0.99)  
    G2 = non strenuous LTPA    • G3 = 0.53 (0.40-0.70)  
    G3 = Any Strenuous   
    LTPA   
    Outcome measure: non fatal CHD   
    Logistic regression   
Manson et al 1999 [242] To assess the comparative roles of walking and vigorous exercise in the prevention of coronary events in women. • n = 72,488 PA assessment:    • Number of Cases: 645 coronary events Both walking and VPA are associated with a substantial reductions in incidence of CHD. Risk reductions for each were similar hen total PAy was similar. Walking 3 or more hours per week could reduce the risk of CHD by 30-40%.
   • Sex: Women Questionnaire with detailed information on PA.   
   • Age: 40-65 yr   Multivariate RR (95% CI) by total PA score  
USA   • Characteristics: Healthy, no Previous history of CHD      • G1 = 1.00 (referent)  
        • G2 = 0.88 (0.71-1.10)  
Prospective cohort    Total PA score    • G3 = 0.81(0.64-1.02)  
    G1 = 1-2.0    • G4 = 0.74 (0.58-0.95)  
   Nurses' Health Study G2 = 2.1-4.6    • G5 = 0.66 (0.51-0.86)  
D & B score = 12    G3 = 4.7-10.4 p = 0.002  
    G4 = 10.5-21.7   
    G5 = >21.7   
     Multivariate RR (95% CI) by walking activity  
        • G1 = 1.00 (referent)  
    Walking, in those who did not participate in VPA: (MET hr/wk)    • G2 = 0.78 (0.57-1.06)  
    G1 = 0.5    • G3 = 0.88 (0.65-1.21)  
    G2 = 0.6-2.0    • G4 = 0.70 (0.51-0.95)  
    G3 = 2.1-3.8    • G5 = 0.65 (0.47-0.91)  
    G4 = 3.9-9.9 p = 0.02  
    G5 = ≥ 10   
     Multivariate RR (95% CI) by walking pace  
        • 1.00 (referent)  
    Walking pace (mph)    • 0.75 (0.59-0.96)  
    G1 = <2.0    • 0.64 (0.47-0.88)  
    G2 = 2.0-2.9   
    G3 = ≥ 3.0   
Mora et al 2007 [243] To investigate whether differences in several CV risk factors mediate the effect of PA on reduced risk of CVD. • n = 27,055 10.9 ± 1.6 yr of follow up    • Number of Cases: 640 There remained a borderline significant inverse association between PA and risk of CHD after adjustment for all sets of risk factors.
   • Sex: Women    
   • Age: ≥ 45 yr PA assessment: Questionnaires at study entry for categories of EE from PA (kcal/wk), 4 groups HR (95% CI), basic model  
USA   • Characteristics: Healthy      • G1 = 1.00 (referent)  
        • G2 = 0.84 (0.67-1.06)  
Prospective cohort   • Women's health study      • G3 = 0.76 (0.61-0.96)  
        • G4 = 0.62 (0.48-0.82)  
    G1 = <200 p = 0.001  
D & B score = 13    G2 = 200-599   While all sets of risk factors should some mediation on the effect of PA on CHD none made the relationship insignificant
    G3 = 600-1499 Multivariate adjusted HR (95% CI)  
    G4 = ≥ 1500    • G1 = 1.00 (referent)  
        • G2= 0.71 (0.58-0.87)  
    Outcome measure:    • G3 = 0.64 (0.52-0.78)  
    Incidence of CVD and    • G4 = 0.48 (0.38-0.62)  
     p = <0.001  
    Cox proportional HR   
O'Connor et al 1995 [244] To examine the association between intensity of exercise and CHD risk. • n = 680 (532 men and 148 women) PA assessment: Home interview for PA, divided into quartiles    • Number of Cases: 340 Significant inverse association between PA level and the risk of non fatal MI in men, which persisted after adjustment for other risk factors.
     Adjusted OR (95% CI) by PA level, men  
        • Q1 = 1.00 (referent)  
USA   • Sex: Men and women Q1 = Lowest    • Q2 = 0.60 (0.32-1.13)  
    Q2    • Q3 = 0.41 (0.21-0.78)  
Case control   • Age: < 76 yr Q3    • Q4 = 0.41 (0.22-0.77)  
   • Characteristics: Cases: Diagnosed MI (non-fatal), no previous history of CHD. Controls: no history of CHD. Q4 = Highest p = 0.003  
D & B score = 12    Outcome Measure: non-fatal MI Adjusted OR (95% CI) by PA level, women  
        • Q1 = 1.00 (referent)  
    Moderate- vigorous sports men Cut-points kcal/wk    • Q2 = 1.07 (0.27-4.17)  
    Q1 = Lowest    • Q3 = 2.02 (0.56-7.38)  
    Q2    • Q4 = 1.29 (0.31-5.35)  
    Q3 p = 0.51  
    Q4 = Highest   
     Adjusted OR (95% CI) by moderate-vigorous sports, men  
        • Q1 = 1.00 (referent)  
    Moderate- vigorous sports Women    • Q2 = 1.12 (0.60-2.10)  
    Cut-points kcal/wk    • Q3 = 0.61 (0.30-1.24)  
    Q1 = Lowest    • Q4 = 0.43 (0.20-0.92)  
    Q2 p = 0.02  
    Q3   
    Q4 = Highest Adjusted OR (95% CI) by moderate-vigorous sports, women  
    Logistic regression analysis    • Q1 = 1.00 (referent)  
        • Q2 = 1.31 (0.37-4.66)  
        • Q3 = 1.90 (0.44-8.28)  
        • Q4 = 0.35 (0.07-1.84)  
     p = 0.62  
Rastogi et al 2004 [245] To examine the relation between PA and CHD risk in India. • n = 1,050 PA assessment: Questionnaire Number of Cases: 350 Observed a strong and dose dependent inverse association between LTPA and non fatal CHD.
   • Sex: Men and women   Multivariate OR (95% CI) by LTPA  
USA   • Age: 21-74 yr LTPA (MET min/d)    • G1 = 1.00 (referent)  
   • Characteristics: Cases: Diagnosed with MI (non fatal) Controls: non- cardiac patients G1 = 0    • G2 = 0.96 (0.59-1.55)  
Case control    G2 = 0-145    • G3 = 0.44 (0.27-0.71)  
D & B score = 12    G3 = ≥145 p = 0.001  
    Sedentary time (min/d) Multivariate OR (95% CI) by sedentary time  
    G1 = <70    • G1 = 1.00 (referent)  
    G2 = 70-130    • G2 = 1.15 (0.68-1.95)  
    G3 = 130-215    • G3 = 1.04 (0.61-1.76)  
    G4 = ≥215    • G4 = 1.88 (1.09-3.21)  
     p = 0.02  
    Outcome Measure: Non-fatal MI   
    Conditional logistic regression   
Rodriguez et al 1994 [246] To examine the relationship between PA and 23 yr incidence of CHD morbidity and mortality. • n = 7,074 23 year follow-up    • Number of Cases: 789 PA was associated with a significant reduction in the risk of CHD morbidity and mortality.
   • Sex: Men    
   • Age: 45-64 yr PA assessment: Questionnaire for PA index, divided into tertiles Age adjusted RR (95% CI), CHD incidence  
USA   • Characteristics: Japanese- American living in Oahu, Hawaii in 1965, < 65 years to reduce effect of retirement on PA levels      • T1 = 1.00 (referent)  
        • T2 = 1.01 (.86-1.19)  
Prospective cohort    T1 = Low    • T3 = 0.83 (0.86-1.19) These data support the hypothesis that PA is associated with a favorable profile of CVD risk factors.
    T2 = Moderate   
    T3 = High Multivariate adjusted RR (95% CI), CHD incidence  
D & B score = 11    Cox proportional regression model    • T1 = 1.00 (referent)  
        • T2 = 1.07 (0.90-1.26) This study did not show a dose- response relationship since the medium tertile of PA showed increased rates of CHD compared to the inactive group.
   • The Honolulu Heart Program      • T3 = 0.95 (0.80-1.14)  
     Age adjusted RR (95% CI), CHD mortality  
        • T1 = 1.00 (referent)  
        • T2 = 1.12 (0.88-1.44)  
        • T3 = 0.74 (0.56-0.97)  
     Multivariate adjusted RR (95% CI)  
        • T1 = 1.00 (referent)  
        • T2 = 1.19 (0.93-1.53)  
        • T3 = 0.85 (0.65-1.13)  
Rothenbacher et al 2003 [247] To estimate the risk for CHD associated with LTPA. • n = 791 (312 cases; 479 controls) PA assessment: Interview Number of Cases: 312 LTPA showed a clear inverse association with risk of CHD.
    LTPA (h/wk) Multivariate OR (95% CI), LTPA  
Germany   • Sex: Men and Women G1 = 0 Winter  
    G2 = <1    • G1 = 1.00 (referent)  
Case control   Age: 40-68 yr G3 = 1-2    • G2 = 0.48 (0.27-0.84)  
   Characteristics: Cases: stable CHD diagnosed within 2 years, no recent MI, Controls: no history of CHD. G4 = >2    • G3 = 0.54 (0.369-0.82)  
D & B score = 12        • G4 = 0.27 (0.19-0.47)  
    Workday activity by   
    bike/foot, (min/workday) Summer  
    G1 = <15    • G1 = 1.00 (referent)  
    G2 = 15-30    • G2 = 0.85 (0.47-1.53)  
    G3 = 30-60    • G3 = 0.60 (0.38-0.95)  
    G4 = >60    • G4 = 0.39 (0.26-0.59)  
    Outcome Measure: non fatal CHD Multivariate OR (95% CI), workday activity by bike/foot  
    Unconditional logistic regression, linear regression model    • G1 = 1.00 (referent)  
        • G2 = 0.53 (0.30-0.93)  
        • G3 = 0.36 (0.21-0.62)  
        • G4 = 0.58 (0.36-0.94)  
Seccareccia and Menotti 1992 [248] To examine the relationship between OPA and the risk of CHD death. • n = 1,621 25 year of follow-up • 189 cases Increase in OPA is inversely related to risk of CHD death.
   • Sex: Men    
   • Age: 40-59 yr PA assessment: Questionnaire for OPA (kcal/d), 3 groups Age Standardized CHD and deaths rates:  
   • Characteristics: Healthy      • G1 = 18.9 ± 3.1  
Italy        • G2 = 13.1 ± 1.7  
    G1 = Sedentary, < 2400    • G3 = 11.0 ± 0.9  
Prospective cohort    G2 = Moderate, 2400-3199   
D & B score = 11    G3 = Heavy ≥ 3200   
    Indicators of PF including HR, vital capacity, FEV in 3/4 of sec, and corrected arm circumference (minus contribution of fat).   
    End Point: Fatal CHD   
Sesso et al 2000 [249] To examine the association of the quantity and intensity of PA with CHD risk and the impact of other coronary risk factors. • n = 12,516 PA assessment: Questionnaire Number of Cases: 2,135 L-Shaped association between PA and the risk of CHD, with a reduction in CHD risk of approximately 20% for total PA levels >4200 kJ/wk
   • Sex: Men    
   • Age: 39-88 yr   Multivariate HR (95% CI)  
USA   • Characteristics: Healthy PA Index (kJ/wk)    • G1 = 1.00 (referent)  
    G1 = <2100    • G2 = 0.90 (0.79-1.03)  
Prospective cohort   • Harvard Alumni G2 = 2100-4199    • G3 = 0.81 (0.71-0.92)  
   Study G3 = 4200-8399    • G4 = 0.80 (0.69-0.93)  
    G4 = 8400-12599    • G5 = 0.81 (0.71-0.94)  
D & B score = 12    G5 = >12600 p = 0.003 Suggests that vigorous activities are associated with a reduced risk of CHD, whereas moderate or light PA has no clear association with risk of CHD.
    Cox proportional HR   
Sundquist et al 2005 [250] To examine the long term effect of LTPA on incident cases of CHD. • n = 5,196 (2,645 men, 2,551 women) PA assessment: Questionnaire Levels of PA Age and sex adjusted RR (95% CI) Positive long term effect of LTPA on CHD risk among men and women.
        • Q1 = 1.00 (referent)  
Sweden   • Sex: Men and women Q1 = None    • Q2 = 0.72 (0.51-1.00)  
    Q2 = Occasionally    • Q3 = 0.64 (0.46-0.89)  
Prospective cohort   Age: 35-74 yr Q3 = 1-2 times per week    • Q4 = 0.46 (0.29-0.74)  
   • Characteristics: Those not hospitalized for CHD in the last 2 years and those who rate their general health as poor were excluded Q4 = Vigorous ≥2 times per week Multivariate adjusted RR (95% CI)  
D & B score = 11    Outcome Measure: Fatal or non fatal CHD    • Q1 = 1.00 (referent)  
        • Q2 = 0.76 (0.55-1.07)  
        • Q3 = 0.74 (0.53-1.04)  
        • Q4 = 0.59 (0.37-0.95)  
    Cox regression model   
Talbot et al 2002 [251] To examine the contributions of LTPA and aerobic fitness to the risk of coronary events in healthy younger and older adults. • n = 689 Surveys began in 1960 and were completed on every visit    • Number of Cases: 63 In younger men PF predicts a reduced risk of CHD but not LTPA.
   • Sex: Men    
   • Age:   After adjusting for coronary risk factors there was:  
USA   51.6 ± 16.8 yr    
   • Characteristics: Community dwelling PA assessment: Survey for LTPA (97 activities) at every visit. RR: 0.53 (p < 0.001) and In older men, high intensity LTPA and PF appear to be of similar importance in reducing CHD risk.
Prospective cohort     RR: 0.61 (p = 0.024) in older men.  
D & B score = 12   • Baltimore Longitudinal Study of Aging PF assessment: Treadmill VO2 max test on alternate visits Total LTPA was unrelated to coronary risk in either age group.  
     With 3 levels of LTPA intensity substituted for total LTPA:  
    Unpaired t-tests and chi square tests. Cox Proportional hazards Analysis RR = 0.39 for tertile 3 vs. tertile 1  
Tanasescu et al 2002 [252] To assess the amount, type and intensity of PA in relation to risk of CHD in men. • n = 44,452 PA assessment: Questionnaire    • Number of Cases: 1,700 Total PA, running, weight training, and walking were associated with a reduced risk for CVD.
   • Sex: Men    
   • Age: 40-75 yr   Age adjusted HR (95% CI) by total PA  
USA   • Characteristics: Health professionals, no history of CHD and in good health Total PA (MET hr/wk)    • Q1 = 1.00 (referent)  
    Q1 = 0-6.32    • Q2 = 0.85 (0.74 0.98)  
Prospective cohort    Q2 = 6.33-14.49    • Q3 = 0.78 (0.67-0.92)  
    Q3 = 14.50-25.08    • Q4 = 0.72 (0.62-0.83) The average exercise intensity was associated with a reduced risk (independent of total PA).
    Q4 = 25.09-41.98    • Q5 = 0.58 (0.49-0.68)  
D & B score = 11    Q5 = > 41.99 p = .001  
   • Health Professionals follow-up study Exercise intensity (METs) Age adjusted HR (95% CI) by exercise intensity  
    G1 = Low-1-4    • G1 = .00 (referent)  
    G2 = Mod.-4-6    • G2 = 0.94 (0.83-1.04)  
    G3 = High 6-12   
    Walking pace independent of total volume of PA (mph)    • G3 = 0.83 (0.72-0.97)  
     p = 0.02  
    Q1 = <2 Age adjusted HR (95% CI) by walking pace  
    Q2 = 2-3    • Q1 = 1.00 (referent)  
    Q3 = 3-4    • Q2 = 0.72 (0.54-0.94)  
    Q4 = > 4    • Q3 = 0.61 (0.45-0.81)  
        • Q4 = 0.51 (0.31-0.84)  
    Outcome Measure: Nonfatal MI or Fatal CHD occurring during follow-up p <0.001  
    Cox proportional HR   
Vatten et al 2006 [253] To investigate whether obesity- related CV mortality could be modified by PA. • n = 54,284 (27,769 men; 26,515 women) Length of Follow-up: 16 years    • Number of Cases: 2,462 Increased PA reduces the risk of death in women, but not in men.
     Multivariate HR (95% CI), men  
Norway   • Sex: Men and women PA assessment:    • Q1 = 1.00 (referent)  
    Questionnaire    • Q2 = 1.01 (0.89-1.16)  
Prospective cohort   Age: ≥ 20 yr Divided into 4 groups    • Q3 = 0.98 (0.84-1.14)  
   • Characteristics: Free from CVD at baseline Q1 = High    • Q4 = 1.18 (1.00-1.38)  
    Q2 = Medium p = 0.11  
D & B score = 12    Q3 = Low   
   • HUNT study Q4 = Never Multivariate HR (95% CI), women  
    Outcome Measure: Ischemic heart disease mortality    • Q1 = 1.00 (referent)  
        • Q2 = 1.23 (1.01-1.51)  
        • Q3 = 1.54 (1.24-1.91)  
        • Q4 = 1.52 (1.23-1.88)  
    Cox proportional HR p <0.001  
Wagner et al 2002 [254] To investigate if the association between PA patterns and incidence of coronary events could explain the gradient in CHD observed between 2 countries. • n = 9,758 Length of Follow-up: 5 yrs Number of Cases: 167 hard CHD, 154 angina events Beneficial effect of LTPA EE on hard CHD incidence in middle aged men.
   • Sex: Men and women PA assessment: Questionnaire for LTPA, 3 groups: Number of Dropouts: < 2%  
Ireland/France   • Age: 50-59 yr    
   • Characteristics: Healthy at Baseline   HR (95% CI), hard events  
Prospective cohort    G1 = Lowest    • G1 = 1.00 (referent)  
    G2 = Middle    • G2 = 0.73 (0.51-1.05)  
    G3 = Highest    • G3 = 0.66 (0.46-0.96)  
D & B score = 12    Outcome Measure: CHD hard events and Angina p = 0.04  
     HR (95% CI), angina  
        • G1 = 1.00 (referent)  
    Cox proportional HR    • G2 = 0.83 (0.55-1.25)  
        • G3 = 1.28 (0.88-1.86)  
     p = 0.10  
  1. D & B score, Downs and Black quality score; YR, years; G, groups; CHD, coronary heart disease; RR, risk ratio; 95% CI, 95% confidence interval; PA, physical activity; VPA, vigorous physical activity; CV, cardio vascular; MET, metabolic equivalent; kcal/wk, kilocalories per week; Q, quartile or quintile; km/h, kilometers per hour; LTPA, leisure-time physical activity; HR, hazard ratio; OPA, occupational physical activity; kcal/kg/day kilocalories per kilogram per day; MI, myocardial infarction; ECG, electrocardiogram; kcal/kg/h kilocalories per kilogram per hour; mph, miles per hour; CVD, cardiovascular disease.