Observational population-based studies have consistently shown an inverse dose-response gradient between physical activity or fitness and coronary heart disease. This relationship is more firmly established in men. Existing studies suggest that the physical activity gradient, and perhaps the fitness gradient, is produced by a combination of varying levels of both the intensity and the amount of habitual physical activity. It is not at present possible to definitively describe the dose-response association between the intensity of physical activity and the risk of coronary heart disease. An answer to this important question awaits further research.
PowellKEThompsonPDCaspersenCJKendrickJS: Physical activity and coronary heart diseaseAnnu Rev Public Health1987, 8:253–287. Thispaper provides a summary of the literature on physical activity and CHD up to 1987. The authors concluded that the relative risk of inactivity appears to be similar in magnitude to that of hypertension, hypercholesterolemia and smoking.
2.
BerlinJAColditzA: A meta-analysis of physical activity in the prevention of coronary heart diseaseAm J Epidemiol1990, 132:612–627. Usinga meta-analysis the authors confirm the findings of Powell et al. [1] and extend the review by including papers published up to 1990.
3.
American Heart Association: Statement on exercise: Benefits and recommendations for physical activity programs for all AmericansCirculation1992, 86:340–344. Thisstatement from the American Heart Association summarizes the health benefits associated with physical activity and sets out new recommendations for physical activity programs.
4.
FIMS: Physical exercise – an important factor for healthInt J Sports Med1989, 10:460–461.
5.
PateRRPrattMBlairSNHaskellWLMaceraCABouchardC: Physical activity and public health: A recommendation from the Centers for Disease Control and Prevention and the American College of Sports MedicineJAMA1995, 273:402–407. Thissummary statement from the Center for Disease Control and the American College of Sports Medicine sets forth revised physical activity recommendations based on the health benefits associated with moderate physical activity.
6.
BlairSN: Physical activity, fitness, and coronary heart disease In Physical Activity, Fitness, and Health. Edited by BouchardCShepardRJStephensT.Champaign: Human Kinetics Publishers; 1994:579–590.
7.
HaskellWL: Health consequences of physical activity: Understanding and challenges regarding dose-responseMed Sci Sports Exerc1994, 26:649–660.
8.
MorrisJN: Exercise in the prevention of coronary heart disease: Today's best buy in public healthMed Sci Sports Exerc1994, 26:807–814.
9.
PaffenbargerRSKampertJBLeeIMHydeRTLeungRWWingAL: Changes in physical activity and other lifeway patterns influencing longevityMed Sci Sports Exerc1994, 26:857–865. Thispaper extends the findings from the authors' earlier report [20]. Both an increase in total energy expenditure above 1500 kcals/week and the adoption of moderately vigorous sport (4.5 METs) during the follow-up period were associated with a significant decline in the risk of death.
10.
MorrisJNClaytonDGEverittMGSemmenceAMBurgessEH: Exercise in leisure time: Coronary attack and death ratesBr Heart J1990, 63:325–334. Thispaper is the most recent analysis of the British Civil Service cohort on physical activity and CHD. The authors concluded that an intensity threshold in excess of 7.5 kcals/min or 65% of maximal oxygen uptake was necessary to reduce the risk of CHD. They also concluded that after excluding vigorous aerobic exercise, the total quantity of less-intense activity was not associated with CHD.
11.
LeonASConnettJ: Physical activity and 10.5-year mortality in the Multiple Risk Factor Intervention Trial (MRFIT)Int J Epidemiol1991, 20:690–697. Thiswas a follow-up analysis to a study of men in the MRFIT [28] that extended the follow-up to 10.5 years. The authors concluded that moderate amounts of primarily light- to moderate-intensity physical activity were associated with a decreased risk of death from CHD in these high-risk men. However, they reported that very few of the men in their cohort engaged in vigorous activities, and, therefore, their study lacked the statistical power to test whether more vigorous activites could have further reduced risk.
12.
LindstedKDTonstadSKuzmaJW: Self-report of physical activity and patterns of mortality in Seventh-Day AdventistsJ Clin Epidemiol1991, 44:355–364.
13.
ShaperAGWannametheeG: Physical activity and ischaemic heart disease in middle-aged British menBr Heart J1991, 66:384–394. Theauthors concluded that the risk of heart attack decreased significantly with increasing physical activity, with the men who reported moderate or moderately vigorous activity experiencing half the attack rate of more sedentary men. The authors also reported an increase in the risk of heart attack for the most active men. They speculate that the increased risk for the most active men is related to hypertension.
14.
ShaperAGWannametheeGWalkerM: Physical activity, hypertension and risk of heart attack in men without evidence of ischaemic heart diseaseJ Hum Hypertens1994, 8:3–10. Theauthors confirmed observations made in their earlier study [13]. In addition, they evaluated the observed increased risk of heart attack in the most active men and concluded that this excess risk was confined to those men with hypertension.
15.
ArraizGAWigleDTMaoY: Risk assessment of physical activity and physical fitness in the Canadian Health Survey Mortality Follow-Up StudyJ Clin Epidemiol1992, 45:419–428.
16.
HeinHOSuadicaniPGyntelbergF: Physical fitness or physical activity as a predictor of ischaemic heart disease? A 17-year follow-up in the Copenhagen Male StudyJ Intern Med1992, 232:471–479. Thisstudy included crude measures of both physical activity and physical fitness and attempted to test whether one or the other was more important in defining the risk of heart diseases. The authors concluded that being physically fit provided no protection against ischemic heart disease in sedentary men but that unfit sedentary men have a higher risk of disease than unfit active men.
17.
LakkaTAVenalainenJMRauramaaRSalonenRTuomilehtoJSalonenJT: Relation of leisure-time physical activity and cardiorespiratory fitness to the risk of acute myocardial infarctionN Engl J Med1994, 330:1549–1554. Thisstudy included good measures of both physical activity and physical fitness. The authors concluded that both measures were independently related to CHD and that higher levels of both leisure-time physical activity and physical fitness were stronger and inversely associated with acute myocardial infarction. A high level of physical activity was defined as more than 2.2 h/week conditioning exercise (6 METs), and a high level of fitness was defined as a maximal oxygen uptake in excess of 33.6 ml/kg/min (9.6 METs) in their middle-aged men.
18.
RodriguezBLCurbDBurchfielCMAbbottRDPetrovitchHMasakiK: Physical activity and 23-year incidence of coronary heart disease morbidity and mortality among middle-aged menCirculation1994, 89:2540–2544.
19.
ShermanSED'AgostinoRBCobbJLKannelWB: Physical activity and mortality in women in the Framingham Heart StudyAm Heart J1994, 128:879–884.
20.
PaffenbargerRSHydeRTWingALLeeIMJungDLKampertJB: The association of changes in physical-activity level and other lifestyle characteristics with mortality among menN Engl J Med1993, 328:538–545. Theauthors reported results from an analysis in which changes in physical activity habits were quantified during a lengthy follow-up period and mortalities were compared among groups defined by the changes in physical activity habits. Men who increased their participation in moderately vigorous sports (4.5 METs) showed a significant reduction in CHD mortality compared with men who did not take up such activities.
21.
SlatteryMLJacobsDR: Physical fitness and cardiovascular disease mortality: The US Railroad StudyAm J Epidemiol1988, 127:571–580.
22.
BlairSNKohlHWPaffenbargerRSClarkDGCooperKHGibbonsLW: Physical fitness and all-cause mortality: A prospective study of healthy men and womenJAMA1989, 262:2395–2401. Thisstudy used a strong measure of physical fitness and analyzed a large sample of men and women. The results show a strong, independent and inverse gradient for cardiovascular risk across fitness categories in both men and women. The authors reported significant reductions in risk for men and women in the middle of the age-adjusted fitness distribution and concluded that moderate levels of fitness, attainable by most adults, were associated with considerable protection against early death.
23.
SandvikLErikssenJThaulowEErikssenGMundalRRodahlK: Physical fitness as a predictor of mortality among healthy, middle-aged Norwegian menN Engl J Med1993, 328:533–537. Thispaper extends the follow-up detailed in the group's earlier report [35] to 16 years and concludes that the risk of death from CHD was inversely related to physical fitness. The authors reported a marked difference in cardiovascular mortality between participants with intermediate levels of physical fitness and those with higher levels. This finding would have remained undetected if the cohort had been followed for only 10 years.
24.
BlairSNKohlHWBarlowCEPaffenbargerRSGibbonsLWMaceraCA: Changes in physical fitness and all-cause mortality: A prospective study of healthy and unhealthy menJAMA1995, 273:1093–1098. Thispaper presents results from an analysis in which changes in physical fitness were defined using two maximal exercise tests, and the risk of death was assessed as a function of the observed changes in fitness. The authors report significant reductions in risk for men who either remained or became more physically fit compared with those who remained unfit during the follow-up period.
25.
DonahueRPAbbottRDReedDMYanoK: Physical activity and coronary heart disease in middle-aged and elderly men: The Honolulu Heart ProgramAm J Public Health1988, 78:683–885.
26.
KannelWBSorlieP: Some health benefits of physical activity: The Framingham StudyArch Intern Med1979, 139:857–861.
27.
BlairSNKohlHWBarlowCE: Physical activity, physical fitness, and mortality in women: Do women need to be active?J Am Coll Nutr1993, 12:368–371.
28.
LeonASConnettJJacobsDRRauramaaR: Leisure-time physical activity levels and risk of coronary heart disease and death: The Multiple Risk Factor Intervention TrialJAMA1987, 258:2388–2395. Thisis the report on physical activity and mortality from the MRFIT. The authors concluded that a total energy expenditure of approximately 1500 kcals/week in mostly light- to moderate-intensity leisure-time physical activities was associated with a significant decrease in CHD mortality.
29.
PaffenbargerRSHydeRTWingALHsiehCC: Physical activity, all-cause mortality, and longevity of college alumniN Engl J Med1986, 314:605–613. Thispaper from the Harvard Alumni Study reports an inverse relationship between physical activity and CHD mortality. The authors reported mortalities one-quarter to one-third lower among men who expended 2000 or more kilocalories per week during exercise compared with those who expended less energy.
30.
MundalRErikssenJRodahlK: Assessment of physical activity by questionnaire and personal interview with particular reference to fitness and coronary mortalityEur J Appl Physiol1987, 56:245–252.
31.
PetersRKCadyLDBischoffDPBernsteinLPikeMC: Physical fitness and subsequent myocardial infarction in healthy workersJAMA1983, 249:3052–3056. Thisstudy included measures of both physical activity and fitness, and the authors concluded that their measure of physical fitness was more strongly associated with the incidence of myocardial infarction than with their measure of physical activity.
32.
EkelundLGHaskellWLJohnsonJLWhaleyFSCriquiMH: Physical fitness as a predictor of cardiovascular mortality in asymptomatic North American men: The Lipid Research Clinics Mortality Follow-Up StudyN Engl J Med1988, 319:1379–1384.
33.
SobolskiJKornitzerMBackerGDDramaixMAbramowiczMDegreS: Protection against ischemic heart disease in the Belgian Physical Fitness Study: Physical fitness rather than physical activity?Am J Epidemiol1987, 125:601–610.
34.
ErikssenJ: Physical fitness and coronary heart disease morbidity and mortality: A prospective study in apparently healthy, middle-aged menActa Med Scand1986, 711 (suppl):189–192.
35.
LieHMundalRErikssenJ: Coronary risk factors and incidence of coronary death in relation to physical fitness: Seven-year follow-up study of middle-aged and elderly menEur Heart J1985, 6:147–157.
36.
WilhelmsenLBjureJEkstrom-JodalBAurellMGrimbyGSvardsuddK: Nine years' follow-up of a maximal exercise test in a random population sample of middle-aged menCardiology1981, 68:1–8.
37.
PollockMLBohannonRLCooperKHAyersJWardAWhiteS: A comparative analysis of four protocols for maximal treadmill stress testingAm Heart J1976, 92:39–46.
38.
American Heart Association: Exercise Testing and Training of Apparently Healthy Individuals: A Handbook for Physicians. Dallas: American Heart Association; 1972.
