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Review Article
Exercise for Prevention of Cardiovascular Disease: Evidence‑based
Recommendations
Geevar Zachariah1, MD, DM; Anoop George Alex2, MD, DM

1
Department of Cardiology, Sedentary lifestyle is one of the major risk factors for cardiovascular disease (CVD).

Abstract
Mother Hospital, Thrissur,
Kerala, 2Department of
In India, a large percentage of the people are physically inactive with fewer
Cardiology, Christian Medical than 10% engaging in recreational physical activity. Physical activity has many
College, Vellore, beneficial effects on the risk factors for CVD. Apart from improving fitness level,
Tamil Nadu, India it decreases myocardial oxygen demand and improves myocardial perfusion. There
is an inverse association between physical activity and all‑cause mortality. In
primary prevention, physical inactivity is associated with a two‑fold increase in
the risk for coronary events. In secondary prevention, data confirm the existence
of an inverse dose–response relationship between cardiovascular fitness and the
all‑cause mortality in large populations of cardiovascular patients. Guidelines
from the American authorities as well as the European Society of Cardiology
provide specific recommendations for exercise depending on the clinical setting
(primary or secondary prevention of CVD) and the patient‑specific factors (the
patient’s physical activity level and the perceived CVD risk). The present review
summarizes the clinical evidence regarding the role of exercise in CVD prevention
and the exercise recommendations from the leading Cardiac societies.

Keywords: Aerobic exercise program, European Society of Cardiology

Received: February, 2017.
Accepted: March, 2017. guidelines, exercise intensity, physical activity, US guidelines

Introduction purposeful with the objective of improving or maintaining one

R egular physical activity and exercise are important in
reducing risk of death and cardiovascular events in the
primary as well as in the secondary prevention.[1‑4] A sedentary
lifestyle is one of the major risk factors for cardiovascular
disease (CVD).[5] More than 25% of the population attributable
risk for myocardial infarction (MI) is due to physical inactivity.[6]
Most international guidelines emphasize the importance of regular
exercise as a valuable nonpharmacological tool for prevention of
CVD.[7‑9] In India, a large percentage of the people are physically
inactive with fewer than 10% engaging in recreational physical
activity.[10] India is now facing a huge burden of CAD and efforts
to promote physical activity and reduce sedentary lifestyle plays
an important role containing the problem.
or more components of physical fitness. Physical fitness is
defined as the ability to carry out daily tasks with vigor and
alertness, without undue fatigue, and with ample energy to
enjoy leisure‑time pursuits and meet unforeseen emergencies.
Exercise can be dynamic (isotonic) where there is a movement
of the limb or static (isometric) which is not associated with
movement of the limb. Dynamic exercise is further classified
as either concentric (associated with shortening of muscle
fibers) or eccentric (associated with lengthening of muscle
fibers as that which occur when weight is lowered against
gravity). Exercise can also be classified as aerobic when
oxygen is available and anaerobic in the absence of oxygen.
Most physical activities have dynamic and static components

Definitions
Physical activity is any bodily movement produced by
the contraction of skeletal muscle that increases energy
expenditure above the basal level.[9] Exercise is a subcategory
of physical activity, that is, planned, structured, repetitive, and
Address for correspondence: Dr. Geevar Zachariah MD, DM,
Chief of Cardiology and Chairman Mother Heart Care, Mother
Hospital, Pantheon, Remadevi Mandir Lane, Punkunnam,
Thrissur ‑ 680 002, Kerala, India.
E‑mail: geevarzachariah@gmail.com

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How to cite this article: Zachariah G, Alex AG. Exercise for prevention
DOI: 10.4103/JCPC.JCPC_9_17 of cardiovascular disease: Evidence-based recommendations. J Clin Prev
Cardiol 2017;6:109-14.

© 2017 Journal of Clinical and Preventive Cardiology | Published by Wolters Kluwer - Medknow 109
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Zachariah and Alex: Exercise for CVD prevention
as well as aerobic and anaerobic metabolism. A particular
physical activity is classified based on dominant, mechanical,
or metabolic characteristics. Dynamic aerobic exercise cause
volume load on heart whereas isometric exercise cause
pressure overload. Both kinds of exercise increase physical
fitness. Endurance training leads to improvements in aerobic
capacity and favorable effects on cardiopulmonary and
metabolic variables. Isometric exercise and resistance training
enhances muscular strength, endurance, and muscle mass.[11]
Types of Physical Activity and Intensity
Examples of physical activity involve not only sport‑related
activities but also lifestyle‑common activities such as walking
briskly, climbing stairs, doing more housework and gardening
work, and engaging in active recreational pursuits.[12] Absolute
intensity of physical activity is the amount of energy expended
per minute of activity. This can be assessed by oxygen uptake
per unit of time (mL/min) or by metabolic equivalent (MET).
One MET is the rate of energy expenditure of an adult while
sitting at rest. It is taken by convention to be an oxygen uptake
of 3.5 mL/kg of body weight per minute. Moderate intensity
physical activity implies activity performed at an intensity of
3–6 METs and vigorous intensity physical activity includes
that performed at >6 METs.[13]
Absolute intensity does not take into account of individual
factors such as body weight, sex, and fitness level. An older
person exercising at the vigorous intensity of 6 METs may be
exercising at their maximum intensity while a younger person
working at the same absolute intensity may be exercising
moderately.[7] Relative intensity is the level of effort required to
perform an activity. Less‑fit individuals require higher level of
effort than fitter people. Relative intensity is determined relative
to an individual’s level of cardio‑respiratory fitness (VO2 max)
or as a percentage of a person’s measured or estimated heart
rate (HR) (%max HR) which is 220‑age. It is also expressed as
an index of the individual rate of effort (how hard the person
feels he is exercising), that is, the rating of perceived exertion
or by frequency of breathing.[7] Moderate‑intensity physical
activity should be defined in relative terms as an activity
performed at 40%–59% of VO2 or HR reserve, or at a rate of
perceived exertion of 5–6 in CR10 Borg scale, which would
correspond to an absolute energy expenditure of 4.8–7.1 METs
in the young, 4.0–5.9 METs in the middle‑aged, 3.2–4.7 METs
in the old, and 2.0–2.9 METs in the very old.[14] Analogously,
vigorous‑intensity physical activity is performed at 60%–85%
of VO2 or HR reserve, or at a rate of perceived exertion of 7–8
in the CR10 Borg scale, corresponding to an absolute energy
expenditure of 7.2–10.1 METs in the young, 6.0–8.4 METs in
the middle‑aged, 4.8–6.7 METs in the old, and 3.0–4.2 METs
in the very old.[14]
Mechanism of Benefit of Exercise
Regular aerobic physical activity improves exercise
performance. Ideally, one should exercise to the intensity
of 40%–85% of VO2.[15] Exercise improves fitness level
and thereby quality of life.[16] It also decreases myocardial
oxygen demand by decreasing the product of HR and systolic
blood pressure and reducing myocardial ischemia. Regular
110 Journal of Clinical and Preventive Cardiology ¦ Volume 6 ¦ Issue 3 ¦ July-September 2017
exercise also improves myocardial perfusion. It increases the
diameter of epicardial coronary arteries and also has favorable
effects on microcirculation and endothelial function. Regular
exercise has antithrombotic effects and helps to prevent
coronary occlusion. Antithrombotic effects are mediated
through increased plasma volume, reduced viscosity of blood,
decreased platelet aggregation, and increased thrombolytic
activity.[17] Regular exercise also reduces risk of an arrhythmic
event by affecting the autonomic function.[18] Physical activity
has many beneficial effects on the risk factors for coronary
artery disease. Regular physical activity not only reduces
blood pressure in established hypertension but also helpful
in preventing development of hypertension. It is well known
to increase protective HDL cholesterol, improve glycemic
control in diabetics, prevents onset of diabetes, and helpful in
maintaining ideal bodyweight.[9] Regular exercise also helps
in ischemic preconditioning, by which transient myocardial
ischemia during exercise protects the myocardium from
subsequent more prolonged ischemia.[19]
Evidence of Benefit of Exercise in Primary
Prevention
Randomized trials to observe the effects of physical activity
and exercise on the primary prevention of cardiovascular
outcomes has been scarce due to many factors such as ethical
issues in assigning people to control group and nonadherence
to long‑term exercise regimen. The available randomized
trials are not very informative because they enrolled only
small number of participants. Hence, most data come from
observational trials.
Physical Activity and Coronary Events
Physical inactivity is associated with at least a two‑fold
increase in the risk for coronary events.[20] Prolonged sitting or
sedentary time has also been associated with an increased risk
for diabetes and CVD.[21] The results of studies investigating
the relation between habitual physical activity and morbidity
and/or mortality associated with CVD, published since
1996 quite consistently show lower event rates in more
physically active men and women than for their least active
counterparts.[1]
A systemic review of 16 prospective, cohort studies and
4 case‑control studies on coronary heart disease (CHD) in
men, involving 124,000 men aged 15–96 years, clearly showed
the benefit of regular exercise in preventing cardiovascular
events.[1] Among the prospective cohort studies, the median
RR was 0.81 for moderate intensity activity versus no or light
activity, and 0.68 for vigorous intensity activity versus light
or no activity. For the 6 case‑control studies, the median RR
was 0.65 for moderate intensity versus no or light activity, and
0.53 for vigorous intensity activity versus no or light activity.
In the Nurses’ Health Study of 72488 women between 40 and
65 years of age, it was found that brisk walking or vigorous
exercise was inversely related to the risk of a coronary
event.[22] In a review of over 70,000 postmenopausal women in
the Women’s Health Initiative Observational Study, prolonged
sitting predicted an increase in cardiovascular risk.[23]
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Zachariah and Alex: Exercise for CVD prevention
In a systemic review of studies of women reporting CHD
clinical events which included more than 200,000 participants
aged 20–85 years, the median RR of having a CHD clinical
event for women reporting participation in moderate intensity
of physical activity compared to women reporting no or only
light intensity activity was 0.78, while the RR for women
performing vigorous or high amounts of activity as compared
to women reporting no or light activity was 0.62.[1]
Physical Activity and Mortality
Available data strongly support an inverse association between
physical activity and all‑cause mortality.[1] Active individuals
have approximately a 30% lower risk of dying during follow‑up,
compared with inactive individuals. This inverse relationship
has been observed irrespective of country of residence, age,
race, and ethnicity. In one study, even in persons with impaired
mobility (unable to walk 2 km or climb one flight of stairs
without difficulty), physical activity was associated with lower
all‑cause mortality rates. A 2014 meta‑analysis of cohort
studies in elite athletes found that compared with the general
population, athletes have 67 percent lower mortality.[24]
In a retrospective study of over 12 years, physical activity habits
were analyzed in 10,269 Harvard alumni (mean age 58).[25]
Those engaged in moderately vigorous sports activity (defined
as total physical activity levels >4200 kJ/week or brisk
walking, recreational cycling or swimming, home repair, and
yard work for 30 min/day on most days) had a 23% lower risk
of death than those who were less active.
In a systematic review of studies looking at the relationship
between physical activity and premature mortality, 31% of lower
risk for all‑cause mortality was observed in the most active
individuals. The median risk reduction was 32%.[1] The greatest
differences in risk occurred between the lowest adjacent activity
and fitness categories, suggesting that sedentary individuals can
markedly reduce their risk for all‑cause mortality with relatively
minor increments in physical activity.
It has been estimated that by eliminating physical inactivity,
6% of CVD worldwide may be eliminated and life expectancy
of the world may be increased by 0.68 years.[26]
Recommendations for Primary Prevention
of Cardiovascular Disease
Based on the available literature, there is compelling evidence
that the recommendation of 30 min of moderate intensity
exercise on most days of the week (equivalent to 4.2 MJ/week
or 1,000 kcal/week) reaches a threshold associated with
significant reductions in cardiovascular‑related mortality.[27,28]
Brisk walking has also been shown to be preferable to a slower
pace.[29] Current recommendations require at least 1000 kcal
of caloric expenditure per week to achieve exercise‑induced
protection against premature cardiovascular death.[30] Evidence
also suggests that the benefits of exercise on reducing
mortality may plateau after a certain activity level.[31]
Doses above 100 min/day for moderate‑intensity physical
activity in healthy individuals do not appear to be associated
with additional reductions in mortality rates.[32]
Journal of Clinical and Preventive Cardiology ¦ Volume 6 ¦ Issue 3 ¦ July-September 2017
US Recommendations for Physical Activity
for Primary Prevention of Cardiovascular
Disease
Following are the recommendations from the American
Heart Associations and the American College of Sports
Medicine.[33,34]
• All adults aged 18–65 years should perform
moderate‑intensity aerobic (endurance) physical activity
for a minimum of 30 min on 5 days each week or
vigorous‑intensity aerobic activity for a minimum of
20 min on 3 days each week (I [A])
• Combinations of moderate‑ and vigorous‑intensity
activity can be performed to meet this
recommendation (IIa [B])
• Above activities are in addition to the light intensity
activities frequently performed during daily life
• Multiple bouts of exercise each lasting 10 or more
minutes can be performed to satisfy the goal of
minimum 30 min moderate intensity physical
activity (I [B])
• In addition, at least twice each week adults will benefit
by performing activities using the major muscles of the
body that maintain or increase muscular strength and
endurance (Ia [A])
• Exceeding the minimum recommended amount of
physical activity may provide additional benefit (I [A]).
For older adults, recommendations for moderate‑ and
vigorous‑intensity physical activity are the same as for younger
adults. They should also perform muscle strengthening
activities. Like younger adults, they can also if desired further
exceed the minimum recommended amount of physical
activity.
However, to maintain the flexibility necessary for regular
physical activity and daily life, older adults should perform
activities that maintain or increase flexibility on at least 2 days
each week for at least 10 min each day (IIb [B]) and to reduce
risk of injury from falls, community‑dwelling older adults with
substantial risk of falls should perform exercises that maintain
or improve balance (IIa [A]) Many months of activity at
less than recommended levels is appropriate for some older
adults (e.g., those with low fitness) as they increase activity in
a stepwise manner.
European Society of Cardiology
Recommendations for Physical Activity
for Primary Prevention of Cardiovascular
Disease
• Healthy adults of all ages should perform at least
150 min a week of moderate‑intensity or 75 min a week
of vigorous‑intensity aerobic physical activity or an
equivalent combination thereof (I [A])[7]
• For additional benefit, a gradual increase to 300 min
a week of moderate‑intensity or 150 min a week of
vigorous‑intensity aerobic physical activity or an
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Zachariah and Alex: Exercise for CVD prevention
equivalent combination is recommended (I [A])
• Regular assessment and counseling are recommended
to support an increase in volume of exercise over
time (I [B]). For low‑risk individuals, further assessment
is not required
• Multiple sessions of physical activity should be
considered each lasting >10 min, preferably every day
of the week (IIa [B]).
Clinical evaluation should be considered for sedentary people
with CV risk factors who intent to engage in vigorous physical
activity or sports [IIa (C)]. Starting with a low‑intensity
activity is recommended in sedentary individuals and those
with cardiovascular risk factors.
Physical Activity and Exercise for
Secondary Prevention of Cardiovascular
Disease
Evidence of benefit of exercise in secondary
prevention
Aerobic physical activity in patients with known CVD
is usually considered as part of the cardiac rehabilitation
program. Hence, data on influence of habitual physical
activity level on cardiovascular outcomes in cardiac patients
is scarce. Further, effects of physical activity alone on
cardiovascular risk may not be easily discernible. However,
a meta‑analysis which included mainly middle‑aged men,
with a previous acute MI, prior coronary artery bypass
grafting (CABG), prior percutaneous transluminal coronary
angioplasty or stable angina pectoris, showed around 30%
reduction in total cardiovascular mortality with aerobic
exercise training programs of at least 3‑months’ duration.[12]
However, aerobic exercise training did not show any effect
on the occurrence of nonfatal MI. In the recent years,
wide spread use of revascularization procedures and drug
treatments has reduced the overall risks of mortality in
cardiac patients, and hence, it is difficult to demonstrate
significant survival advantage with interventions such as
regular physical activity. Yet, data confirms the existence of
an inverse dose–response relationship between cardiovascular
fitness (evaluated by treadmill stress testing and expressed
in METs) and all‑cause mortality in large populations of
both male and female cardiovascular patients (a history of
angiographically documented CHD, MI, CABG, coronary
angioplasty, percutaneous coronary intervention (PCI), or
stable angina).[12] Finally, aerobic exercise training in low‑risk
patients has been shown to be at least as effective as an
invasive strategy such as a PCI, in improving clinical status
and myocardial perfusion, and is also associated with fewer
cardiovascular events.[12]
European society of cardiology
recommendations for physical activity for
secondary prevention of cardiovascular
disease
European society of cardiology guidelines emphasize that
unlike in primary prevention, providing a specific exercise
112 Journal of Clinical and Preventive Cardiology ¦ Volume 6 ¦ Issue 3 ¦ July-September 2017
prescription is not possible in secondary prevention and
recommendations must be individualized.[12] Low‑risk
patients with a previous acute MI, CABG, PCI, or affected
by stable angina pectoris or chronic heart failure should be
advised to undergo an aerobic exercise training program
of moderate to vigorous intensity of 3–5 sessions/week,
30 min/session. The patients with moderate to high clinical
risk should be given an exercise prescription based on
metabolic load known to cause symptoms. Even in patients
with symptoms with ordinary level of activities, small
amount of supervised exercise is beneficial.
Risk stratification tools can be used to identify the patients
at increased risk for exercise‑related cardiovascular events.
Safety of medically supervised exercise programs is well
established. Possibility of major cardiovascular events
occurring during supervised aerobic exercise training is rare
and varies from 1 in 50,000 to 1 in 120,000 patient‑hours of
exercise. Chance of a fatal event occurring during exercise is
extremely rare at 1 in 340,000–1 in 750,000 patient hours of
exercise.[12]
American College of Cardiology/American
Heart Associations recommendations for
physical activity for secondary prevention of
cardiovascular disease
• Assess patient’s risk with a physical activity history
and/or an exercise test (I [B])[35]
• Advise 30–60 min of moderate‑intensity aerobic
activity, such as brisk walking on most, preferably
all days of the week supplemented by an increase in
daily lifestyle activities (e.g., walking breaks at work,
gardening, and household work) (I [B])
• Encourage resistance training 2 days/week (IIb [C])
• Advise medically supervised programs for high‑risk
patients (e.g. recent acute coronary syndrome or
revascularization, heart failure (I [B]).
Conclusions
It is well‑known that a sedentary lifestyle is one of the
major risk factors for CVD. A large percentage of Indians
are physically inactive and <10% of our adult population
engages in recreational physical activity. Promoting physical
activity is of paramount importance to reduce cardiovascular
burden in India. Even though there are only very few
randomized clinical trials showing benefit of physical activity
in reducing cardiovascular events and mortality, large number
of observational studies both in men and women have shown
benefits of regular physical activity. Regular physical activity
exerts its beneficial effects primarily by reducing risk factors for
coronary artery disease. In addition, it enhances fitness level,
reduces myocardial oxygen demand, improves myocardial
perfusion, and has antithrombotic effects. Most professional
societies recommend 150 min of moderate‑intensity physical
activity or 75 min of vigorous physical activity per week
along with 2 days/week of muscle‑strengthening exercises
for primary prevention. Less‑fit individuals should start
with less strenuous exercise and gradually increase activity.
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Zachariah and Alex: Exercise for CVD prevention
For secondary prevention, recommendations should be
individualized. The patients should be evaluated by history
and exercise stress test before recommending regular physical
activity. It is preferable for patients with established CVD to
go for a medically supervised exercise program. Based on
the robust evidence for the benefit of exercise in primary and
secondary prevention, there is urgent need promote physical
activity in our population.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
References
1. US Department of Health and Human Services. Physical
Activity Guidelines Advisory Committee Report; 2008.
Available from: http://www.health.gov/PAguidelines/Report/pdf/
CommitteeReport.pdf. [Last accessed on 2017 Jan 29].
2. Löllgen H, Böckenhoff A, Knapp G. Physical activity and
all‑cause mortality: An updated meta‑analysis with different
intensity categories. Int J Sports Med 2009;30:213‑24.
3. Taylor RS, Brown A, Ebrahim S, Jolliffe J, Noorani H,
Rees K, et al. Exercise‑based rehabilitation for patients with
coronary heart disease: Systematic review and meta‑analysis of
randomized controlled trials. Am J Med 2004;116:682‑92.
4. Richardson CR, Kriska AM, Lantz PM, Hayward RA. Physical
activity and mortality across cardiovascular disease risk groups.
Med Sci Sports Exerc 2004;36:1923‑9.
5. Warren TY, Barry V, Hooker SP, Sui X, Church TS, Blair SN.
Sedentary behaviors increase risk of cardiovascular disease
mortality in men. Med Sci Sports Exerc 2010;42:879‑85.
6. Yusuf S, Hawken S, Ounpuu S, Dans T, Avezum A, Lanas F,
et al. Effect of potentially modifiable risk factors associated with
myocardial infarction in 52 countries (the INTERHEART study):
case‑control study. Lancet 2004;364:937‑52.
7. Piepoli MF, Arno WH, Agewell S, Albus C, Brotons C,
Alberico LC, et al. 2016 European guidelines on cardiovascular
disease prevention in clinical practice. Eur Heart J
2016;37:2315‑81.
8. Smith SC Jr., Benjamin EJ, Bonow RO, Braun LT,
Creager MA, Franklin BA, et al. AHA/ACCF secondary
prevention and risk reduction therapy for patients with
coronary and other atherosclerotic vascular disease: 2011
update: A guideline from the American Heart Association
and American College of Cardiology Foundation. Circulation
2011;124:2458‑73.
9. US Department of Health and Human Services. 2008 Physical
Activity Guidelines for Americans; 2008. Available from: http://
www.health.gov/paguidelines/pdf/paguide.pdf. [Last accessed on
2017 Jan 29].
10. Anjana RM, Pradeepa R, Das AK, Deepa M, Bhansali A,
Joshi SR, et al. ICMR– INDIAB Collaborative Study Group.
Physical activity and inactivity patterns in India‑results from the
ICMR‑INDIAB study (Phase‑1) [ICMR‑INDIAB‑5]. Int J Behav
Nutr Phys Act 2014;11:26.
11. Williams MA, Haskell WL, Ades PA, Amsterdam EA, Bittner V,
Franklin BA, et al. Resistance exercise in individuals with
and without cardiovascular disease: 2007 update: A scientific
statement from the American Heart Association Council on
Clinical Cardiology and Council on Nutrition, Physical Activity,
and Metabolism. Circulation 2007;116:572‑84.
Journal of Clinical and Preventive Cardiology ¦ Volume 6 ¦ Issue 3 ¦ July-September 2017
12. Perk J, De Backer G, Gohike H, Graham I, Reiner Z,
Verschuren M, et al. European Guidelines on cardiovascular
disease prevention in clinical practice (version 2012). Eur Heart
J 2012;33:1635‑701.
13. Caspersen CJ, Powell KE, Christenson GM. Physical activity,
exercise, and physical fitness: Definitions and distinctions for
health‑related research. Public Health Rep 1985;100:126‑31.
14. Kodama S, Saito K, Tanaka S, Maki M, Yachi Y, Asumi M, et al.
Cardiorespiratory fitness as a quantitative predictor of all‑cause
mortality and cardiovascular events in healthy men and women:
A meta‑analysis. JAMA 2009;301:2024‑35.
15. Durstine JL, Painter P, Franklin BA, Morgan D, Pitetti KH,
Roberts SO. Physical activity for the chronically ill and disabled.
Sports Med 2000;30:207‑19.
16. Eijsvogels TM, Molossi S, Lee DC, Emery MS, Thompson PD.
Exercise at the extremes: The amount of exercise to reduce
cardiovascular events. J Am Coll Cardiol 2016;67:316‑29.
17. Lippi G, Maffulli N. Biological influence of physical exercise on
hemostasis. Semin Thromb Hemost 2009;35:269‑76.
18. Billman GE. Cardiac autonomic neural remodeling and
susceptibility to sudden cardiac death: Effect of endurance
exercise training. Am J Physiol Heart Circ Physiol
2009;297:H1171‑93.
19. Kavazis AN. Exercise preconditioning of the myocardium.
Sports Med 2009;39:923‑35.
20. Powell KE, Thompson PD, Caspersen CJ, Kendrick JS. Physical
activity and the incidence of coronary heart disease. Annu Rev
Public Health 1987;8:253‑87.
21. van der Ploeg HP, Chey T, Korda RJ, Banks E, Bauman A.
Sitting time and all‑cause mortality risk in 222 497 Australian
adults. Arch Intern Med 2012;172:494‑500.
22. Manson JE, Hu FB, Rich‑Edwards JW, Colditz GA,
Stampfer MJ, Willett WC, et al. A prospective study of walking
as compared with vigorous exercise in the prevention of coronary
heart disease in women. N Engl J Med 1999;341:650‑8.
23. Manson JE, Greenland P, LaCroix AZ, Stefanick ML,
Mouton CP, Oberman A, et al. Walking compared with vigorous
exercise for the prevention of cardiovascular events in women.
N Engl J Med 2002;347:716‑25.
24. Garatachea N, Santos‑Lozano A, Sanchis‑Gomar F,
Fiuza‑Luces C, Pareja‑Galeano H, Emanuele E, et al. Elite
athletes live longer than the general population: A meta‑analysis.
Mayo Clin Proc 2014;89:1195‑200.
25. Sesso HD, Paffenbarger RS Jr., Lee IM. Physical activity and
coronary heart disease in men: The Harvard alumni health study.
Circulation 2000;102:975‑80.
26. Lee IM, Shiroma EJ, Lobelo F, Puska P, Blair SN,
Katzmarzyk PT; Lancet Physical Activity Series Working
Group. Effect of physical inactivity on major non‑communicable
diseases worldwide: An analysis of burden of disease and life
expectancy. Lancet 2012;380:219‑29.
27. Myers J, Kaykha A, George S, Abella J, Zaheer N, Lear S, et al.
Fitness versus physical activity patterns in predicting mortality in
men. Am J Med 2004;117:912‑8.
28. Paffenbarger RS Jr., Hyde RT, Wing AL, Hsieh CC. Physical
activity, all‑cause mortality, and longevity of college alumni.
N Engl J Med 1986;314:605‑13.
29. Schnohr P, Scharling H, Jensen JS. Intensity versus duration of
walking, impact on mortality: The Copenhagen city heart study.
Eur J Cardiovasc Prev Rehabil 2007;14:72‑8.
30. Warburton DE, Charlesworth S, Ivey A, Nettlefold L, Bredin SS.
A systematic review of the evidence for Canada’s physical activity
guidelines for adults. Int J Behav Nutr Phys Act 2010;7:39.
113
[Downloaded free from http://www.jcpconline.org on Wednesday, April 20, 2022, IP: 27.109.14.146]

Zachariah and Alex: Exercise for CVD prevention

31. Eijsvogels TM, Thompson PD. Exercise is medicine: At any
dose? JAMA 2015;314:1915‑6.
32. Arem H, Moore SC, Patel A, Hartge P, Berrington de Gonzalez A,
Visvanathan K, et al. Leisure time physical activity and mortality:
a detailed pooled analysis of the dose‑response relationship.
JAMA Intern Med 2015;175:959‑67.
33. Haskell WL, Lee IM, Pate RR, Powell KE, Blair SN,
Franklin BA, et al. Physical activity and public health: Updated
recommendation for adults from the American College of Sports
Medicine and the American Heart Association. Circulation
2007;116:1081‑93.
34. Nelson ME, Rejeski WJ, Blair SN, Duncan PW, Judge JO,
King AC, et al. Physical activity and public health in older
adults: Recommendation from the American College of Sports
Medicine and the American Heart Association. Med Sci Sports
Exerc 2007;39:1435‑45.
35. Smith SC Jr., Allen J, Blair SN, Bonow RO, Brass LM,
Fonarow GC, et al. AHA/ACC guidelines for secondary
prevention for patients with coronary and other
atherosclerotic vascular disease: 2006 update: Endorsed by
the National Heart, Lung, and Blood Institute. Circulation
2006;113:2363‑72.

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