With increasing survival rates among patients with myocardial infarction (MI), more demands are placed on secondary prevention. While physical activity (PA) efforts to obtain a sufficient PA level are part of secondary preventive recommendations, it is still underutilized. Importantly, the effect of changes in PA after MI is largely unknown. Therefore, we sought to investigate the effect on survival from changes in PA level, post‐MI.随着心肌梗死（MI）患者生存率的提高，对二级预防提出了更高的要求。虽然体力活动（PA）努力获得足够的PA水平是二级预防建议的一部分，但它仍然没有得到充分利用。重要的是，心肌梗死后PA变化的影响在很大程度上是未知的。因此，我们试图从PA水平、心肌梗死后的变化来探讨其对存活的影响。
Methods and Results
Data from Swedish national registries were combined, totaling 22 227 patients with MI. PA level was self‐reported at 6 to 10 weeks post‐MI and 10 to 12 months post‐MI. Patients were classified as constantly inactive, increased activity, reduced activity, and constantly active. Proportional hazard ratios were calculated. During 100 502 person‐years of follow‐up (mean follow‐up time 4.2 years), a total of 1087 deaths were recorded. Controlling for important confounders (including left ventricular function, type of MI, medication, smoking, participation in cardiac rehabilitation program, quality of life, and estimated kidney function), we found lower mortality rates among constantly active (hazard ratio: 0.29, 95% confidence interval: 0.21–0.41), those with increased activity (0.41, 95% confidence interval: 0.31–0.55), and those with reduced activity (hazard ratio: 0.56, 95% confidence interval: 0.45–0.69) during the first year post‐MI, compared with those being constantly inactive. Stratified analyses indicated strong effect of PA level among both sexes, across age, MI type, kidney function, medication, and smoking status.合并了瑞典国家登记册的数据，共有22227名MI患者。PA水平在心肌梗死后6～10周及心肌梗死后10～12个月时自我报告。患者被分类为持续不活动、增加活动、减少活动和持续活动。计算比例危险比。在100 502人随访(平均随访时间4.2年)期间，共记录1087人死亡。控制重要的混杂因素（包括左心室功能、心肌梗死类型、药物、吸烟、参与心脏康复计划、生活质量和估计肾功能），我们发现，在不断活跃的人群中（危险比：0.29，95%可信区间：0.21-0.41），那些活动性增加的人群死亡率较低。在心肌梗死后的第一年，ty值（0.41，95%置信区间：0.31-0.55）和活动性降低（危险比：0.56，95%置信区间：0.45-0.69）的患者与那些经常不活动的患者相比。分层分析显示，PA水平在两性之间、不同年龄、MI类型、肾功能、药物和吸烟状况之间有很强的影响。
Conclusions
The present article shows that increasing the PA level, compared with staying inactive the first year post‐MI, was related to reduced mortality.与MI后第一年不活动相比，PA水平的提高与死亡率的降低有关。
Clinical Perspective
What Is New?
Patients who remained physically active over the first year post‐myocardial infarction (MI) had the lowest risk of mortality, over a 4.2‐year follow‐up period.在心肌梗死（MI）后第一年内保持体力活动的患者死亡率最低，随访4.2年以上。However, changes in physical activity level the first‐year post‐MI is important, lowering the risk of mortality in patients increasing their activity and increasing risk in those with decreased activity.然而，MI后第一年的体力活动水平的改变是重要的，降低了增加活动患者死亡的风险，增加了活动减少患者的风险。It seems not to be too late to start being active post‐MI, since the group with increased activity post‐MI did not differ in survival from the constantly active group.在心肌梗死后开始活动似乎还不算太晚，因为心肌梗死后活动增加的组与持续活动组的存活率没有差别。
What Are the Clinical Implications?
The shown relation to survival, in patients who maintain or increase their level of physical activity post‐MI, reinforces the importance of the present guidelines and highlights the need for their implementation in secondary prevention.在心肌梗死后维持或提高其体力活动水平的患者中，所显示的与生存的关系加强了本指南的重要性，并强调了在二级预防中实施本指南的必要性。Being active post‐MI seems to be equally important for different subgroups.对于不同的子组来说，积极的后MI似乎同样重要。
Introduction
Myocardial infarction (MI) remains one of the most feared complications of cardiovascular disease (CVD), being associated with substantial morbidity and mortality. However, because of the advancements in emergency care, including the widespread use of cardiac interventions as well as antithrombotic, antihypertensive, and dyslipidemia treatment, a larger proportion of patients now survive their first MI.1 This positive development has resulted in more focus being put on secondary prevention.心肌梗死（MI）仍然是心血管疾病（CVD）最令人担忧的并发症之一，其发病率和死亡率都很高。然而，由于紧急护理的进步，包括心脏介入治疗以及抗血栓、抗高血压和血脂异常治疗的广泛使用，现在较大比例的患者在第一次心肌梗死后存活。这种积极的发展使得人们更加关注二级预防。Physical activity (PA) is a well‐recognized factor in the primary prevention of CVD.3 Also in patients with established CVD, structured physical activity (PA)5 as well as increases in PA6 have been shown to be associated with reduced cardiovascular mortality. These effects rest on multiple positive effects on traditional risk factors for CVD, including hypertension, dyslipidemia, obesity, and diabetes mellitus as well as on possible effects on atherosclerotic progression, endothelial dysfunction, autonomic control, and subsequent arrhythmia risk.8 Thus, a sufficiently high PA level is recommended as first‐line treatment in primary and secondary prevention guidelines10 globally. However, the adherence to these PA recommendations, and the use of exercise as part of regular treatment in health care, vary to a great extent.11体力活动（PA）是心血管疾病一级预防中公认的因素。同样在已确诊为CVD的患者中，结构性体力活动（PA）以及PA的增加已被证明与降低心血管死亡率有关。这些影响取决于对包括高血压、血脂异常、肥胖和糖尿病在内的心血管疾病传统危险因素的多重积极影响，以及对动脉粥样硬化进展、内皮功能障碍、自主控制和随后的心律失常风险的可能影响。因此，在全球一级和二级预防指南中，建议将足够高的PA水平作为第一线治疗。然而，遵守这些PA建议，以及将运动作为常规治疗一部分用于卫生保健，在很大程度上各不相同。Atherosclerosis is a progressing disease, and the disease itself, and its consequences, may affect the ability of the individual to be sufficiently physically active both before and after a cardiac event. One limitation of earlier studies on the association between the level of PA and survival post‐MI is the risk of selection bias (ie, that the individuals with the most advanced disease are also the least active because of their functional status). Therefore, changes in PA level during the period following the event, rather than a single measure of PA, may provide more information when assessing the effect of rehabilitation interventions. The effect of lifestyle‐focused cardiac rehabilitation has been investigated, showing reduced risk of readmissions and decreased cardiovascular mortality, while inconsistent findings for total mortality exist.12 Cardiac rehabilitation focusing on risk reduction has also been shown to reduce mortality.14 However, many patients are not offered cardiac rehabilitation for various reasons. Also, cardiac rehabilitation is multifactorial in its nature, and the isolated effect from exercise may be difficult to identify.15动脉粥样硬化是一种进展性疾病，该疾病本身及其后果可能影响个体在心脏事件之前和之后充分身体活动的能力。早期关于PA水平与MI后存活率之间关系的研究的一个局限性是选择偏倚的风险（即，患有最晚期疾病的个体由于其功能状态也是最不活跃的）。因此，在评估康复干预的效果时，在事件发生后的时间段内PA水平的变化，而不是PA的单一测量，可以提供更多的信息。以生活方式为重点的心脏康复的效果已经被调查，显示出再入院的风险降低和心血管死亡率降低，而总的死亡率却存在不一致的发现。以降低风险为重点的心脏康复也被证明可以降低死亡率。然而，由于各种原因，许多患者没有接受心脏康复治疗。此外，心脏康复本质上是多因素的，并且运动产生的单独作用可能难以确定。Little is known about the long‐term effects on mortality from changes in PA levels in patients with MI. In a pioneer article, Steffen‐Batey et al16 reported considerably lowered mortality in patients who increased their activity (Relative risk (RR)=0.11), compared with those who remained physically inactive, in a cohort of 406 male and female MI patients. Recently, another study on 856 women in the Women's Health Initiative‐Observational study, showed similar results.7 However, additional and larger studies are needed, to be able to study these relations in important strata, related to the severity of the MI, comorbidities, or consequences, such as kidney function, quality of life, and the degree of tolerated medication. Such comparisons would be of clinical importance, directly influencing the treatment post‐MI.对于心肌梗死患者PA水平变化对死亡率的长期影响知之甚少。在一篇开创性的文章中，Steffen Batey等人在406名男性和女性心肌梗死患者的队列中报告，与那些保持身体不活动的患者相比，活动性增加的患者的死亡率显著降低(相对风险(RR)=0.11)。最近，在妇女健康倡议观察研究中，对856名妇女进行的另一项研究显示出类似的结果。然而，需要更多和更大的研究，以便能够在与MI的严重程度、合并症或后果相关的重要地层中研究这些关系，例如肾功能、生活质量和耐受药物的程度。这种比较具有临床意义，直接影响MI后的治疗。Therefore, the aim of this study was to assess the long‐term survival among patients with MI in relation to changes in self‐reported PA in a large nationwide cohort of Swedish patients with MI. Furthermore, we aimed to assess any moderating effects from known risk factors on this relationship.因此，本研究的目的是评估MI患者的长期存活率与瑞典一大批MI患者自我报告的PA变化之间的关系。此外，我们旨在评估已知风险因素对这种关系的任何调节作用。
Methods
Data, analytical methods, and study materials will not be made available to other researchers by the authors for purpose of reproducing the results or replicating the procedure. The authors are not authorized to share SWEDEHEART data.作者将不向其他研究人员提供数据、分析方法和研究材料，以便再现结果或复制程序。作者没有权限共享SWEDEHEART数据。We obtained data from the national SWEDEHEART registry (Swedish Web‐system for Enhancement and Development of Evidence‐based care in Heart disease Evaluated According to Recommended Therapies17 including the initial care [subregistry RIKS‐HIA] and all subsequent MI‐related care [subregistry SEPHIA]). SWEDEHEART has an uptake of >90% of all cardiology units in Sweden, and the cohort can be regarded as representative of the Swedish patients with MI. The SWEDEHEART subregistry SEPHIA (Secondary Prevention after Heart Intensive Care Admissions)18 provided information from 2 follow‐up visits, at 6 to 10 weeks and 12 months post‐MI, which included data on secondary prevention treatments, lifestyle, and prevalence of risk factors. The primary outcome was mortality, which was obtained from the Swedish Census registry. Mortality data were extracted on October 7, 2014. Mean follow‐up time (ie, between date for MI and date of death or end of study) was 1635 days or 4.2 years.我们从瑞典国家SWEDEHEART注册中心(瑞典Web系统，用于增强和发展心脏病循证护理，根据推荐治疗进行评估，包括初始护理[分区域RIKS HIA]和随后所有MI相关护理[分区域SEPHIA])获得数据。在瑞典，所有心脏科单位的90%以上为瑞典人所接受，该队列可被视为瑞典MI患者的代表。SWEDEHEART分区域SEPHIA(入院后心脏强化护理的二级预防)提供了MI后6至10周和12个月的2次随访的信息，包括二级预防治疗、生活方式和危险因素流行率的数据。主要结果是死亡率，这是从瑞典人口普查登记处获得的。2014年10月7日提取了死亡率数据。平均随访时间为1635天或4.2年。We included all patients (n=22 227) between ages 18 and 75 years who were diagnosed with their first MI (International Classification of Diseases, Tenth revision [ICD‐10] code I.21) between December 28, 2004 and October 25, 2013 and who provided complete data in the SWEDEHEART registry (Figure 1).我们包括2004年12月28日至2013年10月25日之间被诊断出患有第一例MI(国际疾病分类，第十次修订[ICD 10]代码I.21)的18至75岁之间的所有患者(n=22 227)，他们在SWEDEHEART登记处提供了完整的数据(图1)。Figure 1Flow chart for inclusion in analyses. BMI indicates body mass index; EF, ejection fraction; eGFR, estimated glomerular filtration rate; EQ‐5D, EuroQol‐5 dimensions; PA, physical activity; STEMI, ST‐segment–elevation myocardial infarction.From the SWEDEHEART registry, age, body mass index, serum creatinine, height, sex, type of MI, and left ventricular function were obtained. Type of MI was based on a clinical assessment and patients were classified as having had a ST‐segment‐elevation MI (STEMI), or a non‐ST‐segment‐elevation MI (NSTEMI). Left ventricular function was expressed as ejection fraction (EF) in percent, and was further divided into >50%, 49% to 40%, or ≤40%. The use of percutaneous cardiac interventions during treatment was also recorded in the SWEDEHEART and coded as yes or no. Estimated glomerular filtration rate (eGFR) was based on plasma creatinine values calculated according to the Cockcroft‐Gault formula [eGFR=(1.23×(140−age)×body mass)/serum creatinine and eGFR=(1.04×(140−age)×body mass)/serum creatinine, for men and women, respectively], which has previously been used in analyses of the SWEDEHEART registry.19 eGFR was dichotomized at 60 mL/min per 1.73 m2, to identify normal or mildly decreased GFR from moderately decreased or more pronouncedly decreased GFR.根据SWEDEHEART登记，获得年龄、体重指数、血清肌酐、身高、性别、MI类型和左心功能。MI的类型基于临床评估，患者被分为ST段抬高MI（STEMI）或非ST段抬高MI（NSTEMI）。左室功能以射血分数（EF）百分数表示，进一步分为＞50％、49％～40％或≤40％。SWEDEHEART也记录了治疗期间经皮心脏介入治疗的使用情况，并编码为是或否。肾小球滤过率(eGFR)的估计值是基于根据Cockcroft-Gault公式[eGFR=(1.23×(140_岁)×体重)/血清肌酐和eGFR=(1.04×(140_岁)×体重)计算的血浆肌酐值。ss)/血清肌酐，分别用于男性和女性]，它以前用于瑞典心脏登记处的分析。每隔1.73米60mL/min对eGFR进行二分法，以鉴别正常或轻度降低的GFR与中度降低或更显著降低的GFR。PA was reported in the SEPHIA subregistry at both follow‐up visits as self‐reported number of PA sessions, 30 minutes or longer, during the last 7 days. Values between zero and 7 were accepted in the registry. Patients were classified as “inactive” if they reported none or 1 session of PA per week, only. Patients reporting 2 or more sessions per week were classified as “active.” Patients were further classified according to changes in activity level between the 2 secondary prevention visits (at 6–10 weeks and 12 months, respectively), as constantly being inactive, having reduced activity, increased activity, or being constantly active. Full pharmacological treatment was identified as being treated with angiotensin‐converting enzyme inhibitors, β‐blocking agent, statins, or other lipid‐lowering agents and antithrombogenic agents (coded as yes or no). Smoking status (never‐smoker, ex‐smoker since >1 month or smoker) was recorded at the first rehabilitation visit, 6 to 10 weeks after discharge from the hospital. When data were missing on smoking (n=32), additional data were obtained from the second visit. Data on participation in exercise‐based cardiac rehabilitation during the year following MI was obtained from the second rehabilitation visit. Data from the Euro‐Qol 5 dimensions (EQ‐5D) from the first visit was used to estimate health‐related quality of life.20 The Regional Ethics Board in Stockholm, Sweden approved this study (2013/2067‐31). No informed consent was required. The corresponding author had full access to all the data in the study and takes responsibility for its integrity and the data analysis.在两次后续访问中，SEPHIA分区域报告了PA，因为自报在过去7天内PA会期为30分钟或更长。注册表中接受0到7之间的值。如果患者每周只报告1次或不报告一次PA，则被归类为“不活动”。报告每周2次或更多次治疗的患者被归类为“活跃”。根据两次二级预防访问(分别在6-10周和12个月)之间的活动水平的变化进一步将患者归类为持续不活跃、活动减少、活动增加或持续活跃。全部的药理学治疗被鉴定为使用血管紧张素转换酶抑制剂、β阻断剂、他汀类药物或其他降脂剂和抗血栓形成剂(编码为是或否)治疗。出院后6至10周，在第一次康复探视时记录吸烟状况(从不吸烟，自>1个月后即已戒烟或吸烟)。当关于吸烟的数据缺失(n=32)时，从第二次访问中获得额外的数据。在心肌梗死后一年中，有关参与以运动为基础的心脏康复的数据是从第二次康复访问中获得的。使用首次访问的欧洲生活质量5维度(EQ-5D)数据评估与健康相关的生活质量。瑞典斯德哥尔摩地区伦理委员会批准了这项研究(2013/2067-31)。不需要知情同意。相应的作者完全访问了研究中的所有数据，并负责其完整性和数据分析。
Statistics
Descriptive demographic and clinical characteristics were analyzed using means (SDs) and percentage. Differences between survivors and fatal cases were tested using the t test and χ2 test. Hazard ratios (HRs) and their 95% confidence interval were computed using Cox proportional hazard ratios using the SPSS Cox regression with time‐dependent covariate module. Hazard ratios for the 4 PA strata (constantly active, reduced activity, increased activity, or constantly inactive) were computed unadjusted and controlled for potential confounders. In the fully adjusted models, age, sex, date for MI, body mass index, EQ‐5D, EF, type of MI, the use of percutaneous cardiac interventions, eGFR, smoking, pharmacological treatment, and participation in cardiac rehabilitation training were included. We checked the proportionality assumption using scaled Schönfelts residuals. All variables were checked for proportionality, including the separate measures from the first and second PA assessment. A weak and borderline significance was noted only for PA strata. Because of this, we included an interaction term for time × PA strata in all analyses. Formal interaction analyses for HRs between PA strata were performed as proposed by Bland and Altman.21 HRs was considered to be statistically significant if the 95% confidence interval did not include the value of 1. All statistics were performed in IBM SPSS (version 21).描述性人口统计和临床特征分析使用手段（SDs）和百分比。采用t检验和检验对存活者和死亡病例之间的差异进行检测。使用具有时间相关协变量模块的SPSS Cox回归，使用Cox比例风险比计算危险比及其95%置信区间。对4个PA地层（持续活跃、活动减少、活动增加或持续不活跃）的危害比进行未调整的计算，并对潜在的混杂因素进行控制。在完全调整的模型中，包括年龄、性别、心肌梗死日期、体重指数、EQ5D、EF、心肌梗死类型、经皮心脏介入治疗的使用、eGFR、吸烟、药物治疗和参与心脏康复训练。我们用比例Schnfelts残差检验了比例假设。检查所有变量的比例性，包括从第一和第二PA评估中分离的措施。仅对PA层具有弱的边界意义。正因为如此，我们在所有的分析中都包括了时间×PA地层的相互作用项。根据Bland和Altman的建议，对PA层之间的HRs进行了形式化相互作用分析。如果95%的置信区间不包括1.所有统计信息都在IBM SPSS（版本21）中执行。
Results
Subject inclusion is described in Figure 1. The included and nonincluded patients differ in some aspects. Those with PA data, compared with those without, were less likely to be smokers (11.0% versus 13.6%), and have a low eGFR (8.2% versus 10.1%). Also their survival was lower (90.0% versus 94.2%). When comparing those included with PA data and those with PA data but lacking other variables, the latter group was less likely to have full medication (64.2% versus 69.6%), have had a STEMI (37.7% versus 41.1%), and more likely to be female (28.7% versus 26.1%). Also their survival was lower (92.0% versus 95.1%).图1描述了主题包含。入选患者与非入选患者在某些方面存在差异。与没有PA数据的人相比，那些有PA数据的人吸烟的可能性较低（11.0%比13.6%），eGFR较低（8.2%比10.1%）。存活率也较低（90.0%和94.2%）。当比较那些包括PA数据和那些没有其他变量的PA数据时，后一组不太可能完全用药（64.2%对69.6%），有STEMI（37.7%对41.1%），更有可能为女性（28.7%对26.1%）。存活率也较低（92.0%和95.1%）。Subject characteristics, for the 22 227 included MI patients, are given in Table 1. All the examined variables differed across PA strata, except for pharmacological treatment, where no difference could be seen between PA groups. Some differences were small, albeit statistically significant (age, body mass index). Women and current smokers were overrepresented in the constantly inactive strata, as were patients with NSTEMI. Constantly active participants also participated in exercise‐based cardiac rehabilitation to a higher degree (40.9% versus 21.6%) compared with the constantly inactive group.表1列出了22227例包括MI患者的受试者特征。除了药理治疗之外，所有被检测的变量在PA地层中都有所不同，在PA组之间没有观察到差异。有些差异很小，尽管在统计学上有显著性（年龄、体重指数）。妇女和现在的吸烟者在持续不活动的阶层中比例过高，NSTEMI患者也是如此。与持续不活动组相比，持续活跃组参与运动性心脏康复的程度更高（40.9%对21.6%）。Table 1 Subject Description
Constantly Inactive (n=2361)
Reduced Activity (n=3418)
Increased Activity (n=1998)
Constantly Active (n=14 450)
Number of deaths (total 1087)
291
198
103
495
Person‐y at risk (total 100 502 person‐y)
10 213
15 593
8932
65 764
n (%)
n (%)
n (%)
n (%)
P Value
Sex
Female
785 (33.2)
892 (26.1)
587 (29.4)
3542 (24.5)
<>
Male
1576 (66.8)
2526 (73.9)
1411 (70.6)
10 908 (75.5)
STEMI
874 (37.0)
1459 (42.7)
818 (40.9)
6284 (43.5)
<>
Ejection fraction
>50
1434 (60.7)
2189 (64.0)
1295 (64.8)
9955 (68.9)
<>
40–49
528 (22.4)
732 (21.4)
416 (20.8)
2818 (19.5)
<>
399 (16.9)
497 (14.5)
287 (14.4)
1677 (11.6)
Participation in cardiac rehabilitation training (@12 mo)
Patients reporting being active at both 6 to 10 weeks, and 1‐year post‐MI, had higher EQ‐5D, less prevalence of low eGFR, more often underwent percutaneous cardiac interventions, and had a higher EF post‐MI (Table 1).报告在心肌梗死后6～10周和1年都活跃的患者具有较高的情商5D，较低的eGFR发生率较低，更经常接受经皮心脏介入治疗，并且在心肌梗死后具有较高的EF(表1)。In uncontrolled analyses, mortality (cases per 1000 person‐years with 95% confidence interval) in the 4 PA strata was 28.5 (25.3–32.0) among the constantly inactive, 12.7 (11.0–14.6) among those who reduced their activity, 11.5 (9.4–14.0) among those who increased their activity, and 7.5 (6.9–8.2) among the constantly active patients. In the fully controlled model, HRs for mortality were lower for those being constantly active, and for those with increased and decreased activity strata compared with those in the constantly inactive strata. However, HR for patients who increased and patients who decreased their PA did not differ. Constantly active patients had lower HR compared with individuals decreasing their PA level. HR for patients who increased their PA level did not differ from those being constantly active (Table 2, Figure 2).在无对照分析中，4PA层死亡率（每1000人年有95%置信区间的病例）在持续不活动者中为28.5（25.3-32.0），在减少活动者中为12.7（11.0-14.6），在增加活动者中为11.5（9.4-14.0），在持续活动者中为7.5（6.9-8.2）。在完全控制模型中，与那些处于持续不活动层的人相比，那些处于持续活动层和活动层增加和减少的人的死亡率HRs较低。然而，对于增加PA的患者和降低PA的患者，HR没有差别。与降低PA水平的个体相比，持续活动患者的HR较低。增加PA水平的患者的HR与持续活动患者的HR没有差别(表2，图2)。Table 2 HR (95% CI) for the PA Strata in Age‐ and Sex‐Adjusted and Fully Adjusted Models
Constantly Inactive
Reduced Activity
Increased Activity
Constantly Active
Full sample
1087 deaths
100 502 person‐y
Age‐sex
1 (ref)
0.43 (0.35–0.53)
1 (ref)
0.32 (0.24–0.43)
0.83 (0.62–1.12)
1 (ref)
0.19 (0.14–0.26)
0.54 (0.37–0.80)
0.82 (0.49–1.37)
1087 deaths
100 502 person‐y
Fully adjusted
1 (ref)
0.56 (0.45–0.69)
1 (ref)
0.41 (0.31–0.55)
0.82 (0.61–1.10)
1 (ref)
0.29 (0.21–0.41)
0.64 (0.43–0.94)
0.95 (0.57–1.61)
Fully adjusted for age, sex, date of myocardial infarction, body mass index, estimated glomerular filtration rate, EuroQol‐5 dimensions, ejection fraction, ST‐elevation myocardial infarction, percutaneous coronary intervention, smoking status, pharmacological treatment, participation in cardiac rehabilitation training, and an interaction term for time × physical activity strata. CI indicates confidence interval; HR, hazard ratio; PA, physical activity.
Figure 2All‐cause mortality age and sex adjusted (upper) and fully adjusted (lower) among individuals with different physical activity (PA) strata. Fully adjusted for age, sex, date of myocardial infarction, body mass index, estimated glomerular filtration rate, EuroQol‐5 dimensions, ejection fraction, ST‐elevation myocardial infarction, percutaneous coronary intervention, smoking status, pharmacological treatment, participation in cardiac rehabilitation training, and an interaction term for time × PA strata.No interactions were found for any of the variables in the full model, indicating similar differences between PA strata and mortality between age, sex, STT changes, the use of percutaneous cardiac interventions, Eq‐5D, eGFR, cardiac rehabilitation, smoking status, and pharmacological treatment. The exception was EF, where HRs in the reduced PA strata were 0.42 (0.27–0.67) and 0.63 (0.42–0.93) for EF 40% to 50% and EF <40%, respectively.="" for="" the="" increased="" pa="" strata,="" corresponding="" values="" were="" 0.56="" (0.30–1.10)="" and="" 0.20="" (0.10–0.41)="" and="" for="" the="" constantly="" active="" strata="" 0.39="" (0.19–0.79)="" and="" 0.20="">在完整模型中没有发现任何变量的相互作用，表明PA层与年龄、性别、STT变化、经皮心脏介入治疗、Eq 5D、eGFR、心脏康复、吸烟状况和药物治疗之间的死亡率之间的相似差异。除EF外，降低的PA层的HR分别为0.42（0.27～0.67）和0.63（0.42～0.93），EF为40％～50％，EF＜40％。对于增加的PA地层，对应的值分别为0.56（0.30-1.10）和0.20（0.10-0.41），对于持续活动的地层为0.39（0.19-0.79）和0.20（0.10-0.41）。We also related mortality to activity levels at the 2 assessments separately. In age‐ and sex‐controlled analyses, active patients had lower mortality at both assessments, with HR (95% confidence interval=0.42 [0.38–0.48] and 0.41 [0.36–0.46]) for the first and second assessment, respectively. In fully controlled analyses, corresponding values were 0.58 (0.51–0.67) and 0.53 (0.47–0.60), for the first and second assessment, respectively.我们还将死亡率分别与两个评估中的活动水平联系起来。在年龄和性别对照分析中，活动期患者的死亡率在两项评估中都较低，第一和第二项评估的HR（95%置信区间=0.42[0.38-0.48]和0.41[0.36-0.46]）。在完全对照分析中，第一和第二评估的相应值分别为0.58（0.51-0.67）和0.53（0.47-0.60）。
Discussion
The main result of this study, based on a national registry of unselected patients with MI, is that the mortality among inactive patients, who increase their PA level during the first year following a MI, was much lower, over a 4.2‐year follow‐up period, compared with those who remained inactive. The lowest risk was seen in patients who remained physically active over the first year, post‐MI. Results for the group increasing their PA level is interesting, since the results indicate that patients who were initially inactive (which previous single‐assessment‐based studies have indicated to be at high risk) can reduce the risk by increasing activity. HRs in the group with increasing activity post‐MI did not differ from the constantly active group at follow‐up. The previous studies have also concluded that this group may be more affected by unmeasured factors or residual confounding, which in turn worsen the prognosis. Although this might well be present in this study, results from the group increasing their activity level post‐MI clearly show that mortality is lower in this group compared with the constantly inactive group, controlled for a large number of covariates.本研究的主要结果是，根据全国未选择的心肌梗死患者登记册，在心肌梗死后的第一年内增加PA水平的不活动患者的死亡率比那些保持不活动患者的死亡率要低得多。MI后第一年内仍保持体力活动的患者风险最低。对于提高PA水平的人群来说，结果很有趣，因为结果表明最初不活动的患者（先前基于单项评估的研究已经表明处于高风险）可以通过增加活动来降低风险。MI后活动增加组的HR与随访时持续活动组无差异。先前的研究也已经得出结论，这个组可能更受未测量的因素或残余混杂的影响，这反过来又恶化了预后。虽然本研究中很可能存在这种情况，但MI后活动水平提高组的结果清楚地表明，与持续不活动组相比，该组的死亡率较低，控制在大量协变量中。Similarly, results from the group decreasing their PA level indicate that those who were active 6 to 10 weeks after MI but reduced PA have a worse prognosis, as compared with those remaining physically active. Again, even if unmeasured and uncontrolled factors may differ between active and inactive patients at 6 to 10 weeks after MI, changes in PA level over 1 year were still related to mortality. Patients potentially having a more severe disease still benefit from PA increase to a similar extent as those with less severe disease. The exception was between patients with EF between 40% and 50% and EF <40%, where="" hrs="" differed="" between="" pa="" strata.="" results="" indicated="" that="" patients="" with="" a="" low="" ef=""><40%), compared="" with="" a="" moderately="" reduced="" ef="" 40%="" to="" 50%,="" showed="" an="" even="" stronger="" risk="" reduction="" among="" constantly="" active="" patients="" and="" patients="" increasing="" their="" pa="">类似地，该组降低其PA水平的结果表明，与那些保持身体活动的人相比，那些在心肌梗死后6-10周活动但PA降低的人的预后更差。同样，即使未测量和不受控制的因素在心肌梗死后6至10周活动期和非活动期患者之间可能有所不同，但1年以上PA水平的变化仍与死亡率有关。可能患有更严重疾病的患者仍然受益于PA的增加，其程度与那些患有较轻严重疾病的患者相似。EF在40%～50%之间，EF<40%之间为例外，而pa层间hrs存在差异。结果表明，低ef（＜40％）患者与低ef（＜40％）患者相比，中度降低ef>When analyzing the 2 assessments separately, we found smaller risk reductions among active patients as compared with those being constantly active. One possible explanation for this is that the inactive group at a single assessment will include participants with either a more active future or being more active in the past, which would dilute the contrast. This stresses the importance of studying PA level at more than 1 time point. Also, these results add to previous studies, by showing that these relations seem independent of cardiac rehabilitation participation in major subgroups post‐MI. Also, the similarity of the HRs found at the 2 assessments (6–10 weeks and 10–20 months post‐MI) when analyzed separately can be taken as an argument against a possible competing hypothesis that the type or intensity of the PA performed at the 2 time points differ.当分别分析这两项评估时，我们发现活动期患者与持续活动期患者相比风险降低较小。对此的一种可能的解释是，在单一评估中，不活跃的小组将包括未来更积极或过去更积极的参与者，这将稀释对比。这强调了在一个以上的时间点研究PA水平的重要性。此外，这些结果还补充了以前的研究，表明这些关系似乎独立于心肌梗死后主要亚群的心脏康复参与。此外，当分开分析时，在2次评估(MI后6-10周和10-20个月)中发现的HR的相似性可被看作反对在2个时间点执行的PA的类型或强度不同的可能相互竞争的假说的论据。Presently, the association between higher levels of PA and lower risk of events in those with cardiovascular disease22 is well established. We were able to confirm this association and also expand on the previous findings by Stefen‐Batey16 and Gorczyca7 by identifying a lower risk in those patients with MI who increased their activity and an increased risk in those decreasing their activity, during the first year post‐MI. The present study, however, includes >22 000 patients with MI, and allowed for adjusting for multiple possible confounders, which was not possible in the previous studies. We could also show that this was true for several important subgroups, including older patients, those having heart failure, those with decreased kidney function, smokers, and for both sexes.目前，在患有心血管疾病的人中，高水平的PA与较低的事件风险之间的关系已经得到确认。我们能够证实这种联系，并且通过识别那些在心肌梗死后第一年活动性增加的心肌梗死患者的较低风险以及活动性降低患者的增加风险来扩展Stefen Batey和Gorczyca先前的发现。然而，本研究包括超过22,000名MI患者，并允许调整多种可能的混杂因素，这在以前的研究中是不可能的。我们也可以证明这对于几个重要的亚组是真实的，包括老年患者、心力衰竭患者、肾功能减退患者、吸烟者以及男女。Importantly, our study included the sum of all self‐reported PA and exercise, and not only exercise‐based cardiac rehabilitation, which has earlier been found be related to lower mortality post‐MI.12 Indeed, our results were independent of participation or nonparticipation in cardiac rehabilitation. Exercise‐based cardiac rehabilitation performed at home or at the hospital have both been related to CVD reduction in patients with MI.23 However, far from all patients are offered cardiac rehabilitation for different reasons, often related to severity of the MI or other health‐related factors, including older age. Of those offered hospital‐based cardiac rehabilitation, not all choose to participate, perhaps because of practical reasons (such as living a long distance from the hospital or lack of interest). Thus, those investigated in studies of hospital or home‐based cardiac rehabilitation may constitute a selected subgroup. In addition, when entering a physical training program, such as cardiac rehabilitation, other parts of the activity pattern, such as everyday activity or hobbies, may be compensatorily decreased, leading to a status quo regarding total PA.24 Similarly, sedentary activity may increase again after the end of cardiac rehabilitation.25 Unfortunately, Hansen et al showed that the cardiovascular disease risk profile worsened significantly during long‐term follow‐up after cardiac rehabilitation.26 Therefore, focusing on all PA, regardless of context, may offer an important target for improved clinical secondary prevention post‐MI.重要的是，我们的研究包括所有自我报告的PA与运动的总和，而不仅仅是基于运动的心脏康复，早先发现与MI后低死亡率有关。事实上，我们的结果独立于参与或不参与心脏康复。在家里或医院进行的以运动为基础的心脏康复都与MI患者的CVD减少有关。然而，并非所有患者都因不同原因接受心脏康复治疗，常常与MI的严重程度或其他健康相关因素有关，包括老年人。在那些提供以医院为基础的心脏康复治疗的人中，并非所有人都选择参加，也许是因为实际的原因（比如住在离医院很远的地方或缺乏兴趣）。因此，那些在医院或家庭心脏康复研究中被调查的人可以组成一个选定的亚组。此外，在进入诸如心脏康复的体育训练项目时，活动模式的其他部分，例如日常活动或爱好，可能被补偿性地减少，导致总的PA的状况。同样，在心脏康复结束后，久坐活动可能再次增加。不幸的是，Hansen等人在心脏康复后的长期随访中显示，心血管疾病风险谱显著恶化。因此，不分上下文，关注所有PA，可为改善MI后临床二级预防提供重要指标。The relative intensity of the performed activities in the present study is unknown. The intensity of the PA performed may be of importance, since aerobic fitness has been shown to be an important predictor of survival, also post‐MI,27 and cardiac rehabilitation has been shown to increase aerobic fitness.28 However, both high‐intensity exercise and less‐intense continuous exercise have been shown to reduce CVD risk in cardiac patients,29 while Williams et al showed that walking had equal CVD‐risk‐reducing effects as running did in patients at high cardiac risk.22 Regarding frequency of PA, we showed that two 30‐minute sessions/wk of physical exercise, or an increase to that level within the first year post‐MI, were related to lowered mortality post‐MI, while 0 to 1 sessions/wk seems be too little. The lowered mortality related to activity may be even smaller, as self‐reported PA generally is higher than the levels found by more objective measures, such as accelerometry.30 Interestingly, these findings are consistent with the findings of Hansen et al, showing that a smaller exercise volume during phase II rehabilitation generated equal long‐term clinical benefits, compared with a greater exercise volume.26 Such findings may be associated with a lower compliance of greater exercise volumes and higher‐intensity activity.本研究中所进行的活动的相对强度是未知的。由于有氧健身已被证明是存活的重要预测因子，心肌梗死后PA的强度可能很重要，并且心脏康复已被证明能提高有氧健身。然而，高强度运动和较低强度的连续运动均可降低心脏患者的心血管疾病风险，而Williams等人则表明步行与跑步对高心脏风险患者的心血管疾病风险降低效果相同。关于PA的频率，我们发现，两次30分钟的体育锻炼/wk，或者在MI后的第一年内增加到那个水平，与降低MI后的死亡率有关，而0到1次/wk似乎太少。与活动有关的死亡率的降低可能甚至更小，因为自我报告的PA通常高于通过更客观的措施，如加速计发现的水平。有趣的是，这些发现与Hansen等人的发现是一致的，表明与较大的运动量相比，在II期康复期间较小的运动量产生相等的长期临床益处。这些发现可能与较低的运动量顺应性和较高的强度活动有关。Thus, the findings of the present study may have important clinical implications, since although universally recommended,10 PA is still underutilized as part of preventive and treatment strategies in health care. This is troublesome, since other commonly used components in secondary prevention, such as patient education, have been shown to be less efficient.15 The shown relation to survival, in patients who maintain or increase their level of PA post‐MI, reinforces the importance of the present guidelines and highlights the need for improved secondary prevention including the implementation of PA advice as part of regular postinfarction treatment. At present not enough is known regarding how to design effective counseling for increased PA among MI survivors, despite many studies. Promising initiatives and methods, such as PA on prescription (PAP) and Exercise is medicine (EiM), have been shown to increase the level of PA,31 and may receive a large boost, as a result of the present findings, but need to be investigated further in patients with MI before it can be suggested to be an alternative to exercise‐based rehabilitation. Other interventions include different forms of automated feedback from wearable electronic devices. One such system has been tested in a randomized clinical trial study, reporting important changes in activity levels,33 although contradicting data have been published.34 Patients should receive counseling on PA after having an MI, and this could be offered as a continuation of, or as an alternative to, cardiac rehabilitation, when this is not available.因此，本研究的结果可能具有重要的临床意义，因为尽管普遍推荐，PA作为卫生保健预防和治疗战略的一部分仍然未得到充分利用。这很麻烦，因为在二级预防中其他常用组件，如病人教育，已被证明效率较低。在维持或提高MI后PA水平的患者中，所显示的生存关系加强了本指南的重要性，并强调需要改善二级预防，包括作为常规梗死后治疗的一部分实施PA建议。尽管有许多研究，但是目前对于如何设计有效的心理咨询来增加MI幸存者的PA知之甚少。有希望的举措和方法，如处方药PA(PAP)和运动是医学(EiM)，已被证明可提高PA的水平，并可能得到很大的提高，由于目前的发现，但需要在MI患者中进一步调查，才能建议将其作为运动康复的替代。在。其他干预措施包括来自可穿戴电子设备的不同形式的自动反馈。一个这样的系统已经在随机临床试验研究中进行了测试，报告了活动水平的重要变化，尽管矛盾的数据已经发表。患者在发生心肌梗死后应接受PA咨询，当无法获得此咨询时，可提供此咨询作为心脏康复的继续或替代。An obvious strength of the present study is the large sample size, and its representativeness of the whole Swedish MI population over 10 years. The large sample size allows us to perform subgroup analyses on important subgroups, as described above. In addition, the study took place in the 2000s, confirming the role of changes in PA for secondary prevention in the modern era of MI treatment, including a high rate of invasive treatment and effective medication for secondary prevention.本研究的一个明显优点是样本量大，而且在10年内它代表了整个瑞典MI人群。大样本量允许我们对重要子组执行子组分析，如上所述。此外，该研究发生在2000年代，证实了PA在二级预防中的作用在现代心肌梗死治疗时代的变化，包括高侵袭性治疗率和有效的二级预防药物。The mean follow‐up time is relatively short, possibly making the results sensitive to reverse causation. To investigate this, we undertook analyses with patients with a shorter follow‐up time than 2 years after admission is excluded (n=3424, 151 deaths). The main analyses were repeated and only limited and nonsignificant differences were noted, when applying formal testing.21 This indicated that the effect of reverse causation might be limited.平均随访时间相对较短，可能使结果对反向原因敏感。为了研究这一点，我们对那些随访时间短于入院后2年（n=3424，151例死亡）的患者进行了分析。在应用正式测试时，主要分析被重复，并且只注意到有限的和非显著的差异。这说明反向因果关系的作用可能是有限的。A limitation of the study is the exposure measure. The criterion‐related validity of the PA assessment in patients with MI is unknown. Furthermore, it does not include measures of sedentary behaviors and variations in intensity of the PA, which would have added to the study. However, the predictive validity of the question is strong, as shown by the present article. Another limitation is the possibility of residual confounding (ie, although measures were taken to control for important factors, there is a possibility that some variation was unmeasured). Also, we lack data on potential important socioeconomic variables. Yet another limitation is the absence of nutritional information. This was not included in the SWEDEHEART registry at the time of this study and therefore could not be accounted for.这项研究的一个局限是暴露测量。MI患者PA评估的相关效度尚不清楚。此外，它还没有包括久坐行为和PA强度变化的测量，而这些将添加到研究中。然而，如本文所示，该问题的预测有效性很强。另一个限制是残留混淆的可能性（即，虽然已采取措施控制重要因素，但有可能未测量某些变化）。此外，我们缺乏关于潜在的重要社会经济变量的数据。另一个限制是缺乏营养信息。这项研究时，这并没有包括在SWEDEHEART注册表中，因此无法解释。Included and nonincluded patients differ in several aspects, as noted in the Results section. Included patients were generally less often smokers, had better eGFR, were less likely to have had a STEMI, and had a higher survival. Investigating a cohort biased to be healthier may lead to an underestimation of the effect of changes in PA. However, the absences of interaction between the variables in the full model and PA strata indicates that findings are generally robust across strata (ie, similar results among those with high/low eGFR, STEMI/NSTEMI, etc), with the exception of EF. Therefore, it is assumed that this bias is limited. As mentioned in the Results, PA strata differ in several aspects. It is possible that, despite both controlling for these differences and performing stratified analyses, being inactive serves as a proxy for MI severity or other ongoing illness. However, the similarities in the stratified analyses can be taken as an argument against this.如结果部分所述，包括和非包括的患者在几个方面存在差异。纳入的患者通常较少吸烟，有较好的eGFR，较少发生STEMI，有较高的存活率。调查一个偏向于更健康的队列可能导致对PA变化的影响的低估。然而，在完整模型和PA地层中变量之间缺乏交互作用表明发现通常跨地层是稳健的（即，在高/低eGFR、STEMI/NSTEMI等人群中类似的结果），例外EF的N。因此，假定这种偏置是有限的。正如在结果中提到的，PA地层在几个方面是不同的。有可能，尽管控制这些差异并执行分层分析，但是非活动性充当MI严重性或其他正在进行的疾病的代理。然而，分层分析中的相似之处可以视为对此的一种反驳。Three categories for exposure to smoking were used. A more precise measure, such as pack‐years, may have reduced possible residual confounding regarding this variable.使用三种类型的暴露于吸烟。更精确的测量，例如包装年份，可能已经减少了关于这个变量的可能的残余混淆。In conclusion, increased PA in the first year post‐MI is associated with a lower risk of subsequent death. This is the largest study to assess the effects of changes in PA post‐MI in the modern era of MI treatment, in a nationwide representative cohort. The results of the present study will have great clinical impact, highlighting the use of PA as part of regular secondary preventive measures after MI. Hopefully, we now have no excuses not to improve the adherence to existing guidelines on secondary prevention.总之，心肌梗死后第一年PA增加与随后死亡的风险降低有关。这是规模最大的研究，以评估PA后MI在现代MI治疗时代的影响，在全国代表性的队列。本研究的结果将具有很大的临床影响，强调使用PA作为心肌梗死后常规二级预防措施的一部分。希望我们现在没有借口不改进对现有二级预防指导方针的遵守。
Sources of Funding
Ekblom and Ek were funded by ICA Sweden. There was no other specific grant from any funding agency in the public, commercial, or not‐for‐profit sectors.Ekblom和Ek由ICA瑞典资助。在公共、商业或非营利部门，没有任何资金机构提供其他特别资助。
Disclosures
None.
Footnotes
*Correspondence to: Örjan Ekblom, PhD, The Åstrand Laboratory of Work Physiology, The Swedish School of Sport and Health Sciences, Lidingövägen 1, P. O. Box 5626, 114 86 Stockholm, Sweden. E‐mail: orjan.******se
References
1 The National Board of Health and Welfare . Statistics on myocardial infarctions 2015. 2017.2 Johansson S, Rosengren A, Young K, Jennings E. Mortality and morbidity trends after the first year in survivors of acute myocardial infarction: a systematic review. BMC Cardiovasc Disord. 2017;17:53.3 Wijndaele K, Sharp SJ, Wareham NJ, Brage S. Mortality risk reductions from substituting screen time by discretionary activities. Med Sci Sports Exerc. 2017;49:1111–1119.4 Li J, Siegrist J. Physical activity and risk of cardiovascular disease—a meta‐analysis of prospective cohort studies. Int J Environ Res Public Health. 2012;9:391–407.5 Miura Y, Fukumoto Y, Miura T, Shimada K, Asakura M, Kadokami T, Ando S, Miyata S, Sakata Y, Daida H, Matsuzaki M, Yasuda S, Kitakaze M, Shimokawa H. Impact of physical activity on cardiovascular events in patients with chronic heart failure. A multicenter prospective cohort study. Circ J. 2013;77:2963–2972.6 Yates T, Haffner SM, Schulte PJ, Thomas L, Huffman KM, Bales CW, Califf RM, Holman RR, McMurray JJ, Bethel MA, Tuomilehto J, Davies MJ, Kraus WE. Association between change in daily ambulatory activity and cardiovascular events in people with impaired glucose tolerance (NAVIGATOR trial): a cohort analysis. Lancet. 2014;383:1059–1066.7 Gorczyca AM, Eaton CB, LaMonte MJ, Manson JE, Johnston JD, Bidulescu A, Waring ME, Manini T, Martin LW, Stefanick ML, He K, Chomistek AK. Change in physical activity and sitting time after myocardial infarction and mortality among postmenopausal women in the Women's Health Initiative‐Observational Study. J Am Heart Assoc. 2017;6:e005354. DOI: DOI: 10.1161/JAHA.116.005354.8 Palmefors H, DuttaRoy S, Rundqvist B, Borjesson M. The effect of physical activity or exercise on key biomarkers in atherosclerosis—a systematic review. Atherosclerosis. 2014;235:150–161.9 Martinez DG, Nicolau JC, Lage RL, Toschi‐Dias E, de Matos LD, Alves MJ, Trombetta IC, Dias da Silva VJ, Middlekauff HR, Negrao CE, Rondon MU. Effects of long‐term exercise training on autonomic control in myocardial infarction patients. Hypertension. 2011;58:1049–1056.10 Piepoli MF, Hoes AW, Brotons C, Hobbs RFD, Corra U; Task Force for the guidelines on cardiovascular disease prevention in clinical p . Main messages for primary care from the 2016 European Guidelines on cardiovascular disease prevention in clinical practice. Eur J Gen Pract. 2018;24:51–56.11 Hansen D, Rovelo Ruiz G, Doherty P, Iliou MC, Vromen T, Hinton S, Frederix I, Wilhelm M, Schmid JP, Abreu A, Ambrosetti M, Garcia‐Porrero E, Coninx K, Dendale P; Group EEw . Do clinicians prescribe exercise similarly in patients with different cardiovascular diseases? Findings from the EAPC EXPERT working group survey. Eur J Prev Cardiol. 2018;25:682–691. DOI: DOI: 10.1177/2047487318760888.12 Anderson L, Oldridge N, Thompson DR, Zwisler AD, Rees K, Martin N, Taylor RS. Exercise‐based cardiac rehabilitation for coronary heart disease: cochrane systematic review and meta‐analysis. J Am Coll Cardiol. 2016;67:1–12.13 Lawler PR, Filion KB, Eisenberg MJ. Efficacy of exercise‐based cardiac rehabilitation post‐myocardial infarction: a systematic review and meta‐analysis of randomized controlled trials. Am Heart J. 2011;162(571–584):e2.14 van Halewijn G, Deckers J, Tay HY, van Domburg R, Kotseva K, Wood D. Lessons from contemporary trials of cardiovascular prevention and rehabilitation: a systematic review and meta‐analysis. Int J Cardiol. 2017;232:294–303.15 Anderson L, Brown JP, Clark AM, Dalal H, Rossau HK, Bridges C, Taylor RS. Patient education in the management of coronary heart disease. Cochrane Database Syst Rev. 2017;6:CD008895.16 Steffen‐Batey L, Nichaman MZ, Goff DC, Frankowski RF, Hanis CL, Ramsey DJ, Labarthe DR. Change in level of physical activity and risk of all‐cause mortality or reinfarction: the Corpus Christi Heart Project. Circulation. 2000;102:2204–2209.17 Jernberg T, Attebring MF, Hambraeus K, Ivert T, James S, Jeppsson A, Lagerqvist B, Lindahl B, Stenestrand U, Wallentin L. The Swedish Web‐system for enhancement and development of evidence‐based care in heart disease evaluated according to recommended therapies (SWEDEHEART). Heart. 2010;96:1617–1621.18 Hambraeus K, Tyden P, Lindahl B. Time trends and gender differences in prevention guideline adherence and outcome after myocardial infarction: data from the SWEDEHEART registry. Eur J Prev Cardiol. 2016;23:340–348.19 Sederholm Lawesson S, Alfredsson J, Szummer K, Fredrikson M, Swahn E. Prevalence and prognostic impact of chronic kidney disease in STEMI from a gender perspective: data from the SWEDEHEART register, a large Swedish prospective cohort. BMJ Open. 2015;5:e008188.20 Janssen MF, Pickard AS, Golicki D, Gudex C, Niewada M, Scalone L, Swinburn P, Busschbach J. Measurement properties of the EQ‐5D‐5L compared to the EQ‐5D‐3L across eight patient groups: a multi‐country study. Qual Life Res. 2013;22:1717–1727.21 Altman DG, Bland JM. Interaction revisited: the difference between two estimates. BMJ. 2003;326:219.22 Williams PT, Thompson PD. Increased cardiovascular disease mortality associated with excessive exercise in heart attack survivors. Mayo Clin Proc. 2014;89:1187–1194.23 Anderson L, Sharp GA, Norton RJ, Dalal H, Dean SG, Jolly K, Cowie A, Zawada A, Taylor RS. Home‐based versus centre‐based cardiac rehabilitation. Cochrane Database Syst Rev. 2017;6:CD007130.24 Gomersall SR, Rowlands AV, English C, Maher C, Olds TS. The ActivityStat hypothesis: the concept, the evidence and the methodologies. Sports Med. 2013;43:135–149.25 Ter Hoeve N, Sunamura M, van Geffen ME, Fanchamps MH, Horemans HL, Bussmann JB, Stam HJ, van Domburg RT, van den Berg‐Emons RJ. Changes in physical activity and sedentary behavior during cardiac rehabilitation. Arch Phys Med Rehabil. 2017;98:2378–2384.26 Hansen D, Dendale P, Raskin A, Schoonis A, Berger J, Vlassak I, Meeusen R. Long‐term effect of rehabilitation in coronary artery disease patients: randomized clinical trial of the impact of exercise volume. Clin Rehabil. 2010;24:319–327.27 Barons MJ, Turner S, Parsons N, Griffiths F, Bethell H, Weich S, Thorogood M. Fitness predicts long‐term survival after a cardiovascular event: a prospective cohort study. BMJ Open. 2015;5:e007772.28 Hannan AL, Hing W, Simas V, Climstein M, Coombes JS, Jayasinghe R, Byrnes J, Furness J. High‐intensity interval training versus moderate‐intensity continuous training within cardiac rehabilitation: a systematic review and meta‐analysis. Open Access J Sports Med. 2018;9:1–17.29 Elliott AD, Rajopadhyaya K, Bentley DJ, Beltrame JF, Aromataris EC. Interval training versus continuous exercise in patients with coronary artery disease: a meta‐analysis. Heart Lung Circ. 2015;24:149–157.30 Ekblom O, Ekblom‐Bak E, Bolam KA, Ekblom B, Schmidt C, Soderberg S, Bergstrom G, Borjesson M. Concurrent and predictive validity of physical activity measurement items commonly used in clinical settings—data from SCAPIS pilot study. BMC Public Health. 2015;15:978.31 Rodjer L, H Jonsdottir I, Borjesson M. Physical activity on prescription (PAP): self‐reported physical activity and quality of life in a Swedish primary care population, 2‐year follow‐up. Scand J Prim Health Care. 2016;34:443–452.32 Börjesson M, Arvidsson D, Blomqvist Å, Daxberg E‐L, Jonsdottir IH, Lundqvist S, Mellén A, Onerup A, Perrson J, Sjögren P, Svanberg T, Jivegård L. Efficacy of the Swedish model for physical activity on prescription. Regional activity based HTA2018.33 Martin SS, Feldman DI, Blumenthal RS, Jones SR, Post WS, McKibben RA, Michos ED, Ndumele CE, Ratchford EV, Coresh J, Blaha MJ. mActive: a randomized clinical trial of an automated mHealth intervention for physical activity promotion. J Am Heart Assoc. 2015;4:e002239. DOI: DOI: 10.1161/JAHA.115.002239.34 Maddison R, Pfaeffli L, Whittaker R, Stewart R, Kerr A, Jiang Y, Kira G, Leung W, Dalleck L, Carter K, Rawstorn J. A mobile phone intervention increases physical activity in people with cardiovascular disease: results from the HEART randomized controlled trial. Eur J Prev Cardiol. 2015;22:701–709.
Increased Physical Activity Post–Myocardial Infarction Is Related to Reduced Mortality; Results From the SWEDEHEART Registry
JAHA research-article Dec 18, 2018: 7 (24), e010108 10.1161/JAHA.118.010108
