Table 12.

Studies examining the relationship between physical activity and cardiovascular disease.

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

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.