heart disease, stroke, peripheral arterial disease and...
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Heart disease, stroke, peripheral arterial disease and exercise
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Learning objectives
1. Appreciate the burden of cardiovascular disease BHF, WHO
2. Understand the role of physical activity in the prevention and treatment of cardiovascular disease NICE Guidance CG68, CG94, CG108, CG147, CG162, CG172, CG181
3. Be able to provide safe and effective exercise advice to patients with heart disease, stroke or peripheral arterial disease
4. Know the contraindications to exercise in patients with cardiovascular disease BACPR
5. Understand the efficacy and cost effectiveness of cardiac rehabilitation programmes NICE CMG40
6. Make Every Contact Count NICE QS 84
WHO and
BHF Cardiovascular disease statistics 2015; Nation Institute for Clinical Excellence (NICE)WHO/WHF/WSO Global atlas on cardiovascular disease prevention and controlBritish Association for Cardiovascular prevention and rehabilitation
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Annual Cardiovascular Disease (CVD) Mortality
Stroke 39,000
deaths
41,000 premature
deaths
CHD 69,000
deaths
CHD single biggest cause of
death
28% of all UK
Deaths
BHF Cardiovascular disease statistics 2015WHO/WHF/WSO Global atlas on cardiovascular disease prevention and control 2011
UK World
NCD = Non Communicable DiseaseCHD = Coronary Heart Disease
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The role of physical inactivity in Cardiovascular Disease and associated costs
£11bn1.7
million hospital episodes
370 million prescriptions
Lee et al. Lancet 2012, Effect of physical inactivity on major NCDs BHF Cardiovascular disease statistics 2015; Centre for economic and business research 2014
Physical inactivity is directly responsible for a high proportion of CVD mortality in the UK and worldwide
% due to inactivity Coronary Heart Disease All-cause mortality
United Kingdom 11% 17%
World Average 6% 9%
Annual NHS CVD burdenBHF 2015, CEBR 2014
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Contractility ↑
Coronary blood flow ↑
Oxygen demand ↓
Stroke volume (SV) ↑
Heart rate (HR) ↓
Cardiovascular effects of exercise
Blood Pressure ↓Oxygen uptake ↑
Oxygen utilisation ↑Endothelial function ↑
Plasma volume ↑Blood viscosity↓
DURING exercise:SV ↑ initially, but most of the ↑ in cardiac output is reliant on ↑ HR
HR monitors are useful in moderate/vigorous, but not light activity
FYSS 21: Coronary artery diseaseWilson et al. Heart 2015: Basic Science behind the cardiovascular benefits of exercise
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Prevention of CVDRelationship with physical activity
Greatest health benefits NO physical activity SOME physical activity
Tanasescu et al. JAMA 2002: Exercise type and intensity in relation to coronary heart diseaseWoodcock et al. Int J Epi 2011: Non-vigorous physical activity and mortalityEuropean Guidelines 2012; Kyu et al. BMJ 2016 Analysis of the Global Burden of Disease studyDoH UK 2011: Start Active Stay Active; NICE CG68, CG94, CG172, CG181 Woodcock 2011, Kyu 2016
Physical activity
is beneficial in the primary
and secondary prevention of
all CVD
Mortalityin patients with
CVD
20-35% LOW HIGH
Physical activity level
1
0.5
0
Ad
just
ed r
elat
ive
risk
of
coro
nar
y h
ear
t d
isea
se
EACPR, NICE CG68, CG94, CG172, CG181
DoH 2011
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Prevention of CVD Direct benefits and risk reduction due to physical activity
Risk factor PAR Effects of physical activity
Smoking 36% Cessation adjunct
Abnormal lipids 49% ↓ triglyceride, total & LDL cholesterol
Hypertension 18% 30-50% risk reduction
Type 2 Diabetes 10% 30-40% risk reduction
Obesity 20% Weight maintenance
Psychosocial factors
33% 20-30% ↓ depression, anxiety & stress
Low fruit & veg 14% No direct effect of physical activity
Regular alcohol 7% No direct effect of physical activity
Physicalinactivity
12% Direct Benefit
WHO/WHF/WSO Global atlas on cardiovascular disease prevention and control Yusuf S,et al. Lancet 2004: INTERHEART study; DoH UK 2011: Start Active Stay Active Ussher et al. Cochrane 2014: Exercise interventions for smoking cessation AHA scientific statement 2003
PAR = Population Attributable Risk
Collectively,
these modifiable risk factors account for
90% of the risk of heart attack
worldwide
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Prevention of CVDAs good as medicines?
Network meta analysis of mortality outcomes in trials comparing drugs and exercise with controls
Favours intervention Favours control
Exercise is often as good as
medications in the secondary prevention of cardiovascular
disease
Naci & Ioannidis BMJ 2013: comparative effectiveness of exercise and drug interventions on mortality
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Coronary Artery Disease (CAD) and Exercise
Hambrecht et al. Circulation. 2004; PCI compared with exercise training; FYSS 21: Coronary artery diseaseWalther et al. Prev Cardio 2008: Regular exercise training compared with PCIACSM Position stand: Exercise and coronary artery disease; NICE CG94, CG172, CG181
88% with Exercise (£2328)
70% with PCI (£4722)
Exercise is
BETTER and CHEAPER than PCI for stable CAD
Exercise is indicated in the primary and secondary prevention of CAD
Patients with CAD should undertake baseline stress and fitness tests with ECG monitoring to assess risk and tailor exercise to current physical capacity
PCI = Percutaneous Coronary Intervention
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Heart Failure (HF) and exercise
All patients with chronic HF should be offered exercise-based rehabilitation
Meta-analysis showing effects of exercise in patients with heart failure
Hospitalisation
Quality of life &Exercise tolerance
Belardinelli et al JACC 2014: 10 yr exercise training in CHF; Piepoli et al. EJHF 2011: Exercise training in heart failureVan Tol et al EJHF 2006: Effects of exercise training in heart failureHagerman et al. IJC 2005: Hospitalisation in chronic heart failure; NICE CG108
HR=heart rateSBP=systolic blood
pressureCO=cardiac output VO2=peak oxygen
uptakeAT=anaerobic
threshold6-MWD=6-min
walking distanceMLWHFQ=Minnesota
Living with Heart Failure Questionnaire
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Stroke and Exercise NICE CG68
Vicious cycle
DeconditioningStroke
Variable Disability
Exercise intolerance
Increased Disability
Increased CVD risk
Reduced function
Reduced QOL
Improves walking & tolerance for ADLs
Exercise benefits
Naci & Ioannidis BMJ 2013: comparative effectiveness of exercise and drug interventions on mortalityNICE CG68; FYSS 47 Stroke; Stoller et al. BMC neurology: Effects of cardiovascular exercise after strokeSaunders et al. Cochrane 2013: Physical fitness training for stroke patients; ADLs Activities of Daily Living, QoL Quality of Life
Exercise significantly reduces mortality following stroke
Anticoagulants and Antiplatelets do NOT Naci, 2012
PersonaliseGoals
Reduces CVD risk directly
Improved QoL & Self-confidence
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Peripheral Arterial Disease and Exercise NICE CG147
Exercise promotes collateral blood flow, improves oxygen extraction and cardiovascular function in Peripheral Arterial Disease
Patients should exercise to the point of maximal pain
NICE CG147; Parmenter et al. Sports Med 2015: Exercise training for management of PADLane et al. Cochrane 2014: Exercise for intermittent claudication; FYSS 41 Peripheral arterial diseaseVemulapalli et al. 2015 Clin Cardiol network meta-analysis; Gupta & Elkins BJSM 2014: Walking training in intermittent claudication
Walking distanceWalking speed Perceived walking endurancePhysical activity levels
AmputationsFoot infectionsMortalityPain
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Cardiac Rehabilitation NICE CG108, CG172, CMG 40
Anderson & Taylor, Cochrane overview 2014: Cardiac rehabilitation; Lawler et al. AHJ 2011: Cardiac rehabilitation following MIACSM & AHA Joint position statement: Exercise and acute cardiovascular eventsBHF Cardiovascular disease statistics 2015; FYSS 21: Coronary artery disease; NICE CG108, CG172, CMG 40
~50% of all cardiac complications occur during the first month following a cardiac event FYSS 21
Therefore patients need assessment, screening and safe exercise prescription during this time ACSM
Cardiac rehabilitation is safe and effective and should start within 10 days of discharge from hospital NICE CG172
UK referral rates range from 13-88% with large inequalities and low heart failure access (2%)NICE CMG 40
Favours usual care
Favours cardiac
rehabilitation
Mortality ↓
Odds of dying
↓ 20%
Meta-analysis showing odds ratios for total mortality: exercise based cardiac rehabilitation versus usual care following MI Lawler 2011
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BUT…
Cardiac Rehabilitation
Overall mortality CVD mortality Re-infarction Hospital admissionsBP, lipids, disabilityTime off work
Only 14-43% uptake following MI Davies et al
Those most likely to benefit have lowest uptake Beswick et al 2005
Treatment for secondary prevention
Cost of adding 1 year to a
patients life
Aspirin/B-blocker <£1000
Cardiac rehab £1957
ACE inhibitor £3398
Statin £4246
CABG £3239-4601
PCI £3845-5889
Anderson & Taylor, Cochrane overview 2014: Cardiac rehabilitation; FYSS 21: Coronary artery disease; NICE CG108, CG172, CMG 40; Anderson et al. Cochrane 2016 Cardiac rehabilitation for CHD; ACSM & AHA Joint statement: Exercise and acute cardiovascular events; Lawler et al. AHJ 2011: Cardiac rehabilitation following MI; Heran et al. Cochrane; Exercise rehabilitation for patients with CHD; Fidan et al. QJM 2007:Economic analysis of treatments; Taylor et al. Cochrane 2014: Exercise rehabilitation for heart failure
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Considerations when exercising on medicines
Medication Exercise related pharmacology Patient implications
ß-blocker Maximum heart rate ↓Skeletal muscle blood flow ↓
↓ maximal exercise capacity↑ muscle fatigue
Diuretics ↑ salt loss (N.B. Hypokalaemia)↑urine output
↑ risk of dehydrationAvailability of toilets important
Calcium channel blocker
Negative chronotropes ↓ maximum capacity
ACE inhibitors No significant effects on exercise capacity
Digoxin ↑ contractility and stroke volume ↑ exercise capacity
Nitrates VasodilatationAnti-anginal
Risk of postural hypotensionCan be used prophylactically
Anticoagulants Risk of bleeding increased Tailor advice re: ↓ falls risk etc.
Statins No clear evidence supporting reduced performance or ↑ muscle pain
Caution in vigorous endurance sport
FYSS 21: Coronary artery diseaseParker et al. Circulation 2013: Effect of statins on skeletal muscle function
Medicines are not a contraindication to exercise
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Absolute Contraindications to Exercise in CVD
1. New or uncontrolled arrhythmia2. Resting or uncontrolled tachycardia3. Resting SBP >180mmHg or DBP
>100mmHg4. Symptomatic hypotension5. Unstable/ crescendo angina6. Acute or unstable heart failure7. Unstable diabetes8. Acute febrile illness
Adapted from British Association of Cardiac rehabilitation 2012ACSM position statement
Any patients with unstable or uncontrolled symptoms must be reviewed
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Safety Considerations in CVD patients
Exclude high-risk patients from vigorous activity
Screen high risk patients before exercise
• Recent cardiac event
• Heart failure, Recent/previous Stroke, PAD
• Re-screen anyone with unstable/uncontrolled symptoms
Stop exercise and promptly evaluate/refer if ANY of these symptoms (inform patients of these)
• chest pain or tightness
• dizziness or faintness
• pain in the arm or jaw
• severe shortness of breath
• an irregular heartbeat
• excessive fatigue
Adapted from British Association of Cardiac rehabilitation 2012; ACSM position statement; Thompson et al. Circulation 2007 : Exercise and acute cardiovascular events AHA statement
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• High intensity exercises carry a higher risk ACSM
• Warm up 15 minutes. Cool down 10 minutes • Avoid lying down until after cool down period• ICDs have a 10-30s delay between arrhythmia
and shock, so give safe exercise advice such as avoid swimming FYSS 30
• Avoid dehydration (increased risk of arrhythmia) FYSS 21
• Progression (duration & intensity) of exercise should be slow and gradual ACSM
• Stroke patients are 3x more likely to fall or suffer hip fractures so make the environment safe FYSS 47
• Good footwear and foot care are very important in PAD and/or type 2 diabetes
• Inactive individuals should start with a 2-3 month transition phase of light exercise only ACSM
Exercise Considerations in Cardiovascular Disease
ACSM Current comment: Exercise for persons with cardiovascular diseaseFYSS 21 Coronary artery disease; FYSS 30 Heart rhythm disturbanceFYSS 47 Stroke; ACSM 2015: Updated recommendations for Exercise Preparticipation Health Screening
Prescribing physical activity in daily practice for cardiovascular disease prevention using the acronym ACTIVE
Tina Varghese et al. Heart doi:10.1136/heartjnl-2015-308773 and Heart BMJ podcast
Copyright © BMJ Publishing Group Ltd & British Cardiovascular Society. All rights reserved.
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Weekly Physical Activity Recommendations
Sit Less
– excess sedentary behaviour causes death
Walk More
– walking is safe & effective
Tailor advice to the individual
American Heart Association; DoH UK 2011: Start Active Stay ActiveAdapted from British Association of Cardiac rehabilitation 2012Biddle et al. BMC 2016: Too much sitting and all-cause mortality
Refer these patients for
Cardiac Rehabilitation:
• Recent Myocardial Infarction• IHD/ Heart failure• Heart surgery/ Percutaneous
coronary intervention• Implantable Cardiac
Defibrillator
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Learning summary Heart disease, stroke, peripheral arterial disease and exercise
• Reassure your patientsExercise is safe following appropriate screening and assessment
• Educate your patientsUnstable/uncontrolled symptoms require clinical review
• Empower your patientsThe least active stand to gain the most
• Rehabilitate your patientsCARDIAC REHABILITATION saves lives, is effective, safe, cheap, underused and undervalued
• Exercise your patientsExercise can be as good as medicines
• Make Every Contact CountYOUR exercise advice can save lives
British Association of Cardiac Rehabilitation; ACSM position statementWoodcock et al. Int J Epi 2011: Non-vigorous physical activity and mortalityThompson et al. Circulation 2007 : Exercise and acute cardiovascular events AHA statementAnderson & Taylor, Cochrane overview 2014: Cardiac rehabilitation; NICE CMG 40 Naci 2013 Heart BMJ Podcast
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Supplement: A case study examplePre-participation Screening Summary of updated ACSM recommendations ACSM 2015
IntensityMedical
clearance required?
Known disease?
*Signs or Symptoms?
Regular Exerciser?
Yes
Yes Yes STOP
No
Yes No Mod
No No Mod/Vig
No
Yes Yes
No
Yes Yes
No No Light/Mod
ACSM 2015, Updated recommendations for Exercise Preparticipation Health Screening
DURING EXERCISEStop and promptly evaluate/refer if ANY of the above symptoms occur (inform patients of these)
*Active Signs & Symptomspain or discomfort in the chest, neck, jaw, arms; shortness of breath at rest or mild exertion; dizziness or syncope; orthopnoea or PND; ankle oedema; palpitations or tachycardia; intermittent claudication; known heart murmur; unusual fatigue or shortness of breath with usual activities
Q3Q2Q1
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Resources
• NICE Guidelines
• BACPR
• FYSS Physical activity in the prevention and treatment of disease
• ACSM Position Stands
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References
ACSM, 1994. ACSM Position stand: Exercise for Patients with Coronary Artery Disease. Med. Sci. Sports Exerc., 26(3), pp.i–iv.
ACSM, 1998. AHA/ACSM Joint Position Statement: Recommendations for Cardiovascular Screening, Staffing, and Emergency Policies at Health/Fitness Facilities. Medicine & Science in Sports & Exercise, 30(6).
AHA, 2015. American Heart Association. Available at: http://www.heart.org.
Anderson, L. & Taylor, R.S., 2014. Cardiac rehabilitation for people with heart disease: an overview of Cochrane systematic reviews. The Cochrane database of systematic reviews, 12, p.CD011273.
Anderson, L., Oldridge, N., Thompson, D. R., Zwisler, A.-D., Rees, K., Martin, N., & Taylor, R. S. (2016). Exercise-Based Cardiac Rehabilitation for Coronary Heart Disease: Cochrane Systematic Review and Meta-Analysis. Journal of the American College of Cardiology, 67(1), 1–12.
Belardinelli, R. et al., 2012. 10-Year Exercise Training in Chronic Heart Failure. Journal of the American College of Cardiology, 60(16), pp.1521–1528.
Biddle, S. J. H., Bennie, J. A., Bauman, A. E., Chau, J. Y., Dunstan, D., Owen, N., … van Uffelen, J. G. Z. (2016). Too much sitting and all-cause mortality: is there a causal link? BMC Public Health, 16, 635.
Centre for Economic and Business Research (2014). The economic cost of cardiovascular disease from 2014-2020 in six European Economies. www.cebr.com/wp-content/ uploads/2015/08/Short-Report-18.08.14.pdf
DoH, 2011. Start Active , Stay Active. Strategy, p.62.
Eckel, R.H. et al., 2014. 2013 AHA/ACC Guideline on Lifestyle Management to Reduce Cardiovascular Risk: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Journal of the American College of Cardiology, 63(25 Pt B), pp.2960–84.
Fidan, D. et al., 2007. Economic analysis of treatments reducing coronary heart disease mortality in England and Wales, 2000-2010. QJM : monthly journal of the Association of Physicians, 100(5), pp.277–89.
Garber, C.E. et al., 2011. Quantity and quality of exercise for developing and maintaining cardiorespiratory, musculoskeletal, and neuromotor fitness in apparently healthy adults: Guidance for prescribing exercise. Medicine and Science in Sports and Exercise, 43(7), pp.1334–1359.
Grimby, G. et al., 2011. 47. Stroke. In FYSS Physical Activity in the prevention and treatment of disease. pp. 611–621.
Gupta, S. & Elkins, M.R., 2014. Supervised walking training improves maximum and pain-free walking distances in people with intermittent claudication. British journal of sports medicine, 48(14), pp.1130–2.
Hagerman, I., Tyni-Lenné, R. & Gordon, A., 2005. Outcome of exercise training on the long-term burden of hospitalisation in patients with chronic heart failure. A retrospective study. International journal of cardiology, 98(3), pp.487–91.
Hambrecht, R. et al., 2004. Percutaneous coronary angioplasty compared with exercise training in patients with stable coronary artery disease: a randomized trial. Circulation, 109(11), pp.1371–8.
Heran, B.S. et al., 2011. Exercise-based cardiac rehabilitation for coronary heart disease. The Cochrane database of systematic reviews, (7), p.CD001800.
Kyu, H. H., Bachman, V. F., Alexander, L. T., Mumford, J. E., Afshin, A., Estep, K., … Forouzanfar, M. H. (2016). Physical activity and risk of breast cancer, colon cancer, diabetes, ischemic heart disease, and ischemic stroke events: systematic review and dose-response meta-analysis for the Global Burden of Disease Study 2013. BMJ, 354(1), 869–82.
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References (cont.)
Lane, R. et al., 2014. Exercise for intermittent claudication. The Cochrane database of systematic reviews, 7, p.CD000990.
Lawler, P.R., Filion, K.B. & Eisenberg, M.J., 2011. Efficacy of exercise-based cardiac rehabilitation post-myocardial infarction: A systematic review and meta-analysis of randomized controlled trials. American Heart Journal, 162(4), pp.571–584.e2.
Manage, R.M., 2012. The BACPR Standards and Core Components for Cardiovascular Disease Prevention and Rehabilitation 2012.
Mendis, S., Puska, P. & Norrving, B., 2011. Global atlas on cardiovascular disease prevention and control. World Health Organization, pp.2–14.
Naci, H. & Ioannidis, J.P.A., 2013. Comparative effectiveness of exercise and drug interventions on mortality outcomes: metaepidemiological study. BMJ (Clinical research ed.), 347, p.f5577.
NICE, 2010a. CG 108 Chronic heart failure. NICE Guidelines.
NICE, 2012. CG 147 Lower limb peripheral arterial disease: diagnosis and management. NICE Guidelines, pp.1–30.
NICE, 2013a. CG 172 MI – secondary prevention care for patients following a myocardial. NICE Guidelines, (November).
NICE, 2008a. CG 68 Stroke and transient ischaemic attack. NICE Guidelines.
NICE, 2010b. CG 94 Unstable Angina and NSTEMI: The Early Management of Unstable Angina and Non-ST-Segment-Elevation Myocardial Infarction. NICE Guidelines, (November).
NICE, 2013b. CMG 40 Cardiac rehabilitation services. NICE Comissioning guides, (November 2013), pp.1–49.
NICE, 2008b. NICE CG 67 Lipid modification: cardiovascular risk assessment and the modification of blood lipids for the primary and secondary prevention of cardiovascular disease. NICE Guidelines, 94(10), pp.1331–1332.
NICE, 2013c. NICE CG162 Stroke rehabilitation. NICE Guidelines.
NICE, 2015. QS 84 Physical activity : encouraging activity in all people in contact with the NHS. NICE quality standard, (March).
Parker, B.A. et al., 2013. Effect of statins on skeletal muscle function. Circulation, 127(1), pp.96–103.
Parker, B.A. & Thompson, P.D., 2012. Effect of statins on skeletal muscle: exercise, myopathy, and muscle outcomes. Exercise and sport sciences reviews, 40(4), pp.188–94.
Parmenter, B.J., Dieberg, G. & Smart, N.A., 2015. Exercise training for management of peripheral arterial disease: a systematic review and meta-analysis. Sports medicine (Auckland, N.Z.), 45(2), pp.231–44.
Piepoli, M.F. et al., 2011. Exercise training in heart failure: from theory to practice. A consensus document of the Heart Failure Association and the European Association for Cardiovascular Prevention and Rehabilitation. European journal of heart failure, 13(4), pp.347–57.
Reibe, D., Franklin, B. A., Thompson, P. D., Garber, C. E., Whitefield, G. P., Magal, M., & Pesctello, L. S. (2015). Updating ACSM’s Recommendations for Exercise Preparticipation Health Screening. Medicine & Science in Sports & Exercise, 47(11), 2473–2479.
Saunders, D.H. et al., 2013. Physical fitness training for stroke patients. The Cochrane database of systematic reviews, 10, p.CD003316.
Sciences, C. et al., 2010. 30. Heart rhythm disturbances. FYSS.
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References (cont.)
Stahle, A. & Cider, A., 2010. 21. Coronary artery disease. In FYSS Physical Activity in the prevention and treatment of disease.
Stoller, O. et al., 2012. Effects of cardiovascular exercise early after stroke: systematic review and meta-analysis. BMC neurology, 12, p.45.
Tanasescu, M., 2002. Exercise Type and Intensity in Relation to Coronary Heart Disease in Men. JAMA, 288(16), p.1994.
Taylor, R.S. et al., 2014. Exercise-based rehabilitation for heart failure. The Cochrane database of systematic reviews, 4, p.CD003331.
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Walther, C. et al., 2008. Regular exercise training compared with percutaneous intervention leads to a reduction of inflammatory markers and cardiovascular events in patients with coronary artery disease. European journal of cardiovascular prevention and rehabilitation : official journal of the European Society of Cardiology, Working Groups on Epidemiology & Prevention and Cardiac Rehabilitation and Exercise Physiology, 15, pp.107–112.
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Yusuf, S. et al., 2004. Effect of potentially modifiable risk factors associated with myocardial infarction in 52 countries (the INTERHEART study): case-control study. Lancet, 364(9438), pp.937–52. Available at: http://www.sciencedirect.com/science/article/pii/S0140673604170189 [Accessed January 27, 2015].