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
本文由“天納”臨床學(xué)術(shù)信息人工智能系統(tǒng)自動(dòng)翻譯
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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.隨著心肌梗死（MI）患者生存率的提高，對(duì)二級(jí)預(yù)防提出了更高的要求。雖然體力活動(dòng)（PA）努力獲得足夠的PA水平是二級(jí)預(yù)防建議的一部分，但它仍然沒有得到充分利用。重要的是，心肌梗死后PA變化的影響在很大程度上是未知的。因此，我們?cè)噲D從PA水平、心肌梗死后的變化來探討其對(duì)存活的影響。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.合并了瑞典國(guó)家登記冊(cè)的數(shù)據(jù)，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個(gè)月時(shí)自我報(bào)告?；颊弑环诸悶槌掷m(xù)不活動(dòng)、增加活動(dòng)、減少活動(dòng)和持續(xù)活動(dòng)。計(jì)算比例危險(xiǎn)比。在100 502人隨訪(平均隨訪時(shí)間4.2年)期間，共記錄1087人死亡?？刂浦匾幕祀s因素（包括左心室功能、心肌梗死類型、藥物、吸煙、參與心臟康復(fù)計(jì)劃、生活質(zhì)量和估計(jì)腎功能），我們發(fā)現(xiàn)，在不斷活躍的人群中（危險(xiǎn)比：0.29，95%可信區(qū)間：0.21-0.41），那些活動(dòng)性增加的人群死亡率較低。在心肌梗死后的第一年，ty值（0.41，95%置信區(qū)間：0.31-0.55）和活動(dòng)性降低（危險(xiǎn)比：0.56，95%置信區(qū)間：0.45-0.69）的患者與那些經(jīng)常不活動(dòng)的患者相比。分層分析顯示，PA水平在兩性之間、不同年齡、MI類型、腎功能、藥物和吸煙狀況之間有很強(qiáng)的影響。Conclusions
The present article shows that increasing the PA level, compared with staying inactive the first year post‐MI, was related to reduced mortality.與MI后第一年不活動(dòng)相比，PA水平的提高與死亡率的降低有關(guān)。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）后第一年內(nèi)保持體力活動(dòng)的患者死亡率最低，隨訪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后第一年的體力活動(dòng)水平的改變是重要的，降低了增加活動(dòng)患者死亡的風(fēng)險(xiǎn)，增加了活動(dòng)減少患者的風(fēng)險(xiǎn)。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.在心肌梗死后開始活動(dòng)似乎還不算太晚，因?yàn)樾募」Ｋ篮蠡顒?dòng)增加的組與持續(xù)活動(dòng)組的存活率沒有差別。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.在心肌梗死后維持或提高其體力活動(dòng)水平的患者中，所顯示的與生存的關(guān)系加強(qiáng)了本指南的重要性，并強(qiáng)調(diào)了在二級(jí)預(yù)防中實(shí)施本指南的必要性。Being active post‐MI seems to be equally important for different subgroups.對(duì)于不同的子組來說，積極的后MI似乎同樣重要。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?。–VD）最令人擔(dān)憂的并發(fā)癥之一，其發(fā)病率和死亡率都很高。然而，由于緊急護(hù)理的進(jìn)步，包括心臟介入治療以及抗血栓、抗高血壓和血脂異常治療的廣泛使用，現(xiàn)在較大比例的患者在第一次心肌梗死后存活。這種積極的發(fā)展使得人們更加關(guān)注二級(jí)預(yù)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體力活動(dòng)（PA）是心血管疾病一級(jí)預(yù)防中公認(rèn)的因素。同樣在已確診為CVD的患者中，結(jié)構(gòu)性體力活動(dòng)（PA）以及PA的增加已被證明與降低心血管死亡率有關(guān)。這些影響取決于對(duì)包括高血壓、血脂異常、肥胖和糖尿病在內(nèi)的心血管疾病傳統(tǒng)危險(xiǎn)因素的多重積極影響，以及對(duì)動(dòng)脈粥樣硬化進(jìn)展、內(nèi)皮功能障礙、自主控制和隨后的心律失常風(fēng)險(xiǎn)的可能影響。因此，在全球一級(jí)和二級(jí)預(yù)防指南中，建議將足夠高的PA水平作為第一線治療。然而，遵守這些PA建議，以及將運(yùn)動(dòng)作為常規(guī)治療一部分用于衛(wèi)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動(dòng)脈粥樣硬化是一種進(jìn)展性疾病，該疾病本身及其后果可能影響個(gè)體在心臟事件之前和之后充分身體活動(dòng)的能力。早期關(guān)于PA水平與MI后存活率之間關(guān)系的研究的一個(gè)局限性是選擇偏倚的風(fēng)險(xiǎn)（即，患有最晚期疾病的個(gè)體由于其功能狀態(tài)也是最不活躍的）。因此，在評(píng)估康復(fù)干預(yù)的效果時(shí)，在事件發(fā)生后的時(shí)間段內(nèi)PA水平的變化，而不是PA的單一測(cè)量，可以提供更多的信息。以生活方式為重點(diǎn)的心臟康復(fù)的效果已經(jīng)被調(diào)查，顯示出再入院的風(fēng)險(xiǎn)降低和心血管死亡率降低，而總的死亡率卻存在不一致的發(fā)現(xiàn)。以降低風(fēng)險(xiǎn)為重點(diǎn)的心臟康復(fù)也被證明可以降低死亡率。然而，由于各種原因，許多患者沒有接受心臟康復(fù)治療。此外，心臟康復(fù)本質(zhì)上是多因素的，并且運(yùn)動(dòng)產(chǎn)生的單獨(dú)作用可能難以確定。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.對(duì)于心肌梗死患者PA水平變化對(duì)死亡率的長(zhǎng)期影響知之甚少。在一篇開創(chuàng)性的文章中，Steffen Batey等人在406名男性和女性心肌梗死患者的隊(duì)列中報(bào)告，與那些保持身體不活動(dòng)的患者相比，活動(dòng)性增加的患者的死亡率顯著降低(相對(duì)風(fēng)險(xiǎn)(RR)=0.11)。最近，在婦女健康倡議觀察研究中，對(duì)856名婦女進(jìn)行的另一項(xiàng)研究顯示出類似的結(jié)果。然而，需要更多和更大的研究，以便能夠在與MI的嚴(yán)重程度、合并癥或后果相關(guān)的重要地層中研究這些關(guān)系，例如腎功能、生活質(zhì)量和耐受藥物的程度。這種比較具有臨床意義，直接影響MI后的治療。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，本研究的目的是評(píng)估MI患者的長(zhǎng)期存活率與瑞典一大批MI患者自我報(bào)告的PA變化之間的關(guān)系。此外，我們旨在評(píng)估已知風(fēng)險(xiǎn)因素對(duì)這種關(guān)系的任何調(diào)節(jié)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.作者將不向其他研究人員提供數(shù)據(jù)、分析方法和研究材料，以便再現(xiàn)結(jié)果或復(fù)制程序。作者沒有權(quán)限共享SWEDEHEART數(shù)據(jù)。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.我們從瑞典國(guó)家SWEDEHEART注冊(cè)中心(瑞典Web系統(tǒng)，用于增強(qiáng)和發(fā)展心臟病循證護(hù)理，根據(jù)推薦治療進(jìn)行評(píng)估，包括初始護(hù)理[分區(qū)域RIKS HIA]和隨后所有MI相關(guān)護(hù)理[分區(qū)域SEPHIA])獲得數(shù)據(jù)。在瑞典，所有心臟科單位的90%以上為瑞典人所接受，該隊(duì)列可被視為瑞典MI患者的代表。SWEDEHEART分區(qū)域SEPHIA(入院后心臟強(qiáng)化護(hù)理的二級(jí)預(yù)防)提供了MI后6至10周和12個(gè)月的2次隨訪的信息，包括二級(jí)預(yù)防治療、生活方式和危險(xiǎn)因素流行率的數(shù)據(jù)。主要結(jié)果是死亡率，這是從瑞典人口普查登記處獲得的。2014年10月7日提取了死亡率數(shù)據(jù)。平均隨訪時(shí)間為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).我們包括2004年12月28日至2013年10月25日之間被診斷出患有第一例MI(國(guó)際疾病分類，第十次修訂[ICD 10]代碼I.21)的18至75歲之間的所有患者(n=22 227)，他們?cè)赟WEDEHEART登記處提供了完整的數(shù)據(jù)(圖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.根據(jù)SWEDEHEART登記，獲得年齡、體重指數(shù)、血清肌酐、身高、性別、MI類型和左心功能。MI的類型基于臨床評(píng)估，患者被分為ST段抬高M(jìn)I（STEMI）或非ST段抬高M(jìn)I（NSTEMI）。左室功能以射血分?jǐn)?shù)（EF）百分?jǐn)?shù)表示，進(jìn)一步分為＞50％、49％～40％或≤40％。SWEDEHEART也記錄了治療期間經(jīng)皮心臟介入治療的使用情況，并編碼為是或否。腎小球?yàn)V過率(eGFR)的估計(jì)值是基于根據(jù)Cockcroft-Gault公式[eGFR=(1.23×(140_歲)×體重)/血清肌酐和eGFR=(1.04×(140_歲)×體重)計(jì)算的血漿肌酐值。ss)/血清肌酐，分別用于男性和女性]，它以前用于瑞典心臟登記處的分析。每隔1.73米60mL/min對(duì)eGFR進(jìn)行二分法，以鑒別正?；蜉p度降低的GFR與中度降低或更顯著降低的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.在兩次后續(xù)訪問中，SEPHIA分區(qū)域報(bào)告了PA，因?yàn)樽詧?bào)在過去7天內(nèi)PA會(huì)期為30分鐘或更長(zhǎng)。注冊(cè)表中接受0到7之間的值。如果患者每周只報(bào)告1次或不報(bào)告一次PA，則被歸類為“不活動(dòng)”。報(bào)告每周2次或更多次治療的患者被歸類為“活躍”。根據(jù)兩次二級(jí)預(yù)防訪問(分別在6-10周和12個(gè)月)之間的活動(dòng)水平的變化進(jìn)一步將患者歸類為持續(xù)不活躍、活動(dòng)減少、活動(dòng)增加或持續(xù)活躍。全部的藥理學(xué)治療被鑒定為使用血管緊張素轉(zhuǎn)換酶抑制劑、β阻斷劑、他汀類藥物或其他降脂劑和抗血栓形成劑(編碼為是或否)治療。出院后6至10周，在第一次康復(fù)探視時(shí)記錄吸煙狀況(從不吸煙，自>1個(gè)月后即已戒煙或吸煙)。當(dāng)關(guān)于吸煙的數(shù)據(jù)缺失(n=32)時(shí)，從第二次訪問中獲得額外的數(shù)據(jù)。在心肌梗死后一年中，有關(guān)參與以運(yùn)動(dòng)為基礎(chǔ)的心臟康復(fù)的數(shù)據(jù)是從第二次康復(fù)訪問中獲得的。使用首次訪問的歐洲生活質(zhì)量5維度(EQ-5D)數(shù)據(jù)評(píng)估與健康相關(guān)的生活質(zhì)量。瑞典斯德哥爾摩地區(qū)倫理委員會(huì)批準(zhǔn)了這項(xiàng)研究(2013/2067-31)。不需要知情同意。相應(yīng)的作者完全訪問了研究中的所有數(shù)據(jù)，并負(fù)責(zé)其完整性和數(shù)據(jù)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 Sch?nfelts 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).描述性人口統(tǒng)計(jì)和臨床特征分析使用手段（SDs）和百分比。采用t檢驗(yàn)和檢驗(yàn)對(duì)存活者和死亡病例之間的差異進(jìn)行檢測(cè)。使用具有時(shí)間相關(guān)協(xié)變量模塊的SPSS Cox回歸，使用Cox比例風(fēng)險(xiǎn)比計(jì)算危險(xiǎn)比及其95%置信區(qū)間。對(duì)4個(gè)PA地層（持續(xù)活躍、活動(dòng)減少、活動(dòng)增加或持續(xù)不活躍）的危害比進(jìn)行未調(diào)整的計(jì)算，并對(duì)潛在的混雜因素進(jìn)行控制。在完全調(diào)整的模型中，包括年齡、性別、心肌梗死日期、體重指數(shù)、EQ5D、EF、心肌梗死類型、經(jīng)皮心臟介入治療的使用、eGFR、吸煙、藥物治療和參與心臟康復(fù)訓(xùn)練。我們用比例Schnfelts殘差檢驗(yàn)了比例假設(shè)。檢查所有變量的比例性，包括從第一和第二PA評(píng)估中分離的措施。僅對(duì)PA層具有弱的邊界意義。正因?yàn)槿绱?，我們?cè)谒械姆治鲋卸及藭r(shí)間×PA地層的相互作用項(xiàng)。根據(jù)Bland和Altman的建議，對(duì)PA層之間的HRs進(jìn)行了形式化相互作用分析。如果95%的置信區(qū)間不包括1.所有統(tǒng)計(jì)信息都在IBM SPSS（版本21）中執(zhí)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%).圖1描述了主題包含。入選患者與非入選患者在某些方面存在差異。與沒有PA數(shù)據(jù)的人相比，那些有PA數(shù)據(jù)的人吸煙的可能性較低（11.0%比13.6%），eGFR較低（8.2%比10.1%）。存活率也較低（90.0%和94.2%）。當(dāng)比較那些包括PA數(shù)據(jù)和那些沒有其他變量的PA數(shù)據(jù)時(shí)，后一組不太可能完全用藥（64.2%對(duì)69.6%），有STEMI（37.7%對(duì)41.1%），更有可能為女性（28.7%對(duì)26.1%）。存活率也較低（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患者的受試者特征。除了藥理治療之外，所有被檢測(cè)的變量在PA地層中都有所不同，在PA組之間沒有觀察到差異。有些差異很小，盡管在統(tǒng)計(jì)學(xué)上有顯著性（年齡、體重指數(shù)）。婦女和現(xiàn)在的吸煙者在持續(xù)不活動(dòng)的階層中比例過高，NSTEMI患者也是如此。與持續(xù)不活動(dòng)組相比，持續(xù)活躍組參與運(yùn)動(dòng)性心臟康復(fù)的程度更高（40.9%對(duì)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)291198103495
Person‐y at risk (total 100 502 person‐y)10 21315 593893265 764
n (%)n (%)n (%)n (%)P Value
Sex
Female785 (33.2)892 (26.1)587 (29.4)3542 (24.5)
Male1576 (66.8)2526 (73.9)1411 (70.6)10 908 (75.5)
STEMI874 (37.0)1459 (42.7)818 (40.9)6284 (43.5)
Ejection fraction
>501434 (60.7)2189 (64.0)1295 (64.8)9955 (68.9)
40–49528 (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)510 (21.6)1258 (36.8)611 (30.6)5909 (40.9)
PCI during treatment1782 (75.5)2707 (79.2)1547 (77.4)11 683 (80.9)
Smoking status (@6–10 wks)
Never‐smoker541 (22.9)943 (27.6)616 (30.8)5180 (35.8)
Ex‐smoker1347 (57.1)2010 (58.8)1101 (55.1)8075 (55.9)
Smoker473 (20.0)465 (13.6)281 (14.1)1195 (8.3)
eGFR 2336 (14.2)243 (7.1)197 (9.9)1011 (7.0)
Full pharmacological treatment1648 (69.8)2417 (70.7)1369 (68.5)10 045 (69.5)0.36
Age, y
Mean (SD)62.8 (9.1)60.8 (9.0)62.0 (8.9)61.9 (8.4)
Age distribution
Under 40 y, n436438202
40–49, n2094191961376
50–59, n60210605114017
60–69, n97313269026627
≥70, n5345493512228
EQ‐5D score (SD)0.69 (0.3)0.81 (0.22)0.77 (0.25)0.86 (0.18)
BMI, kg/m2 (SD)28.3 (5.5)28.3 (0.22)27.6 (4.44)27.1 (5.3)
BMI indicates body mass index; eGFR, estimated glomerular filtration rate; EQ‐5D, EuroQol‐5 dimensions; PCI, percutaneous coronary intervention; STEMI, ST‐segment‐elevation myocardial infarction.
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).報(bào)告在心肌梗死后6～10周和1年都活躍的患者具有較高的情商5D，較低的eGFR發(fā)生率較低，更經(jīng)常接受經(jīng)皮心臟介入治療，并且在心肌梗死后具有較高的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).在無對(duì)照分析中，4PA層死亡率（每1000人年有95%置信區(qū)間的病例）在持續(xù)不活動(dòng)者中為28.5（25.3-32.0），在減少活動(dòng)者中為12.7（11.0-14.6），在增加活動(dòng)者中為11.5（9.4-14.0），在持續(xù)活動(dòng)者中為7.5（6.9-8.2）。在完全控制模型中，與那些處于持續(xù)不活動(dòng)層的人相比，那些處于持續(xù)活動(dòng)層和活動(dòng)層增加和減少的人的死亡率HRs較低。然而，對(duì)于增加PA的患者和降低PA的患者，HR沒有差別。與降低PA水平的個(gè)體相比，持續(xù)活動(dòng)患者的HR較低。增加PA水平的患者的HR與持續(xù)活動(dòng)患者的HR沒有差別(表2，圖2)。Table 2 HR (95% CI) for the PA Strata in Age‐ and Sex‐Adjusted and Fully Adjusted Models
Constantly InactiveReduced ActivityIncreased ActivityConstantly Active
Full sample
1087 deaths
100 502 person‐y
Age‐sex1 (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 adjusted1 (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 在完整模型中沒有發(fā)現(xiàn)任何變量的相互作用，表明PA層與年齡、性別、STT變化、經(jīng)皮心臟介入治療、Eq 5D、eGFR、心臟康復(fù)、吸煙狀況和藥物治療之間的死亡率之間的相似差異。除EF外，降低的PA層的HR分別為0.42（0.27～0.67）和0.63（0.42～0.93），EF為40％～50％，EF＜40％。對(duì)于增加的PA地層，對(duì)應(yīng)的值分別為0.56（0.30-1.10）和0.20（0.10-0.41），對(duì)于持續(xù)活動(dòng)的地層為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.我們還將死亡率分別與兩個(gè)評(píng)估中的活動(dòng)水平聯(lián)系起來。在年齡和性別對(duì)照分析中，活動(dòng)期患者的死亡率在兩項(xiàng)評(píng)估中都較低，第一和第二項(xiàng)評(píng)估的HR（95%置信區(qū)間=0.42[0.38-0.48]和0.41[0.36-0.46]）。在完全對(duì)照分析中，第一和第二評(píng)估的相應(yīng)值分別為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.本研究的主要結(jié)果是，根據(jù)全國(guó)未選擇的心肌梗死患者登記冊(cè)，在心肌梗死后的第一年內(nèi)增加PA水平的不活動(dòng)患者的死亡率比那些保持不活動(dòng)患者的死亡率要低得多。MI后第一年內(nèi)仍保持體力活動(dòng)的患者風(fēng)險(xiǎn)最低。對(duì)于提高PA水平的人群來說，結(jié)果很有趣，因?yàn)榻Y(jié)果表明最初不活動(dòng)的患者（先前基于單項(xiàng)評(píng)估的研究已經(jīng)表明處于高風(fēng)險(xiǎn)）可以通過增加活動(dòng)來降低風(fēng)險(xiǎn)。MI后活動(dòng)增加組的HR與隨訪時(shí)持續(xù)活動(dòng)組無差異。先前的研究也已經(jīng)得出結(jié)論，這個(gè)組可能更受未測(cè)量的因素或殘余混雜的影響，這反過來又惡化了預(yù)后。雖然本研究中很可能存在這種情況，但MI后活動(dòng)水平提高組的結(jié)果清楚地表明，與持續(xù)不活動(dòng)組相比，該組的死亡率較低，控制在大量協(xié)變量中。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 類似地，該組降低其PA水平的結(jié)果表明，與那些保持身體活動(dòng)的人相比，那些在心肌梗死后6-10周活動(dòng)但PA降低的人的預(yù)后更差。同樣，即使未測(cè)量和不受控制的因素在心肌梗死后6至10周活動(dòng)期和非活動(dòng)期患者之間可能有所不同，但1年以上PA水平的變化仍與死亡率有關(guān)?？赡芑加懈鼑?yán)重疾病的患者仍然受益于PA的增加，其程度與那些患有較輕嚴(yán)重疾病的患者相似。EF在40%～50%之間，EFWhen 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.當(dāng)分別分析這兩項(xiàng)評(píng)估時(shí)，我們發(fā)現(xiàn)活動(dòng)期患者與持續(xù)活動(dòng)期患者相比風(fēng)險(xiǎn)降低較小。對(duì)此的一種可能的解釋是，在單一評(píng)估中，不活躍的小組將包括未來更積極或過去更積極的參與者，這將稀釋對(duì)比。這強(qiáng)調(diào)了在一個(gè)以上的時(shí)間點(diǎn)研究PA水平的重要性。此外，這些結(jié)果還補(bǔ)充了以前的研究，表明這些關(guān)系似乎獨(dú)立于心肌梗死后主要亞群的心臟康復(fù)參與。此外，當(dāng)分開分析時(shí)，在2次評(píng)估(MI后6-10周和10-20個(gè)月)中發(fā)現(xiàn)的HR的相似性可被看作反對(duì)在2個(gè)時(shí)間點(diǎn)執(zhí)行的PA的類型或強(qiáng)度不同的可能相互競(jìng)爭(zhēng)的假說的論據(jù)。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與較低的事件風(fēng)險(xiǎn)之間的關(guān)系已經(jīng)得到確認(rèn)。我們能夠證實(shí)這種聯(lián)系，并且通過識(shí)別那些在心肌梗死后第一年活動(dòng)性增加的心肌梗死患者的較低風(fēng)險(xiǎn)以及活動(dòng)性降低患者的增加風(fēng)險(xiǎn)來擴(kuò)展Stefen Batey和Gorczyca先前的發(fā)現(xiàn)。然而，本研究包括超過22,000名MI患者，并允許調(diào)整多種可能的混雜因素，這在以前的研究中是不可能的。我們也可以證明這對(duì)于幾個(gè)重要的亞組是真實(shí)的，包括老年患者、心力衰竭患者、腎功能減退患者、吸煙者以及男女。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，我們的研究包括所有自我報(bào)告的PA與運(yùn)動(dòng)的總和，而不僅僅是基于運(yùn)動(dòng)的心臟康復(fù)，早先發(fā)現(xiàn)與MI后低死亡率有關(guān)。事實(shí)上，我們的結(jié)果獨(dú)立于參與或不參與心臟康復(fù)。在家里或醫(yī)院進(jìn)行的以運(yùn)動(dòng)為基礎(chǔ)的心臟康復(fù)都與MI患者的CVD減少有關(guān)。然而，并非所有患者都因不同原因接受心臟康復(fù)治療，常常與MI的嚴(yán)重程度或其他健康相關(guān)因素有關(guān)，包括老年人。在那些提供以醫(yī)院為基礎(chǔ)的心臟康復(fù)治療的人中，并非所有人都選擇參加，也許是因?yàn)閷?shí)際的原因（比如住在離醫(yī)院很遠(yuǎn)的地方或缺乏興趣）。因此，那些在醫(yī)院或家庭心臟康復(fù)研究中被調(diào)查的人可以組成一個(gè)選定的亞組。此外，在進(jìn)入諸如心臟康復(fù)的體育訓(xùn)練項(xiàng)目時(shí)，活動(dòng)模式的其他部分，例如日?；顒?dòng)或愛好，可能被補(bǔ)償性地減少，導(dǎo)致總的PA的狀況。同樣，在心臟康復(fù)結(jié)束后，久坐活動(dòng)可能再次增加。不幸的是，Hansen等人在心臟康復(fù)后的長(zhǎng)期隨訪中顯示，心血管疾病風(fēng)險(xiǎn)譜顯著惡化。因此，不分上下文，關(guān)注所有PA，可為改善MI后臨床二級(jí)預(yù)防提供重要指標(biāo)。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.本研究中所進(jìn)行的活動(dòng)的相對(duì)強(qiáng)度是未知的。由于有氧健身已被證明是存活的重要預(yù)測(cè)因子，心肌梗死后PA的強(qiáng)度可能很重要，并且心臟康復(fù)已被證明能提高有氧健身。然而，高強(qiáng)度運(yùn)動(dòng)和較低強(qiáng)度的連續(xù)運(yùn)動(dòng)均可降低心臟患者的心血管疾病風(fēng)險(xiǎn)，而Williams等人則表明步行與跑步對(duì)高心臟風(fēng)險(xiǎn)患者的心血管疾病風(fēng)險(xiǎn)降低效果相同。關(guān)于PA的頻率，我們發(fā)現(xiàn)，兩次30分鐘的體育鍛煉/wk，或者在MI后的第一年內(nèi)增加到那個(gè)水平，與降低MI后的死亡率有關(guān)，而0到1次/wk似乎太少。與活動(dòng)有關(guān)的死亡率的降低可能甚至更小，因?yàn)樽晕覉?bào)告的PA通常高于通過更客觀的措施，如加速計(jì)發(fā)現(xiàn)的水平。有趣的是，這些發(fā)現(xiàn)與Hansen等人的發(fā)現(xiàn)是一致的，表明與較大的運(yùn)動(dòng)量相比，在II期康復(fù)期間較小的運(yùn)動(dòng)量產(chǎn)生相等的長(zhǎng)期臨床益處。這些發(fā)現(xiàn)可能與較低的運(yùn)動(dòng)量順應(yīng)性和較高的強(qiáng)度活動(dòng)有關(guān)。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，本研究的結(jié)果可能具有重要的臨床意義，因?yàn)楸M管普遍推薦，PA作為衛(wèi)生保健預(yù)防和治療戰(zhàn)略的一部分仍然未得到充分利用。這很麻煩，因?yàn)樵诙?jí)預(yù)防中其他常用組件，如病人教育，已被證明效率較低。在維持或提高M(jìn)I后PA水平的患者中，所顯示的生存關(guān)系加強(qiáng)了本指南的重要性，并強(qiáng)調(diào)需要改善二級(jí)預(yù)防，包括作為常規(guī)梗死后治療的一部分實(shí)施PA建議。盡管有許多研究，但是目前對(duì)于如何設(shè)計(jì)有效的心理咨詢來增加MI幸存者的PA知之甚少。有希望的舉措和方法，如處方藥PA(PAP)和運(yùn)動(dòng)是醫(yī)學(xué)(EiM)，已被證明可提高PA的水平，并可能得到很大的提高，由于目前的發(fā)現(xiàn)，但需要在MI患者中進(jìn)一步調(diào)查，才能建議將其作為運(yùn)動(dòng)康復(fù)的替代。在。其他干預(yù)措施包括來自可穿戴電子設(shè)備的不同形式的自動(dòng)反饋。一個(gè)這樣的系統(tǒng)已經(jīng)在隨機(jī)臨床試驗(yàn)研究中進(jìn)行了測(cè)試，報(bào)告了活動(dòng)水平的重要變化，盡管矛盾的數(shù)據(jù)已經(jīng)發(fā)表?；颊咴诎l(fā)生心肌梗死后應(yīng)接受PA咨詢，當(dāng)無法獲得此咨詢時(shí)，可提供此咨詢作為心臟康復(fù)的繼續(xù)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.本研究的一個(gè)明顯優(yōu)點(diǎn)是樣本量大，而且在10年內(nèi)它代表了整個(gè)瑞典MI人群。大樣本量允許我們對(duì)重要子組執(zhí)行子組分析，如上所述。此外，該研究發(fā)生在2000年代，證實(shí)了PA在二級(jí)預(yù)防中的作用在現(xiàn)代心肌梗死治療時(shí)代的變化，包括高侵襲性治療率和有效的二級(jí)預(yù)防藥物。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.平均隨訪時(shí)間相對(duì)較短，可能使結(jié)果對(duì)反向原因敏感。為了研究這一點(diǎn)，我們對(duì)那些隨訪時(shí)間短于入院后2年（n=3424，151例死亡）的患者進(jìn)行了分析。在應(yīng)用正式測(cè)試時(shí)，主要分析被重復(fù)，并且只注意到有限的和非顯著的差異。這說明反向因果關(guān)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.這項(xiàng)研究的一個(gè)局限是暴露測(cè)量。MI患者PA評(píng)估的相關(guān)效度尚不清楚。此外，它還沒有包括久坐行為和PA強(qiáng)度變化的測(cè)量，而這些將添加到研究中。然而，如本文所示，該問題的預(yù)測(cè)有效性很強(qiáng)。另一個(gè)限制是殘留混淆的可能性（即，雖然已采取措施控制重要因素，但有可能未測(cè)量某些變化）。此外，我們?nèi)狈﹃P(guān)于潛在的重要社會(huì)經(jīng)濟(jì)變量的數(shù)據(jù)。另一個(gè)限制是缺乏營(yíng)養(yǎng)信息。這項(xiàng)研究時(shí)，這并沒有包括在SWEDEHEART注冊(cè)表中，因此無法解釋。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.如結(jié)果部分所述，包括和非包括的患者在幾個(gè)方面存在差異。納入的患者通常較少吸煙，有較好的eGFR，較少發(fā)生STEMI，有較高的存活率。調(diào)查一個(gè)偏向于更健康的隊(duì)列可能導(dǎo)致對(duì)PA變化的影響的低估。然而，在完整模型和PA地層中變量之間缺乏交互作用表明發(fā)現(xiàn)通?？绲貙邮欠€(wěn)健的（即，在高/低eGFR、STEMI/NSTEMI等人群中類似的結(jié)果），例外EF的N。因此，假定這種偏置是有限的。正如在結(jié)果中提到的，PA地層在幾個(gè)方面是不同的。有可能，盡管控制這些差異并執(zhí)行分層分析，但是非活動(dòng)性充當(dāng)MI嚴(yán)重性或其他正在進(jìn)行的疾病的代理。然而，分層分析中的相似之處可以視為對(duì)此的一種反駁。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.使用三種類型的暴露于吸煙。更精確的測(cè)量，例如包裝年份，可能已經(jīng)減少了關(guān)于這個(gè)變量的可能的殘余混淆。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.總之，心肌梗死后第一年P(guān)A增加與隨后死亡的風(fēng)險(xiǎn)降低有關(guān)。這是規(guī)模最大的研究，以評(píng)估PA后MI在現(xiàn)代MI治療時(shí)代的影響，在全國(guó)代表性的隊(duì)列。本研究的結(jié)果將具有很大的臨床影響，強(qiáng)調(diào)使用PA作為心肌梗死后常規(guī)二級(jí)預(yù)防措施的一部分。希望我們現(xiàn)在沒有借口不改進(jìn)對(duì)現(xiàn)有二級(jí)預(yù)防指導(dǎo)方針的遵守。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瑞典資助。在公共、商業(yè)或非營(yíng)利部門，沒有任何資金機(jī)構(gòu)提供其他特別資助。Disclosures
None.Footnotes
*Correspondence to: ?rjan Ekblom, PhD, The ?strand Laboratory of Work Physiology, The Swedish School of Sport and Health Sciences, Liding?v?gen 1, P. O. Box 5626, 114 86 Stockholm, Sweden. E‐mail: orjan.******se
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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
