Correlation Between Physical Activity and Clinical Variables in Patients with Acute Myocardial Infarction

Ana Teresa Glaser Carvalho Thays Fraga Duarte Andressa Sarda Maiochi Roberto Leo da Silva Tammuz Fattah Daniel Medeiros Moreira About the authors

Abstract

Background:

Physical activity reduces the risk of coronary heart disease, one of the leading causes of death in the world.

Objectives:

This study intends to correlate physical activity and clinical variables of the patients hospitalized in public hospitals of Santa Catarina after the first acute myocardial infarction.

Methods:

The selected patients answered a questionnaire on different clinical variables. Physical activity was measured using the Baecke's questionnaire. Data were tabulated and analyzed using the SPSS 13.0 for Windows software. Normality was assessed using the Kolmogorov-Smirnov test. Correlations between two quantitative variables were evaluated by Pearson's correlation. Values of p < 0.05 were considered statistically significant.

Results:

The study showed a weak positive correlation between the Baecke score and years of schooling (r = 0.361; p = 0.001). There was a weak negative correlation between the Baecke score and the PHQ9 depression score (r = -0.252; p = 0.009). The study also showed a weak negative correlation between the PHQ9 depression score and the Mini Mental score (r = -0.258; p = 0.007), as well as a weak negative correlation between PHQ9 and schooling years with (r = -0.199, p = 0.039).

Conclusions:

There is a positive correlation between physical activity and years of schooling in hospitalized patients with first acute myocardial infarction. Negative correlations were found between physical activity and depression, between depression and the Mini-Mental State Examination, and between depression and years of schooling in these patients.

Keywords:
Exercise; Myocardial Infarction; Coronary Artery Disease / prevention & control; Physical Fitness

Resumo

Fundamentos:

A atividade física reduz o risco de doença coronariana, uma das principais causas de morte no mundo.

Objetivos:

Este estudo pretende correlacionar as atividades físicas com variáveis clínicas de pacientes internados em hospitais públicos de Santa Catarina após o primeiro infarto agudo do miocárdio.

Métodos:

Os pacientes selecionados foram submetidos a questionário que engloba diferentes variáveis clínicas. A atividade física foi mensurada através do Escore de Baecke. Os dados obtidos foram tabulados e analisados através do software SPSS 13.0 for Windows. A avaliação da normalidade foi realizada pelo teste de Kolmogorov-Smirnov. A correlação entre duas variáveis quantitativas foi avaliada pela Correlação de Pearson. Foram considerados significativos valores de p < 0,05.

Resultados:

O estudo evidenciou uma correlação positiva fraca entre o escore de Baecke e anos de escolaridade com r = 0,361 (p = 0,001). Houve uma correlação negativa fraca entre o escore de Baecke e o escore de depressão PHQ9 com r = -0,252 (p = 0,009). O estudo também apresentou correlação negativa fraca entre o escore de depressão PHQ9 e o Mini Mental com r = -0,258 (p = 0,007), assim como uma correlação negativa fraca entre o PHQ9 e os anos de escolaridade com r = -0,199 (p = 0,039).

Conclusões:

Existe uma correlação positiva entre atividade física e anos de escolaridade em pacientes internados com o primeiro infarto agudo do miocárdio. Há também uma correlação negativa entre atividade física e depressão nesses pacientes, assim como uma correlação negativa entre depressão e o Mini-Mental, e depressão e anos de escolaridade.

Palavras-chave:
Exercício; Infarto do Miocárdio; Doença da Artéria Coronariana / prevenção & controle; Aptidão Física

Introduction

Myocardial ischemia is the initial step in the development of acute myocardial infarction, and results from an imbalance between oxygen supply and demand. It is mainly caused by coronary artery disease, which is the leading cause of mortality and morbidity in the world.11 Thygesen K, Alpert JS, Jaffe AS, Simoons ML, Chaitman BR, White HD, et al; ESC Committee for Practice Guidelines (CPG). Third universal definition of myocardial infarction. Eur Heart J. 2012;33(20):2551-2567. doi: 10.1093/eurheartj/ehs184.
https://doi.org/10.1093/eurheartj/ehs184...

Studies suggest that changes in lifestyle are of paramount importance for individuals of both sexes and all ages, from all geographic regions, and belonging to the main ethnic groups. Practice of moderate physical activity should be one of the priorities in the prevention of coronary artery disease in all populations worldwide.22 Yusuf S, Hawken S, Ounpuu S, Dans T, Avezum A, Lanas F, et al; INTERHEART Study Investigators. Effect of potentially modifiable risk factors associated with myocardial infarction in 52 countries (the INTERHEART study): case-control study. Lancet. 2004;364(9438):937-52. doi: 10.1016/S0140-6736(04)17018-9.
https://doi.org/10.1016/S0140-6736(04)17...

Several studies have shown the benefits of physical activities in the reduction of the risks of coronary disease. Sedentary lifestyle is an independent risk factor for acute myocardial infarction, and is directly related to low HDL-cholesterol levels, weight gain, increase in blood pressure and in coagulation factors.33 Saad EA. Prevenção primária e secundária da aterosclerose: perspectivas atuais e futuras. Rev SOCERJ. 2004;17(2):112-32.

There is evidence indicating a dose-dependent, inverse relationship between physical activity and cardiovascular events. Aerobic physical activity from moderate-to-vigorous intensity is recommended, on average, from three to four times a week, with 40-minute duration.44 Eckel RH, Jakicic JM, Ard JD, Jesus JM, Miller NH, Hubbard VS, et al; American College of Cardiology/American Heart Association Task Force on Practice Guidelines. 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. Circulation. 2014;129(25 Suppl 2):S76-S99. doi: 10.1161/01cir.0000437740.48606.d1. Erratum in: Circulation. 2014;129(25 Suppl 2):S100-1. Circulation. 2015;131(4):e326.
https://doi.org/10.1161/01cir.0000437740...

The present study aims to correlate physical activity, measured by the Baecke questionnaire, with other clinical variables in inpatients after a first acute myocardial infarction at public hospitals in Santa Catarina, Brazil.

Methods

This was an analysis of Catarina Heart Study, a cohort, prospective study that intends to evaluate 1,426 patients by the year 2020. A convenience sample of consecutive patients, attending public hospitals in Santa Catarina, diagnosed with first acute myocardial infarction, answered a questionnaire on clinical, laboratory, electrocardiographic, echocardiographic and angiographic variables between July and December 2016.

Physical activity was assessed by the Baecke questionnaire, composed of 16 questions that encompassed three scores of habitual physical activity in the last 12 months: score of occupational physical activity (eight questions), score of physical activity during leisure time (four questions), and score of leisure- or transport-related physical activity (four questions). In this study, we used the scores of physical activity during leisure time, and the score of leisure- or transport-related physical activity, validated for the Brazilian population; the sum of these two scores yielded the total score.55 Florindo AA, Latorre MR. Validação e reprodutibilidade do questionário de Baecke da avaliação da atividade física habitual em homens adultos. Rev Bras Med Esporte. 2003;9(3):121-8.

Depression was assessed by the PHQ9, consisting of a nine-question questionnaire that evaluates the presence of each of the symptoms of major depression, described in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV). The nine symptoms were depressed mood, anhedonia, sleeping problems, tiredness or loss of energy, appetite or weight change, psychomotor agitation or retardation, suicidal ideation.66 Santos IS, Tavares BF, Munhoz TN, Almeida LS, Silva NT, Tams BD, et al. Sensibilidade e especificidade do Pattient Health Questionnaire 9 (PHQ-9) entre adultos da população geral. Cad Saúde Pública. 2013;29(8):1533-43. doi: http://dx.doi.org/10.1590/0102-311x00144612.
http://dx.doi.org/10.1590/0102-311x00144...

Inclusion criteria were the following: age older than 18 years, precordial pain suggestive of acute myocardial infarction associated with new ST elevation at the J-point in two contiguous leads of > 0.1 mV in all leads other than leads V2-V3. For leads V2-V3, the following cut points were apply: ≥ 0.2 mV in men ≥ 40 years, ≥ 0.25 mV in men < 40 years, or ≥ 0.15 mV in women; or presence of precordial pain suggestive of acute myocardial infarction associated with elevation or troponin I or CK-MB above the 99th percentile of normal. Exclusion criteria included previous acute myocardial infarction, and disagreement of consent form and terms.

The primary outcome of the study was to assess the physical activity of inpatients with first infarction using the Baecke score, and its correlation with years of schooling. Secondary outcomes were the correlation of physical activity with depressive moods, evaluated by the PHQ9; the correlation of physical activity with mental state using the Mini-Mental State Examination, and the relation of depressive moods with years of schooling and the Mini-Mental State Examination.

In conformity with the 466/2012 resolution of the Brazilian National Health Council, all patients signed the informed consent form. The study was approved by the ethics committee of the institutions participating in the study.

Statistical analysis

A minimum sample size of 92 patients was calculated for a 0.3 correlation, power of 90% and alpha of 0.05. Data were tabulated and analyzed using the SPSS 13.0 software for Windows. Normality test was performed by the Kolmogorov-Smirnov test. Quantitative variables with normal distribution were expressed as mean ± standard deviation. Categorical variables were expressed as absolute number and percentage. Correlations between two quantitative variables were evaluated by the Pearson Correlation. A p < 0.05 was considered statistically significant.

Results

A total of 108 patients were assessed from July 2016 to December 2016, with mean age of 59.3 ± 11.6 years. Seventy-five patients (69.4%) were men. Fifty-one (47.2%) patients had ST-segment elevation myocardial infarction, and 57 (52.7%) patients had non-ST segment elevation myocardial infarction. The classical risk factors for coronary artery disease and potential risk factors in the study population are described in Table 1.

Table 1
Characteristics of the study population

A weak, positive correlation between Baeck score and years of schooling was found (r = 0.361, p = 0.001).

The analyses revealed a weak negative correlation between Baecke’s and PHQ9 depression scores (r = -0.252, p = 0.009). The study also showed a weak negative correlation between PHQ9 depression score and the Mini-Mental State Examination (r = -0.258, p = 0.007), as well as a negative correlation of PHQ9 score with years of schooling (r = -0.199; p = 0.039).

Discussion

The present study showed a weak, positive correlation between physical activity and years of schooling. These data make this study original, since there were few studies in the literature correlating these variables in hospitalized patients with acute myocardial infarction. A longitudinal study carried out in Greece and published in 2016 evaluated the association between educational status in hospitalized patients with acute coronary syndrome and the prognosis of these patients. All-cause mortality and recurrent coronary events were higher in patients with lower education level. This study also showed that patients with higher education level were more physically active.77 Notara V, Panagiotakos DB, Kogias Y, Stravopodis P, Antonoulas A, Zombolos S, et al. The impact of educational status on 10-year (2004-2014) cardiovascular disease prognosis and all-cause mortality among acute coronary syndrome patients in the Greek Acute Coronary Syndrome (GREECS) longitudinal study. J Prev Med Public Health. 2016;49(4):220-9. doi: 10.3961/jpmph.16.005.
https://doi.org/10.3961/jpmph.16.005...

Results of the present study indicate a weak negative correlation between physical activity and depression in inpatients with infarction. These results are in agreement with those of previous studies correlating these variables in other populations. Recent studies have suggested that moderate-to-vigorous physical activity is inversely associated with anxiety and depressive symptoms.88 Doré I, O'Loughlin JL, Beauchamp G, Martineau M, Fournier L. Volume and social context of physical activity in association with mental health, anxiett and depression among youth. Prev Med. 2016;91:344-50. doi: 10.1016/j.ypmed.2016.09.006.
https://doi.org/10.1016/j.ypmed.2016.09....
The correlation between physical activity and depression was also studied in other populations. In patients with Alzheimer’s disease, for example, physical activity also showed a negative correlation with depressive symptoms.99 Vital TM, Hernandez SS, Stein AM, Garuff M, Corazza DI, de Andrade LP, et al. Depressive symptoms and level of physical activity in pacientes with Alzheimer's disease. Geriatr Gerontol Int. 2012;12(4):637-42. doi: 10.1111/j.1447-0594.2011.00830.x.
https://doi.org/10.1111/j.1447-0594.2011...
In patients with major depression, sedentary habits were shown to be independent risk factors for cardiovascular diseases and early mortality.1010 Schuch F, Vancamfort D, Firth J, Rosembaum S, Ward P, Reichert T, et al. Physical activity and sedentary behavior in people with major depressive disorder: a systemic review and meta-analysis. J Affect Disord. 2017;210:139-50. doi: 10.1016/j.jad.2016.10.050.
https://doi.org/10.1016/j.jad.2016.10.05...

In addition, a weak negative correlation was found between depression scores and the Mini-Mental State Examination. A similar study conducted in the USA with 116 heart failure patients also showed a correlation between depression and cognitive dysfunction in these patients.1111 Garcia S, Spitznagel MB, Cohen R, Raz N, Sweet L, Colbert L, et al. Depression is associated with cognitive dysfunction in older adults with hearth failure. Cardiovasc Psychiatry Neurol. 2011;2011:368324. doi: 10.1155/2011/368324.
https://doi.org/10.1155/2011/368324...

This original study has some limitations that should be considered. The sample size of the study was small, although it had sufficient power to show significant correlations between these variables; these correlations did not prove a cause-effect relationship and may be just associations. Besides, the significant results may result from mere chance. These limitations, however, do not invalidate our findings, which gives a contribution to the Brazilian and international literature on cardiology.

Conclusions

There is a positive correlation between physical activity and years of schooling in hospitalized patients with acute myocardial infarction in Santa Catarina.

There is a negative correlation between physical activity and depression in these patients, and a negative correlation between depression and years of schooling, and between depression and Mini-Mental State Examination.

  • Sources of Funding
    There were no external funding sources for this study.
  • Study Association
    This article is part of the thesis of master submitted by Ana Teresa Glaser Carvalho, from Instituto de Cardiologia de Santa Catarina.
  • Ethics approval and consent to participate
    This study was approved by the Ethics Committee of the Instituto de Cardiologia de Santa Catarina under the protocol number Nº 1.519.838, CAAE 55450816.0.1001.0113. All the procedures in this study were in accordance with the 1975 Helsinki Declaration, updated in 2013. Informed consent was obtained from all participants included in the study.

References

  • 1
    Thygesen K, Alpert JS, Jaffe AS, Simoons ML, Chaitman BR, White HD, et al; ESC Committee for Practice Guidelines (CPG). Third universal definition of myocardial infarction. Eur Heart J. 2012;33(20):2551-2567. doi: 10.1093/eurheartj/ehs184.
    » https://doi.org/10.1093/eurheartj/ehs184
  • 2
    Yusuf S, Hawken S, Ounpuu S, Dans T, Avezum A, Lanas F, et al; INTERHEART Study Investigators. Effect of potentially modifiable risk factors associated with myocardial infarction in 52 countries (the INTERHEART study): case-control study. Lancet. 2004;364(9438):937-52. doi: 10.1016/S0140-6736(04)17018-9.
    » https://doi.org/10.1016/S0140-6736(04)17018-9
  • 3
    Saad EA. Prevenção primária e secundária da aterosclerose: perspectivas atuais e futuras. Rev SOCERJ. 2004;17(2):112-32.
  • 4
    Eckel RH, Jakicic JM, Ard JD, Jesus JM, Miller NH, Hubbard VS, et al; American College of Cardiology/American Heart Association Task Force on Practice Guidelines. 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. Circulation. 2014;129(25 Suppl 2):S76-S99. doi: 10.1161/01cir.0000437740.48606.d1. Erratum in: Circulation. 2014;129(25 Suppl 2):S100-1. Circulation. 2015;131(4):e326.
    » https://doi.org/10.1161/01cir.0000437740.48606.d1
  • 5
    Florindo AA, Latorre MR. Validação e reprodutibilidade do questionário de Baecke da avaliação da atividade física habitual em homens adultos. Rev Bras Med Esporte. 2003;9(3):121-8.
  • 6
    Santos IS, Tavares BF, Munhoz TN, Almeida LS, Silva NT, Tams BD, et al. Sensibilidade e especificidade do Pattient Health Questionnaire 9 (PHQ-9) entre adultos da população geral. Cad Saúde Pública. 2013;29(8):1533-43. doi: http://dx.doi.org/10.1590/0102-311x00144612
    » http://dx.doi.org/10.1590/0102-311x00144612
  • 7
    Notara V, Panagiotakos DB, Kogias Y, Stravopodis P, Antonoulas A, Zombolos S, et al. The impact of educational status on 10-year (2004-2014) cardiovascular disease prognosis and all-cause mortality among acute coronary syndrome patients in the Greek Acute Coronary Syndrome (GREECS) longitudinal study. J Prev Med Public Health. 2016;49(4):220-9. doi: 10.3961/jpmph.16.005.
    » https://doi.org/10.3961/jpmph.16.005
  • 8
    Doré I, O'Loughlin JL, Beauchamp G, Martineau M, Fournier L. Volume and social context of physical activity in association with mental health, anxiett and depression among youth. Prev Med. 2016;91:344-50. doi: 10.1016/j.ypmed.2016.09.006.
    » https://doi.org/10.1016/j.ypmed.2016.09.006
  • 9
    Vital TM, Hernandez SS, Stein AM, Garuff M, Corazza DI, de Andrade LP, et al. Depressive symptoms and level of physical activity in pacientes with Alzheimer's disease. Geriatr Gerontol Int. 2012;12(4):637-42. doi: 10.1111/j.1447-0594.2011.00830.x.
    » https://doi.org/10.1111/j.1447-0594.2011.00830.x
  • 10
    Schuch F, Vancamfort D, Firth J, Rosembaum S, Ward P, Reichert T, et al. Physical activity and sedentary behavior in people with major depressive disorder: a systemic review and meta-analysis. J Affect Disord. 2017;210:139-50. doi: 10.1016/j.jad.2016.10.050.
    » https://doi.org/10.1016/j.jad.2016.10.050
  • 11
    Garcia S, Spitznagel MB, Cohen R, Raz N, Sweet L, Colbert L, et al. Depression is associated with cognitive dysfunction in older adults with hearth failure. Cardiovasc Psychiatry Neurol. 2011;2011:368324. doi: 10.1155/2011/368324.
    » https://doi.org/10.1155/2011/368324

Publication Dates

  • Publication in this collection
    Jan-Feb 2018

History

  • Received
    22 Feb 2017
  • Reviewed
    10 Aug 2017
  • Accepted
    21 Aug 2017
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