Cardiac rehabilitation (CR) is a comprehensive disease management program recommended for secondary cardiovascular prevention by the European Society of Cardiology (ESC) in its “2021 Guidelines on Cardiovascular Disease Prevention in Clinical Practice.”1 Exercise training is a core component of CR that has proven effective in reducing mortality among patients with coronary artery disease (CAD).2 In its guidelines, the ESC has recommended engaging in ≥150 minutes per week of moderate to vigorous physical activity (MVPA), generally defined as physical activity (PA) with an intensity ≥3 metabolic equivalents.1 However, previous studies have reported that only 30% to 50% of patients with CAD achieve recommended PA levels.3,4 A meta-analysis of randomized controlled trials also failed to show a significant impact of CR on duration of MVPA.5 Preventing relapse to low PA levels is another clinical challenge of PA promotion. Although one study reported temporary increases in patients’ exercise frequency with short-term (2 wk) CR after myocardial infarction, approximately 50% of these patients had not maintained this after 6 months.6 These outcomes suggest a need for better PA counseling to promote MVPA in patients with CAD.
Individualized interventions based on personalized goal setting and guidance have been reported as effective for lifestyle modification.7 For targeted PA, setting difficult goals improved objective PA levels more than setting easy ones.8 Thus, patients fare better with individualized goal setting. PA has been associated with socio-demographic,9,10 clinical,11,12 psychological,11 and other factors used for individualized goal setting.13 In addition to the known PA-related factors, CAD classification may affect the change in PA after discharge, due to differences in symptoms and the revascularization process. For example, acute coronary syndrome (ACS) is characterized by the sudden onset of substernal chest discomfort or pressure. It is generally treated by emergency percutaneous coronary intervention (PCI) after transport by ambulance. Stable angina, a major contributor in chronic coronary syndrome (CCS), is characterized by substernal chest discomfort or pressure that increases with exercise stress and is treated with elective revascularization. One study has reported that the experience of symptoms before revascularization and the perceived severity of disease may affect participation in CR.14 Episodes of chest pain and CAD severity may also be associated with changes in PA, and these factors should also be considered during individualized PA goal setting.
There are 2 key aspects to developing a PA or MVPA prediction model. One is the study design, and the other is a suitable device for objective measurements. To date, most studies evaluating PA and associated factors in patients with CAD have been carried out with a cross-sectional design. A single study did not, but it measured PA using a questionnaire and without an accelerometer.15 Therefore, there is a lack of prospective studies incorporating longitudinal PA assessment. Such assessments are needed to identify the predictive factors for PA level improvement and relapse during PA promotion. In addition, to our knowledge, there are no published reports investigating the factors associated with changes in MVPA of patients with CAD that incorporate longitudinal PA assessment using an accelerometer. In this study, we aimed to clarify changes in MVPA and associated factors using objective measurements in patients after PCI.
Methods
Study Design and Participants
This was a multicenter, prospective cohort study. The eligibility criteria were patients aged 74 years and younger who underwent PCI for CCS or ACS. This study included both new-onset and recurrent CAD cases. The exclusion criteria were as follows: (1) inability to walk, (2) receiving artificial dialysis, (3) comorbid heart failure, and (4) having difficulty answering the questionnaires. The study protocol was approved by the local ethics committee (approval number: 2017-0242), and all participants provided written informed consents during hospitalization after PCI.
Study Protocol
Clinical data were collected using medical records at discharge. Self-administered questionnaires were completed by each participant before discharge. Follow-up surveys were conducted at 1 and 3 months after discharge. Patients received a questionnaire and an accelerometer through the mail and returned them to the Nagoya University after completing the measurements.
Outcome Measurements
MVPA was objectively measured for 7 consecutive days using an accelerometer (Kenz Lifecorder, Suzuken). This device has shown good reliability and data validity.16,17 The duration of MVPA was calculated for each participant. The intensity of PA was categorized into 11 levels (0, 0.5, 1–9) based on the acceleration pattern. An acceleration intensity of >4 was considered as MVPA (activity at an intensity of >3 metabolic equivalents).18 The participants were instructed to wear the accelerometer on their waist for 24 hours per day for 1 week, except while bathing and sleeping, and to continue their routine activities of daily living as normal. The accelerometer was set to withhold measurement data from the screen display, and participants were blinded to their daily step count and MVPA during measurement to avoid stimulating PA. Based on previous research,19 we excluded participants with fewer than 4 valid days of data collection and defined a valid day as one with at least 10 hours of data collected while awake.
Data Collection
Clinical data included demographics (age, sex, and body mass index); diagnosis (CCS or ACS); blood pressure and heart rate at discharge; angiographic and procedural characteristics (lesion location, multivessel disease, residual stenosis, in-stent restenosis); coronary risk factors (hypertension, dyslipidemia, and diabetes mellitus); medical history of CAD (myocardial infarction, PCI, coronary artery bypass graft); prescribed medications at discharge; blood biochemistry (lipid profile, blood glucose, hemoglobin A1c, creatinine, estimated glomerular filtration rate, and hemoglobin); and echocardiographic data. The above demographics and clinical findings were collected as candidate PA-related factors, based on previous studies.9–12
The questionnaires analyzed factors reported in previous study10,11,14 to be associated with PA and behavioral intentions, including the severity of chest pain at the onset of heart attack or angina pectoris (low, moderate, or severe), and a number of “yes or no” questions, including the physician’s explanation regarding long-term prognosis, exercise environments at home, social support for exercise, employment status, and exercise habits. There were also questions regarding smoking, walking self-efficacy, difficulty in daily activities, and depression. The Self-Efficacy for Walking-7 (SEW-7)20 scale, composed of 7 items rated on a 5-point Likert scale, was used for total scores of 7 to 35 points. SEW-7 has been favorably correlated with step counts (r = .596) and MVPA (r = .581).20 The Performance Measure for Activity of Daily Living-8 (PMADL-8) measured daily activity. The PMADL-8 is a standardized questionnaire with a 4-category response scale comprising 8 items that potentially require daily PA.21 It was developed to assess functional limitations in patients with chronic heart failure and has been highly correlated with peak VO2 (r = −.743) in patients with heart failure.22 Depression was assessed using the Hospital Anxiety and Depression Scale23 and classified with 8 or more points. Data other than employment status and exercise habits were collected at discharge, and employment status and exercise habits were collected at the 1-month follow-up survey.
Statistical Analysis
Patients with missing PA data were excluded from the analysis. For variables with missing data, pairwise deletion was performed to reduce the risk of bias from the exclusion of too many participants. Continuous variables are presented as median [interquartile range (IQR)]. Categorical variables are presented as frequencies and percentages. Differences in MVPA at 1 and 3 months were compared using the Wilcoxon signed-rank test.
Analysis 1: Factors Associated With Increased MVPA
Analysis 1 aimed to evaluate factors associated with increased MVPA (≥150 min/wk at 3 mo) in patients who did not reach the target MVPA (150 min/wk) at 1 month. First, univariate logistic regression analysis (LRA) was performed to explore variables potentially associated with increased MVPA, using MVPA ≥ 150 minutes per week at 3 months as the dependent variable. Next, multivariate LRA was performed for variables with P < .05 on univariate analysis and for clinically important factors previously reported as independent variables affecting PA. The number of independent variables was based on one variable per 10 outcome events on the LRA.24
Analysis 2: Factors Associated With Decreased MVPA
Analysis 2 aimed to evaluate factors associated with decreased MVPA (<150 min/wk at 3 mo) in patients who had achieved the target MVPA at 1 month. Univariate LRA was performed to explore the associations of decreased MVPA, using MVPA < 150 minutes per week at 3 months as a dependent variable. Multivariate LRA was performed for variables with P < .05 on the univariate analysis and for clinically important factors previously reported as independent variables affecting PA.
All statistical analyses were performed using the Stata SE 15 software (Stata Corporation). Statistical significance was set at a P value < .05.
Results
Participant Characteristics
We registered 806 patients in the present study and excluded those who dropped out at 1 (n = 114) and 3 months (n = 67), as well as those with missing PA data (n = 48). Finally, we analyzed data from 577 patients (Figure 1). Table 1 presents the participants’ characteristics. Overall, the median age was 64 [IQR 58–68] years, and 13.5% were women. The prevalence of CCS and ACS were 79.5% and 20.5%, respectively. Participants with CCS had higher prevalence of having a history of PCI than participants with ACS.
—Flowchart of patient selection. MVPA indicates moderate to vigorous physical activity.
Citation: Journal of Physical Activity and Health 20, 4; 10.1123/jpah.2022-0396
Participant Characteristics
| The number of missing | Overall (N = 577) | ACS (n = 118) | CCS (n = 459) | MVPA < 150 min/wk at 1 mo (n = 388) | MVPA ≥ 150 min/wk at 1 mo (n = 189) | |
|---|---|---|---|---|---|---|
| Age, y | 0 | 64 [58–68] | 62 [53–67] | 64 [59–69] | 64 [60–68] | 62 [55–67] |
| Female, % | 0 | 78 (13.5) | 14 (11.9) | 64 (13.9) | 58 (14.9) | 20 (10.6) |
| ACS, % | 0 | 118 (20.5) | 118 (100.0) | 0 (0) | 88 (22.7) | 30 (15.9) |
| Body mass index, kg/m2 | 0 | 24.3 [22.2–26.8] | 23.6 [21.2–26.3] | 24.4 [22.4–26.9] | 24.4 [22.2–26.9] | 23.8 [22.0–26.1] |
| Body mass index ≥ 25, % | 0 | 234 (40.6) | 41 (34.7) | 193 (42.0) | 165 (42.5) | 69 (36.5) |
| Systolic blood pressure at discharge, mmHg | 4 | 117 [108–130] | 114 [105–123.5] | 119 [109–131] | 118 [108–130] | 117 [109–130] |
| Diastolic blood pressure at discharge, mmHg | 4 | 67 [60–75] | 68 [60–77] | 66 [59–75] | 67 [59–74] | 67 [60–77] |
| Heart rate at discharge, beats/min | 4 | 68 [61–76] | 69 [62–77] | 66 [61–75] | 68 [60–77] | 68 [61–74] |
| Angiographic characteristics, % | ||||||
| Right coronary artery stenosis | 0 | 155 (26.9) | 39 (33.1) | 116 (25.3) | 106 (27.3) | 49 (25.9) |
| Left main trunk stenosis | 0 | 8 (1.4) | 3 (2.5) | 5 (1.1) | 7 (1.8) | 1 (0.5) |
| Left anterior descending artery stenosis | 0 | 345 (59.8) | 72 (61.0) | 273 (59.5) | 228 (58.8) | 117 (61.9) |
| Left circumflex artery stenosis | 0 | 122 (21.1) | 22 (18.6) | 100 (21.8) | 80 (20.6) | 42 (22.2) |
| Multivessel disease ≥ 2VD | 0 | 225 (39.0) | 52 (44.1) | 173 (37.7) | 157 (40.5) | 68 (36.0) |
| In-stent restenosis | 0 | 60 (10.4) | 6 (5.1) | 54 (11.8) | 37 (9.5) | 23 (12.2) |
| Residual stenosis | 0 | 150 (26.0) | 36 (30.5) | 114 (24.8) | 106 (27.3) | 44 (23.3) |
| Past medical history of CAD, % | ||||||
| Myocardial infarction | 0 | 101 (17.5) | 14 (11.9) | 87 (19.0) | 71 (18.3) | 30 (15.9) |
| PCI | 0 | 245 (42.5) | 11 (9.3) | 234 (51.0) | 166 (42.8) | 79 (41.8) |
| Coronary artery bypass graft | 0 | 10 (1.7) | 1 (0.8) | 9 (2.0) | 7 (1.8) | 3 (1.6) |
| Coronary risk factors, % | ||||||
| Diabetes | 0 | 213 (36.9) | 30 (25.4) | 183 (39.9) | 148 (38.1) | 65 (34.4) |
| Hypertension | 0 | 390 (67.6) | 78 (66.1) | 312 (68.0) | 268 (69.1) | 122 (64.6) |
| Dyslipidemia | 0 | 425 (73.7) | 80 (67.8) | 345 (75.2) | 292 (75.3) | 133 (70.4) |
| LVEF at discharge | 13 | 61.7 [55.9–66.5] | 57.0 [49.0–62.8] | 62.7 [57.0–67.3] | 61.7 [55.8–66.6] | 61.7 [56.0–66.3] |
| Biochemical data at discharge | ||||||
| LDL cholesterol, mg/dL | 5 | 101 [80–125] | 113 [85–141] | 98 [79–119] | 100 [79–120] | 103 [83–128] |
| HDL cholesterol, mg/dL | 5 | 48.9 [41–58] | 45.8 [37.4–55.0] | 49.3 [41.8–60.0] | 47.3 [40.1–56.9] | 51.9 [42.5–61.4] |
| Triglyceride, mg/dL | 5 | 134.5 [95–202] | 111 [85–173] | 142 [100–205] | 130 [95–203] | 141 [97–201] |
| HbA1c, % | 33 | 6 [5.7–6.7] | 5.9 [5.6–6.4] | 6.0 [5.7–6.8] | 6.0 [5.7–6.8] | 5.9 [5.6–6.6] |
| Blood glucose, mg/dL | 3 | 114 [98–140] | 107 [97–132] | 116 [99–140] | 115 [98–141] | 112 [99–134] |
| Creatinine, mg/dL | 3 | 0.88 [0.77–1.00] | 0.90 [0.80–1.01] | 0.87 [0.77–1.00] | 0.87 [0.77–1.01] | 0.89 [0.79–0.99] |
| eGFR, mL/min/1.73 m2 | 3 | 67.3 [58.3–75.4] | 65.7 [58.4–75.8] | 67.7 [58.3–75.0] | 66.8 [58.0–75.4] | 67.9 [59.3–75.1] |
| Hemoglobin, g/dL | 0 | 13.5 [12.5–14.6] | 13.9 [12.7–14.8] | 13.4 [12.4–14.5] | 13.4 [12.4–14.6] | 13.7 [12.7–14.6] |
| Prescription at discharge, % | ||||||
| Statin | 0 | 473 (82) | 108 (91.5) | 365 (79.5) | 316 (81.4) | 157 (83.1) |
| Antiplatelet agent | 0 | 570 (98.8) | 113 (95.8) | 457 (99.6) | 382 (98.5) | 188 (99.5) |
| DAPT | 0 | 537 (93.1) | 103 (87.3) | 434 (94.6) | 362 (93.3) | 175 (92.6) |
| Anticoagulant agent | 0 | 26 (4.5) | 15 (12.7) | 11 (2.4) | 18 (4.6) | 8 (4.2) |
| ACEi/ARB | 0 | 299 (51.8) | 81 (68.6) | 218 (47.5) | 211 (54.4) | 88 (46.6) |
| Beta blocker | 0 | 218 (37.8) | 70 (59.3) | 148 (32.2) | 159 (41.0) | 59 (31.2) |
| Diuretic | 0 | 26 (4.5) | 5 (4.2) | 21 (4.6) | 20 (5.2) | 6 (3.2) |
| Calcium channel blocker | 0 | 164 (28.4) | 17 (14.4) | 147 (32.0) | 118 (30.4) | 46 (24.3) |
| Hypoglycemic drug | 0 | 177 (30.7) | 23 (19.5) | 154 (33.6) | 126 (32.5) | 51 (27.0) |
| Participation in outpatient CR | 0 | 21 (3.6) | 18 (15.3) | 3 (0.7) | 17 (4.4) | 4 (2.1) |
| Questionnaire data at discharge | ||||||
| Severity of chest pain at onset, % | ||||||
| Low | 4 | 287 (50.1) | 28 (23.7) | 259 (56.9) | 187 (48.4) | 100 (53.5) |
| Moderate | 199 (34.7) | 46 (39.0) | 153 (33.6) | 141 (36.5) | 58 (31.0) | |
| Severe | 87 (15.2) | 44 (37.3) | 43 (9.5) | 58 (15.0) | 29 (15.5) | |
| Physician’s explanation regarding long-term prognosis, % | 20 | 473 (84.9) | 103 (88.0) | 370 (84.1) | 314 (84.0) | 159 (86.9) |
| Social support, % | 15 | 358 (63.7) | 70 (61.4) | 288 (64.3) | 236 (62.8) | 122 (65.6) |
| Exercise environment, % | 3 | 289 (50.3) | 58 (49.2) | 231 (50.7) | 192 (49.6) | 97 (51.9) |
| Smoking, % | ||||||
| Nonsmoker | 4 | 158 (27.6) | 29 (24.8) | 129 (28.3) | 98 (25.5) | 60 (31.9) |
| Past smoker | 290 (50.6) | 46 (39.3) | 244 (53.5) | 190 (49.4) | 100 (53.2) | |
| Current smoker | 125 (21.8) | 42 (35.9) | 83 (18.2) | 97 (25.2) | 28 (14.9) | |
| Depression, % | 10 | 228 (40.2) | 45 (38.8) | 183 (40.6) | 153 (40.1) | 75 (40.5) |
| SEW-7 (points) | 10 | 26 (21–30) | 25 (21–28) | 26 (21–30) | 24 (20–29) | 28 (23–31) |
| PMADL-8 (points) | 9 | 14 (10–18) | 14 (11–18) | 14 (10–18) | 15 (11–18) | 12 (10–17) |
| Working, % | 28 | 394 (71.8) | 85 (74.6) | 309 (71.0) | 261 (70.7) | 133 (73.9) |
| Exercise habits, % | 40 | 148 (27.6) | 33 (29.7) | 115 (27.0) | 82 (22.7) | 66 (37.7) |
Abbreviations: ACEi, angiotensin-converting enzyme; ACS, acute coronary syndrome; ARB, angiotensin II receptor blocker; CAD, coronary artery disease; CCS, chronic coronary syndrome; CR, cardiac rehabilitation; DAPT, dual antiplatelet therapy; eGFR, estimated glomerular filtration rate; HbA1c, hemoglobin A1c; HDL, high-density lipoprotein; LDL, low-density lipoprotein; LVEF, left ventricular ejection fraction; MVPA, moderate to vigorous physical activity; PCI, percutaneous coronary intervention; PMADL-8, Performance Measure for Activities of Daily Living-8; SEW-7, Self-Efficacy for Walking-7; VD, vessel disease. Note: Continuous variables and categorical variables are shown by median [interquartile range] and the number of participants (%), respectively.
PA at 1 and 3 Months
The distributions of MVPA at 1 and 3 months are presented in Table 2. The prevalence of MVPA ≥ 150 minutes per week at 1 and 3 months was 32.8% and 35.9%, respectively. Of participants with MVPA < 150 minutes per week at 1 month, 65 (16.8%) participants increased to MVPA ≥ 150 minutes per week, and 323 (83.2%) participants remained at MVPA < 150 minutes per week at the 3-month measurement. Of participants with MVPA ≥ 150 minutes per week at 1 month, 47 (24.9%) participants decreased to MVPA <150 minutes per week, and 142 (75.1%) participants maintained MVPA ≥ 150 minutes per week at 3 months (Figure 2). Four categories of participants’ characteristics are presented in Appendix.
The Distributions of MVPA at 1 and 3 Months
| 1 mo | 3 mo | P | |
|---|---|---|---|
| Overall (n = 577) | 105 [55.1–183.0] | 109.3 [52.6–195.7] | .07 |
| ACS (n = 118) | 89.3 [43.9–151.1] | 103.4 [43.2–189.0] | .001 |
| OCR (n = 18) | 89.8 [58.9–126.8] | 145.8 [60.3–199.6] | .008 |
| Non-OCR (n = 100) | 89.3 [43.4–156.5] | 99.4 [42.8–184.2] | .02 |
| CCS (n = 459) | 109.1 [58.0–188.0] | 111.7 [54.2–197.5] | .64 |
Abbreviations: ACS, acute coronary syndrome; CCS, chronic coronary syndrome; MVPA, moderate to vigorous physical activity; OCR, outpatient cardiac rehabilitation. Note: Data are presented as median [interquartile range]. Patients with ACS was divided into 2 group based on OCR.
—Time course changes of MVPA from 1 to 3 months. *1: increased MVPA; *2: decreased MVPA. MVPA indicates moderate to vigorous physical activity.
Citation: Journal of Physical Activity and Health 20, 4; 10.1123/jpah.2022-0396
Analysis 1: Factors Associated With Increased MVPA
Of 388 participants engaged in MVPA < 150 minutes per week at 1 month, 65 achieved MVPA ≥ 150 minutes per week at 3 months. The univariate LRA identified several variables that were significantly associated with increasing MVPA. Six variables (age, diabetes mellitus, PCI for left main trunk [LMT] stenosis, hemoglobin, participation in outpatient CR, and SEW) were included as independent variables on multivariate analysis. On multivariate analysis with data from 382 participants, the parameters of outpatient CR participation (odds ratio 3.67; 95% confidence interval, 1.22–11.0), PCI for LMT stenosis (13.0; 2.49–68.2), diabetes mellitus (0.42; 0.22–0.81), and hemoglobin (1.47 per 1 SD; 1.09–1.97) were significantly associated with increasing MVPA (Table 3).
Univariate and Multivariate Logistic Regression Analyses to Explore Factors of Increasing MVPA
| Variables | The number of missing | Unit | Univariate | Multivariate | ||||
|---|---|---|---|---|---|---|---|---|
| Odds ratio | 95% CI | P | Odds ratio | 95% CI | P | |||
| Age, y | 0 | Per 1 y | 0.96 | (0.93–0.99) | .01 | 0.98 | (0.94–1.01) | .22 |
| Female | 0 | Yes | 0.77 | (0.34–1.70) | .51 | |||
| ACS | 0 | Yes | 0.92 | (0.48–1.76) | .81 | |||
| Body mass index, kg/m2 | 0 | Per 1 kg/m2 | 0.96 | (0.89–1.03) | .28 | |||
| Body mass index ≥ 25 | 0 | Yes | 0.70 | (0.40–1.21) | .20 | |||
| Systolic blood pressure at discharge, mmHg | 3 | Per 1 SD | 0.86 | (0.66–1.12) | .27 | |||
| Diastolic blood pressure at discharge, mmHg | 3 | Per 1 SD | 1.00 | (0.76–1.31) | .98 | |||
| Heart rate at discharge, beats/min | 3 | Per 1 SD | 0.94 | (0.73–1.22) | .65 | |||
| Angiographic characteristics | ||||||||
| Right coronary artery stenosis | 0 | Yes | 0.85 | (0.46–1.56) | .59 | |||
| Left main trunk stenosis | 0 | Yes | 6.99 | (1.53–32.03) | .01 | 13.0 | (2.49–68.2) | <.01 |
| Left anterior descending artery stenosis | 0 | Yes | 0.99 | (0.57–1.69) | .96 | |||
| Left circumflex artery stenosis | 0 | Yes | 0.57 | (0.27–1.21) | .14 | |||
| Multivessel disease ≥ 2VD | 0 | Yes | 0.55 | (0.31–0.99) | <.05 | 0.56 | (0.30–1.04) | .07 |
| In-stent restenosis | 0 | Yes | 0.26 | (0.06–1.11) | .07 | |||
| Residual stenosis | 0 | Yes | 0.85 | (0.46–1.56) | .59 | |||
| Past medical history of CAD | ||||||||
| Myocardial infarction | 0 | Yes | 0.78 | (0.38–1.62) | .51 | |||
| PCI | 0 | Yes | 0.75 | (0.43–1.29) | .30 | |||
| Coronary artery bypass graft | 0 | Yes | 0.83 | (0.10–6.97) | .86 | |||
| Coronary risk factors | ||||||||
| Diabetes | 0 | Yes | 0.43 | (0.23–0.80) | .01 | 0.42 | (0.22–0.81) | <.01 |
| Hypertension | 0 | Yes | 0.62 | (0.35–1.07) | .09 | |||
| Dyslipidemia | 0 | Yes | 0.76 | (0.42–1.37) | .36 | |||
| LVEF at discharge, % | 11 | Per 1 SD | 0.95 | (0.73–1.24) | .70 | |||
| Biochemical data at discharge | ||||||||
| LDL cholesterol, mg/dL | 5 | Per 1 SD | 1.07 | (0.82–1.40) | .62 | |||
| HDL cholesterol, mg/dL | 5 | Per 1 SD | 1.05 | (0.80–1.37) | .75 | |||
| Triglyceride, mg/dL | 5 | Per 1 SD | 1.06 | (0.85–1.32) | .61 | |||
| HbA1c, % | 22 | Per 1 SD | 0.70 | (0.49–0.99) | <.05 | |||
| Blood glucose, mg/dL | 3 | Per 1 SD | 0.75 | (0.55–1.03) | .08 | |||
| Creatinine, mg/dL | 3 | Per 1 SD | 0.84 | (0.56–1.26) | .40 | |||
| eGFR, mL/min/1.73 m2 | 3 | Per 1 SD | 1.14 | (0.88–1.47) | .31 | |||
| Hemoglobin, g/dL | 0 | Per 1 SD | 1.42 | (1.08–1.88) | .01 | 1.47 | (1.10–1.97) | .01 |
| Prescription at discharge | ||||||||
| Statin | 0 | Yes | 1.76 | (0.80–3.88) | .16 | |||
| Antiplatelet agent | 0 | Yes | N/A | |||||
| DAPT | 0 | Yes | 1.58 | (0.46–5.44) | .47 | |||
| Anticoagulant agent | 0 | Yes | 0.61 | (0.14–2.72) | .52 | |||
| ACEi/ARB | 0 | Yes | 0.62 | (0.37–1.07) | .09 | |||
| Beta blocker | 0 | Yes | 0.75 | (0.43–1.31) | .32 | |||
| Diuretic | 0 | Yes | 0.25 | (0.03–1.90) | .18 | |||
| Calcium channel blocker | 0 | Yes | 0.64 | (0.34–1.19) | .16 | |||
| Hypoglycemic drug | 0 | Yes | 0.46 | (0.24–0.89) | .02 | |||
| Participation in outpatient CR | 0 | Yes | 2.88 | (1.03–8.10) | .04 | 3.67 | (1.22–11.04) | .02 |
| Questionnaire data at discharge | ||||||||
| Severity of chest pain at onseta | 2 | 0.79 | (0.54–1.17) | .24 | ||||
| Physician’s explanation regarding long-term prognosis | 14 | Yes | 1.64 | (0.71–3.80) | .25 | |||
| Social support | 12 | Yes | 1.07 | (0.61–1.87) | .81 | |||
| Exercise environment | 1 | Yes | 0.85 | (0.50–1.44) | .54 | |||
| Smoker | 3 | Yes | 1.17 | (0.64–2.13) | .61 | |||
| Depression | 6 | Yes | 1.11 | (0.65–1.92) | .70 | |||
| SEW-7 (points) | 6 | Per 1 point | 1.04 | (1.00–1.09) | <.05 | 1.03 | (0.99–1.09) | .14 |
| PMADL-8 (points) | 5 | Per 1 point | 0.97 | (0.92–1.03) | .36 | |||
| Working | 19 | Yes | 0.72 | (0.38–1.34) | .30 | |||
| Exercise habits | 26 | Yes | 1.51 | (0.82–2.79) | .19 | |||
Abbreviations: ACEi, angiotensin-converting enzyme; ACS, acute coronary syndrome; ARB, angiotensin II receptor blocker; CAD, coronary artery disease; CI, confidence interval; CR, cardiac rehabilitation; DAPT, dual antiplatelet therapy; eGFR, estimated glomerular filtration rate; HbA1c, hemoglobin A1c; HDL, high-density lipoprotein; LDL, low-density lipoprotein; LVEF, left ventricular ejection fraction; MVPA, moderate to vigorous physical activity; N/A, not applicable; PCI, percutaneous coronary intervention; PMADL-8, Performance Measure for Activities of Daily Living-8; SEW-7, Self-Efficacy for Walking-7; VD, vessel disease. Note: Multivariate logistic regression analyses based on 382/388 participants. Continuous variables show the odds ratio corresponded to a change from the lower to higher value per unit. Categorical variables show the odds ratio of “Yes” relative to “No.” A higher odds ratio indicates that MVPA is more likely to increase.
aSeverity of chest pain at onset: 1 = “low”; 2 = “moderate”; 3 = “severe.”
Analysis 2: Factors Associated With Decreased MVPA
Of 189 participants with MVPA ≥ 150 minutes per week at 1 month, 47 dropped to MVPA < 150 minutes per week at 3 months. The univariate LRA identified 2 variables, age and body mass index, that were significantly associated with declining MVPA. According to the one variable per 10 outcomes concept, the subsequent multivariate analysis included age, body mass index, and 3 other variables (SEW, depression, and physician’s explanation regarding long-term prognosis) that were previously reported to be significantly associated with PA. The multivariate analyses were performed on 178 participants, and declining MVPA was significantly associated with depression (0.31; 0.14–0.74) and SEW (0.92 per 1 point; 0.86–0.98) (Table 4).
Univariate and Multivariate Logistic Regression Analyses to Explore Factors of Declining MVPA
| Variables | The number of missing | Unit | Univariate | Multivariate | ||||
|---|---|---|---|---|---|---|---|---|
| Odds ratio | 95% CI | P | Odds ratio | 95% CI | P | |||
| Age, y | 0 | Per 1 y | 0.95 | (0.91–0.99) | .03 | 0.97 | (0.92–1.02) | .29 |
| Female | 0 | Yes | 1.01 | (0.35–2.94) | .99 | |||
| ACS | 0 | Yes | 0.56 | (0.20–1.55) | .26 | |||
| Body mass index, kg/m2 | 0 | Per 1 kg/m2 | 1.13 | (1.03–1.24) | .01 | 1.11 | (1.00–1.23) | .05 |
| Body mass index ≥ 25 | 0 | Yes | 1.25 | (0.63–2.46) | .52 | |||
| Systolic blood pressure at discharge, mmHg | 1 | Per 1 SD | 0.96 | (0.68–1.36) | .82 | |||
| Diastolic blood pressure at discharge, mmHg | 1 | Per 1 SD | 1.03 | (0.75–1.42) | .84 | |||
| Heart rate at discharge, beats/min | 1 | Per 1 SD | 0.96 | (0.67–1.38) | .83 | |||
| Angiographic characteristics | ||||||||
| Right coronary artery stenosis | 0 | Yes | 1.49 | (0.72–3.07) | .28 | |||
| Left main trunk stenosis | 0 | Yes | N/A | |||||
| Left anterior descending artery stenosis | 0 | Yes | 1.12 | (0.56–2.21) | .75 | |||
| Left circumflex artery stenosis | 0 | Yes | 0.54 | (0.22–1.30) | .17 | |||
| Multivessel disease ≥ 2VD | 0 | Yes | 0.60 | (0.29–1.25) | .17 | |||
| In-stent restenosis | 0 | Yes | 1.38 | (0.53–3.59) | .51 | |||
| Residual stenosis | 0 | Yes | 0.50 | (0.20–1.20) | .12 | |||
| Past medical history of CAD | ||||||||
| Myocardial infarction | 0 | Yes | 1.65 | (0.71–3.83) | .25 | |||
| PCI | 0 | Yes | 1.31 | (0.68–2.55) | .42 | |||
| Coronary artery bypass graft | 0 | Yes | N/A | |||||
| Coronary risk factors | ||||||||
| Diabetes | 0 | Yes | 1.42 | (0.72–2.80) | .32 | |||
| Hypertension | 0 | Yes | 0.85 | (0.43–1.68) | .64 | |||
| Dyslipidemia | 0 | Yes | 0.99 | (0.48–2.04) | .98 | |||
| LVEF at discharge, % | 2 | Per 1 SD | 1.27 | (0.88–1.83) | .20 | |||
| Biochemical data at discharge | ||||||||
| LDL cholesterol, mg/dL | 0 | Per 1 SD | 1.16 | (0.84–1.60) | .37 | |||
| HDL cholesterol, mg/dL | 0 | Per 1 SD | 0.81 | (0.58–1.14) | .23 | |||
| Triglyceride, mg/dL | 0 | Per 1 SD | 1.26 | (0.84–1.89) | .27 | |||
| HbA1c, % | 11 | Per 1 SD | 1.06 | (0.79–1.40) | .71 | |||
| Blood glucose, mg/dL | 0 | Per 1 SD | 1.17 | (0.83–1.66) | .38 | |||
| Creatinine, mg/dL | 0 | Per 1 SD | 0.99 | (0.78–1.26) | .91 | |||
| eGFR, mL/min/1.73 m2 | 0 | Per 1 SD | 0.90 | (0.63–1.29) | .57 | |||
| Hemoglobin, g/dL | 0 | Per 1 SD | 1.37 | (0.94–1.98) | .10 | |||
| Prescription at discharge | ||||||||
| Statin | 0 | Yes | 0.48 | (0.21–1.07) | .07 | |||
| Antiplatelet agent | 0 | Yes | N/A | |||||
| DAPT | 0 | Yes | 0.57 | (0.18–1.79) | .33 | |||
| Anticoagulant agent | 0 | Yes | 1.87 | (0.43–8.13) | .41 | |||
| ACEi/ARB | 0 | Yes | 1.27 | (0.66–2.46) | .48 | |||
| Beta blocker | 0 | Yes | 1.73 | (0.87–3.44) | .12 | |||
| Diuretic | 0 | Yes | N/A | |||||
| Calcium channel blocker | 0 | Yes | 1.09 | (0.51–2.33) | .83 | |||
| Hypoglycemic drug | 0 | Yes | 1.38 | (0.67–2.84) | .38 | |||
| Participation in outpatients CR | 0 | Yes | 1.01 | (0.10–9.92) | 1.00 | |||
| Questionnaire data at discharge | ||||||||
| Severity of chest pain at onseta | 2 | 1.00 | (0.64–1.58) | .98 | ||||
| Physician’s explanation regarding long-term prognosis | 6 | Yes | 4.08 | (0.92–18.1) | .06 | 3.31 | (0.69–15.86) | .13 |
| Social support | 3 | Yes | 0.71 | (0.36–1.40) | .32 | |||
| Exercise environment | 2 | Yes | 1.28 | (0.66–2.50) | .47 | |||
| Smoker | 1 | Yes | 0.79 | (0.30–2.09) | .64 | |||
| Depression | 4 | Yes | 0.49 | (0.24–1.01) | .05 | 0.32 | (0.14–0.74) | <.01 |
| SEW-7 (points) | 4 | Per 1 point | 0.96 | (0.91–1.01) | .11 | 0.92 | (0.86–0.98) | .01 |
| PMADL-8 (points) | 4 | Per 1 point | 1.04 | (0.97–1.11) | .28 | |||
| Working | 9 | Yes | 0.66 | (0.29–1.51) | .33 | |||
| Exercise habits | 14 | Yes | 0.74 | (0.36–1.54) | .42 | |||
Abbreviations: ACEi, angiotensin-converting enzyme; ACS, acute coronary syndrome; ARB, angiotensin II receptor blocker; CAD, coronary artery disease; CI, confidence interval; CR, cardiac rehabilitation; DAPT, dual antiplatelet therapy; eGFR, estimated glomerular filtration rate; HbA1c, hemoglobin A1c; HDL, high-density lipoprotein; LDL, low-density lipoprotein; LVEF, left ventricular ejection fraction; MVPA, moderate to vigorous physical activity; N/A, not applicable; PCI, percutaneous coronary intervention; PMADL-8, Performance Measure for Activities of Daily Living-8; SEW-7, Self-Efficacy for Walking-7; VD, vessel disease. Note: Multivariate logistic regression analyses based on 178/189 participants. Continuous variables show the odds ratio corresponded to a change from the lower to higher value per unit. Categorical variables show the odds ratio of “Yes” relative to “No.” A higher odds ratio indicates that MVPA is more likely to decrease.
aSeverity of chest pain at onset: 1 = “low”; 2 = “moderate”; 3 = “severe.”
Discussion
To our knowledge, this is the first study to use an accelerometer to investigate short-term changes in MVPA in patients with post-PCI after hospital discharge. The results of our study showed that MVPA from 1 to 3 months increased only in patients with ACS, and not in those with CCS. In patients with MVPA < 150 minutes per week at 1 month, factors associated with increased MVPA at 3 months included participation in outpatient CR, PCI for LMT stenosis, no history of diabetes, and higher hemoglobin levels. In contrast, lower SEW and lack of depression were associated with decreased 3-month MVPA in patients with MVPA ≥ 150 minutes per week at 1 month. These factors may serve as predictive variables both in promoting increased or preventing decreased PA levels, contributing to individualized goal setting and guidance in clinical practice for patients with post-PCI.
MVPA in Patients After PCI
Despite the benefits of MVPA for secondary prevention, 65% of the participants in this study did not reach the guideline recommended MVPA (≥150 min/wk) at either 1 or 3 months after hospital discharge. The prevalence of patients with less than recommended MVPA is similar to that in previous reports on patients with CAD.4,15 The findings of the present study also showed that the time course changes of MVPA differed between ACS and CCS; patients with ACS increased their MVPA during the convalescent phase (median: 89.3–103.4 min/wk), but patients with CCS did not (median: 105.0–109.3 min/wk). To our knowledge, there have been no reports investigating changes in MVPA over time according to CAD diagnosis. Previous studies have reported increased PA in ACS over the short term, which supports our results.15,25 Differences in the MVPA changes between ACS and CCS may be influenced by differences in symptoms and the intensity of secondary prevention care. Approximately 50% of patients with CCS in this study had a prior history of PCI, indicating the longer duration since diagnosis. A previous study reported that patients with prior PCI were less likely to participate in CR.26 These results suggest that the motivation toward behavioral change for secondary prevention may decrease as time passes from disease onset. In addition, the length of hospital stay for PCI is generally shorter in patients with CCS versus those with ACS.27 This may mean insufficient time for secondary prevention instruction, including recommendations regarding PA. In patients with ACS, those participating in outpatient CR achieved further increases in MVPA (median: 89.8–145.8 min/wk), suggesting that CR may promote MVPA. Therefore, lack of opportunity to receive lifestyle guidance was likely one explanation for poor PA improvement among patients who underwent PCI.
Factors Associated With Increased MVPA
In this study, increased MVPA was associated with participation in outpatient CR, PCI for LMT stenosis, no history of diabetes mellitus, and high hemoglobin levels. The finding that outpatient CR participation was more likely to increase MVPA in our study differed from the previous meta-analysis that did not show a favorable impact of CR on MVPA.5 The results of our study indicate that patients participating in outpatient CR may have been highly conscious of improving PA. Another factor is that collaborating hospitals in our study were actively involved in promoting MVPA. Although outpatient CR was selected as a predictor of improved MVPA, interventions that contributes to the positive effects of CR on MVPA should also be examined in the future.
Patients who underwent PCI for LMT stenosis also significantly increased their MVPA. LMT stenosis is the highest risk lesion and is associated with poorer clinical outcomes compared with single-vessel CAD.28 Patients with LMT stenosis are also likely to be at increased risk of cardiac events during exercise.29 Therefore, patients who underwent PCI for LMT stenosis may have been more likely to receive secondary prevention guidance from the medical staff, resulting in postdischarge behavioral changes.
The results of this study also showed that patients with diabetes were less likely to increase MVPA, and higher hemoglobin levels were associated with increased MVPA. Several reports have shown that individuals with diabetes engage in less PA than those without.30,31 In patients with diabetes, emotional factors like willpower and confidence in exercise ability have been reported as major barriers to increasing PA.32,33 Similar factors may have been involved for patients with diabetes in our study. The association between hemoglobin levels and increased MVPA is likely mediated by exercise capacity. Anemia reduces oxygen-carrying capacity, resulting in reduced maximal aerobic capacity.34 We can speculate that decreased aerobic capacity increased fatigue, thus restricting MVPA.
Factors Associated With Decreased MVPA
A low SEW level was associated with declining MVPA during follow-up. This suggests that patients with low self-efficacy may relapse even if they reach recommended levels at 1-month postdischarge. Although the causal effect is unknown, several reports have found that low self-efficacy for exercise is associated with low PA, whereas higher self-efficacy is associated with high PA.9,11 Our results were in line with a previous systematic review of prospective cohort studies, which also reported that individuals with higher self-efficacy had lower risk of relapse.35 Self-efficacy refers to the belief in one’s capabilities to organize and execute the actions required to achieve given targets. Self-efficacy is thought to reflect engagement in health behaviors and is enhanced by past successful experiences.36 Therefore, a low level of SEW may indicate a lack of habitual walking exercise in such patients. In our study, several factors may have stimulated the 1-month PA in patients with low SEW. For example, there is increasing interest in lifestyle improvements by wearing accelerometers. They were likely to be more active than usual at 1 month because of this but may have resumed previous activity levels at 3 months due to difficulties maintaining motivation.
Contrary to our expectations, patients with depression were less likely to decrease MVPA at 3 months. As depression has been considered to be associated with low PA levels,37 our contradictory findings may be explained by the influence of personality traits on patients’ lifestyles. In general, high neuroticism has been associated with both depressive symptoms and poor health behaviors including daily PA.38,39 However, a previous study has suggested that neuroticism positively affects the promotion of health behaviors when it is combined with high conscientiousness.40 Therefore, the positive association between depression and maintained PA may have been mediated by personality traits, although supporting data for this hypothesis was not examined in this study.
Clinical Implications
The findings of our study provide insights for the clinical practice of individualized goal setting and effective PA counseling to promote MVPA and prevent the relapse in PA promotion. The strategy to promote MVPA and prevent the PA relapse in patients with post-PCI has room for innovation. The strategies include increasing PA gradually for patients who have barriers to exercise, setting achievable goals to first obtain a successful experience, maintaining motivation for patients with low self-efficacy to prevent relapse, and having the potential to prescribe outpatient CR. In any case, one substantial problem is that most patients do not have a chance to participate in outpatient CR. In Japan, the participation rate by patients with ACS and CCS is only 9% and 3%, respectively.27 Increasing opportunities for lifestyle improvements such as CR remain a major challenge, but the development of effective PA interventions using these strategies may contribute to MVPA promotion and, in turn, secondary CAD prevention in the future.
Strengths and Limitations
The strength of our study was that the change in MVPA was measured longitudinally using an accelerometer. In addition, factors potentially related to MVPA changes were comprehensively investigated in a single prospective cohort study.
However, our study had several limitations. First, post-PCI survey participants were enrolled. This causes a selection bias, and the generalizability of our findings should be carefully weighed. Second, because of the small number of patients with ACS, we analyzed the associated factors in all patients. As stated, MVPA changes differed between the ACS and CCS groups; predictors of MVPA may need to be examined separately. Third, 2-point MVPA measurements may be affected by external factors, including weather and working circumstances. Fourth, confounders that were not measured in this study may exist (eg, education level and economic status). Finally, this was an observational study, and the causal relationship between changes in MVPA and related factors could not be addressed. Nevertheless, our study identified factors associated with these changes using objectively measured MVPA. Further studies are required to confirm our results.
Conclusion
Identifying factors associated with changes in MVPA may provide detailed insight into behavioral changes affecting PA levels and, in turn, lead to individualized PA promotion.
Acknowledgments
We thank all participants for their cooperation in the study. The authors would like to thank Dr. Masahiro Nakatochi (Nagoya University Graduate School of Medicine) for useful comment on statistical analysis. This study was supported by the Suzuken Memorial Foundation (Grant No. 20-034), JSPS KAKENHI (Grant No. 19K24311), and JST SPRING (Grant No. JPMJSP2125).
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Appendix: Participant Characteristics for Each MVPA Category
| The number of missing | MVPA < 150 min/wk at 1 mo (n = 388) | MVPA ≥ 150 min/wk at 1 mo (n = 189) | |||
|---|---|---|---|---|---|
| MVPA < 150 min/wk at 3 mo (n = 323) | MVPA ≥ 150 min/wk at 3 mo (n = 65) | MVPA < 150 min/wk at 3 mo (n = 47) | MVPA ≥ 150 min/wk at 3 mo (n = 142) | ||
| Age, y | 0 | 65 [60–69] | 63 [54–68] | 59 [53–66] | 63 [56–68] |
| Female, n (%) | 0 | 50 (15.5) | 8 (12.3) | 5 (10.6) | 15 (10.6) |
| ACS, n (%) | 0 | 74 (22.9) | 14 (21.5) | 5 (10.6) | 25 (17.6) |
| Body mass index, kg/m2 | 0 | 24.4 [22.2–27.0] | 24.5 [22.4–25.8] | 24.0 [23.2–27.2] | 23.7 [21.7–25.9] |
| Body mass index ≥ 25, n (%) | 0 | 142 (44.0) | 23 (35.4) | 19 (40.4) | 50 (35.2) |
| Systolic blood pressure at discharge, mmHg | 4 | 118 [109–130] | 117 [104–129] | 117 [107–128] | 117 [109–132] |
| Diastolic blood pressure at discharge, mmHg | 4 | 67 [59–75] | 68 [58–74] | 68 [58–76] | 67 [60–77] |
| Heart rate at discharge, beats/min | 4 | 68 [61–77] | 66 [60–78] | 68 [60–74] | 68 [62–73] |
| Angiographic characteristics | |||||
| Right coronary artery stenosis, n (%) | 0 | 90 (27.9) | 16 (24.6) | 15 (31.9) | 34 (23.9) |
| Left main trunk stenosis, n (%) | 0 | 3 (0.9) | 4 (6.2) | 0 (0.0) | 1 (0.7) |
| Left anterior descending artery stenosis, n (%) | 0 | 190 (58.8) | 38 (58.5) | 30 (63.8) | 87 (61.3) |
| Left circumflex artery stenosis, n (%) | 0 | 71 (22.0) | 9 (13.8) | 7 (14.9) | 35 (24.6) |
| Multi vessel disease ≥ 2VD, n (%) | 0 | 138 (42.7) | 19 (29.2) | 13 (27.7) | 55 (38.7) |
| In-stent restenosis, n (%) | 0 | 35 (10.8) | 2 (3.1) | 7 (14.9) | 16 (11.3) |
| Residual stenosis, n (%) | 0 | 90 (27.9) | 16 (24.6) | 7 (14.9) | 37 (26.1) |
| Past medical history of CAD | |||||
| Myocardial infarction, n (%) | 0 | 61 (18.9) | 10 (15.4) | 10 (21.3) | 20 (14.1) |
| PCI, n (%) | 0 | 142 (44.0) | 24 (36.9) | 22 (46.8) | 57 (40.1) |
| Coronary artery bypass graft, n (%) | 0 | 6 (1.9) | 1 (1.5) | 0 (0.0) | 3 (2.1) |
| Coronary risk factors | |||||
| Diabetes, n (%) | 0 | 133 (41.2) | 15 (23.1) | 19 (40.4) | 46 (32.4) |
| Hypertension, n (%) | 0 | 229 (70.9) | 39 (60.0) | 29 (61.7) | 93 (65.5) |
| Dyslipidemia, n (%) | 0 | 246 (76.2) | 46 (70.8) | 33 (70.2) | 100 (70.4) |
| LVEF at discharge, % | 13 | 61.8 [55.8–66.7] | 61.6 [55.1–66.3] | 63.7 [60.0–68.0] | 60.8 [55.9–65.7] |
| Biochemical data at discharge | |||||
| LDL cholesterol, mg/dL | 5 | 100 [78–120] | 98 [80–125] | 109 [86–127] | 100 [81–128] |
| HDL cholesterol, mg/dL | 5 | 48.0 [40.1–56.8] | 46.7 [40.6–58.5] | 49 [41.8–60.5] | 52.1 [44.8–63.4] |
| Triglyceride, mg/dL | 5 | 130 [95–204] | 129 [94–203] | 154 [118–220] | 131 [85–183] |
| HbA1c, % | 33 | 6.1 [5.8–6.8] | 5.8 [5.6–6.4] | 5.9 [5.7–7.0] | 6.0 [5.6–6.5] |
| Blood glucose, mg/dL | 3 | 116 [99–146] | 108 [95.5–129.5] | 120 [104–147] | 111 [98–132] |
| Creatinine, mg/dL | 3 | 0.87 [0.77–1.02] | 0.87 [0.77–0.95] | 0.89 [0.83–0.99] | 0.89 [0.78–0.99] |
| eGFR, mL/min/1.73 m2 | 3 | 66.6 [57.0–74.9] | 68.7 [61.8–76.1] | 67.3 [58.4–75.0] | 68.0 [59.5–75.4] |
| Hemoglobin, g/dL | 0 | 13.3 [12.3–14.5] | 14.0 [13.1–14.8] | 14.0 [13.1–14.8] | 13.5 [12.5–14.4] |
| Prescription at discharge | |||||
| Statin, n (%) | 0 | 259 (80.2) | 57 (87.7) | 35 (74.5) | 122 (85.9) |
| Antiplatelet agent, n (%) | 0 | 317 (98.1) | 65 (100.0) | 46 (97.9) | 142 (100.0) |
| DAPT, n (%) | 0 | 300 (92.9) | 62 (95.4) | 42 (89.4) | 133 (93.7) |
| Anticoagulant agent, n (%) | 0 | 16 (5.0) | 2 (3.1) | 3 (6.4) | 5 (3.5) |
| ACEi/ARB, n (%) | 0 | 182 (56.3) | 29 (44.6) | 24 (51.1) | 64 (45.1) |
| Beta blocker, n (%) | 0 | 136 (42.1) | 23 (35.4) | 19 (40.4) | 40 (28.2) |
| Diuretic, n (%) | 0 | 19 (5.9) | 1 (1.5) | 0 (0.0) | 6 (4.2) |
| Calcium channel blocker, n (%) | 0 | 103 (31.9) | 15 (23.1) | 12 (25.5) | 34 (23.9) |
| Hypoglycemic drug, n (%) | 0 | 113 (35.0) | 13 (20.0) | 15 (31.9) | 36 (25.4) |
| Participation in outpatient CR, n (%) | 0 | 11 (3.4) | 6 (9.2) | 1 (2.1) | 3 (2.1) |
| Questionnaire data at discharge | |||||
| Severity of chest pain at the onset, n (%) | |||||
| Low | 4 | 154 (48.0) | 33 (50.8) | 23 (51.1) | 77 (54.2) |
| Moderate | 114 (35.5) | 27 (41.5) | 16 (35.6) | 42 (29.6) | |
| Severe | 53 (16.5) | 5 (7.7) | 6 (13.3) | 23 (16.2) | |
| Physician’s explanation regarding long-term prognosis, n (%) | 20 | 258 (83.0) | 56 (88.9) | 43 (95.6) | 116 (84.1) |
| Social support, n (%) | 15 | 195 (62.5) | 41 (64.1) | 28 (59.6) | 94 (67.6) |
| Exercise environment, n (%) | 3 | 162 (50.3) | 30 (46.2) | 26 (56.5) | 71 (50.4) |
| Smoking, n (%) | |||||
| Nonsmoker | 4 | 79 (24.7) | 19 (29.2) | 11 (23.4) | 49 (34.8) |
| Past smoker | 162 (50.6) | 28 (43.1) | 30 (63.8) | 70 (49.6) | |
| Current smoker | 79 (24.7) | 18 (27.7) | 6 (12.8) | 22 (15.6) | |
| Depression, n (%) | 10 | 126 (39.6) | 27 (42.2) | 13 (28.3) | 62 (44.6) |
| SEW-7 (points) | 10 | 24 [20–29] | 26 [22–30] | 26.5 [21–30] | 28 [24–31] |
| PMADL-8 (points) | 9 | 15 [11–18] | 14 [11–18] | 13 [10–18] | 12 [9–17] |
| Employment status, n (%) | 28 | 213 (69.6) | 48 (76.2) | 35 (79.5) | 98 (72.1) |
| Exercise habit, n (%) | 40 | 64 (21.3) | 18 (29.0) | 14 (32.6) | 52 (39.4) |
| Physical activity data, min/wk | |||||
| MVPA at 1 mo | 0 | 62.9 [33.5–95.9] | 109.3 [86.6–136.4] | 182.7 [158.4–223.4] | 255.9 [206.5–344.3] |
| MVPA at 3 mo | 0 | 61.1 [33.5–96.3] | 199.3 [167.4–242.4] | 111.9 [94.3–130.7] | 254.7 [202.1–353.5] |
Abbreviations: ACEi, angiotensin-converting enzyme; ACS, acute coronary syndrome; ARB, angiotensin II receptor blocker; CAD, coronary artery disease; CCS, chronic coronary syndrome; CR, cardiac rehabilitation; DAPT, dual antiplatelet therapy; eGFR, estimated glomerular filtration rate; HbA1c, hemoglobin A1c; HDL, high-density lipoprotein; LDL, low-density lipoprotein; LVEF, left ventricular ejection fraction; MVPA, moderate to vigorous physical activity; PCI, percutaneous coronary intervention; PMADL-8, Performance Measure for Activities of Daily Living-8; SEW-7, Self-Efficacy for Walking-7; VD, vessel disease. Note: Continuous variables and categorical variables are shown by median [interquartile range] and the number of participants (%), respectively.
