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Regular exercise behaviour and intention and symptoms of anxiety and depression in coronary heart disease patients across Europe: Results from the EUROASPIRE III survey.

Identifieur interne : 000B35 ( Main/Exploration ); précédent : 000B34; suivant : 000B36

Regular exercise behaviour and intention and symptoms of anxiety and depression in coronary heart disease patients across Europe: Results from the EUROASPIRE III survey.

Auteurs : Christof Prugger [Allemagne] ; Jürgen Wellmann [Allemagne] ; Jan Heidrich [Allemagne] ; Dirk De Bacquer [Belgique] ; Delphine De Smedt [Belgique] ; Guy De Backer [Belgique] ; Željko Reiner [Croatie] ; Jean-Philippe Empana [France] ; Zlatko Fras [Slovénie] ; Dan Gaita [Roumanie] ; Catriona Jennings [Royaume-Uni] ; Kornelia Kotseva [Royaume-Uni] ; David Wood [Royaume-Uni] ; Ulrich Keil [Allemagne]

Source :

RBID : pubmed:27587188

Descripteurs français

English descriptors

Abstract

BACKGROUND

Regular exercise lowers the risk of cardiovascular death in coronary heart disease (CHD) patients. We aimed to investigate regular exercise behaviour and intention in relation to symptoms of anxiety and depression in CHD patients across Europe.

DESIGN

This study was based on a multicentre cross-sectional survey.

METHODS

In the EUROpean Action on Secondary and Primary Prevention through Intervention to Reduce Events (EUROASPIRE) III survey, 8966 CHD patients <80 years of age from 22 European countries were interviewed on average 15 months after hospitalisation. Whether patients exercised or intended to exercise regularly was assessed using the Stages of Change questionnaire in 8330 patients. Symptoms of anxiety and depression were evaluated using the Hospital Anxiety and Depression Scale. Total physical activity was measured by the International Physical Activity Questionnaire in patients from a subset of 14 countries.

RESULTS

Overall, 50.3% of patients were not intending to exercise regularly, 15.9% were intending to exercise regularly, and 33.8% were exercising regularly. Patients with severe symptoms of depression less frequently exercised regularly than patients with symptoms in the normal range (20.2%, 95% confidence interval (CI) 14.8-26.8 vs 36.7%, 95% CI 29.8-44.2). Among patients not exercising regularly, patients with severe symptoms of depression were less likely to have an intention to exercise regularly (odds ratio 0.62, 95% CI 0.46-0.85). Symptoms of anxiety did not affect regular exercise intention. In sensitivity analysis, results were consistent when adjusting for total physical activity.

CONCLUSIONS

Lower frequency of regular exercise and decreased likelihood of exercise intention were observed in CHD patients with severe depressive symptoms. Severe symptoms of depression may preclude CHD patients from performing regular exercise.


DOI: 10.1177/2047487316667781
PubMed: 27587188


Affiliations:


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<name sortKey="De Backer, Guy" sort="De Backer, Guy" uniqKey="De Backer G" first="Guy" last="De Backer">Guy De Backer</name>
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<name sortKey="Gaita, Dan" sort="Gaita, Dan" uniqKey="Gaita D" first="Dan" last="Gaita">Dan Gaita</name>
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<name sortKey="Keil, Ulrich" sort="Keil, Ulrich" uniqKey="Keil U" first="Ulrich" last="Keil">Ulrich Keil</name>
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<title level="j">European journal of preventive cardiology</title>
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<term>Anxiety (diagnosis)</term>
<term>Anxiety (physiopathology)</term>
<term>Anxiety (psychology)</term>
<term>Cardiac Rehabilitation (methods)</term>
<term>Coronary Disease (diagnosis)</term>
<term>Coronary Disease (physiopathology)</term>
<term>Coronary Disease (psychology)</term>
<term>Coronary Disease (rehabilitation)</term>
<term>Cross-Sectional Studies (MeSH)</term>
<term>Depression (diagnosis)</term>
<term>Depression (physiopathology)</term>
<term>Depression (psychology)</term>
<term>Europe (MeSH)</term>
<term>Exercise Therapy (MeSH)</term>
<term>Health Behavior (MeSH)</term>
<term>Health Knowledge, Attitudes, Practice (MeSH)</term>
<term>Health Surveys (MeSH)</term>
<term>Humans (MeSH)</term>
<term>Intention (MeSH)</term>
<term>Logistic Models (MeSH)</term>
<term>Multivariate Analysis (MeSH)</term>
<term>Odds Ratio (MeSH)</term>
<term>Primary Prevention (MeSH)</term>
<term>Retrospective Studies (MeSH)</term>
<term>Secondary Prevention (MeSH)</term>
<term>Self Care (MeSH)</term>
<term>Severity of Illness Index (MeSH)</term>
<term>Time Factors (MeSH)</term>
<term>Treatment Outcome (MeSH)</term>
</keywords>
<keywords scheme="KwdFr" xml:lang="fr">
<term>Analyse multifactorielle (MeSH)</term>
<term>Anxiété (diagnostic)</term>
<term>Anxiété (physiopathologie)</term>
<term>Anxiété (psychologie)</term>
<term>Autosoins (MeSH)</term>
<term>Comportement en matière de santé (MeSH)</term>
<term>Connaissances, attitudes et pratiques en santé (MeSH)</term>
<term>Dépression (diagnostic)</term>
<term>Dépression (physiopathologie)</term>
<term>Dépression (psychologie)</term>
<term>Enquêtes de santé (MeSH)</term>
<term>Europe (MeSH)</term>
<term>Facteurs temps (MeSH)</term>
<term>Humains (MeSH)</term>
<term>Indice de gravité de la maladie (MeSH)</term>
<term>Intention (MeSH)</term>
<term>Maladie coronarienne (diagnostic)</term>
<term>Maladie coronarienne (physiopathologie)</term>
<term>Maladie coronarienne (psychologie)</term>
<term>Maladie coronarienne (rééducation et réadaptation)</term>
<term>Modèles logistiques (MeSH)</term>
<term>Odds ratio (MeSH)</term>
<term>Prévention primaire (MeSH)</term>
<term>Prévention secondaire (MeSH)</term>
<term>Réadaptation cardiaque (méthodes)</term>
<term>Résultat thérapeutique (MeSH)</term>
<term>Traitement par les exercices physiques (MeSH)</term>
<term>Études rétrospectives (MeSH)</term>
<term>Études transversales (MeSH)</term>
</keywords>
<keywords scheme="MESH" qualifier="diagnosis" xml:lang="en">
<term>Anxiety</term>
<term>Coronary Disease</term>
<term>Depression</term>
</keywords>
<keywords scheme="MESH" qualifier="diagnostic" xml:lang="fr">
<term>Anxiété</term>
<term>Dépression</term>
<term>Maladie coronarienne</term>
</keywords>
<keywords scheme="MESH" qualifier="methods" xml:lang="en">
<term>Cardiac Rehabilitation</term>
</keywords>
<keywords scheme="MESH" qualifier="méthodes" xml:lang="fr">
<term>Réadaptation cardiaque</term>
</keywords>
<keywords scheme="MESH" qualifier="physiopathologie" xml:lang="fr">
<term>Anxiété</term>
<term>Dépression</term>
<term>Maladie coronarienne</term>
</keywords>
<keywords scheme="MESH" qualifier="physiopathology" xml:lang="en">
<term>Anxiety</term>
<term>Coronary Disease</term>
<term>Depression</term>
</keywords>
<keywords scheme="MESH" qualifier="psychologie" xml:lang="fr">
<term>Anxiété</term>
<term>Dépression</term>
<term>Maladie coronarienne</term>
</keywords>
<keywords scheme="MESH" qualifier="psychology" xml:lang="en">
<term>Anxiety</term>
<term>Coronary Disease</term>
<term>Depression</term>
</keywords>
<keywords scheme="MESH" qualifier="rehabilitation" xml:lang="en">
<term>Coronary Disease</term>
</keywords>
<keywords scheme="MESH" qualifier="rééducation et réadaptation" xml:lang="fr">
<term>Maladie coronarienne</term>
</keywords>
<keywords scheme="MESH" xml:lang="en">
<term>Cross-Sectional Studies</term>
<term>Europe</term>
<term>Exercise Therapy</term>
<term>Health Behavior</term>
<term>Health Knowledge, Attitudes, Practice</term>
<term>Health Surveys</term>
<term>Humans</term>
<term>Intention</term>
<term>Logistic Models</term>
<term>Multivariate Analysis</term>
<term>Odds Ratio</term>
<term>Primary Prevention</term>
<term>Retrospective Studies</term>
<term>Secondary Prevention</term>
<term>Self Care</term>
<term>Severity of Illness Index</term>
<term>Time Factors</term>
<term>Treatment Outcome</term>
</keywords>
<keywords scheme="MESH" xml:lang="fr">
<term>Analyse multifactorielle</term>
<term>Autosoins</term>
<term>Comportement en matière de santé</term>
<term>Connaissances, attitudes et pratiques en santé</term>
<term>Enquêtes de santé</term>
<term>Europe</term>
<term>Facteurs temps</term>
<term>Humains</term>
<term>Indice de gravité de la maladie</term>
<term>Intention</term>
<term>Modèles logistiques</term>
<term>Odds ratio</term>
<term>Prévention primaire</term>
<term>Prévention secondaire</term>
<term>Résultat thérapeutique</term>
<term>Traitement par les exercices physiques</term>
<term>Études rétrospectives</term>
<term>Études transversales</term>
</keywords>
</textClass>
</profileDesc>
</teiHeader>
<front>
<div type="abstract" xml:lang="en">
<p>
<b>BACKGROUND</b>
</p>
<p>Regular exercise lowers the risk of cardiovascular death in coronary heart disease (CHD) patients. We aimed to investigate regular exercise behaviour and intention in relation to symptoms of anxiety and depression in CHD patients across Europe.</p>
</div>
<div type="abstract" xml:lang="en">
<p>
<b>DESIGN</b>
</p>
<p>This study was based on a multicentre cross-sectional survey.</p>
</div>
<div type="abstract" xml:lang="en">
<p>
<b>METHODS</b>
</p>
<p>In the EUROpean Action on Secondary and Primary Prevention through Intervention to Reduce Events (EUROASPIRE) III survey, 8966 CHD patients <80 years of age from 22 European countries were interviewed on average 15 months after hospitalisation. Whether patients exercised or intended to exercise regularly was assessed using the Stages of Change questionnaire in 8330 patients. Symptoms of anxiety and depression were evaluated using the Hospital Anxiety and Depression Scale. Total physical activity was measured by the International Physical Activity Questionnaire in patients from a subset of 14 countries.</p>
</div>
<div type="abstract" xml:lang="en">
<p>
<b>RESULTS</b>
</p>
<p>Overall, 50.3% of patients were not intending to exercise regularly, 15.9% were intending to exercise regularly, and 33.8% were exercising regularly. Patients with severe symptoms of depression less frequently exercised regularly than patients with symptoms in the normal range (20.2%, 95% confidence interval (CI) 14.8-26.8 vs 36.7%, 95% CI 29.8-44.2). Among patients not exercising regularly, patients with severe symptoms of depression were less likely to have an intention to exercise regularly (odds ratio 0.62, 95% CI 0.46-0.85). Symptoms of anxiety did not affect regular exercise intention. In sensitivity analysis, results were consistent when adjusting for total physical activity.</p>
</div>
<div type="abstract" xml:lang="en">
<p>
<b>CONCLUSIONS</b>
</p>
<p>Lower frequency of regular exercise and decreased likelihood of exercise intention were observed in CHD patients with severe depressive symptoms. Severe symptoms of depression may preclude CHD patients from performing regular exercise.</p>
</div>
</front>
</TEI>
<pubmed>
<MedlineCitation Status="MEDLINE" Owner="NLM">
<PMID Version="1">27587188</PMID>
<DateCompleted>
<Year>2018</Year>
<Month>02</Month>
<Day>12</Day>
</DateCompleted>
<DateRevised>
<Year>2018</Year>
<Month>04</Month>
<Day>05</Day>
</DateRevised>
<Article PubModel="Print-Electronic">
<Journal>
<ISSN IssnType="Electronic">2047-4881</ISSN>
<JournalIssue CitedMedium="Internet">
<Volume>24</Volume>
<Issue>1</Issue>
<PubDate>
<Year>2017</Year>
<Month>01</Month>
</PubDate>
</JournalIssue>
<Title>European journal of preventive cardiology</Title>
<ISOAbbreviation>Eur J Prev Cardiol</ISOAbbreviation>
</Journal>
<ArticleTitle>Regular exercise behaviour and intention and symptoms of anxiety and depression in coronary heart disease patients across Europe: Results from the EUROASPIRE III survey.</ArticleTitle>
<Pagination>
<MedlinePgn>84-91</MedlinePgn>
</Pagination>
<Abstract>
<AbstractText Label="BACKGROUND">Regular exercise lowers the risk of cardiovascular death in coronary heart disease (CHD) patients. We aimed to investigate regular exercise behaviour and intention in relation to symptoms of anxiety and depression in CHD patients across Europe.</AbstractText>
<AbstractText Label="DESIGN">This study was based on a multicentre cross-sectional survey.</AbstractText>
<AbstractText Label="METHODS">In the EUROpean Action on Secondary and Primary Prevention through Intervention to Reduce Events (EUROASPIRE) III survey, 8966 CHD patients <80 years of age from 22 European countries were interviewed on average 15 months after hospitalisation. Whether patients exercised or intended to exercise regularly was assessed using the Stages of Change questionnaire in 8330 patients. Symptoms of anxiety and depression were evaluated using the Hospital Anxiety and Depression Scale. Total physical activity was measured by the International Physical Activity Questionnaire in patients from a subset of 14 countries.</AbstractText>
<AbstractText Label="RESULTS">Overall, 50.3% of patients were not intending to exercise regularly, 15.9% were intending to exercise regularly, and 33.8% were exercising regularly. Patients with severe symptoms of depression less frequently exercised regularly than patients with symptoms in the normal range (20.2%, 95% confidence interval (CI) 14.8-26.8 vs 36.7%, 95% CI 29.8-44.2). Among patients not exercising regularly, patients with severe symptoms of depression were less likely to have an intention to exercise regularly (odds ratio 0.62, 95% CI 0.46-0.85). Symptoms of anxiety did not affect regular exercise intention. In sensitivity analysis, results were consistent when adjusting for total physical activity.</AbstractText>
<AbstractText Label="CONCLUSIONS">Lower frequency of regular exercise and decreased likelihood of exercise intention were observed in CHD patients with severe depressive symptoms. Severe symptoms of depression may preclude CHD patients from performing regular exercise.</AbstractText>
<CopyrightInformation>© The European Society of Cardiology 2016.</CopyrightInformation>
</Abstract>
<AuthorList CompleteYN="Y">
<Author ValidYN="Y">
<LastName>Prugger</LastName>
<ForeName>Christof</ForeName>
<Initials>C</Initials>
<AffiliationInfo>
<Affiliation>Institute of Public Health, Charité-Universitätsmedizin Berlin, Germany christof.prugger@charite.de.</Affiliation>
</AffiliationInfo>
</Author>
<Author ValidYN="Y">
<LastName>Wellmann</LastName>
<ForeName>Jürgen</ForeName>
<Initials>J</Initials>
<AffiliationInfo>
<Affiliation>Institute of Epidemiology and Social Medicine, University of Münster, Germany.</Affiliation>
</AffiliationInfo>
</Author>
<Author ValidYN="Y">
<LastName>Heidrich</LastName>
<ForeName>Jan</ForeName>
<Initials>J</Initials>
<AffiliationInfo>
<Affiliation>Institute of Epidemiology and Social Medicine, University of Münster, Germany.</Affiliation>
</AffiliationInfo>
<AffiliationInfo>
<Affiliation>Institute of Occupational and Maritime Medicine, University Medical Centre Hamburg-Eppendorf, Germany.</Affiliation>
</AffiliationInfo>
</Author>
<Author ValidYN="Y">
<LastName>De Bacquer</LastName>
<ForeName>Dirk</ForeName>
<Initials>D</Initials>
<AffiliationInfo>
<Affiliation>Department of Public Health, Ghent University, Belgium.</Affiliation>
</AffiliationInfo>
</Author>
<Author ValidYN="Y">
<LastName>De Smedt</LastName>
<ForeName>Delphine</ForeName>
<Initials>D</Initials>
<AffiliationInfo>
<Affiliation>Department of Public Health, Ghent University, Belgium.</Affiliation>
</AffiliationInfo>
</Author>
<Author ValidYN="Y">
<LastName>De Backer</LastName>
<ForeName>Guy</ForeName>
<Initials>G</Initials>
<AffiliationInfo>
<Affiliation>Department of Public Health, Ghent University, Belgium.</Affiliation>
</AffiliationInfo>
</Author>
<Author ValidYN="Y">
<LastName>Reiner</LastName>
<ForeName>Željko</ForeName>
<Initials>Ž</Initials>
<AffiliationInfo>
<Affiliation>Department of Internal Medicine, University Hospital Centre, School of Medicine, University of Zagreb, Croatia.</Affiliation>
</AffiliationInfo>
</Author>
<Author ValidYN="Y">
<LastName>Empana</LastName>
<ForeName>Jean-Philippe</ForeName>
<Initials>JP</Initials>
<AffiliationInfo>
<Affiliation>Paris Cardiovascular Research Centre, University Paris Descartes, Sorbonne Paris Cité, France.</Affiliation>
</AffiliationInfo>
</Author>
<Author ValidYN="Y">
<LastName>Fras</LastName>
<ForeName>Zlatko</ForeName>
<Initials>Z</Initials>
<AffiliationInfo>
<Affiliation>Department of Vascular Medicine, University Medical Centre Ljubljana, Slovenia.</Affiliation>
</AffiliationInfo>
<AffiliationInfo>
<Affiliation>Internal Medicine, Faculty of Medicine, University of Ljubljana, Slovenia.</Affiliation>
</AffiliationInfo>
</Author>
<Author ValidYN="Y">
<LastName>Gaita</LastName>
<ForeName>Dan</ForeName>
<Initials>D</Initials>
<AffiliationInfo>
<Affiliation>Institute of Cardiovascular Diseases, University of Medicine and Pharmacy of Timisoara, Romania.</Affiliation>
</AffiliationInfo>
</Author>
<Author ValidYN="Y">
<LastName>Jennings</LastName>
<ForeName>Catriona</ForeName>
<Initials>C</Initials>
<AffiliationInfo>
<Affiliation>Cardiovascular Medicine, Imperial College London, UK.</Affiliation>
</AffiliationInfo>
</Author>
<Author ValidYN="Y">
<LastName>Kotseva</LastName>
<ForeName>Kornelia</ForeName>
<Initials>K</Initials>
<AffiliationInfo>
<Affiliation>Cardiovascular Medicine, Imperial College London, UK.</Affiliation>
</AffiliationInfo>
</Author>
<Author ValidYN="Y">
<LastName>Wood</LastName>
<ForeName>David</ForeName>
<Initials>D</Initials>
<AffiliationInfo>
<Affiliation>Cardiovascular Medicine, Imperial College London, UK.</Affiliation>
</AffiliationInfo>
</Author>
<Author ValidYN="Y">
<LastName>Keil</LastName>
<ForeName>Ulrich</ForeName>
<Initials>U</Initials>
<AffiliationInfo>
<Affiliation>Institute of Epidemiology and Social Medicine, University of Münster, Germany.</Affiliation>
</AffiliationInfo>
</Author>
<Author ValidYN="Y">
<CollectiveName>EUROASPIRE Study Group</CollectiveName>
</Author>
</AuthorList>
<Language>eng</Language>
<PublicationTypeList>
<PublicationType UI="D016428">Journal Article</PublicationType>
<PublicationType UI="D016448">Multicenter Study</PublicationType>
<PublicationType UI="D013485">Research Support, Non-U.S. Gov't</PublicationType>
</PublicationTypeList>
<ArticleDate DateType="Electronic">
<Year>2016</Year>
<Month>09</Month>
<Day>01</Day>
</ArticleDate>
</Article>
<MedlineJournalInfo>
<Country>England</Country>
<MedlineTA>Eur J Prev Cardiol</MedlineTA>
<NlmUniqueID>101564430</NlmUniqueID>
<ISSNLinking>2047-4873</ISSNLinking>
</MedlineJournalInfo>
<CitationSubset>IM</CitationSubset>
<MeshHeadingList>
<MeshHeading>
<DescriptorName UI="D001007" MajorTopicYN="N">Anxiety</DescriptorName>
<QualifierName UI="Q000175" MajorTopicYN="N">diagnosis</QualifierName>
<QualifierName UI="Q000503" MajorTopicYN="N">physiopathology</QualifierName>
<QualifierName UI="Q000523" MajorTopicYN="Y">psychology</QualifierName>
</MeshHeading>
<MeshHeading>
<DescriptorName UI="D000072038" MajorTopicYN="N">Cardiac Rehabilitation</DescriptorName>
<QualifierName UI="Q000379" MajorTopicYN="Y">methods</QualifierName>
</MeshHeading>
<MeshHeading>
<DescriptorName UI="D003327" MajorTopicYN="N">Coronary Disease</DescriptorName>
<QualifierName UI="Q000175" MajorTopicYN="N">diagnosis</QualifierName>
<QualifierName UI="Q000503" MajorTopicYN="N">physiopathology</QualifierName>
<QualifierName UI="Q000523" MajorTopicYN="N">psychology</QualifierName>
<QualifierName UI="Q000534" MajorTopicYN="Y">rehabilitation</QualifierName>
</MeshHeading>
<MeshHeading>
<DescriptorName UI="D003430" MajorTopicYN="N">Cross-Sectional Studies</DescriptorName>
</MeshHeading>
<MeshHeading>
<DescriptorName UI="D003863" MajorTopicYN="N">Depression</DescriptorName>
<QualifierName UI="Q000175" MajorTopicYN="N">diagnosis</QualifierName>
<QualifierName UI="Q000503" MajorTopicYN="N">physiopathology</QualifierName>
<QualifierName UI="Q000523" MajorTopicYN="Y">psychology</QualifierName>
</MeshHeading>
<MeshHeading>
<DescriptorName UI="D005060" MajorTopicYN="N">Europe</DescriptorName>
</MeshHeading>
<MeshHeading>
<DescriptorName UI="D005081" MajorTopicYN="Y">Exercise Therapy</DescriptorName>
</MeshHeading>
<MeshHeading>
<DescriptorName UI="D015438" MajorTopicYN="Y">Health Behavior</DescriptorName>
</MeshHeading>
<MeshHeading>
<DescriptorName UI="D007722" MajorTopicYN="N">Health Knowledge, Attitudes, Practice</DescriptorName>
</MeshHeading>
<MeshHeading>
<DescriptorName UI="D006306" MajorTopicYN="N">Health Surveys</DescriptorName>
</MeshHeading>
<MeshHeading>
<DescriptorName UI="D006801" MajorTopicYN="N">Humans</DescriptorName>
</MeshHeading>
<MeshHeading>
<DescriptorName UI="D033182" MajorTopicYN="Y">Intention</DescriptorName>
</MeshHeading>
<MeshHeading>
<DescriptorName UI="D016015" MajorTopicYN="N">Logistic Models</DescriptorName>
</MeshHeading>
<MeshHeading>
<DescriptorName UI="D015999" MajorTopicYN="N">Multivariate Analysis</DescriptorName>
</MeshHeading>
<MeshHeading>
<DescriptorName UI="D016017" MajorTopicYN="N">Odds Ratio</DescriptorName>
</MeshHeading>
<MeshHeading>
<DescriptorName UI="D011322" MajorTopicYN="N">Primary Prevention</DescriptorName>
</MeshHeading>
<MeshHeading>
<DescriptorName UI="D012189" MajorTopicYN="N">Retrospective Studies</DescriptorName>
</MeshHeading>
<MeshHeading>
<DescriptorName UI="D055502" MajorTopicYN="N">Secondary Prevention</DescriptorName>
</MeshHeading>
<MeshHeading>
<DescriptorName UI="D012648" MajorTopicYN="Y">Self Care</DescriptorName>
</MeshHeading>
<MeshHeading>
<DescriptorName UI="D012720" MajorTopicYN="N">Severity of Illness Index</DescriptorName>
</MeshHeading>
<MeshHeading>
<DescriptorName UI="D013997" MajorTopicYN="N">Time Factors</DescriptorName>
</MeshHeading>
<MeshHeading>
<DescriptorName UI="D016896" MajorTopicYN="N">Treatment Outcome</DescriptorName>
</MeshHeading>
</MeshHeadingList>
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<Keyword MajorTopicYN="Y">Coronary heart disease</Keyword>
<Keyword MajorTopicYN="Y">anxiety</Keyword>
<Keyword MajorTopicYN="Y">depression</Keyword>
<Keyword MajorTopicYN="Y">exercise</Keyword>
<Keyword MajorTopicYN="Y">physical activity</Keyword>
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<PubMedPubDate PubStatus="received">
<Year>2015</Year>
<Month>11</Month>
<Day>26</Day>
</PubMedPubDate>
<PubMedPubDate PubStatus="accepted">
<Year>2016</Year>
<Month>08</Month>
<Day>16</Day>
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<Year>2016</Year>
<Month>9</Month>
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<Hour>6</Hour>
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