1

The Effects of Physical Activity on Stroke and Myocardial Infarction

Johannah Hollobaugh, Katie Sekola, Chloe Simmerman, and Jesse Wright

Centofanti School of Nursing, Youngstown State University

NURS 3749: Nursing Research

Ms. Heasley

April 6, 2022
 2

The Effects of Physical Activity on Stroke and Myocardial Infarction

Heart disease is one of the major causes of death worldwide. Researchers are analyzing

the correlation between different intensities of physical activity and the incidence of heart attack

and stroke compared to those who spend most of their time sedentary. Lifestyle changes, like

physical activity, are key in preventing myocardial infarction (MI) and stroke. Since heart

disease is significant worldwide, this paper emphasizes researching the effects of exercise in

correlation to stroke and MI.

Search Strategy

In the creation of this paper, several search strategies were employed to create a well-

informed, fact-based research paper. YSU MAAG library was a viable resource to find scholarly

articles, as well as CINAHL and Medline, which were invaluable in finding reliable articles that

explored the correlations between physical activity and cardiovascular disease. The search terms

used had to be very specific in order to trend articles that fit the criteria of the paper and to

provide information that was deemed valuable to the question, “In patients who have heart

disease, does physical activity help prevent strokes or heart attacks compared to those that do not

do physical activity?”. Keywords such as Stroke, Cardiovascular, and Exercise were used to

search for viable articles. Searches showed articles related to these keywords as was the

intention, but the search topics were far too broad. A new search was created using adjectives

combined with the word ‘or’ to allow for those words to be used synonymously throughout the

paper, expanding the related articles to an even greater extent, but then “risk of stroke” was

added in quotations to only produce articles with that exact phrase contained within them. The

results were still broad despite the refined criteria; one student’s search alone yielded over

285,000 results. The final step to narrowing the search was to read titles and do a quick analysis
 3

of articles to determine their usefulness within the research paper. Through a more extended

analysis of articles that were deemed important, eight articles were chosen to be used within this

research paper. This analysis included reading abstracts and key components of the article such

as the results and the method of the study to confirm the legitimacy of the articles and their

usefulness in this paper.

Literature Review

Stroke

The intensity of exercise is indirectly proportional to a person’s risk of stroke. In a

retrospective study done by Morovatdar et al. (2020), of volunteers who suffered a stroke, it was

found that physical activity level before the occurrence of a stroke delayed the occurrence of

stroke and lessened mortality rates. 395 participants were categorized based on their physical

activity level (PAL) which was determined by comparing their average energy expenditure per

day with the calories their body naturally burned without activity- their basal metabolic rate

(BMR). Participants were divided into groups based on PAL, or <1.70 or >1.70, to denote no

physical activity or low physical activity to moderate to intense physical activity. In those who

were of moderate physical activity or better, results showed that on average their stroke

occurrence was 6 years later than those with a PAL <1.70. Participants with a PAL of less than

1.70 were also much more likely to die of stroke complications at the 1 and 5-year mark

Morovatdar et al (2020).

In addition to the intensity of exercise, muscle strength also has a direct correlation to the

risk of stroke. In another study by Jiménez-Pavón, D., & Laukkanen, J. A. (2021), 284,767

participants showed that a person’s handgrip, a direct correlation to muscle strength unaffected
 4

by BMI, was inversely proportional to the risk of stroke and independent of genetic risk factors.

Genetic risk factors are unavoidable, but this study found these risk factors could be slightly

attenuated by increased muscle strength. Those persons with lesser muscle strength were at an

increased risk of stroke, independent of genetic risk factors.

Lifestyle changes are key when it comes to preventing heart disease. Different intensity,

duration, and frequency of exercise have been found to lower the risk of stroke compared to

those who are sedentary. Everyone is unique in their activity-related habits and preferences. In

Ghozy et al. (2022) study, light, moderate, and vigorous levels of activity were analyzed among

102,578 individuals, of which 3,851 had a history of stroke. Ghozy et al. (2022) study used

logistic regression and the results were expressed as odds ratio (OR) and 95 % confidence

interval (95 % CI) and P-value <0.05 was considered significant. In his study, it revealed that

light and moderate exercise such as walking and bicycling for >60 to 120 minutes (OR= 0.6,

95% CI= 0.5-0.7; P <0.001) had the greatest reduction in odds of stroke. Vigorous activity >60-

120 min was found to be associated with the greatest reduction in risk of stroke (OR= 0.7, 95%

CI= 0.6-0.9; P= 0.018) while durations above this interval did not show a similar effect (Ghozy

et al., 2022). In comparison, daily use of TV, video, or computer use for more than 4 hours was

associated with an increase in risk for stroke (OR= 2.42, 95 % CI_ 1.79-2.96; P < 0.001). This

suggests that being sedentary daily becomes harmful when for more than 4 hours. Results further

showed that 30-60 minutes of daily moderate exercise such as walking or bicycling and

performing tasks around the home for 60-120 minutes were associated with a lower risk for

stroke. Vigorous activity can reduce stroke odds by 40%, but the only way to get to 60% is to do

it daily, which may not be suitable for all populations (Ghozy et al., 2022). Overall, this study

demonstrated that there is some type of physical activity for everyone, and the risk of stroke is
 5

decreased. On the other hand, excessive duration of sedentary behavior is related to poor

cardiopulmonary function, increasing the risk for cardiovascular and cerebrovascular conditions.

Not only does the intensity of physical activity affect stroke risk, but a change in the

amount of physical activity done over time does as well. In the study done by Äijö et al. (2016),

558 participants all between the ages of 75 and 80 were interviewed about their level of physical

activity. Five years later, 357 of the original participants answered questions about their current

level of physical activity at the follow-up interview. These participants were then put into four

study groups based on their five-year follow-up: remained active (RA), changed to inactive (CI),

remained inactive (RI), and changed to active (CA). The participants’ cause of death was then

recorded over the next 18 years to determine how a change in physical activity will affect all-

cause mortality. Chronic diseases such as stroke and heart disease were other variables that were

recorded during this study in correlation to changes in physical activity. From the results, it was

found that “In the groups that were physically inactive at the end of our baseline period (RI or

CI), a higher mortality rate, slower walking time, and more cardiac diseases, stroke and other

diseases were observed than in the physically active groups (RA or CA)” (para. 22). 7

participants (4.6%) in the RA group and 3 participants (14.3) in the CA group had a stroke

whereas 12 participants (9.8%) in the CI group and 11 participants (17.7%) in the RI group had

a stroke (Äijö et al., 2016). This study shows that physical activity does affect stroke risk by

lowering it, even in the elderly.

In a study done by Andrea Chomistek ScD et al. (2018), it was found that there is an

inverse correlation between physical activity and cardiovascular disease (CVD). This study takes

into account the Reynolds risk score (RRS) which is a score used to predict the chance healthy

people without diabetes have of having a stroke, heart attack, or other heart diseases in the next
 6

ten years of their life and pooled cohort equations (PCE) which predicts the ten-year possibility

of coronary death or nonfatal stroke. It also uses CVD hazard ratios (HR) which are relative risk

factors for developing CVD. This study had 27,536 women participants all of which had to have

plasma samples taken so they could receive a RRS. The RRS, HR, PCE, and physical activities

were all used in this study to develop a correlation between the risk of CVD and physical

activity. The physical activity included eight recreational activities and also included flights of

stairs climbed daily all of which were assessed during the study and for observational follow-up

post-study.

Categorizing women into groups based on energy in kilocalories per week helped to

estimate HRs and 95% confidence intervals for incidence of stroke. Active women were

categorized as burning greater than 500 kilocalories a week and inactive women burned less than

500 kilocalories per week. This is based on the current physical activity guidelines and they were

further categorized into groups of time spent walking per week. The time is from zero minutes

up to greater than two and a half hours. This showed that there is a significant effect between

leisure time, physical activity, and the risks of stroke and total CVD. Time spent walking

throughout the week that was self-reported was also associated with significantly lower

cardiovascular risk and the results were similar to stroke and myocardial infarction. In this study,

the PCE and RRS estimated cardiovascular risk and showed that physical activity lowers the risk

of cardiovascular diseases including stroke, even in participants that had higher CVD risks.

Myocardial Infarction

Cardiovascular disease is a major issue worldwide and a majority of deaths are caused by

myocardial infarction. “Per the World Health Organization, 80% of all myocardial infarctions

may be prevented through lifestyle changes” (Ballin et al., 2020, p. 340). Light and moderate
 7

physical activity have both been found to decrease the risk for MI. In Ballin’s (2020) study 3343

men and women aged 70 participated in measuring light-intensity physical activity (LPA),

moderate-intensity PA (MPA), and sedentary time (ST) for 1 week to see whether there was a

decreased risk for MI. This was done by using accelerometers to measure physical activity

accurately and objectively. The accelerometers were worn all day except when bathing or

showering. They were followed up after about 3 years to review the results. It was found that

every 30-minutes/day of LPA was associated with an 11 % lower risk and every 30-minutes/day

of MPA was associated with a 36% lower risk (Ballin, et al., 2020). These findings overall mean

that “Regardless of intensity, the more you move and the less you sit, the better”. (Ballin, et al.,

2020, p. 340). It was also found that if able, moderate physical activity such as brisk walking, is

best and may have the largest benefits. These results were also related to a decreased risk for

stroke. On the other hand, sedentary time has been found to increase the risk for MI depending

on how long and if any physical activity is done. Per Ballin (2020), it was found that every 1-

hour/day increment in sedentary time was associated with an increased risk for MI by 33%. If

moderate physical activity is increased, risks pertaining to sedentary behavior are mitigated. It

was found that even just 15 minutes per day of MPA can decrease the risk, and 30 minutes per

day of MPA lowered the risk even more.

The intensity of physical activity plays a significant role when analyzing how it affects

myocardial infarction risk. A study by Stewart et al. (2017) found that “In patients with stable

CHD, more physical activity was associated with lower mortality. The largest benefits occurred

between sedentary patient groups and between those with the highest mortality risk” (para. 5).

Along with looking at mortality rates, rates of other cardiovascular events such as myocardial

infarctions were looked at. 15,486 patients with stable coronary heart disease reported their
 8

amount of physical activity for 3.7 years. Adverse events were also recorded during the 3.7

years. Participants were asked to estimate how much time per week was spent doing activities

that were classified as mild, moderate, or vigorous, and each activity was assigned a range of

metabolic equivalents (METs). From this, METs hour/week were calculated and divided by the

total hours of exercise per week to get the average intensity of physical activity the participant

performed, and the participants were put into three tertiles: Least Active, Intermediate Activity,

and Most Active. Outcomes were looked at by tertile of physical activity and before adjusting for

covariates, 4.70% of participants in the Least Active group had an MI, whereas 4.31% of

participants in the Intermediate Activity group and 3.67% of participants in the Most Active

group had an MI. After adjusting for covariates, 14,896 participants were included, and 4.71%,

4.36%, and 3.65% were the MI rate percentages for Least Active, Intermediate Activity, and

Most Active tertiles respectively (Stewart et al., 2017). These percentages show that as physical

activity is increased, the percentage of myocardial infarctions decreased.

In the population-based study by Daniel Ramirez MD et al. (2017) it was found that there

are nine potentially modifiable risk factors (PMRF) for myocardial infarction that account for

greater than 90% of the population's risk. It is stated that, “ischemic heart disease remains among

the leading causes of morbidity and mortality” (para. 1). One of the major PMRFs identified in

this study was physical activity along with the perceived need to improve physical health

(PNIPH). The study found that participants who self-reported their PMRFs already associated

that with PNIPH. 52% of the participants that reported PNIPH referred to the behavioral change

of increasing exercise whereas 70% of the participants were planning on adding in exercise

within the year as a behavioral change. The most frequently reported barriers to adding in

physical activity were the lack of self-discipline/willpower, work schedule, and family
 9

responsibilities. Ischemic heart disease, like myocardial infarctions, is highly preventable when

assessing PMRFs by changing one’s lifestyle practices. 26.1% to 59.5% of North Americans

have substantial risks for MI based on the PMRFs studied. In this study, it was found that

cardiovascular risk significantly declines with at least 150 minutes of exercise weekly which is

based on the current recommendations.

Recommendations for Practice

In nursing, patient teaching about exercising is important because nurses should be

promoting lifestyle changes to prevent diseases. These studies found that individuals that have

cardiovascular risks along with existing CVD feel they do not need to change their physical

health. This means nurses play a role in identifying this. Nurses need to identify and assess a

patient’s willingness to change and learn new behaviors. Nurses need to get patients outside

resources which can be physical or occupational therapy and help modify the public’s health

behaviors and perceptions of health. Nurses can also find free gyms based on insurance and age

or send them to someone who can get them the correct resources they need. Physical activity is

not something nurses generally think about while working with patients. Printing off instructions

and offering some exercises that are a good fit for the patients' current physical activity level,

their current knowledge base, and writing how often to perform these exercises would be very

beneficial to patients who have existing cardiovascular diseases or are at risk for CVD. If

mobility is good, nurses can get patients to ambulate in the hallway and talk about the major

benefits of just walking because brisk walking has great benefits on cardiovascular health.

Conclusion

In summary, heart disease is a prevalent issue worldwide and especially in the United

States, which is why the PICOT question “In patients who have heart disease, does physical
 10

activity help prevent strokes or heart attacks compared to those that do not do physical activity?”

was created to guide the search for articles using MAAG library and databases such as CINAHL

and Medline. 8 articles were found and a literature review was conducted. From the literature

review, it was concluded that physical activity does lower the risk for both stroke and MI. Many

of the articles found a correlation between differences in the intensity of physical activity and the

risk for stroke and MI, meaning that the more activity that was done, the lower the risk. Other

articles related muscle strength, sedentary time, calories burned, and a change in physical activity

over time to the risk of stroke and MI. Overall, physical activity is beneficial when it comes to

stroke and MI risk in those with cardiovascular disease.

References
 11

Äijö, M., Kauppinen, M., Kujala, U. M., & Parkatti, T. (2016). Physical activity, fitness, and all-

cause mortality: An 18-year follow-up among old people. Journal of Sport and Health

Science, 5(4), 437-442. https://doi.org/10.1016/j.jshs.2015.09.008

Ballin, M., Nordström, P., Niklasson, J., & Nordström, A. (2020). Associations of

objectively measured physical activity and sedentary time with the risk of stroke,

myocardial infarction or all-cause mortality in 70-Year- Old men and women: A

prospective cohort study. Sports Medicine, 51, 339-349. https://doi.org/10.1007/s40279-

020-01356-y

Chomistek, A. K., Cook, N. R., Rimm, E. B., Ridker, P. M., Buring, J. E., & Lee, I.-M. (2018).

Physical activity and incident cardiovascular disease in women: Is the relation modified

by level of global cardiovascular risk? Journal of the American Heart Association, 7(12),

1–9. https://doi-org.eps.cc.ysu.edu/10.1161/JAHA.117.008234

Ghozy, S., Zayan, A. H., El-Qushayri, A. E., Parker, K. E., Varney, J., Kallmes, K. M., Morsy,

S., Abbas, A. S., Diestro, J. D. B., Dmytriw, A. A., Shah, J., Hassan, A. E., & Islam, S.

M. S. (2022). Physical activity level and stroke risk in US population: A matched case-

control study of 102,578 individuals. Annals of Clinical and Translational Neurology,

9(3), 264-275. https://doi.org/10.1002/acn3.51511

Jiménez-Pavón, D., & Laukkanen, J. A. (2021). Impact of the physical activity and fitness

components on the genetic risk of stroke. Mayo Clinic Proceedings, 96(7), 1703–1705.

https://doi.org/10.1016/j.mayocp.2021.05.014

Morovatdar, N., Di Napoli, M., Stranges, S., Thrift, A. G., Kapral, M., Behrouz, R., Farzadfard,

M. T., Andalibi, M. S., Oskooie, R. R., Sawant, A., Mokhber, N., & Azarpazhooh, M. R.
 12

(2020). Regular physical activity postpones age of occurrence of first-ever stroke and

improves long-term outcomes. Neurological Sciences, 42(8), 3203–3210.

https://doi.org/10.1007/s10072-020-04903-7

Ramirez, F. D., Chen, Y., Di Santo, P., Simard, T., Motazedian, P., & Hibbert, B. (2017).

Association between self-reported potentially modifiable cardiac risk factors and

perceived need to improve physical health: A population-based study. Journal of the

American Heart Association, 6(5), 1–N.PAG.

https://doi-org.eps.cc.ysu.edu/10.1161/JAHA.117.005491

Stewart, R. A. H., Held, C., Hadziosmanovic, N., Armstrong, P. W., Cannon, C. P., Granger, C.

B., Hagström, E., Hochman, J. S., Koenig, W., Lonn, E., Nicolau, J. C., Steg, P. G.,

Vedin, O., Wallentin, L., & White, H. D. (2017). Physical activity and mortality in

patients with stable coronary heart disease. Journal of the American College of

Cardiology, 70(14), 1689-1700. https://doi.org/10.1016/j.jacc.2017.08.017