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(Chest. 2004;126:1962-1968.)
© 2004 American College of Chest Physicians

Exercise Capacity in Adult African-Americans Referred for Exercise Stress Testing*

Is Fitness Affected by Race?

Carl J. Lavie, MD, FCCP; Tulsidas Kuruvanka, MD; Richard V. Milani, MD; Ananth Prasad, MD and Hector O. Ventura, MD

* From the Ochsner Heart and Vascular Institute, Ochsner Clinic Foundation, New Orleans, LA.

Correspondence to: Carl J. Lavie, MD, FCCP, Ochsner Clinic Foundation, 1514 Jefferson Hwy, New Orleans, LA 70121; e-mail: clavie{at}ochsner.org


   Abstract
TOP
 Abstract
Introduction
 Materials and Methods
 Results
 Discussion
 References
 
Study objectives: To determine the factors associated with exercise capacity.

Design: Retrospective evaluation of large stress-testing database.

Setting: Multispecialty tertiary care center.

Patients: A total of 5,069 consecutive patients who were referred for exercise stress testing.

Measurements: We compared levels of fitness in 641 African-Americans (52% male) with 4,428 whites (73% male), and performed univariate and multivariate analyses to determine the predictors of fitness (including race).

Results: Compared with African-American men (mean [± SD] age, 60 ± 11 years), white men (mean age, 63 ± 11 years) have significantly higher exercise capacity (10.7 ± 3.5 vs 11.4 ± 3.4 metabolic equivalents [METs], respectively; p < 0.001). The exercise capacity in African-American and white women was similar (8.5 ± 2.9 vs 8.7 ± 3.0 METs, respectively). However, body mass indexes (BMIs) were significantly higher in both African-American men (29.1 ± 4.3 vs 28.2 ± 4.3 kg/m2, respectively; p < 0.001) and women (30.2 ± 5.7 vs 27.9 ± 5.5 kg/m2, respectively; p < 0.0001) compared to their white counterparts, as was the prevalence of obesity (men, 44% vs 33%, respectively; women, 37% vs 27%, respectively; both p < 0.001). Although a model containing age, gender, BMI, and race only accounted for 32% of exercise capacity, all independently (p < 0.0001) predicted higher exercise capacity, as follows: younger age (r2 = 0.14); male gender (r2 = 0.12); BMI (r2 = 0.06); and white race (r2 = 0.004).

Conclusions: In an adult population of individuals who were referred for exercise stress testing, African-Americans were more obese and had significantly lower exercise capacity than their white counterparts. Emphasis on weight reduction and increasing physical fitness is particularly needed for the prevention of cardiovascular diseases in African-Americans.

Key Words: aging • exercise testing • fitness • obesity • race


   Introduction
TOP
 Abstract
 Introduction
Materials and Methods
 Results
 Discussion
 References
 
Physical inactivity is considered to be one of the most significant public health concerns,12 and levels of physical fitness are known to be potent predictors of major cardiovascular disease, cardiovascular mortality, as well as all-cause mortality.345678 In fact, low levels of cardiovascular fitness have been shown to be as strong a predictor of mortality as more conventional coronary artery disease (CAD) risk factors, such as smoking, hypertension, and hyperlipidemia.791011 Since there is a high prevalence of sedentary lifestyle, this parameter may contribute to more overall community risk of CAD and mortality than the other risk factors.12 The importance of physical fitness and exercise capacity as indicators of prognosis has been demonstrated in epidemiologic and population-based studies,691013 as well as in cohorts with known or suspected CAD.311131415

During recent decades, the prevalence of overweightness and obesity, including childhood overweightness, has been increasing at alarming proportions, and some data suggest that this increase is more pronounced in the African-American and Hispanic population than in the white population, particularly among women.1617181920 In addition, the risk of death from all causes, cardiovascular disease, and cancer increases throughout the range of overweightness and obesity, although the risk associated with high body mass indexes (BMIs) may be greater for whites than for African-Americans.212223 In fact, recent evidence has indicated that obesity is associated with more morbidity than smoking, alcoholism, and poverty, and, if the current trends continue, will account for > 300,000 deaths annually in the United States, thus overtaking cigarette abuse as the leading preventable cause of death.242526 Part of the rise in obesity has been attributed to sedentary lifestyle, since substantial data indicate that most residents of the United States do not participate in physical activity at recommended levels.27

Although evidence suggests that the decline in physical activity that occurs during adolescence may be more pronounced in African-Americans compared with whites,27 we are not aware of studies assessing exercise capacity in adult African-American patients or assessing the impact of race on levels of fitness. The purpose of our study, therefore, was to assess exercise capacity in African-American men and women who were referred for exercise stress testing and to compare their exercise capacity with their white counterparts, as well as to determine whether race is an independent predictor of fitness.


   Materials and Methods
TOP
 Abstract
 Introduction
 Materials and Methods
Results
 Discussion
 References
 
Patients
Using a stress testing report database, we studied 5,069 consecutive patients who were referred for exercise ECG stress testing at the Ochsner Heart and Vascular Institute in New Orleans, LA, including 4,428 whites (73% men) and 641 African-Americans (52% men), and compared obesity status and levels of fitness in both races. This study was approved by the Institutional Review Board at the Ochsner Clinic Foundation.

Protocol
All patients were referred for exercise ECG testing using a ramping treadmill protocol, as we have previously described.282930313233 These ramping protocols are designed to allow exercise durations of 8 to 12 min, with speed and incline increasing slowly every 15 s. The use of hand rails was discouraged during testing, and all tests were symptom limited, with test termination determined by patients’ symptoms (eg, severe fatigue, and greater than moderate level of angina or dyspnea), ST-segment depression of > 2 mm, severe hypertension, hypotension, or serious arrhythmias, as per standard recommendations from the American Heart Association/American College of Cardiology guidelines.34 Exercise capacity was estimated in metabolic equivalents (METs), using standard formulas based on maximal treadmill speed and incline.35 At the time of the treadmill test, age and gender were recorded, as were height and weight, in order to determine obesity status as determined by BMI criteria: obesity (BMI, ≥ 30 kg/m2); and severe obesity (BMI, ≥ 35 kg/m2).

Statistical Analysis
The baseline characteristics and exercise capacity of African-American and white patients were determined by nonpaired t test and {chi}2 analyses. Predictors of exercise capacity, including age, gender, BMI, and race were assessed using univariate and multivariate analyses. All data are presented as mean ± SD.


   Results
TOP
 Abstract
 Introduction
 Materials and Methods
 Results
Discussion
 References
 
Patient Characteristics
The average age of our cohort was 63 ± 11.5 years, including 70% men and 13% African-Americans (53% men). The average BMI was 28.4 ± 4.9 kg/m2, and the average exercise capacity was 10.6 ± 3.6 estimated METs. Only 3% of patients had ECG evidence of left ventricular hypertrophy, and 11% of patients had ischemic ST-segment responses. There were no significant racial differences in these parameters.

African-Americans vs Whites
Comparing African-American and white men (Table 1 ), the African-American men were, on average, 3 years younger (p < 0.001), had a higher baseline BMI (p < 0.001), and a higher prevalence of obesity (p < 0.001) and severe obesity (p < 0.001). Exercise capacity, however, was 7% higher (p < 0.001) in white men compared with African-American men (Table 1, Fig 1 ).


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  		Table 1.. Clinical Characteristics in African-American and White Men and Women Referred for Exercise Testing*

 


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  		Figure 1.. Exercise capacity in African-American and white (Caucasian) men and women.

 
Comparing African-American and white women (Table 1), the African-American women were, on average, 4 years younger (p < 0.001), had considerably higher BMIs (p < 0.0001), and a considerably higher prevalence of obesity (p < 0.001) and severe obesity (p < 0.001). Despite being older, white women had a slightly higher exercise capacity (3%; difference not significant) than their African-American counterparts (Table 1, Fig 1).

Moreover, a higher percentage of African-Americans had a low exercise capacity (ie, [6 METs) compared with whites (21% vs 14%, respectively; p < 0.01), and a lower percentage of African-Americans had a very high exercise capacity (ie,≥ 13 METs) compared with whites (23% vs 34%, respectively; p < 0.01)

Predictors of Exercise Capacity
Exercise capacity was strongly and inversely related with age (Table 2, Fig 2 ). At any given age, exercise capacity was considerably higher in men than in women, and at most ages and in both genders, more so men, exercise capacity was slightly higher in whites than in African-Americans.


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  		Table 2.. Predictors of Higher Exercise Capacity in Univariate and Multivariate Analyses (n = 5,069)

 


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  		Figure 2.. Relationship between age and exercise capacity in African-American and white men and women. Exercise capacity was strongly and inversely related with age (r = –0.35; p < 0.0001)

 
Exercise capacity was also inversely related with BMI (Table 2, Fig 3 ), but was less so than age and gender. At BMIs of < 30 kg/m2, African-American men had a slightly lower exercise capacity than their white counterparts, although exercise capacity in both African-American and white obese men was similar. At any given level of BMI, African-American and white women had similar exercise capacities.



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  		Figure 3.. Relationship between BMI and exercise capacity in African-American and white men and women. Exercise capacity was inversely related with BMI (r = –0.13; p < 0.0001)

 
In multivariate analysis (Table 2), only slightly > 32% of exercise capacity was predicted by age, gender, BMI, and race. Younger age, male gender, and lower BMI were all independent predictors of higher exercise capacity (all p < 0.0001). Correcting for differences in age, gender, and BMI, white race was a weak (r2 = 0.004), but statistically significant (p < 0.0001), predictor of higher exercise capacity.


   Discussion
TOP
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
References
 
In the present study, we assessed an adult population being evaluated for CAD, and determined that African-American men and women are more obese and have lower exercise capacities, particularly in the men, than their white counterparts. Considerable data exist demonstrating that low cardiorespiratory fitness is a potent predictor of increased risk of premature death, which is mainly due to the increased cardiovascular mortality that has been noticed in unfit individuals.345678 Population-based studies45678910111213 from the United States have suggested that the risk of death associated with low cardiorespiratory fitness or physical inactivity is comparable with that of conventional CAD risk factors, including tobacco abuse, hypertension, obesity, and diabetes mellitus, with the most striking differences in overall mortality rates observed when exercise capacity increased from a very low level to the next lowest level in otherwise healthy subjects.5 These data suggest that the greatest health benefits can be achieved by increasing physical activity among patients who have the highest risk and the lowest exercise capacities.23637 Blair and colleagues467 have demonstrated that exercise of at least moderate duration on an exercise treadmill test was associated with reduced cardiovascular and total mortality, whereas patients who achieved higher durations had only slight reductions in cardiovascular mortality. Importantly, data from this large cohort of men and women have demonstrated inverse associations for exercise capacity and cardiovascular diseases within categories of major CAD risk factors, including obesity.

Overall exercise capacity has also been demonstrated to have a very strong association with cardiac events and all-cause mortality in patients with known or suspected CAD.311131415 In one study,11 the risk of death among those with an exercise capacity of < 5 METs was nearly double the risk among those with peak functional capacities of > 8 METs. In fact, overall exercise capacity has been the only treadmill exercise variable consistently associated with overall outcome, with its prognostic importance being of similar magnitude across a wide range of ages.338

A substantial amount of data has indicated that Americans are becoming overweight at alarming rates, with 31% and 13%, respectively, of Americans classified as overweight and obese in 1960, which had increased to 35% and 26%, respectively, in 1999.20 During the past decade, the prevalence of class III obesity (ie, BMI, ≥ 40 kg/m2) has tripled, from 0.78% in 1992 to 2.2% in 2000.19 The prevalence of overweight children in the United States increased between 1976 and 1980 and 1988 and 1994, and increased by > 10 percentage points between 1988 and 1994 and from 1999 to 2000, with the increase being more marked in Mexican-American and non-Hispanic black adolescents.17 These progressive increases in body weight are certainly not benign, since excess body weight has been shown to increase the risk of death from any cause, and particularly from cardiovascular disease,3940414243 in adults between the ages of 30 and 74 years, although the relative risk associated with higher body weight is more pronounced in the younger subjects.2122 Although the risks associated with higher BMI may be more pronounced for whites than for African-Americans, the prevalence of obesity may be higher in African-Americans, and the risk of death from all causes, cardiovascular disease, cancer, and other diseases increases throughout the range of moderately and severely overweight individuals, both men and women, in all age groups.22 More recent data have indicated that obesity may lessen life expectancy markedly, especially among younger patients, including African-Americans.23

In our patient population, we noted an extremely high prevalence of obesity, which is considerably higher than the high levels noted in population-based studies. The higher prevalence of obesity in African-Americans, particularly African-American women, is consistent with that found in other studies,1617181920 although, as mentioned previously, obesity may be less deleterious to the African-American population (especially to women) than to whites.212223 There are some data that have suggested that there is a decline in physical activity during adolescence that may be partly responsible for the increasing prevalence of obesity, and this decline in physical activity may be more pronounced in African-Americans than in whites.27 We are not aware, however, of previous clinical studies from large populations of adult patients assessing exercise capacity in African-American and white men and women.

Several important study limitations should be emphasized. First, this study was not population-based but rather was conducted using those patients who had been referred for clinical exercise testing, so selection bias may be present. Despite being significantly younger in age, however, the African-American patients had lower exercise capacities than did the older white patients who had been referred for exercise testing. Second, the number of white patients studied was considerably greater than the number of African-Americans. Third, we utilized a database containing information in the stress test clinical report, so we did not have some pertinent clinical information on these patients, including, for example, symptomatic status, reason for referral, prevalence of hypertension and other CAD risk factors, and use of various medications. In addition, we do not know whether the patients had a history of CAD and whether there was a racial difference in the presence and severity of CAD. There is some evidence, however, that hypertension is more prevalent in African-Americans, whereas the prevalence of dyslipidemia is either similar in both races or possibly slightly more prevalent in whites than in African-Americans.44 Although we do not have definitive data on hypertension, dyslipidemia, or CAD, the prevalence of left ventricular hypertrophy (by ECG criteria) and ischemic ST-segment changes was statistically similar in African-American and white patients, suggesting that these groups were most likely similar regarding prevalence of severe hypertension and severe CAD. In addition, we do not have information on occupational (eg, white collar or blue collar), educational, or socioeconomic status, all of which could have an impact on workplace and leisure-time physical activity. Finally, we estimated exercise capacity indirectly in estimated METs, whereas the use of direct measures of oxygen consumption (or peak oxygen consumption) by cardiopulmonary exercise assessment has the advantage of providing a precise determination of levels of fitness.28303345 We have previously demonstrated that estimating exercise capacity in terms of estimated METs generally overestimates true exercise capacity as determined by measured METs during cardiopulmonary assessment,2830 but this overestimation is more marked in younger patients compared with the older patients.30 The fact that the African-American patients were significantly younger than the white patients would suggest that this overestimation may have been even more marked in the African-American group. However, to our knowledge, there are no data comparing the accuracy of standard formulas for estimating exercise capacity based on treadmill speed and incline across various races or other heterogeneous populations.

Despite these study limitations, we believe that our data demonstrate that in an adult population that had been referred for exercise stress testing, African-Americans are more obese and have significantly lower exercise capacity than their white counterparts. These data suggest that a greater emphasis needs to be placed on reducing weight and increasing physical fitness, particularly for the prevention of cardiovascular and other diseases in the African-American population.


   Footnotes
 
Abbreviations: BMI = body mass index; CAD = coronary artery disease; MET = metabolic equivalent

Presented as a Podium Presentation to the Annual Scientific Assembly of the American Heart Association, November 2002, Chicago, IL.

Received for publication April 8, 2004. Accepted for publication July 22, 2004.


   References
TOP
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
 References
 

  1. McGinnis, JM, Foege, WH (1993) Actual causes of death in the United States. JAMA 270,2207-2212[Abstract]
  2. Bouchard, C Physical activity and health: introduction to the dose-response symposium. Med Sci Sports Exerc 2001;33(suppl),S347-S350
  3. Morris, CK, Ueshima, K, Kawaguchi, T, et al The prognostic value of exercise capacity: a review of the literature. Am Heart J 1991;122,1423-1431[CrossRef][ISI][Medline]
  4. Blair, SN, Kohl, HW, III, Paffenbarger, RS, Jr, et al Physical fitness and all-cause mortality: a prospective study of healthy men and women. JAMA 1989;262,2395-2401[Abstract]
  5. Sandvik, L, Erikssen, J, Thaulow, E, et al Physical fitness as a predictor of mortality among healthy, middle-aged Norwegian men. N Engl J Med 1993;328,533-537[Abstract/Free Full Text]
  6. Blair, SN, Kohl, HW, III, Barlow, CE, et al Changes in physical fitness and all-cause mortality: a prospective study of healthy and unhealthy men. JAMA 1995;273,1093-1098[Abstract]
  7. Blair, SN, Kampert, JB, Kohl, HW, III, et al Influences of cardiorespiratory fitness and other precursors on cardiovascular disease and all-cause mortality in men and women. JAMA 1996;276,205-210[Abstract]
  8. Erikssen, G, Liestol, K, Bjornholt, J, et al Changes in physical fitness and changes in mortality. Lancet 1998;352,759-762[CrossRef][ISI][Medline]
  9. Wei, M, Kampert, JB, Barlow, CE, et al Relationship between low cardiorespiratory fitness and mortality in normal-weight, overweight, and obese men. JAMA 1999;282,1547-1553[Abstract/Free Full Text]
  10. Laukkanen, JA, Lakka, TA, Rauramaa, R, et al Cardiovascular fitness as a predictor of mortality in men. Arch Intern Med 2001;161,825-831[Abstract/Free Full Text]
  11. Myers, J, Prakash, M, Froelicher, V, et al Exercise capacity and mortality among men referred for exercise testing. N Engl J Med 2002;346,793-801[Abstract/Free Full Text]
  12. Paffenbarger, RS, Jr, Hyde, RT, Wing, AL, et al Physical activity, all-cause mortality, and longevity of college alumni. N Engl J Med 1986;314,605-613[Abstract]
  13. Ekelund, LG, Haskell, WL, Johnson, JL, et al Physical fitness as a predictor of cardiovascular mortality in asymptomatic North American men: the Lipid Research Clinics Mortality Follow-up Study. N Engl J Med 1988;319,1379-1384[Abstract]
  14. Roger, VL, Jacobsen, SJ, Pellikka, PA, et al Prognostic value of treadmill exercise testing: a population-based study in Olmsted County, Minnesota. Circulation 1998;98,2836-2841[Abstract/Free Full Text]
  15. Prakash, M, Myers, J, Froelicher, VF, et al Clinical and exercise test predictors of all-cause mortality: results from > 6,000 consecutive referred male patients. Chest 2001;120,1003-1013[CrossRef][Medline]
  16. Flegal, KM, Carroll, MD, Ogden, CL, et al Prevalence and trends in obesity among US adults, 1999–2000. JAMA 2002;288,1723-1727[Abstract/Free Full Text]
  17. Ogden, CL, Flegal, KM, Carroll, MD, et al Prevalence and trends in overweight among US children and adolescents, 1999–2000. JAMA 2002;288,1728-1732[Abstract/Free Full Text]
  18. Strauss, RS, Pollack, HA Epidemic increase in childhood overweight, 1986–1998. JAMA 2001;286,2845-2848[Abstract/Free Full Text]
  19. Freedman, DS, Khan, LK, Serdula, MK, et al Trends and correlates of class 3 obesity in the United States from 1990 through 2000. JAMA 2002;288,1758-1761[Abstract/Free Full Text]
  20. McTigue, KM, Garrett, JM, Popkin, BM The natural history of the development of obesity in a cohort of young US adults between 1981 and 1998. Ann Intern Med 2002;136,857-864[Abstract/Free Full Text]
  21. Stevens, J, Cai, J, Pamuk, ER, et al The effect of age on the association between body-mass index and mortality. N Engl J Med 1998;338,1-7[Abstract/Free Full Text]
  22. Calle, EE, Thun, MJ, Petrelli, JM, et al Body-mass index and mortality in a prospective cohort of U.S. adults. N Engl J Med 1999;341,1097-1105[Abstract/Free Full Text]
  23. Fontaine, KR, Redden, DT, Wang, C, et al Years of life lost due to obesity. JAMA 2003;289,187-193[Abstract/Free Full Text]
  24. Manson, JE, Bassuk, SS Obesity in the United States: a fresh look at its high toll. JAMA 2003;289,229-230[Free Full Text]
  25. Allison, DB, Fontaine, KR, Manson, JE, et al Annual deaths attributable to obesity in the United States. JAMA 1999;282,1530-1538[Abstract/Free Full Text]
  26. Sturm, R, Wells, KB Does obesity contribute as much to morbidity as poverty or smoking? Public Health 2001;115,229-235[CrossRef][ISI][Medline]
  27. Kimm, SYS, Glynn, NW, Kriska, AM, et al Decline in physical activity in black girls and white girls during adolescence. N Engl J Med 2002;347,709-715[Abstract/Free Full Text]
  28. Milani, RV, Lavie, CH, Spiva, H Limitations of estimating metabolic equivalents in exercise assessment in patients with coronary artery disease. Am J Cardiol 1995;75,940-942[CrossRef][ISI][Medline]
  29. Milani, RV, Lavie, CJ Disparate effects of out-patient cardiac and pulmonary rehabilitation programs on work efficiency and peak aerobic capacity in patients with coronary disease or severe obstructive pulmonary disease. J Cardiopulm Rehabil 1998;18,17-22[CrossRef][Medline]
  30. Lavie, CJ, Milani, RV Disparate effects of improving aerobic exercise capacity and quality of life after cardiac rehabilitation in young and elderly coronary patients. J Cardiopulm Rehabil 2000;20,235-240[CrossRef][Medline]
  31. Osman, AF, Mehra, MR, Lavie, CJ, et al The incremental prognostic importance of body fat adjusted peak oxygen consumption in chronic heart failure. J Am Coll Cardiol 2000;36,2126-2131[Abstract/Free Full Text]
  32. Milani, RV, Mehra, MR, Reddy, TK, et al Ventilation/carbon dioxide production ratio in early exercise predicts poor functional capacity in congestive heart failure. Heart 1996;76,393-396[Abstract/Free Full Text]
  33. Lavie, CJ, Milani, RV Effects of cardiac rehabilitation and exercise training on peak aerobic capacity and work efficiency in obese patients with coronary artery disease. Am J Cardiol 1999;83,1477-1480[CrossRef][ISI][Medline]
  34. Fletcher, GF, Balady, GJ, Amsterdam, EA, et al Exercise standards for testing and training: a statement for healthcare professionals from the American Heart Association. Circulation 2001;104,1694-1740[Free Full Text]
  35. American College of Sports Medicine. Guidelines for exercise testing and prescription. 1991 Lea & Febiger. Philadelphia, PA:
  36. Pate, RR, Pratt, M, Blair, SN, et al Physical activity and public health: a recommendation from the Centers for Disease Control and Prevention and the American College of Sports Medicine. JAMA 1995;273,402-407[Abstract]
  37. Bouchard, C Physical activity and health: introduction to the dose-response symposium. Med Sci Sports Exerc 2001;33,S347-S350
  38. Goraya, TY, Jacobsen, SJ, Pellikka, PA, et al Prognostic value of treadmill exercise testing in elderly persons. Ann Intern Med 2000;132,862-870[Abstract/Free Full Text]
  39. Lavie, CJ, Milani, RV Effects of cardiac rehabilitation, exercise training, and weight reduction on exercise capacity, coronary risk factors, behavioral characteristics, and quality of life in obese coronary patients. Am J Cardiol 1997;79,397-401[CrossRef][ISI][Medline]
  40. Lavie, CJ, Milani, RV Obesity and cardiovascular disease: the Hippocrates paradox? J Am Coll Cardiol 2003;42,677-679[Free Full Text]
  41. Lavie, CJ, Milani, RV Obesity and the heart: an ever-growing problem. South Med J 2003;96,535-536[ISI][Medline]
  42. Milani, RV, Lavie, CJ Prevalence and profile of metabolic syndrome in patients following acute coronary events and effects of therapeutic lifestyle change with cardiac rehabilitation. Am J Cardiol 2003;92,50-54[ISI][Medline]
  43. Lavie, CJ, Milani, RV, Morshedi, A Impact of obesity on inflammation and metabolic syndrome in coronary patients and effects of cardiac rehabilitation [abstract].J Am Coll Cardiol 2003;41(suppl),177A
  44. American Heart Association Facts. Racial differences in cardiovascular health: findings from the National Health and Nutrition Examination Surveys (NHANES) III and 1999–2000. 2001 American Heart Association. Washington, DC:
  45. Fleg, JL, Pina, IL, Balady, GJ, et al Assessment of functional capacity in clinical and research applications: an advisory from the Committee on Exercise, Rehabilitation, and Prevention, Council on Clinical Cardiology, American Heart Association. Circulation 2000;102,1591-1597[Free Full Text]




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