The DOI matches its Crossref record; 203 of the 205 references it cites were found in a registry or an index; 4 of the 149 sources its claims cite were checked for support.
Exercise benefits in cardiovascular diseases: from mechanisms to clinical implementation
Open accessAbstract
There is a pandemic of physical inactivity that appears to parallel the widespread prevalence of cardiovascular disease (CVD). Yet, regular physical activity (PA) and exercise can play an important role not only in primary cardiovascular prevention but also in secondary prevention. This review discusses some of the main cardiovascular effects of PA/exercise and the mechanisms involved, including a healthier metabolic milieu with attenuation of systemic chronic inflammation, as well as adaptations at the vascular (antiatherogenic effects) and heart tissue (myocardial regeneration and cardioprotection) levels. The current evidence for safe implementation of PA and exercise in patients with CVD is also summarized.
Overview
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TL;DR
This review summarizes epidemiological and mechanistic evidence that regular physical activity/exercise reduces cardiovascular disease risk and mortality in primary and secondary prevention, with dose-dependent benefits and multiple biological mechanisms. It also discusses controversies around high-volume endurance exercise, atrial fibrillation, coronary calcification, and the occupational physical activity paradox.
Key findings
- In primary prevention, meeting WHO recommendations for moderate or vigorous physical activity was associated with 19%–25% and 15%–31% lower CVD and all-cause mortality risk, respectively, in a 30-year follow-up of 116,221 adults; the highest quarter of total moderate-to-vigorous physical activity had 53% lower incident CVD risk, and each 2,000 daily steps was associated with 10% lower CVD incidence up to ∼10,000 steps/day.
- In secondary prevention, a 6-year follow-up of 131,558 CVD patients found 14% mortality risk reduction per 500 MET-min/week versus 7% in CVD-free referents; cardiac rehabilitation participation was associated with 32% lower mortality, and a Cochrane review of 23,430 CHD patients found exercise-based rehabilitation reduced mortality and improved quality of life.
- Regarding “too much” exercise, a meta-analysis of 35,920 athletes found 27% lower standardized mortality rate, and MVPA at 5,000 MET-min/week was associated with 27% lower CVD mortality than 750 MET-min/week; however, sports participation was associated with 64% higher atrial fibrillation risk, while no robust evidence was found for total or intense physical activity.
- Mechanistic evidence includes exercise-induced exerkines, vascular and endothelial improvements, myocardial regeneration, antiarrhythmogenic autonomic effects, and cardiac preconditioning; in obese mice, exercise training reduced myocardial infarction lesions by 67%, and each 1-MET increase in cardiorespiratory fitness was associated with 13% lower CVD mortality risk, with 51% lower risk at highest versus lowest fitness.
Methods
- Design: narrative review of epidemiological, clinical, and preclinical evidence on physical activity/exercise in cardiovascular disease prevention and mechanisms.
- Data or sample: no primary data were generated or analysed; the paper synthesizes cited cohort studies, meta-analyses, randomized controlled trials, and preclinical studies.
- Main analysis: narrative synthesis of dose-response associations, clinical outcomes, and proposed biological mechanisms, without a described systematic search or formal meta-analysis.
Limitations
- Stated: the paper reports that no data were generated or analysed for the manuscript; it notes controversy about high-volume endurance exercise and potential methodological limitations in atrial fibrillation/physical activity studies, mainly non-objective determination of atrial fibrillation or physical activity.
- Evident from the text: as a narrative review, it does not describe a systematic search strategy, formal risk-of-bias assessment, or quantitative pooling; conclusions rely heavily on observational and preclinical evidence, so causality is not established.
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Claims the paper makes
103 Not checked yet · 5 Own interpretation · 2 Supported · 1 Partly supported · accuracy not yet measured
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In the paper
“a higher number of daily step counts, particularly if performed at high intensity (30/min) seems associated with a lower CVD incidence (-10% for each 2000 steps), at least up to ∼10 000 steps/day.5”
§ Exercise benefits in cardiovascular diseases: from mechanisms to clinical implementation > Cardiovascular disease prevention: epidemiological evidence Primary prevention
What the sources say
- Partly supportedcites [5] Del Pozo Cruz, 2022, Prospective associations of daily step counts and intensity with cancer and cardiovascular disease incidence and mortality and all-cause mortality, JAMA Intern Med sourceExperimental — accuracy not yet measured
The Results (Cancer and CVD Incidence; page unavailable) associate more daily steps and higher peak-30 cadence with lower CVD incidence, and the Discussion says the association was observed up to approximately 10,000 steps per day. But the reported change for CVD incidence is −0.04 per 2,000 steps, not approximately −10%; −0.10 is reported for CVD mortality. The Methods (Step Count and Intensity; page unavailable) define peak-30 cadence as the average steps per minute during the 30 highest-cadence minutes, not an intensity of 30 steps per minute. (LLM, conf=0.93)
hedgedcorrelational- Asserted: passes — The authors put it forward as true.
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- Partly supported
Every source the paper cites for this claim was checked and supports it.
In the paper
“these observations were consistent irrespective of the specific type of CVD.”
§ Exercise benefits in cardiovascular diseases: from mechanisms to clinical implementation > Secondary prevention
What the sources say
- Supportedcites [49] Jeong, 2019, Mortality reduction with physical activity in patients with and without cardiovascular disease, Eur Heart J source
The Results section (‘Impact of physical activity on mortality’) explicitly states that the benefit of physical activity in the secondary prevention group was consistent irrespective of the specific type of CVD. The preceding text describes the association between greater physical activity and lower mortality risk among participants with CVD. (LLM, conf=0.95)
plaincorrelationaln = 558- Asserted: passes — The authors put it forward as true.
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- Supported
None of the sources cited for this claim have been checked yet.
In the paper
“although both MVPA and strengthening activities are associated with improvements in cardiometabolic health and mortality risk, it is the combination of the two that provides the greatest effects.[7][8][9]”
§ Exercise benefits in cardiovascular diseases: from mechanisms to clinical implementation > Cardiovascular disease prevention: epidemiological evidence Primary prevention
What the sources say
- Not checked yetcites [7] Momma, 2022, Muscle-strengthening activities are associated with lower risk and mortality in major non-communicable diseases: a systematic review and meta-analysis of cohort studies, Br J Sports Med source
- Not checked yetcites [8] Coleman, 2022, Dose-response association of aerobic and muscle-strengthening physical activity with mortality: a national cohort study of 416 420 US adults, Br J Sports Med
- Not checked yetcites [9] Zhao, 2020, Recommended physical activity and all cause and cause specific mortality in US adults: prospective cohort study, BMJ
plaindirect- Asserted: passes — The authors put it forward as true.
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In the paper
“a ∼40% decrease in CVD mortality risk was nevertheless found at only 15-20 min/week. 6”
§ Exercise benefits in cardiovascular diseases: from mechanisms to clinical implementation > Cardiovascular disease prevention: epidemiological evidence Primary prevention
What the sources say
- Not checked yetcites [6] Ahmadi, 2022, Vigorous physical activity, incident heart disease, and cancer: how little is enough?, Eur Heart J source
plaindirect- Asserted: passes — The authors put it forward as true.
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In the paper
“17% lower risk of CVD mortality with 40-60 min/ week of this type of activity).7”
§ Exercise benefits in cardiovascular diseases: from mechanisms to clinical implementation > Cardiovascular disease prevention: epidemiological evidence Primary prevention
What the sources say
- Not checked yetcites [7] Momma, 2022, Muscle-strengthening activities are associated with lower risk and mortality in major non-communicable diseases: a systematic review and meta-analysis of cohort studies, Br J Sports Med source
plaincorrelational- Asserted: passes — The authors put it forward as true.
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In the paper
“meta-analytical evidence showed a positive association between excessive sedentary time (>10 h/day) and incident CVD 12”
§ Exercise benefits in cardiovascular diseases: from mechanisms to clinical implementation > Cardiovascular disease prevention: epidemiological evidence Primary prevention
What the sources say
- Not checked yetcites [12] Pandey, 2016, Continuous dose-response association between sedentary time and risk for cardiovascular disease: a meta-analysis, JAMA Cardiol source
plaincorrelational- Asserted: passes — The authors put it forward as true.
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- Load-bearing: unclear — It is unclear whether the paper’s conclusions depend on it.
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In the paper
“In a large (n = 116 221) 30-year follow-up, both self-reported leisuretime MPA and VPA were independently and inversely associated with CVD and all-cause mortality risk”
§ Exercise benefits in cardiovascular diseases: from mechanisms to clinical implementation > Cardiovascular disease prevention: epidemiological evidence Primary prevention
What the sources say
- Not checked yetcites [3] Lee, 2022, Long-Term leisure-time physical activity intensity and all-cause and cause-specific mortality: a prospective cohort of US adults, Circulation source
plaincorrelational- Asserted: passes — The authors put it forward as true.
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In the paper
“However, no positive-or negative-association was observed beyond this level.”
§ Exercise benefits in cardiovascular diseases: from mechanisms to clinical implementation > Cardiovascular disease prevention: epidemiological evidence Primary prevention
What the sources say
- Not checked yetcites [3] Lee, 2022, Long-Term leisure-time physical activity intensity and all-cause and cause-specific mortality: a prospective cohort of US adults, Circulation source
plain- Asserted: passes — The authors put it forward as true.
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- Load-bearing: unclear — It is unclear whether the paper’s conclusions depend on it.
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None of the sources cited for this claim have been checked yet.
In the paper
“prolonged daily sedentary time is associated with a higher risk of incident CVD or of all-cause or CVD mortality, regardless of PA level.[10][11][12][13][14][15][16]”
§ Exercise benefits in cardiovascular diseases: from mechanisms to clinical implementation > Cardiovascular disease prevention: epidemiological evidence Primary prevention
What the sources say
- Not checked yetcites [10] Dunstan, 2021, Sit less and move more for cardiovascular health: emerging insights and opportunities, Nat Rev Cardiol source
- Not checked yetcites [11] Katzmarzyk, 2019, . Sedentary behavior and health: update from the 2018 Physical Activity Guidelines Advisory Committee, Med Sci Sports Exerc source
- Not checked yetcites [12] Pandey, 2016, Continuous dose-response association between sedentary time and risk for cardiovascular disease: a meta-analysis, JAMA Cardiol source
plaincorrelational- Asserted: passes — The authors put it forward as true.
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In the paper
“A follow-up report (median ∼5 years) found an inverse dose-response association between objectively determined (with accelerometers) PA levels-whether measured as MPA, VPA, or total MVPA-and incident CVD, with no upper limit for this association.4”
§ Exercise benefits in cardiovascular diseases: from mechanisms to clinical implementation > Cardiovascular disease prevention: epidemiological evidence Primary prevention
What the sources say
- Not checked yetcites [4] Ramakrishnan, 2021, Accelerometer measured physical activity and the incidence of cardiovascular disease: evidence from the UK Biobank cohort study, PLoS Med
plaincorrelational- Asserted: passes — The authors put it forward as true.
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- It may state two separate claims as one. 36
- The quote only partly states this claim. 1
- Probably not a substantial claim. 2
Every source the paper cites for this claim was checked and supports it.
In the paper
“although acute and unaccustomed heavy physical exertion can trigger the onset of acute CVD events such as myocardial infarction (MI) and cardiac sudden death, this is particularly true for the habitually least active individuals, with higher habitual PA levels associated with a reduced risk.27,28”
§ Exercise benefits in cardiovascular diseases: from mechanisms to clinical implementation > Can one do 'too much' exercise?
What the sources say
- Supportedcites [27] Thompson, 2007, Exercise and acute cardiovascular events placing the risks into perspective: a scientific statement from the American Heart Association Council on Nutrition, Physical Activity, and Metabolism and the Council on Clinical Cardiology, Circulation source
Split into 2 atoms — 2 confirmed, 0 partially supported, 0 disputed, 0 misattributed, 0 unverifiable. Expand the claim to see per-atom verdicts.
- Supportedcites [28] Mittleman, 1993, Triggering of acute myocardial infarction by heavy physical exertion. Protection against triggering by regular exertion. Determinants of Myocardial Infarction Onset Study Investigators, N Engl J Med source
Split into 2 atoms — 2 confirmed, 0 partially supported, 0 disputed, 0 misattributed, 0 unverifiable. Expand the claim to see per-atom verdicts.
plaindirect- Asserted: passes — The authors put it forward as true.
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It may state two separate claims as one.
- Supported
In the paper
“(19%-25% and 15%-31% lower risk if meeting aforementioned WHO recommendations of MPA or VPA, respectively).3”
§ Exercise benefits in cardiovascular diseases: from mechanisms to clinical implementation > Cardiovascular disease prevention: epidemiological evidence Primary prevention
What the sources say
- Not checked yetcites [3] Lee, 2022, Long-Term leisure-time physical activity intensity and all-cause and cause-specific mortality: a prospective cohort of US adults, Circulation source
plaincorrelational- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
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It may state two separate claims as one.
In the paper
“whereas regular MVPA has the opposite (and largely dose-responsive) effects. 2”
§ Exercise benefits in cardiovascular diseases: from mechanisms to clinical implementation > Cardiovascular disease prevention: epidemiological evidence Primary prevention
What the sources say
- Not checked yetcites [2] Visseren, 2021, 2021 ESC Guidelines on cardiovascular disease prevention in clinical practice, Eur Heart J source
plaindirect- Asserted: passes — The authors put it forward as true.
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In the paper
“a meta-analysis of prospective studies with low risk of bias reported that, as opposed to sports participation-which was associated with a markedly (7-8-fold) higher risk-self-reported (using validated questionnaires) MVPA was inversely associated with the risk of medically ascertained AF. 39”
§ Exercise benefits in cardiovascular diseases: from mechanisms to clinical implementation > Can one do 'too much' exercise?
What the sources say
- Not checked yetcites [39] Valenzuela, 2022, What do we really know about the association between physical activity, sports, and atrial fibrillation? A systematic review and meta-analysis from unbiased studies, Eur J Prev Cardiol source
plaincorrelational- Asserted: passes — The authors put it forward as true.
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None of the sources cited for this claim have been checked yet.
In the paper
“Recent evidence also suggests no detrimental effects (and actually an inverse association) of objectively measured MVPA, 40,41 even at >395 min/week.42”
§ Exercise benefits in cardiovascular diseases: from mechanisms to clinical implementation > Can one do 'too much' exercise?
What the sources say
- Not checked yetcites [40] Khurshid, 2021, Accelerometer-derived physical activity and risk of atrial fibrillation, Eur Heart J source
- Not checked yetcites [41] Fletcher, 2022, Association of physical activity with the incidence of atrial fibrillation in persons > 65 years old: the Atherosclerosis Risk in Communities (ARIC) study, BMC Cardiovasc Disord source
- Not checked yetcites [42] O'Neal, 2020, Objectively measured physical activity and the risk of atrial fibrillation (from the REGARDS study), Am J Cardiol source
hedgedcorrelational- Asserted: passes — The authors put it forward as true.
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In the paper
“although the slope of the association tended to flatten in healthy individuals above 500 MET-min/week, an inverse dose-response association was still observed beyond this point in patients, and performing very high PA levels (≥1000 MET-min/week) resulted in a mortality risk similar to nonpatients.”
§ Exercise benefits in cardiovascular diseases: from mechanisms to clinical implementation > Secondary prevention
What the sources say
- Not checked yetcites [49] Jeong, 2019, Mortality reduction with physical activity in patients with and without cardiovascular disease, Eur Heart J source
plaincorrelationaln = 558- Asserted: passes — The authors put it forward as true.
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None of the sources cited for this claim have been checked yet.
In the paper
“although very high MVPA levels can be associated with higher CAC scores in the general population, the latter do not seem to be associated with an increased incidence of CVD events or mortality in 'exposed' individuals.32,33”
§ Exercise benefits in cardiovascular diseases: from mechanisms to clinical implementation > Can one do 'too much' exercise?
What the sources say
- Not checked yetcites [32] Gao, 2022, Associations of long-term physical activity trajectories with coronary artery calcium progression and cardiovascular disease events: results from the CARDIA study, Br J Sports Med source
- Not checked yetcites [33] DeFina, 2019, Association of all-cause and cardiovascular mortality with high levels of physical activity and concurrent coronary artery calcification, JAMA Cardiol source
hedgedcorrelational- Asserted: passes — The authors put it forward as true.
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In the paper
“very high levels of self-reported leisure-time PA were associated with a reduced risk (-15%) of major CVD events during a 10-year follow-up, but high levels of occupational PA showed the opposite trend (+35%).46”
§ Exercise benefits in cardiovascular diseases: from mechanisms to clinical implementation > Can one do 'too much' exercise?
What the sources say
- Not checked yetcites [46] Holtermann, 2021, The physical activity paradox in cardiovascular disease and all-cause mortality: the contemporary Copenhagen General Population Study with 104 046 adults, Eur Heart J source
plaincorrelational- Asserted: passes — The authors put it forward as true.
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In the paper
“meeting minimum WHO-recommended levels of MVPA (150 min/week, the equivalent of ∼20 min/day) does not seem enough to offset the association of prolonged sedentary time with higher all-cause mortality risk, with higher levels (30-40 min/day) needed.16”
§ Exercise benefits in cardiovascular diseases: from mechanisms to clinical implementation > Cardiovascular disease prevention: epidemiological evidence Primary prevention
What the sources say
- Not checked yetcites [16] Ekelund, 2020, Joint associations of accelero-meter measured physical activity and sedentary time with all-cause mortality: a harmonised meta-analysis in more than 44 000 middle-aged and older individuals, Br J Sports Med source
hedgedcorrelational- Asserted: passes — The authors put it forward as true.
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In the paper
“In a cohort of 15 486 patients with stable coronary heart disease (CHD), those in the highest PA tertile showed a lower risk of a major CVD event (-19%), as well as of CVD-specific (-29%) and all-cause mortality (-30%), than those in the least active tertile.52”
§ Exercise benefits in cardiovascular diseases: from mechanisms to clinical implementation > Secondary prevention
What the sources say
- Not checked yetcites [52] Stewart, 2017, Physical activity and mortality in patients with stable coronary heart disease, J Am Coll Cardiol source
plaincorrelationaln = 15,486- Asserted: passes — The authors put it forward as true.
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In the paper
“In a study with 122 007 participants, CRF was inversely associated with mortality risk during a median 8.4-year follow-up; the magnitude of this association was similar to-or even greater thanthe influence of traditional CVD risk factors and with no apparent upper limit for the observed benefits.19”
§ Exercise benefits in cardiovascular diseases: from mechanisms to clinical implementation > Cardiovascular disease prevention: epidemiological evidence Primary prevention
What the sources say
- Not checked yetcites [19] Mandsager, 2018, Association of cardiorespiratory fitness with long-term mortality among adults undergoing exercise treadmill testing, JAMA Netw Open source
plaincorrelationaln = 122,007- Asserted: passes — The authors put it forward as true.
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In the paper
“There is, however, no evidence for an increased risk of CVD mortality in former elite athletes, and in fact, there are consistent findings for the opposite trend [23][24][25] (e.g.27% lower standard mortality rate in a meta-analysis including 35 920 athletes 23 ).”
§ Exercise benefits in cardiovascular diseases: from mechanisms to clinical implementation > Can one do 'too much' exercise?
What the sources say
- Not checked yetcites [23] Garatachea, 2014, Elite athletes live longer than the general population: a meta-analysis, Mayo Clin Proc source
- Not checked yetcites [24] Antero-Jacquemin, 2015, Mortality in female and male French Olympians: a 1948–2013 cohort study, Am J Sports Med source
- Not checked yetcites [25] Antero, 2021, Female and male US Olympic athletes live 5 years longer than their general population counterparts: a study of 8124 former US Olympians, Br J Sports Med source
plain- Asserted: passes — The authors put it forward as true.
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In the paper
“A recent umbrella review of meta-analyses reported that sports participation was indeed associated with a higher AF risk (+64%), but no robust evidence was found for total or intense PA. 38”
§ Exercise benefits in cardiovascular diseases: from mechanisms to clinical implementation > Can one do 'too much' exercise?
What the sources say
- Not checked yetcites [38] Valenzuela, 2021, Physical activity, sports and risk of atrial fibrillation: umbrella review of meta-analyses, Eur J Prev Cardiol source
plaincorrelational- Asserted: passes — The authors put it forward as true.
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In the paper
“A recent 6-year follow-up study in 131 558 patients with different types of CVD [e.g.stroke, ischaemic cardiomyopathy, heart failure (HF)] found an inverse association between PA and mortality risk that was actually stronger than in CVD-free referents (14% and 7% risk reduction in patients and nonpatients, respectively, with every 500 MET-min/week).49”
§ Exercise benefits in cardiovascular diseases: from mechanisms to clinical implementation > Secondary prevention
What the sources say
- Not checked yetcites [49] Jeong, 2019, Mortality reduction with physical activity in patients with and without cardiovascular disease, Eur Heart J source
plaincorrelationaln = 131,558- Asserted: passes — The authors put it forward as true.
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In the paper
“A study in 7058 outpatients with CVD also reported that those with highest leisure-time-but not occupational-PA levels had a lower risk of recurrent CVD events and all-cause mortality risk (-28% and -7%, respectively) during a 9-year follow-up than their less active peers.51”
§ Exercise benefits in cardiovascular diseases: from mechanisms to clinical implementation > Secondary prevention
What the sources say
- Not checked yetcites [51] Bonekamp, 2022, Leisure-time and occupational physical activity and health outcomes in cardiovascular disease, Heart
plaincorrelational- Asserted: passes — The authors put it forward as true.
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In the paper
“In patients with AF, physical exercise does not only improve physical capacity but also symptoms' burden and cardiac function.63,64”
§ Exercise benefits in cardiovascular diseases: from mechanisms to clinical implementation > Secondary prevention
What the sources say
- Not checked yetcites [63] Malmo, 2016, Aerobic interval training reduces the burden of atrial fibrillation in the short term: a randomized trial, Circulation source
- Not checked yetcites [64] Smart, 2018, Exercise-based cardiac rehabilitation improves exercise capacity and health-related quality of life in people with atrial fibrillation: a systematic review and meta-analysis of randomised and non-randomised trials, Open Heart source
plaindirect- Asserted: passes — The authors put it forward as true.
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In the paper
“Meta-analytical evidence supports that exercise training improves exercise capacity and QoL in patients with HF, as well as some cardiac function indicators [e.g.left ventricular ejection fraction (LVEF)].62”
§ Exercise benefits in cardiovascular diseases: from mechanisms to clinical implementation > Secondary prevention
What the sources say
- Not checked yetcites [62] Edwards, 2022, Exercise training in heart failure with preserved and reduced ejection fraction: a systematic review and meta-analysis, Sports Med Open source
plaindirect- Asserted: passes — The authors put it forward as true.
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In the paper
“lowering plasma LDL-cholesterol-by reducing intestinal cholesterol resorption, hepatic cholesterol synthesis or, more recently, enhancing hepatic LDL-cholesterol uptake-has led to population-wide reductions in the prevalence of CVD events and is associated with differences in atherosclerotic plaque morphology.85”
§ Exercise benefits in cardiovascular diseases: from mechanisms to clinical implementation > Mechanisms Metabolism, inflammation, and cellular integrity
What the sources say
- Not checked yetcites [85] Pasterkamp, 2017, Temporal shifts in clinical presentation and underlying mechanisms of atherosclerotic disease, Nat Rev Cardiol source
plaindirect- Asserted: passes — The authors put it forward as true.
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- Load-bearing: unclear — It is unclear whether the paper’s conclusions depend on it.
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In the paper
“selfreported PA levels inversely associated with the risk of AF-related adverse events (e.g.thromboembolic event, bleeding) and CVD-specific mortality in affected people.55”
§ Exercise benefits in cardiovascular diseases: from mechanisms to clinical implementation > Secondary prevention
What the sources say
- Not checked yetcites [55] Proietti, 2017, Self-reported physical activity and major adverse events in patients with atrial fibrillation: a report from the EURObservational Research Programme Pilot Survey on Atrial Fibrillation (EORP-AF) General Registry, Europace source
plaincorrelational- Asserted: passes — The authors put it forward as true.
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In the paper
“The role of muscle strength or 'resistance' training (RT) should not be disregarded, as this modality has proven feasible and effective for most CVD 48 (e.g.recent MI, 73 end-stage HF, 74 chronic HF, 75 or CHD 76 ).”
§ Exercise benefits in cardiovascular diseases: from mechanisms to clinical implementation > Secondary prevention
What the sources say
- Not checked yetcites [48] Pelliccia, 2021, 2020 ESC Guidelines on sports cardiology and exercise in patients with cardiovascular disease, Eur Heart J source
- Not checked yetcites [73] Vona, 2009, Effects of different types of exercise training followed by detraining on endothelium-dependent dilation in patients with recent myocardial infarction, Circulation source
- Not checked yetcites [74] Dean, 2011, Resistance training improves vasoreactivity in end-stage heart failure patients on inotropic support, J Cardiovasc Nurs source
boosteddirect- Asserted: passes — The authors put it forward as true.
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In the paper
“meta-analytical evidence suggests that this modality is more effective-or at least more time-efficient-than MICT to improve CRF and QoL in patients with CVD.[70][71][72]”
§ Exercise benefits in cardiovascular diseases: from mechanisms to clinical implementation > Secondary prevention
What the sources say
- Not checked yetcites [70] Gomes-Neto, 2017, High-intensity interval training versus moderate-intensity continuous training on exercise capacity and quality of life in patients with coronary artery disease: a systematic review and meta-analysis, Eur J Prev Cardiol source
- Not checked yetcites [71] Yue, 2022, Effects of high-intensity interval vs. moderate-intensity continuous training on cardiac rehabilitation in patients with cardiovascular disease: a systematic review and meta-analysis, Front Cardiovasc Med source
- Not checked yetcites [72] Hannan, 2018, High-intensity interval training versus moderate-intensity continuous training within cardiac rehabilitation: a systematic review and meta-analysis, Open Access J Sports Med source
hedgedconditional- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: passes — The paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
It may state two separate claims as one.
None of the sources cited for this claim have been checked yet.
In the paper
“this modality has proven to improve not only muscle strength but also CRF, mobility, and body composition in patients with CVD, [77][78][79]”
§ Exercise benefits in cardiovascular diseases: from mechanisms to clinical implementation > Secondary prevention
What the sources say
- Not checked yetcites [77] Yamamoto, 2016, Effects of resistance training on muscle strength, exercise capacity, and mobility in middle-aged and elderly patients with coronary artery disease: a meta-analysis, J Cardiol source
- Not checked yetcites [78] Kirkman, 2022, Resistance exercise for cardiac rehabilitation, Prog Cardiovasc Dis source
- Not checked yetcites [79] Hwang, 2010, Resistance training increases 6-minute walk distance in people with chronic heart failure: a systematic review, J Physiother source
boosteddirect- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: passes — The paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
It may state two separate claims as one.
In the paper
“A recent Cochrane review (n = 23 430 patients with CHD) concluded that exercise-based cardiac rehabilitation results in a reduced mortality risk and an improved quality of life (QoL).50”
§ Exercise benefits in cardiovascular diseases: from mechanisms to clinical implementation > Secondary prevention
What the sources say
- Not checked yetcites [50] Dibben, 2021, Exercise-based cardiac rehabilitation for coronary heart disease, Cochrane Database Syst Rev
plaindirectn = 23,430- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: passes — The paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
It may state two separate claims as one.
In the paper
“A meta-epidemiological study including 16 meta-analyses and 305 randomized controlled trials found not only no consistent differences between drug and exercise intervention for secondary prevention of some conditions such as CHD or prediabetes, but also greater effects provided by exercise intervention in some conditions such as stroke-albeit with a greater mortality risk reduction induced by diu”
§ Exercise benefits in cardiovascular diseases: from mechanisms to clinical implementation > Secondary prevention
What the sources say
- Not checked yetcites [61] Naci, 2015, Comparative effectiveness of exercise and drug interventions on mortality outcomes: metaepidemiological study, Br J Sports Med source
plaindirect- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: passes — The paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
It may state two separate claims as one.
None of the sources cited for this claim have been checked yet.
In the paper
“Chronically elevated plasma levels of low-density lipoprotein (LDL)-cholesterol and triglyceride-rich lipoproteins (e.g.very lowdensity lipoproteins) are both strongly associated with CVD.83,84”
§ Exercise benefits in cardiovascular diseases: from mechanisms to clinical implementation > Mechanisms Metabolism, inflammation, and cellular integrity
What the sources say
- Not checked yetcites [83] Ginsberg, 2021, Triglyceride-rich lipoproteins and their remnants: metabolic insights, role in atherosclerotic cardiovascular disease, and emerging therapeutic strategies-a consensus statement from the European Atherosclerosis Society, Eur Heart J source
- Not checked yetcites [84] Boren, 2020, Low-density lipoproteins cause atherosclerotic cardiovascular disease: pathophysiological, genetic, and therapeutic insights: a consensus statement from the European Atherosclerosis Society Consensus Panel, Eur Heart J source
boostedcorrelational- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: unclear — It is unclear whether the paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
It may state two separate claims as one.
In the paper
“In addition, there is evidence for an important role of IL6 receptor signalling on the reduction of cardiac-especially epicardial-fat depots and increases in LV mass with aerobic training.182”
§ Exercise benefits in cardiovascular diseases: from mechanisms to clinical implementation > Exerkines
What the sources say
- Not checked yetcites [182] Christensen, 2019, Aerobic exercise induces cardiac fat loss and alters cardiac muscle mass through an interleukin-6 receptor-dependent mechanism: cardiac analysis of a double-blind randomized controlled clinical trial in abdominally obese humans, Circulation source
plaindirect- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: unclear — It is unclear whether the paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
It may state two separate claims as one.
In the paper
“which reduces the size of the MI lesion and the risk of ventricular fibrillation.193”
§ Exercise benefits in cardiovascular diseases: from mechanisms to clinical implementation > Cardiac preconditioning
What the sources say
- Not checked yetcites [193] Thijssen, 2018, Association of exercise preconditioning with immediate cardioprotection: a review, JAMA Cardiol source
plaindirect- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: passes — The paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
It may state two separate claims as one.
In the paper
“Exercise is also cardioprotective against necrosis, an effect mediated-at least partly-by activation of δ-opioid receptors or other factors released in a dose-dependent manner with exertion such as adenosine and bradykinin.197”
§ Exercise benefits in cardiovascular diseases: from mechanisms to clinical implementation > Cardiac preconditioning
What the sources say
- Not checked yetcites [197] Miller, 2015, Involvement of the delta-opioid receptor in exercise-induced cardioprotection, Exp Physiol source
hedgeddirect- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: passes — The paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
It may state two separate claims as one.
None of the sources cited for this claim have been checked yet.
In the paper
“Additionally, with regular exercise training blood vessels in barosensitive areas of the carotid arteries become more compliant and are thus able to distend better in response to a rise in BP, with this adaptation increasing afferent signalling to the brainstem and evoking reflex increases in PNS activity to the heart while at the same time decreasing sympathetic nervous system (SNS) activity.[188”
§ Exercise benefits in cardiovascular diseases: from mechanisms to clinical implementation > Protection against malignant arrhythmias
What the sources say
- Not checked yetcites [188] Pearson, 2018, Exercise therapy and autonomic function in heart failure patients: a systematic review and meta-analysis, Heart Fail Rev source
- Not checked yetcites [189] Villafaina, 2017, Physical exercise improves heart rate variability in patients with type 2 diabetes: a systematic review, Curr Diab Rep source
- Not checked yetcites [190] Sandercock, 2005, Effects of exercise on heart rate variability: inferences from meta-analysis, Med Sci Sports Exerc source
plaindirect- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: passes — The paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
It may state two separate claims as one.
None of the sources cited for this claim have been checked yet.
In the paper
“The antiarrhythmogenic effect of exercise is mediated by the improvement in autonomic balance, specifically a higher PNS tone without changes in intrinsic sinoatrial node function together with a reduction of β 2 -adrenergic receptor sensitivity and expression 184,185”
§ Exercise benefits in cardiovascular diseases: from mechanisms to clinical implementation > Protection against malignant arrhythmias
What the sources say
- Not checked yetcites [184] Billman, 2015, Exercise training-induced bradycardia: evidence for enhanced parasympathetic regulation without changes in intrinsic sinoatrial node function, J Appl Physiol (1985) source
- Not checked yetcites [185] Billman, 2009, Cardiac autonomic neural remodeling and susceptibility to sudden cardiac death: effect of endurance exercise training, Am J Physiol Heart Circ Physiol source
plaindirect- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: passes — The paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
It may state two separate claims as one.
In the paper
“and also linked to an increased risk of death from CVD and all-cause death in the general elderly population.179”
§ Exercise benefits in cardiovascular diseases: from mechanisms to clinical implementation > Exerkines
What the sources say
- Not checked yetcites [179] Li, 2017, Circulating interleukin-6 levels and cardiovascular and all-cause mortality in the elderly population: a meta-analysis, Arch Gerontol Geriatr source
plaincorrelational- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: unclear — It is unclear whether the paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
It may state two separate claims as one.
None of the sources cited for this claim have been checked yet.
In the paper
“The mechanisms through which exercise induces cardiac preconditioning include heightened defence against oxidative stress, upregulated expression of sarcolemmal ATP-sensitive potassium channel subunits, mitochondrial adaptations (i.e.improved capacity to withstand apoptotic stimuli or a higher capacity for scavenging endogenous ROS), 194 β 3 -adrenergic receptor stimulation, and increased cardiac”
§ Exercise benefits in cardiovascular diseases: from mechanisms to clinical implementation > Cardiac preconditioning
What the sources say
- Not checked yetcites [194] Frasier, 2011, Exercise-induced cardiac preconditioning: how exercise protects your achy-breaky heart, J Appl Physiol (1985) source
- Not checked yetcites [195] Calvert, 2011, Exercise protects against myocardial ischemia-reperfusion injury via stimulation of beta(3)-adrenergic receptors and increased nitric oxide signaling: role of nitrite and nitrosothiols, Circ Res source
plaindirect- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: passes — The paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
It may state two separate claims as one.
In the paper
“VED 166 (see also previous section on 'endothelial function')”
§ Exercise benefits in cardiovascular diseases: from mechanisms to clinical implementation > Myocardial regeneration
What the sources say
- Not checked yetcites [166] Vona, 2004, Impact of physical training and detraining on endothelium-dependent vasodilation in patients with recent acute myocardial infarction, Am Heart J source
plaindirect- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: unclear — It is unclear whether the paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
The quote only partly states this claim.
In the paper
“In obese mice, exercise training reduced MI lesions (-67%), which was mediated by the activation of pro-survival kinases of the reperfusion injury salvage kinase pathway, a decrease in the levels of phosphatases, and an improved capacity of mitochondria to retain calcium.196”
§ Exercise benefits in cardiovascular diseases: from mechanisms to clinical implementation > Cardiac preconditioning
What the sources say
- Not checked yetcites [196] Pons, 2013, Regular treadmill exercise restores cardioprotective signaling pathways in obese mice independently from improvement in associated co-morbidities, J Mol Cell Cardiol source
plaindirect- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: passes — The paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
It may state two separate claims as one.
None of the sources cited for this claim have been checked yet.
In the paper
“But, its release by contracting muscles leads to direct and indirect anti-inflammatory effects and improvement of skeletal muscle insulin resistance.180,181”
§ Exercise benefits in cardiovascular diseases: from mechanisms to clinical implementation > Exerkines
What the sources say
- Not checked yetcites [180] Lambernd, 2012, Contractile activity of human skeletal muscle cells prevents insulin resistance by inhibiting pro-inflammatory signalling pathways, Diabetologia source
- Not checked yetcites [181] Pedersen, 2017, Anti-inflammatory effects of exercise: role in diabetes and cardiovascular disease, Eur J Clin Invest source
plaindirect- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: passes — The paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
It may state two separate claims as one.
None of the sources cited for this claim have been checked yet.
In the paper
“Other exerkine-induced effects include improved lipolysis, thermogenesis, and glucose metabolism.169,172”
§ Exercise benefits in cardiovascular diseases: from mechanisms to clinical implementation > Exerkines
What the sources say
- Not checked yetcites [169] Fiuza-Luces, 2013, Exercise is the real polypill, Physiology (Bethesda)
- Not checked yetcites [172] Chow, 2022, Exerkines in health, resilience and disease, Nat Rev Endocrinol source
plaindirect- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: unclear — It is unclear whether the paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
It may state two separate claims as one.
In the paper
“Indeed, physical exercise can upregulate myocardial telomere-regulating proteins, thereby decreasing the risk of HF, as suggested by research in aging mice 122”
§ Exercise benefits in cardiovascular diseases: from mechanisms to clinical implementation > Myocardial regeneration
What the sources say
- Not checked yetcites [122] Ludlow, 2017, Acute exercise activates p38 MAPK and increases the expression of telomere-protective genes in cardiac muscle, Exp Physiol source
hedgeddirect- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: unclear — It is unclear whether the paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
It may state two separate claims as one.
A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“Notably, there are numerous biological mechanisms supporting PA/exercise-induced cardiovascular benefits involving not only the heart tissue but also the metabolic and inflammatory milieu.”
§ Exercise benefits in cardiovascular diseases: from mechanisms to clinical implementation > Conclusions
plaindirect- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: passes — The paper’s conclusions depend on it.
- Based: fails — The paper may give no reason why it holds.
Probably not a substantial claim. The paper may give no reason why it holds.
A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“with some evidence for PA benefits even above current WHO recommendations”
§ Exercise benefits in cardiovascular diseases: from mechanisms to clinical implementation > Conclusions
hedgedconditional- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: passes — The paper’s conclusions depend on it.
- Based: fails — The paper may give no reason why it holds.
Probably not a substantial claim. The paper may give no reason why it holds.
The paper relies on this without support.
Maintenance of endothelial barrier function counteracts lipid accumulation in the subendothelial vascular wall, the initial step of atherosclerotic plaque formation.
“Maintenance of endothelial barrier function counteracts lipid accumulation in the subendothelial vascular wall, the initial step of atherosclerotic plaque formation.”
Claims other papers make about this one
Each is checked against this paper’s own text: does it say what the citing paper says it does?
The source backs part of the claim, not all of it — or backs it for a different population, condition or comparison.
In the citing paper
“PA could alleviate the risks of developing vascular events associated with diabetes and prediabetes by improving the established vascular risk factors, including obesity, hyperglycemia, and hyperlipidemia.43,46”
From Accelerometer-measured physical activity, sedentary behavior, and incidence of macrovascular and microvascular events in individuals with type 2 diabetes mellitus and prediabetes (2025) · cites this paper as [46]
Experimental — accuracy not yet measured
Citations
Cites
Items 201–203 of 203
MACEIRA, A., VALENZUELA, P. L., SANTOS-LOZANO, A., GARCÍA-GONZÁLEZ, M. P., ORTEGA, L. H., DÍAZ-GONZALEZ, L., BORAITA, A., BARRANCO-GIL, D., & LUCIA, A. (2023) · Medicine & Science in Sports & Exercise · doi:10.1249/mss.0000000000003043 · Cited by 9
Self-citationStrenuous Endurance Exercise and the Heart: Physiological versus Pathological Adaptations
Valenzuela, P. L., Baggish, A. L., Castillo‐García, A., Santos‐Lozano, A., Boraíta, A., & Lucía, A. (2022) · Comprehensive physiology · doi:10.1002/cphy.c210045 · Cited by 8
Self-citationHartley, A., Shun-Shin, M. J., Caga‐Anan, M., Rajkumar, C., Nowbar, A. N., Foley, M. J., Francis, D. P., Haskard, D. O., Khamis, R., & Al-Lamee, R. K. (2021) · Frontiers in Cardiovascular Medicine · doi:10.3389/fcvm.2021.757030 · Cited by 3
Cited by
Sorted by citations
Systematic profiling reveals betaine as an exercise mimetic for geroprotection
Geng, L., Ping, J., Wu, R., Yan, H., Zhang, H., Zhuang, Y., Ning, T., Wang, J., Liang, C., Zhang, J., et al. (2025) · Cell · doi:10.1016/j.cell.2025.06.001 · Cited by 75
Coronary atherosclerosis in athletes: emerging concepts and preventive strategies
Claessen, G., Eijsvogels, T. M. H., Albert, C. M., Baggish, A. L., Levine, B. D., Marijon, E., Michos, E. D., & La Gerche, A. (2025) · European Heart Journal · doi:10.1093/eurheartj/ehae927 · Cited by 43
Li, Z., Cheng, S., Guo, B., Ding, L., Liang, Y., Shen, Y., Li, J., Hu, Y., Long, T., Guo, X., et al. (2024) · European Heart Journal · doi:10.1093/eurheartj/ehae406 · Cited by 38
Zhu, Y., & Wang, Z. (2024) · BMC Public Health · doi:10.1186/s12889-024-18346-8 · Cited by 44
Metabolic diseases in the East Asian populations
Sun, Z., & Zheng, Y. (2025) · Nature Reviews Gastroenterology & Hepatology · doi:10.1038/s41575-025-01058-8 · Cited by 40
Metadata
- Authors
- Valenzuela, P. L., Ruilope, L. M., Santos-Lozano, A., Wilhelm, M., Kränkel, N., Fiuza-Luces, C., & Lucia, A.
- Affiliations
- Universidad de Alcalá (ES)
- Research Institute Hospital 12 de Octubre (ES)
- Physical Activity and Health Research Group (PaHerg), Research Institute of the Hospital 12 de Octubre (‘imas12’) , 7 Planta, Bloque D., Av. de Córdoba s/n, Madrid 28041 , Spain
- University of Bern (CH)
- Charité – Universitätsmedizin Berlin (DE)
- CIBER of Frailty and Healthy Aging (CIBERFES) , Madrid 28007 , Spain
- Corresponding author
- Valenzuela, Pedro L
- ORCID
- Venue
- European Heart Journal
- Publisher
- Oxford University Press (OUP)
- Published
- 2023-04-03
- Volume
- 44
- Issue
- 21
- Pages
- 1874-1889
- ISSN
- 0195-668X (ISSN-L)
- 1522-9645
- OpenAlex
- W4362505991
- Cited by
- 237
- References
- 205
- Citations by year
- 2026: 67 · 2025: 82 · 2024: 69 · 2023: 19
- FWCI
- 13.88
- Type
- journal article
- Language
- en
- Open access
- hybrid
- doi.org
- Locations
- European Heart Journal (publishedVersion, other-oa)
- PubMed (publishedVersion)
- BORIS (University Library Bern) (submittedVersion)
- RUIdeRA - Institutional University Repository (University of Castilla-La Mancha) (submittedVersion)
- Funders
- postdoctoral
- by Instituto de Salud Carlos III (CP18/00034, CD21/00138).)
- Ministry of Economy and Competitiveness (PI18/00139, PI20/00605)
- Wereld Kanker Onderzoek
- World Cancer Research Fund International (IIG_FULL_2021_007)
- Topics
- Health Sciences › Medicine › Physiology (medical) › Cardiovascular and exercise physiology
- Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Physical Activity and Health
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Cardiovascular Effects of Exercise
- Keywords
- physical activity, cardiovascular disease, primary prevention, secondary prevention, physical inactivity, chronic inflammation, antiatherogenic effects, vascular adaptation, cardiac regeneration, cardioprotection
- MeSH terms
- Cardiovascular Diseases, Cardiovascular System, Heart, Humans, Inflammation, Risk Factors, Exercise
About these checks
Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.
A language model drew the claims from the paper on 2026-10-09, under version 3 of the claim definition (model deepseek-v4.1-flash, prompt extract-v3).
A second model labelled each claim on 2026-10-09 (model jev-1.13-20260917, definition revision gold-guideline-v0.2).
Cited sources are checked with a language model’s help (gpt-6-sol).
Statistics and arithmetic are recomputed, not judged.
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