Cardiac Rehabilitation in the Elderly Arthur R. Menezes, Carl J. Lavie, Daniel E. Forman, Ross Arena, Richard V. Milani, Barry A. Franklin PII: DOI: Reference:
S0033-0620(14)00006-1 doi: 10.1016/j.pcad.2014.01.002 YPCAD 574
To appear in:
Progress in Cardiovascular Diseases
Please cite this article as: Menezes Arthur R., Lavie Carl J., Forman Daniel E., Arena Ross, Milani Richard V., Franklin Barry A., Cardiac Rehabilitation in the Elderly, Progress in Cardiovascular Diseases (2014), doi: 10.1016/j.pcad.2014.01.002
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ACCEPTED MANUSCRIPT Cardiac Rehabilitation in the Elderly
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Arthur R. Menezes, MD*, Carl J. Lavie, MD*#, Daniel E. Forman, M.D. ^, Ross Arena, PhD, PT, Richard V. Milani, MD*, Barry A. Franklin, PhD
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*Department of Cardiovascular Diseases, John Ochsner Heart and Vascular Institute Ochsner Clinical School- The University of Queensland School of Medicine
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#From the Department of Preventive Cardiology, Pennington Biomedical Research Center, Louisiana State University System, Baton Rouge, Louisiana
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^Division of Cardiovascular Medicine, Brigham and Women’s Hospital; New England Geriatric Research, Education, and Clinical Center, VA Boston Healthcare System
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Department of Physical Therapy and Integrative Physiology Laboratory, College of Applied Health Sciences, University of Illinois Chicago, Chicago, Illinois
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Department of Preventive Cardiology and Rehabilitation, William Beaumont Hospital, Royal Oak, MI
Corresponding author: Carl J. Lavie, M.D., FACC, FACP, FCCP Medical Director, Cardiac Rehabilitation and Prevention Director, Exercise Laboratories John Ochsner Heart and Vascular InstituteOchsner Clinical School-The University of Queensland School of Medicine1514 Jefferson Highway New Orleans, LA 70121-2483 (504) 842-5874 Phone (504) 842-5875 Fax Email: [email protected] Abbreviation List
ACCEPTED MANUSCRIPT BMI: Body Mass Index CABG: Coronary Artery Bypass Graft
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CHD: Coronary Heart Disease
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CR: Cardiac Rehabilitation CRET: Cardiac Rehabilitation Exercise Training
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CRF: Cardiorespiratory Fitness CRP: C-reactive Protien
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CV: Cardiovascular CVD: Cardiovascular Disease
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ET: Exercise Training HF: Heart Failure
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HR: Hazard Ratio
MI: Myocardial Infarction
OR: Odds Ratio
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PA:Physical Activity
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PS: Psychological Stress
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MET: Metabolic Equivalent
RT: Resistance Training US: United States
VO2: Oxygen Consumption
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Abstract
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Coronary heart disease (CHD) is the leading cause of death worldwide. Advanced age is associated with
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a higher prevalence of CHD as well as increased morbidity and mortality. One key vulnerability relates to the fact that older individuals are generally among the least fit, least active cohort and at increased risk of complications after an acute cardiac event and/or major surgery. There is ample evidence to
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demonstrate the beneficial effects of exercised-based cardiac rehabilitation (CR) programs on improving functional capacity and other indices of cardiovascular (CV) health. Although the predominant number
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of studies are in middle-aged patients, there is an escalating amount of new information that establishes the cardioprotective role of CR and, in particular, structured exercise therapy (ET) among the elderly. The present review summarizes the current data available regarding CR and ET and its salutary impact on
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today’s growing population of older adults with CHD.
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Introduction Over the past century we have witnessed an exponential increase in the elderly population in the United
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States (US). Average life expectancy has dramatically increased from 50 years of age in the early 1900’s
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to almost 80 years in 2008.1,2 Nevertheless, coronary heart disease (CHD) remains the leading cause of death worldwide. In fact, 86% of all CHD related deaths in the US were among individuals aged 65 and
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older.3
Prior to an initial cardiovascular (CV) event, elderly patients are generally more deconditioned and less fit
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compared to their younger counterparts, with accelerated deconditioning once CHD is established.4 Similarly, elderly patients are typically at a higher risk of complications from myocardial infarction (MI)
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and coronary revascularization procedures compared to their younger counterparts, leading to prolonged hospital stays and greater vulnerability to subsequent clinical sequelae and deconditioning.5 Due to the many demonstrated benefits of formal cardiac rehabilitation (CR) and exercise training (ET) or CRET
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programs on morbidity and mortality, elderly patients would almost certainly benefit from these interventions. Numerous studies have established the beneficial role of CR, regular ET, lifestyle physical
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activity (PA), and the maintenance or enhancement of cardiorespiratory fitness (CRF) on both the primary and secondary prevention of CHD among the general population,6 including elderly patients. the last decade.7
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Consequently, the use and safety of CRET among older patients has gained increasing acceptance over
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There are multiple studies substantiating the benefits of CRET on a number of physiologic parameters and clinical factors including exercise capacity or CRF, inflammation, pre-diabetic or diabetic glucose control, autonomic function, behavioral characteristics, quality of life (QoL), hospitalization costs, and CHD morbidity and mortality after a major CV event (Figure 1).8 Most older patients with CHD also have varied co-morbid conditions, making CR particularly useful as an opportunity to address the interplay of relevant clinical indices and medications. However, despite escalating evidence substantiating the benefits of CRET, this form of treatment remains underutilized among all CHD patients, including older adults.9
This review summarizes selected studies involving CRET, with specific reference to older adults. The information was obtained by reviewing randomized clinical trials, many large observational studies, as well as appropriate review articles and editorials. Finally, we will discuss some of the current barriers to CRET referral and participation by the elderly.
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Aerobic capacity Aerobic capacity or CRF is the highest volume of somatic oxygen consumed per minute at peak or
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maximum physical exertion,10 synergistically utilizing the CV, pulmonary, and skeletal muscle systems.
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One of the most significant benefits of formal CRET, irrespective of age, sex, or body composition, is the increase in aerobic capacity, which is strongly associated with improved survival and prognosis.11 Especially noteworthy is the fact that elderly patients demonstrate greater relative improvements in
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aerobic capacity as compared with their younger counterparts following CRET.12
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One of the initial studies on ET in an elderly cohort with CHD was published in 1985.13 The goal was to evaluate the potential benefits of early exercise programs on young, middle-aged, and elderly CHD
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patients after an acute MI or coronary artery bypass grafting (CABG). The study population included 361 patients who were categorized into 1 of 4 groups based on age. Group I included 60 patients aged ≤ 44 years; group II included 114 patients aged 45 to 54 years of age; group III included 111 patients aged 55
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to 64 years; and group IV included 76 patients aged ≥ 65 years. All patients participated in a 12-week ET program within 6 weeks of acute MI or CABG. The patients aged ≥ 65 years demonstrated significant
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increases in maximal heart rate (126 to 138 beats/minute) and peak metabolic equivalents (METs; 5.3 to 8.1 METs), a surrogate measure of aerobic capacity, as well as other physiologic and clinical
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improvements. Compared to the other groups, these patients also demonstrated similar improvements in body weight, percent body fat, resting heart rate, maximal heart rate, submaximal double product, and submaximal average rating of perceived exertion. However, the elderly had significantly lower absolute
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work capacity after training when equated to groups I-III. Ades et al14 evaluated the impact of resistance training (RT) in disabled older women (≥ 65 years of age) with CHD. Control patients performed light yoga and breathing exercises whereas study participants engaged in a 6-month RT program. The RT group demonstrated statistically significant improvements in physical work capacity over a wide range of household PA that extended beyond strength-related activities such as endurance, balance, coordination, and flexibility. In a similar patient population, RT led to improved measures for upper and lower body strength, endurance, balance and coordination, and 6-min walk performance.15
Among elderly persons with and without CHD, RT appears to promote beneficial effects on muscular strength and endurance, which should enhance the ability to perform activities of daily living. This was
ACCEPTED MANUSCRIPT observed in a study that evaluated the effect of RT on walking endurance among healthy, community dwelling elderly individuals (≥ 65 years of age). Although there was a noticeable increase in leg strength, participants in the RT group also demonstrated a 38% increase in submaximal walking
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endurance (P = .001), whereas the control group remained unchanged.16
Lavie and Milani17 highlighted the therapeutic importance of referring all eligible patients to CR
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programs, irrespective of age. The study population included 92 patients > 65 years and 182 patients < 65 years who were enrolled in phase II CRET after a major CHD event. Elderly patients had lower baseline estimated peak METs (5.6 ± 1.6 vs. 7.7 ± 3.0, P < .0001) when compared with their younger counterparts.
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However, after CRET, older patients showed significant increases in peak METs (5.6 ± 1.6 vs. 7.5 ± 2.3, P < .0001). Moreover, both older and younger individuals demonstrated statistically similar
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improvements in functional capacity, percent body fat, body mass index (BMI), and lipid profiles.
In another age-related study, 125 younger patients (< 55 years) and 57 elderly CHD patients (> 70 years)
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were evaluated to assess the impact of formal CRET programs on cardiopulmonary variables and QoL scores.18 Similar to the aforementioned study, elderly patients had a lower estimated aerobic capacity (-
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27%; P < .001), directly measured peak oxygen consumption (VO2) (-19%; P < .01) and anaerobic threshold (-10%; P < .05), total function scores (-11%; P < .01) and a trend toward lower total QoL scores
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(-5%; P = .06) before the initiation of CRET. However, following CRET, patients in the elderly cohort demonstrated significant improvements in estimated aerobic capacity (+32%; P < .0001), peak VO2
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(+13%; P < .0001), anaerobic threshold (+11%; P = .03), total function scores (+27%; P < .0001), and total QoL scores (+20%; P 70 years of age. This suggests that CR programs may help reduce anxiety in
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selected patients and potentially benefit CV health (Figure 3).
There is also evidence that CR may improve cognitive function among older individuals with CHD.
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Following a 12-week CR program, CHD patients exhibited improvements in multiple cognitive domains including global cognition, attention-executive-psychomotor function, and memory, suggesting that
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cognitive function may be favorably modified by exercise interventions in this population.31 Similar improvements were also reported in another study that included inactive older adults with cognitive challenges. Following a 12-week regimen of physical conditioning plus mental activity, significant
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increases in global cognitive function were noted among the participants.32
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Obesity
The “obesity paradox” is a counterintuitive observation whereby obese individuals with CHD or heart
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failure (HF) have a more favorable prognosis than their leaner counterparts.33,34 Among elderly individuals, this paradoxical effect has been observed even among those without CVD,35 with certain
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exceptions, such as elderly patients with abnormal left ventricular geometry and preserved systolic function.36 Currently, few data are available regarding the beneficial effects of weight loss programs among the elderly. Nevertheless, the benefits of formal CRET programs on obesity indices have been reported,37 including subsets of elderly patients.38-41 Despite the obesity paradox, gradual weight loss in a controlled setting , especially when combined with ET, improvements in CRF and without the loss of valuable lean muscle mass,with proper dietary modification and ET are likely to benefit elderly obese patients with CHD.
CRET and Mortality Perhaps the most widely-reported impact of formal CRET programs is on mortality among patients with CHD. Numerous studies over the last decade have substantiated the associated mortality reduction with participation in CRET. Regular exercise participation can decrease the risk of initial and recurrent CV
ACCEPTED MANUSCRIPT events, presumably from multiple mechanisms, including antiatherosclerotic, anti-ischemic, antiarrhythmic, antithrombotic, and psychological effects. Because > 40% of the CV risk reduction associated with exercise cannot be explained by changes in conventional risk factors, a cardioprotective
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“vascular conditioning” effect has been proposed, including enhanced nitric oxide vasodilator function,
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improved vascular reactivity, altered vascular structure, or combinations thereof.42 Decreased vulnerability to threatening ventricular arrhythmias and increased resistance to ventricular fibrillation have also been postulated to reflect exercise-related adaptations in autonomic control, including reduced
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sympathetic drive and increased vagal tone. Among patients with stable ischemic heart disease, each 1MET increase in exercise capacity is associated with an 8% to 35% (median, 16%) reduction in mortality,
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which compares favorably with the survival benefit conferred by low-dose aspirin, statins, beta-blockers, and angiotensin-converting enzyme inhibitors after acute MI.43 Accordingly, formal CRET programs are
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now widely recognized as an invaluable resource in the treatment armamentarium for secondary
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prevention.
Suaya et al3 evaluated 601,099 US Medicare beneficiaries who were hospitalized for acute
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coronary syndrome or for coronary revascularization procedures. Mortality rates were examined in CR users and nonusers. Only 12.2% of eligible patients participated in CR. Patients who
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participated in ≥ 25 sessions demonstrated a 19% decrease in mortality over 5 years when compared with CR users who attended ≤ 24 sessions (P < .001); overall, CR users demonstrated
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a 21% to 34% decrease in mortality compared with CR non-users. More importantly, mortality reductions with CR participation increased progressively with older age (P < .001 for 75 to 84 years and P < .013 for 85 years and older) when compared with individuals aged 65 to 74 years.
A recent study examined 30,161 elderly patients who attended ≥ 1 CRET session over a 5-year period.39 Patients who attended 36 sessions had a 14% lower risk of death (HR = 0.86) and a 12% lower risk of MI (HR = 0.88) when compared with those who attended ≤ 24 sessions. Moreover, patients who attended 36 sessions had a 22% lower risk of death (HR = 0.78) and a 23% lower risk of MI (HR = 0.77) when compared to those who attended ≤ 12 sessions, and a 47% lower risk of death (HR = 0.53) and a 31% lower risk of MI (HR = 0.69) than those who attended only 1 session. It remains unclear, however, whether the poorer outcomes in non-compliers were due to the lack of participation in CRET or to
ACCEPTED MANUSCRIPT extraneous factors (eg, clinical deterioration) that precluded their continued adherence, as well as
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potentially selection bias in those who are more compliant.
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Underutilization of CRET in the Elderly
Despite the beneficial effects of CR programs on clinical outcomes in patients with CHD, there are
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numerous variables associated with decreased program compliance in all eligible patients, with a reported overall participation rate < 30%.40 Contributing factors may include limited or no encouragement by physicians to participate in CR, and suboptimal referral patterns, especially among women, non-whites,
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elderly, rural inhabitants, and patients of lower socioeconomic status.41
Suaya et al42 evaluated outpatient CRET use post-hospitalization for acute MI or CABG surgery in 267,427 Medicare beneficiaries aged ≥ 65 who survived for a minimum of 30 days after hospital
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discharge. CRET was utilized in only 13.9% of the acute MI patients and 31.0% of the patients who underwent CABG surgery. Furthermore, only 13% of individuals >80 years participated in CRET. 43 In
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fact, older adults are between 1.5 and 2.0 times less likely to enter a CR program compared to younger adults.17 Older individuals, including older women and non-whites, and patients with varied comorbid
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conditions (including HF, previous stroke, diabetes mellitus, or cancer) were significantly less likely to undergo CRET. Other studies have reported that patients > 65 years of age have low CRET participation
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rates.44, 45
In addition to referral, the fervor of the physicians’ recommendation plays a critical role in patient participation in and adherence to CR programs.46,47 In general, older individuals have decreased odds of being referred to CR, and are subsequently less likely to attend. 48, 49 Unfortunately, many older, eligible cardiac patients are oftentimes not strongly encouraged to attend formal or structured secondary prevention programs.50, 51 In addition to this, the type of medical provider that refers patients to CR programs also plays an integral modulating role in participation and attendance. Patients under the care of a cardiologist or cardiac surgeon are more likely to participate in CR programs as compared with those who are predominantly cared for by a primary care physician.52 Older individuals are also less likely to be aware of CR and have a poorer understanding of what to expect at these programs.53 Other factors such as inconvenience,53 limited understanding of the disease process,54,55 inadequate transportation,56,57 and caregiver responsibilities at home58 also contribute to low CR participation rates. Older patients are also
ACCEPTED MANUSCRIPT more likely to cite existing health problems as a deterrent to CR participation. Compared to their younger counterparts, they are more likely to suffer from chronic problems such as diabetes, heart failure, angina, and arthritis that may cause shortness of breath, limited mobility, and other symptoms that may
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dissuade them from attending these programs.59 Inaccessible programs, high copayments, and escalating
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responsibilities of older women in caring for their infirmed spouses are especially common impediments
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to participation in exercise-based CR.57,60
Efforts should be made to routinely increase referral and encouragement to attend CR programs among
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older patients. This subgroup population should be made aware of the various physiological and psychological benefits observed with CR. Simplifying referrals and ‘automatic’ enrollment into these
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programs may also streamline the process. Furthermore, tailoring CR programs to cater to elderly
Safety of CRET in the Elderly
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patients with chronic medical conditions may also help increase participation rates.
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Concerns regarding the safety of exercised-based CR programs among elderly patients may serve to diminish referral and participation rates. Moderate-to-vigorous exercise after an acute CV event or revascularization procedure is probably safer than many patients and referring physicians realize. Van
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Camp et al61 surveyed fatal and nonfatal CV complications resulting in 167 CRET programs that included 51,303 patients with a total of 2,351,916 exercise hours. Over the four-year period, they observed 21
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cardiac arrests and 8 non-fatal MI’s. There were 8.9 cardiac arrests, 3.4 MI’s, and 1.3 fatalities per 1 million patient hours of exercise suggesting that the risk of CV complications, although present, was extremely low. Additionally, these data were obtained before the era of aggressive medical therapy and coronary revascularization after an acute CV event, as well as implanted cardioverter defibrillators, suggesting a higher level of safety for CRET among contemporary CHD patients. Others have reported no significantly higher CV event rate among elderly patients during CRET.62-64 Unfortunately, there have been no large studies that have specifically evaluated the absolute and relative complication rates of CRET programs among the elderly. Nevertheless, there is no evidence to suggest an increased risk of adverse CV events among elderly individuals that have been properly screened and supervised during CRET.
Conclusion
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PS, inflammation, conventional CV risk factors, obesity indices, and mortality. It appears that the
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decreased participation of elderly patients in formal CR programs can be attributed to multiple reasons. Improved efforts are needed to refer and encourage eligible patients to attend and complete these programs, as well as to increase PA in general in the population, particularly in the elderly. 65 These data
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should help to clarify the benefits, risks, and limitations of exercise-based CR for elderly individuals. As the population ages, an increasing proportion of inactive, low-fit adults aged 85 years and older will be
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CR candidates, a cohort that appear to be the primary beneficiary of an exercise intervention.66 Specific processes of care (both in regard to exercise and broader CR goals) can likely be refined and better
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facilitated to respond to our aging population of vulnerable elders.
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58. Arena R, Williams M, Forman DE, et al. Increasing referral and participation rates to outpatient cardiac rehabilitation: the valuable role of healthcare professionals in the inpatient and home health settings: a science advisory from the American Heart Association. Circulation. 2012;125(10):1321-1329.
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59. Farley RL, Wade TD, Birchmore L: Factors influencing attendance at cardiac rehabilitation among coronary heart disease patients. Eur J Cardiovasc Nurs 2003;2:205-212. 60. Gallagher R, McKinley S, Dracup K: Predictors of women's attendance at cardiac rehabilitation programs. Prog Cardiovasc Nurs 2003;18:121-126.
61. Van Camp SP, Peterson RA: Cardiovascular complications of outpatient cardiac rehabilitation programs. JAMA. 1986;256(9):1160-1163. 62. 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. 63. Milani RV, Lavie CJ, Spiva H: Limitations of estimating metabolic equivalents in exercise assessment in patients with coronary artery disease. Am J Cardiol 1995;75:940–942.
ACCEPTED MANUSCRIPT 64. Milani RV, Lavie CJ, Mehra MR, et al: Impact of exercise training and depression on survival in heart failure due to coronary heart disease. Am J Cardiol 2011;107:64–68.
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65. Vuori IM , Lavie CJ, Blair SN. Physical activity promotion in the health care system. Mayo Clin Proc 2013;88:1446-1461.
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66. Franklin BA, Lavie CJ, Squires RW, Milani RV: Exercise-based cardiac rehabilitation and improvements in cardiorespiratory fitness: Implications regarding patient benefit. Mayo Clin Proc 2013;88:431-437.
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Figure Legend
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1) Multiple mechanisms by which moderate-to-vigorous exercise training may reduce the risk for nonfatal and fatal cardiovascular events. BP = blood pressure; EPCs = endothelial progenitor cells; CACs = cultured/circulating angiogenic cells; ↑ = increased; ↓ = decreased; O2 = oxygen. *Nitric oxide also has antithrombotic effects. 2) Important mediators of autonomic tone and CV risk. Adapted from: Menezes AR, Lavie CJ, Milani RV, et al (4). J Geriatr Cardiol. 2012;9:68-75
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3) Prevalence of psychological risk factors among elderly patients with coronary heart disease (CHD) before and after cardiac rehabilitation (CR). (n= 260, mean age 75±3 years). Adapted from Lavie CJ, Milani RV (30). Arch Intern Med 2006;166:1878– 1883.
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S0033-0620(14)00006-1 doi: 10.1016/j.pcad.2014.01.002 YPCAD 574
To appear in:
Progress in Cardiovascular Diseases
Please cite this article as: Menezes Arthur R., Lavie Carl J., Forman Daniel E., Arena Ross, Milani Richard V., Franklin Barry A., Cardiac Rehabilitation in the Elderly, Progress in Cardiovascular Diseases (2014), doi: 10.1016/j.pcad.2014.01.002
This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT Cardiac Rehabilitation in the Elderly
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Arthur R. Menezes, MD*, Carl J. Lavie, MD*#, Daniel E. Forman, M.D. ^, Ross Arena, PhD, PT, Richard V. Milani, MD*, Barry A. Franklin, PhD
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*Department of Cardiovascular Diseases, John Ochsner Heart and Vascular Institute Ochsner Clinical School- The University of Queensland School of Medicine
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#From the Department of Preventive Cardiology, Pennington Biomedical Research Center, Louisiana State University System, Baton Rouge, Louisiana
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^Division of Cardiovascular Medicine, Brigham and Women’s Hospital; New England Geriatric Research, Education, and Clinical Center, VA Boston Healthcare System
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Department of Physical Therapy and Integrative Physiology Laboratory, College of Applied Health Sciences, University of Illinois Chicago, Chicago, Illinois
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Department of Preventive Cardiology and Rehabilitation, William Beaumont Hospital, Royal Oak, MI
Corresponding author: Carl J. Lavie, M.D., FACC, FACP, FCCP Medical Director, Cardiac Rehabilitation and Prevention Director, Exercise Laboratories John Ochsner Heart and Vascular InstituteOchsner Clinical School-The University of Queensland School of Medicine1514 Jefferson Highway New Orleans, LA 70121-2483 (504) 842-5874 Phone (504) 842-5875 Fax Email: [email protected] Abbreviation List
ACCEPTED MANUSCRIPT BMI: Body Mass Index CABG: Coronary Artery Bypass Graft
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CHD: Coronary Heart Disease
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CR: Cardiac Rehabilitation CRET: Cardiac Rehabilitation Exercise Training
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CRF: Cardiorespiratory Fitness CRP: C-reactive Protien
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CV: Cardiovascular CVD: Cardiovascular Disease
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ET: Exercise Training HF: Heart Failure
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HR: Hazard Ratio
MI: Myocardial Infarction
OR: Odds Ratio
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PA:Physical Activity
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PS: Psychological Stress
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MET: Metabolic Equivalent
RT: Resistance Training US: United States
VO2: Oxygen Consumption
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Abstract
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Coronary heart disease (CHD) is the leading cause of death worldwide. Advanced age is associated with
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a higher prevalence of CHD as well as increased morbidity and mortality. One key vulnerability relates to the fact that older individuals are generally among the least fit, least active cohort and at increased risk of complications after an acute cardiac event and/or major surgery. There is ample evidence to
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demonstrate the beneficial effects of exercised-based cardiac rehabilitation (CR) programs on improving functional capacity and other indices of cardiovascular (CV) health. Although the predominant number
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of studies are in middle-aged patients, there is an escalating amount of new information that establishes the cardioprotective role of CR and, in particular, structured exercise therapy (ET) among the elderly. The present review summarizes the current data available regarding CR and ET and its salutary impact on
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today’s growing population of older adults with CHD.
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Introduction Over the past century we have witnessed an exponential increase in the elderly population in the United
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States (US). Average life expectancy has dramatically increased from 50 years of age in the early 1900’s
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to almost 80 years in 2008.1,2 Nevertheless, coronary heart disease (CHD) remains the leading cause of death worldwide. In fact, 86% of all CHD related deaths in the US were among individuals aged 65 and
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older.3
Prior to an initial cardiovascular (CV) event, elderly patients are generally more deconditioned and less fit
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compared to their younger counterparts, with accelerated deconditioning once CHD is established.4 Similarly, elderly patients are typically at a higher risk of complications from myocardial infarction (MI)
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and coronary revascularization procedures compared to their younger counterparts, leading to prolonged hospital stays and greater vulnerability to subsequent clinical sequelae and deconditioning.5 Due to the many demonstrated benefits of formal cardiac rehabilitation (CR) and exercise training (ET) or CRET
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programs on morbidity and mortality, elderly patients would almost certainly benefit from these interventions. Numerous studies have established the beneficial role of CR, regular ET, lifestyle physical
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activity (PA), and the maintenance or enhancement of cardiorespiratory fitness (CRF) on both the primary and secondary prevention of CHD among the general population,6 including elderly patients. the last decade.7
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Consequently, the use and safety of CRET among older patients has gained increasing acceptance over
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There are multiple studies substantiating the benefits of CRET on a number of physiologic parameters and clinical factors including exercise capacity or CRF, inflammation, pre-diabetic or diabetic glucose control, autonomic function, behavioral characteristics, quality of life (QoL), hospitalization costs, and CHD morbidity and mortality after a major CV event (Figure 1).8 Most older patients with CHD also have varied co-morbid conditions, making CR particularly useful as an opportunity to address the interplay of relevant clinical indices and medications. However, despite escalating evidence substantiating the benefits of CRET, this form of treatment remains underutilized among all CHD patients, including older adults.9
This review summarizes selected studies involving CRET, with specific reference to older adults. The information was obtained by reviewing randomized clinical trials, many large observational studies, as well as appropriate review articles and editorials. Finally, we will discuss some of the current barriers to CRET referral and participation by the elderly.
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Aerobic capacity Aerobic capacity or CRF is the highest volume of somatic oxygen consumed per minute at peak or
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maximum physical exertion,10 synergistically utilizing the CV, pulmonary, and skeletal muscle systems.
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One of the most significant benefits of formal CRET, irrespective of age, sex, or body composition, is the increase in aerobic capacity, which is strongly associated with improved survival and prognosis.11 Especially noteworthy is the fact that elderly patients demonstrate greater relative improvements in
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aerobic capacity as compared with their younger counterparts following CRET.12
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One of the initial studies on ET in an elderly cohort with CHD was published in 1985.13 The goal was to evaluate the potential benefits of early exercise programs on young, middle-aged, and elderly CHD
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patients after an acute MI or coronary artery bypass grafting (CABG). The study population included 361 patients who were categorized into 1 of 4 groups based on age. Group I included 60 patients aged ≤ 44 years; group II included 114 patients aged 45 to 54 years of age; group III included 111 patients aged 55
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to 64 years; and group IV included 76 patients aged ≥ 65 years. All patients participated in a 12-week ET program within 6 weeks of acute MI or CABG. The patients aged ≥ 65 years demonstrated significant
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increases in maximal heart rate (126 to 138 beats/minute) and peak metabolic equivalents (METs; 5.3 to 8.1 METs), a surrogate measure of aerobic capacity, as well as other physiologic and clinical
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improvements. Compared to the other groups, these patients also demonstrated similar improvements in body weight, percent body fat, resting heart rate, maximal heart rate, submaximal double product, and submaximal average rating of perceived exertion. However, the elderly had significantly lower absolute
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work capacity after training when equated to groups I-III. Ades et al14 evaluated the impact of resistance training (RT) in disabled older women (≥ 65 years of age) with CHD. Control patients performed light yoga and breathing exercises whereas study participants engaged in a 6-month RT program. The RT group demonstrated statistically significant improvements in physical work capacity over a wide range of household PA that extended beyond strength-related activities such as endurance, balance, coordination, and flexibility. In a similar patient population, RT led to improved measures for upper and lower body strength, endurance, balance and coordination, and 6-min walk performance.15
Among elderly persons with and without CHD, RT appears to promote beneficial effects on muscular strength and endurance, which should enhance the ability to perform activities of daily living. This was
ACCEPTED MANUSCRIPT observed in a study that evaluated the effect of RT on walking endurance among healthy, community dwelling elderly individuals (≥ 65 years of age). Although there was a noticeable increase in leg strength, participants in the RT group also demonstrated a 38% increase in submaximal walking
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endurance (P = .001), whereas the control group remained unchanged.16
Lavie and Milani17 highlighted the therapeutic importance of referring all eligible patients to CR
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programs, irrespective of age. The study population included 92 patients > 65 years and 182 patients < 65 years who were enrolled in phase II CRET after a major CHD event. Elderly patients had lower baseline estimated peak METs (5.6 ± 1.6 vs. 7.7 ± 3.0, P < .0001) when compared with their younger counterparts.
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However, after CRET, older patients showed significant increases in peak METs (5.6 ± 1.6 vs. 7.5 ± 2.3, P < .0001). Moreover, both older and younger individuals demonstrated statistically similar
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improvements in functional capacity, percent body fat, body mass index (BMI), and lipid profiles.
In another age-related study, 125 younger patients (< 55 years) and 57 elderly CHD patients (> 70 years)
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were evaluated to assess the impact of formal CRET programs on cardiopulmonary variables and QoL scores.18 Similar to the aforementioned study, elderly patients had a lower estimated aerobic capacity (-
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27%; P < .001), directly measured peak oxygen consumption (VO2) (-19%; P < .01) and anaerobic threshold (-10%; P < .05), total function scores (-11%; P < .01) and a trend toward lower total QoL scores
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(-5%; P = .06) before the initiation of CRET. However, following CRET, patients in the elderly cohort demonstrated significant improvements in estimated aerobic capacity (+32%; P < .0001), peak VO2
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(+13%; P < .0001), anaerobic threshold (+11%; P = .03), total function scores (+27%; P < .0001), and total QoL scores (+20%; P 70 years of age. This suggests that CR programs may help reduce anxiety in
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selected patients and potentially benefit CV health (Figure 3).
There is also evidence that CR may improve cognitive function among older individuals with CHD.
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Following a 12-week CR program, CHD patients exhibited improvements in multiple cognitive domains including global cognition, attention-executive-psychomotor function, and memory, suggesting that
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cognitive function may be favorably modified by exercise interventions in this population.31 Similar improvements were also reported in another study that included inactive older adults with cognitive challenges. Following a 12-week regimen of physical conditioning plus mental activity, significant
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increases in global cognitive function were noted among the participants.32
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Obesity
The “obesity paradox” is a counterintuitive observation whereby obese individuals with CHD or heart
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failure (HF) have a more favorable prognosis than their leaner counterparts.33,34 Among elderly individuals, this paradoxical effect has been observed even among those without CVD,35 with certain
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exceptions, such as elderly patients with abnormal left ventricular geometry and preserved systolic function.36 Currently, few data are available regarding the beneficial effects of weight loss programs among the elderly. Nevertheless, the benefits of formal CRET programs on obesity indices have been reported,37 including subsets of elderly patients.38-41 Despite the obesity paradox, gradual weight loss in a controlled setting , especially when combined with ET, improvements in CRF and without the loss of valuable lean muscle mass,with proper dietary modification and ET are likely to benefit elderly obese patients with CHD.
CRET and Mortality Perhaps the most widely-reported impact of formal CRET programs is on mortality among patients with CHD. Numerous studies over the last decade have substantiated the associated mortality reduction with participation in CRET. Regular exercise participation can decrease the risk of initial and recurrent CV
ACCEPTED MANUSCRIPT events, presumably from multiple mechanisms, including antiatherosclerotic, anti-ischemic, antiarrhythmic, antithrombotic, and psychological effects. Because > 40% of the CV risk reduction associated with exercise cannot be explained by changes in conventional risk factors, a cardioprotective
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“vascular conditioning” effect has been proposed, including enhanced nitric oxide vasodilator function,
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improved vascular reactivity, altered vascular structure, or combinations thereof.42 Decreased vulnerability to threatening ventricular arrhythmias and increased resistance to ventricular fibrillation have also been postulated to reflect exercise-related adaptations in autonomic control, including reduced
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sympathetic drive and increased vagal tone. Among patients with stable ischemic heart disease, each 1MET increase in exercise capacity is associated with an 8% to 35% (median, 16%) reduction in mortality,
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which compares favorably with the survival benefit conferred by low-dose aspirin, statins, beta-blockers, and angiotensin-converting enzyme inhibitors after acute MI.43 Accordingly, formal CRET programs are
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now widely recognized as an invaluable resource in the treatment armamentarium for secondary
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prevention.
Suaya et al3 evaluated 601,099 US Medicare beneficiaries who were hospitalized for acute
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coronary syndrome or for coronary revascularization procedures. Mortality rates were examined in CR users and nonusers. Only 12.2% of eligible patients participated in CR. Patients who
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participated in ≥ 25 sessions demonstrated a 19% decrease in mortality over 5 years when compared with CR users who attended ≤ 24 sessions (P < .001); overall, CR users demonstrated
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a 21% to 34% decrease in mortality compared with CR non-users. More importantly, mortality reductions with CR participation increased progressively with older age (P < .001 for 75 to 84 years and P < .013 for 85 years and older) when compared with individuals aged 65 to 74 years.
A recent study examined 30,161 elderly patients who attended ≥ 1 CRET session over a 5-year period.39 Patients who attended 36 sessions had a 14% lower risk of death (HR = 0.86) and a 12% lower risk of MI (HR = 0.88) when compared with those who attended ≤ 24 sessions. Moreover, patients who attended 36 sessions had a 22% lower risk of death (HR = 0.78) and a 23% lower risk of MI (HR = 0.77) when compared to those who attended ≤ 12 sessions, and a 47% lower risk of death (HR = 0.53) and a 31% lower risk of MI (HR = 0.69) than those who attended only 1 session. It remains unclear, however, whether the poorer outcomes in non-compliers were due to the lack of participation in CRET or to
ACCEPTED MANUSCRIPT extraneous factors (eg, clinical deterioration) that precluded their continued adherence, as well as
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potentially selection bias in those who are more compliant.
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Underutilization of CRET in the Elderly
Despite the beneficial effects of CR programs on clinical outcomes in patients with CHD, there are
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numerous variables associated with decreased program compliance in all eligible patients, with a reported overall participation rate < 30%.40 Contributing factors may include limited or no encouragement by physicians to participate in CR, and suboptimal referral patterns, especially among women, non-whites,
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elderly, rural inhabitants, and patients of lower socioeconomic status.41
Suaya et al42 evaluated outpatient CRET use post-hospitalization for acute MI or CABG surgery in 267,427 Medicare beneficiaries aged ≥ 65 who survived for a minimum of 30 days after hospital
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discharge. CRET was utilized in only 13.9% of the acute MI patients and 31.0% of the patients who underwent CABG surgery. Furthermore, only 13% of individuals >80 years participated in CRET. 43 In
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fact, older adults are between 1.5 and 2.0 times less likely to enter a CR program compared to younger adults.17 Older individuals, including older women and non-whites, and patients with varied comorbid
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conditions (including HF, previous stroke, diabetes mellitus, or cancer) were significantly less likely to undergo CRET. Other studies have reported that patients > 65 years of age have low CRET participation
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rates.44, 45
In addition to referral, the fervor of the physicians’ recommendation plays a critical role in patient participation in and adherence to CR programs.46,47 In general, older individuals have decreased odds of being referred to CR, and are subsequently less likely to attend. 48, 49 Unfortunately, many older, eligible cardiac patients are oftentimes not strongly encouraged to attend formal or structured secondary prevention programs.50, 51 In addition to this, the type of medical provider that refers patients to CR programs also plays an integral modulating role in participation and attendance. Patients under the care of a cardiologist or cardiac surgeon are more likely to participate in CR programs as compared with those who are predominantly cared for by a primary care physician.52 Older individuals are also less likely to be aware of CR and have a poorer understanding of what to expect at these programs.53 Other factors such as inconvenience,53 limited understanding of the disease process,54,55 inadequate transportation,56,57 and caregiver responsibilities at home58 also contribute to low CR participation rates. Older patients are also
ACCEPTED MANUSCRIPT more likely to cite existing health problems as a deterrent to CR participation. Compared to their younger counterparts, they are more likely to suffer from chronic problems such as diabetes, heart failure, angina, and arthritis that may cause shortness of breath, limited mobility, and other symptoms that may
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dissuade them from attending these programs.59 Inaccessible programs, high copayments, and escalating
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responsibilities of older women in caring for their infirmed spouses are especially common impediments
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to participation in exercise-based CR.57,60
Efforts should be made to routinely increase referral and encouragement to attend CR programs among
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older patients. This subgroup population should be made aware of the various physiological and psychological benefits observed with CR. Simplifying referrals and ‘automatic’ enrollment into these
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programs may also streamline the process. Furthermore, tailoring CR programs to cater to elderly
Safety of CRET in the Elderly
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patients with chronic medical conditions may also help increase participation rates.
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Concerns regarding the safety of exercised-based CR programs among elderly patients may serve to diminish referral and participation rates. Moderate-to-vigorous exercise after an acute CV event or revascularization procedure is probably safer than many patients and referring physicians realize. Van
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Camp et al61 surveyed fatal and nonfatal CV complications resulting in 167 CRET programs that included 51,303 patients with a total of 2,351,916 exercise hours. Over the four-year period, they observed 21
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cardiac arrests and 8 non-fatal MI’s. There were 8.9 cardiac arrests, 3.4 MI’s, and 1.3 fatalities per 1 million patient hours of exercise suggesting that the risk of CV complications, although present, was extremely low. Additionally, these data were obtained before the era of aggressive medical therapy and coronary revascularization after an acute CV event, as well as implanted cardioverter defibrillators, suggesting a higher level of safety for CRET among contemporary CHD patients. Others have reported no significantly higher CV event rate among elderly patients during CRET.62-64 Unfortunately, there have been no large studies that have specifically evaluated the absolute and relative complication rates of CRET programs among the elderly. Nevertheless, there is no evidence to suggest an increased risk of adverse CV events among elderly individuals that have been properly screened and supervised during CRET.
Conclusion
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PS, inflammation, conventional CV risk factors, obesity indices, and mortality. It appears that the
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decreased participation of elderly patients in formal CR programs can be attributed to multiple reasons. Improved efforts are needed to refer and encourage eligible patients to attend and complete these programs, as well as to increase PA in general in the population, particularly in the elderly. 65 These data
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should help to clarify the benefits, risks, and limitations of exercise-based CR for elderly individuals. As the population ages, an increasing proportion of inactive, low-fit adults aged 85 years and older will be
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CR candidates, a cohort that appear to be the primary beneficiary of an exercise intervention.66 Specific processes of care (both in regard to exercise and broader CR goals) can likely be refined and better
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facilitated to respond to our aging population of vulnerable elders.
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53. Ramm C, Robinson S, Sharpe N: Factors determining non-attendance at a cardiac rehabilitation programme following myocardial infarction. N Z Med J 2001;114(1132):227229.
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ACCEPTED MANUSCRIPT 64. Milani RV, Lavie CJ, Mehra MR, et al: Impact of exercise training and depression on survival in heart failure due to coronary heart disease. Am J Cardiol 2011;107:64–68.
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65. Vuori IM , Lavie CJ, Blair SN. Physical activity promotion in the health care system. Mayo Clin Proc 2013;88:1446-1461.
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66. Franklin BA, Lavie CJ, Squires RW, Milani RV: Exercise-based cardiac rehabilitation and improvements in cardiorespiratory fitness: Implications regarding patient benefit. Mayo Clin Proc 2013;88:431-437.
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1) Multiple mechanisms by which moderate-to-vigorous exercise training may reduce the risk for nonfatal and fatal cardiovascular events. BP = blood pressure; EPCs = endothelial progenitor cells; CACs = cultured/circulating angiogenic cells; ↑ = increased; ↓ = decreased; O2 = oxygen. *Nitric oxide also has antithrombotic effects. 2) Important mediators of autonomic tone and CV risk. Adapted from: Menezes AR, Lavie CJ, Milani RV, et al (4). J Geriatr Cardiol. 2012;9:68-75
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3) Prevalence of psychological risk factors among elderly patients with coronary heart disease (CHD) before and after cardiac rehabilitation (CR). (n= 260, mean age 75±3 years). Adapted from Lavie CJ, Milani RV (30). Arch Intern Med 2006;166:1878– 1883.
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