Volume Number
18. 19.
20.
21.
120 3
Doppler-assessed
measurement of flow velocity in the ascending aorta during supine and upright exercise. Br Heart J 1985;54:562-7. Rushmer RF. Constancy of stroke volume in ventricular responses to exertion. Am J Physiol 1959;196:745-50. Bevilacqua M, Savonitto S, Bosisio E, Chebat E, Bertora PG, Sardina M, Norbiato G. Role of the Frank-Starling mechanism in maintaining cardiac output during increasing levels of treadmill exercise in beta-blocked normal men. Am J Cardiol 1989;63:853-7. Higginbotham MB, Morris KG, Williams RS, McHale PA, Coleman RE. Cobb FR. Regulation of stroke volume during submaximal and maximal upright exercise in normal man. Circ Res 1986;58:281-91. Christie J, Sheldahl LM, Tristani FE, Sagar KB, Ptacin MJ, Wann S. Determination of stroke volume and cardiac output during exercise: comparison of two-dimensional and Doppler echocardiography, Fick oximetry, and thermodilution. Circulation 1987;76:539-47.
Cardiopulmonary after conditioning
exercise hemodynamics
22. Ekblom B, Goldbarg AN, Kilbom ASA, Astrand PO. Effects of atropine and propranolol on the oxygen transport system during exercise in man. Stand J Clin Lab Invest 1972;30:3542. 23. Poliner LR, Dehmer GJ, Lewis SE, Parkey RW, Blomquist CG, Willerson JT. Left ventricular performance in normal subjects: a comparison of the responses to exercise in the upright and supine positions. Circulation 1980;62:528-34. 24. Bowditch HP. Uber die Eigenthumlichkeiten der Reizarbeit, welche die Muskelfasern des Herzens zeigen. Ber Verh der Koniglich Sachsischen ges Wissenschaften zu Leipzig. 1871; 23:652. 25. Rerych SK, Scholz PM, Sabiston DC, Jones RH. Effects of exercise training on left ventricular function in normal subjects: a longitudinal study by radionuclide angiography. Am J Cardiol 1980;45:244-52.
exercise testing before and in older coronary patients
Cardiac rehabilitation has been demonstrated to improve aerobic capacity in young and middle-aged coronary patients. The effect of an aerobic conditioning program on cardiopulmonary markers of fitness was assessed in 22 older patients (mean age 66 years) following a coronary event compared with 37 younger patients (mean age 52 years). Before conditioning, peak oxygen consumption was lower in the older patients, 16.9 versus 24.3 cm3/kg/min (p < O.OOl), as was exercise duration and maximal ventilation. Older coronary patients were more likely to stop exercise at a respiratory equivalent ratio of 3mm ST segmentdepression). Patients then entered a 12-week,3-hour per weekprotocol of telemetry-monitored treadmill and stationary bicycle exercisewith intensity levels guided by exerciseheart rate, which waskept at 75% to 85% of maximal heart rate
ratio
= CO* production
24*
+ 02 consumption.
*p
1.00. On the other hand, the changes in peak aerobic capacity in our older patient group were impressive and certainly correlate with physiologic changes in oxygen delivery and utilization during exercise. The 62% improvement in treadmill time on a graded treadmill protocol demonstrates an increased work capacity, relevant to the performance of daily activities. Generally accepted benefits of post-myocardial infarction exercise conditioning programs, demonstrated in younger coronary patients, include a lowered overall
Volume Number
120 3
Exercise conditioningltesting
Maximal Systolic BP (mm Hd
Maximal HR X systolic BP
Pre
Post
Pre
Post
165 * 24 169 k 29
166 f 21 172 + 26
22,000 f 44,000 22,900 f 6,200
22,000 + 5,500 24,600 k 6,100
mortality rate,17-lg improved measures of psychosoin left cial well-being,20 and subtle improvements ventricular function and myocardial perfusion.21l 22 Whether these benefits extend to patients in older age groups is speculative. It is clear, however, that older patients following a cardiac event are significantly less fit than younger patients, and the improved work capacity following a supervised conditioning program effectively distances them from cardiac disability. REFERENCES
1. National Center for Health Statistics. 1986 Summary: National hospital discharge survey. Advance data from vital and health statistics. Hyattsville, Maryland: United States Public Health Service. DHHS Publication No. 145 lPHSl.1987;6:871250. 2. Satler LF, Green CE, Wallace RB, Rackley CE. Coronary arterv disease in the elderlv. Am J Cardiol 1989:63:245-B. 3. Froelicher VF, BrammeliHL, Davis G, Noguera I, Stewart A, Lancaster MO. A comparison of the reproducibility and physiologic response to three maximal treadmill exercise protocols. Chest 1974;65:512-7. 4. Tonino RP, Drisboll PA. Reliability of maximal and submaximal parameters of treadmill testing for the measurement of physical training in older persons. J Gerontol 1988;43: MlOl-4. 5. Sidney KH, Shephard RJ. Frequency and intensity of exercise training for elderly subjects. Med Sci Sports 1978;10:125-31. 6. Suominen H, Heikkinen E, Liesen H, Michel D, Hollman W. Effects of 8 weeks’ endurance training on skeletal muscle metabolism in 57-70 year-old sedentary men. Eur J Appl Physiol 1977;37:173-80. 7. deVries HA. Physiologic effects of an exercise training regimen upon men aged 52-88. J Gerontol 1970;25:325-36.
in CAD
589
8. Thomas SG, Cunningham DA, Rechnitzer PA, Donner AP, Howard JH. Determinants of the training response in elderly men. Med Sci Sports Exert 1985;17:667-72. 9. Seals DR, Hagberg JM, Hurley BF, Ehsani AA, Holloszy JO. Endurance training in older men and women. I. Cardiovascular response to exercise. J Appl Physiol 1984;57:1024-9. 10. Pomerance A. Pathology of the heart with and without cardiac failure in the aged. Br Heart J 1965;27:697-710. 11. Hellerstein HK, Franklin BA. Exercise testing and prescription. In: Wenger NK, Hellerstein HK, eds. Rehabilitation of the coronary patient. New York: John Wiley & Sons, 1984: 272-3. 12. Ades PA, Thomas JD, Hanson JS, Shapiro SM, LaMountain J. Effect of metoprolol on the submaximal stress test performed early after acute myocardial infarction. Am J Cardiol 1987;60:963-6. 13. Blood SM, Ades PA. Effects of beta-adrenergic blockade on exercise conditioning in coronary patients: a review. J Cardiopulmon Rehabilitation 1988;8:123-6. 14. Williams MA, Maresch CM, Esterbrooks DJ, Harbrecht JJ, Sketch MH. Early exercise training in patients older than age 65 years compared with that in younger patients after acute myocardial infarction or coronary artery bypass grafting. Am J Cardiol 1985;55:263-6. 15. Ades PA, Hanson JS, Gunther JGS, Tonino RP. Exercise conditioning in the elderly coronary patient. J Am Geriatr Sot 1987;35:121-4. 16. Sidney KH, Shephard RJ. Maximum and submaximum exercise tests in men and women in the seventh, eighth, and ninth decades of life. J Appl Physiol: Respir Environ Exert Physiol 1977;43:280-7. 17. May GS, Eberlein KA, Furberg CD, Passamani ER, DeMets DL. Secondary prevention after myocardial infarction: a review of long-term trials. Prog Cardiovasc Dis 1982;24,4:33152. 18. Oldridge NB, Guyall GH, Fischer ME, Rimm AA. Cardiac rehabilitation after myocardial infarction. Combined experience of randomized clinical trials. JAMA 1988;260:945-50. 19. O’Connor GT. Burine JE. Yusuf S. Goldhaber SZ. Olmstead EM, Paffenbarger RS, Hennekens’CH. An overview of randomized trials of rehabilitation with exercise after myocardial infarction. Circulation 1989;80:234-44. 20. Erdman RAM, Duivenvoorden HJ, Verhage F, Kazemier M, Hugenholtz PG. Predictability of beneficial effects in cardiac rehabilitation: a randomized clinical trial of psychosocial variables. J Cardiopulmon Rehabilitation 1986;6:206-13. 21. Ehsani AA, Biello DR, Schultz J, Sobel BE, Holloszy JO. Improvement of left ventricular contractile function by exercise training in patients with coronary artery disease. Circulation 1986;74:350-8. 22. Froelicher V, Jensen D, Genter F, Sullivan M, McKirnan MD, Witzum K, Scharg J, Strong ML, Ashburn W. A randomized trial of exercise training in patients with coronary heart disease. JAMA 1984;252:1291-7.
18. 19.
20.
21.
120 3
Doppler-assessed
measurement of flow velocity in the ascending aorta during supine and upright exercise. Br Heart J 1985;54:562-7. Rushmer RF. Constancy of stroke volume in ventricular responses to exertion. Am J Physiol 1959;196:745-50. Bevilacqua M, Savonitto S, Bosisio E, Chebat E, Bertora PG, Sardina M, Norbiato G. Role of the Frank-Starling mechanism in maintaining cardiac output during increasing levels of treadmill exercise in beta-blocked normal men. Am J Cardiol 1989;63:853-7. Higginbotham MB, Morris KG, Williams RS, McHale PA, Coleman RE. Cobb FR. Regulation of stroke volume during submaximal and maximal upright exercise in normal man. Circ Res 1986;58:281-91. Christie J, Sheldahl LM, Tristani FE, Sagar KB, Ptacin MJ, Wann S. Determination of stroke volume and cardiac output during exercise: comparison of two-dimensional and Doppler echocardiography, Fick oximetry, and thermodilution. Circulation 1987;76:539-47.
Cardiopulmonary after conditioning
exercise hemodynamics
22. Ekblom B, Goldbarg AN, Kilbom ASA, Astrand PO. Effects of atropine and propranolol on the oxygen transport system during exercise in man. Stand J Clin Lab Invest 1972;30:3542. 23. Poliner LR, Dehmer GJ, Lewis SE, Parkey RW, Blomquist CG, Willerson JT. Left ventricular performance in normal subjects: a comparison of the responses to exercise in the upright and supine positions. Circulation 1980;62:528-34. 24. Bowditch HP. Uber die Eigenthumlichkeiten der Reizarbeit, welche die Muskelfasern des Herzens zeigen. Ber Verh der Koniglich Sachsischen ges Wissenschaften zu Leipzig. 1871; 23:652. 25. Rerych SK, Scholz PM, Sabiston DC, Jones RH. Effects of exercise training on left ventricular function in normal subjects: a longitudinal study by radionuclide angiography. Am J Cardiol 1980;45:244-52.
exercise testing before and in older coronary patients
Cardiac rehabilitation has been demonstrated to improve aerobic capacity in young and middle-aged coronary patients. The effect of an aerobic conditioning program on cardiopulmonary markers of fitness was assessed in 22 older patients (mean age 66 years) following a coronary event compared with 37 younger patients (mean age 52 years). Before conditioning, peak oxygen consumption was lower in the older patients, 16.9 versus 24.3 cm3/kg/min (p < O.OOl), as was exercise duration and maximal ventilation. Older coronary patients were more likely to stop exercise at a respiratory equivalent ratio of 3mm ST segmentdepression). Patients then entered a 12-week,3-hour per weekprotocol of telemetry-monitored treadmill and stationary bicycle exercisewith intensity levels guided by exerciseheart rate, which waskept at 75% to 85% of maximal heart rate
ratio
= CO* production
24*
+ 02 consumption.
*p
1.00. On the other hand, the changes in peak aerobic capacity in our older patient group were impressive and certainly correlate with physiologic changes in oxygen delivery and utilization during exercise. The 62% improvement in treadmill time on a graded treadmill protocol demonstrates an increased work capacity, relevant to the performance of daily activities. Generally accepted benefits of post-myocardial infarction exercise conditioning programs, demonstrated in younger coronary patients, include a lowered overall
Volume Number
120 3
Exercise conditioningltesting
Maximal Systolic BP (mm Hd
Maximal HR X systolic BP
Pre
Post
Pre
Post
165 * 24 169 k 29
166 f 21 172 + 26
22,000 f 44,000 22,900 f 6,200
22,000 + 5,500 24,600 k 6,100
mortality rate,17-lg improved measures of psychosoin left cial well-being,20 and subtle improvements ventricular function and myocardial perfusion.21l 22 Whether these benefits extend to patients in older age groups is speculative. It is clear, however, that older patients following a cardiac event are significantly less fit than younger patients, and the improved work capacity following a supervised conditioning program effectively distances them from cardiac disability. REFERENCES
1. National Center for Health Statistics. 1986 Summary: National hospital discharge survey. Advance data from vital and health statistics. Hyattsville, Maryland: United States Public Health Service. DHHS Publication No. 145 lPHSl.1987;6:871250. 2. Satler LF, Green CE, Wallace RB, Rackley CE. Coronary arterv disease in the elderlv. Am J Cardiol 1989:63:245-B. 3. Froelicher VF, BrammeliHL, Davis G, Noguera I, Stewart A, Lancaster MO. A comparison of the reproducibility and physiologic response to three maximal treadmill exercise protocols. Chest 1974;65:512-7. 4. Tonino RP, Drisboll PA. Reliability of maximal and submaximal parameters of treadmill testing for the measurement of physical training in older persons. J Gerontol 1988;43: MlOl-4. 5. Sidney KH, Shephard RJ. Frequency and intensity of exercise training for elderly subjects. Med Sci Sports 1978;10:125-31. 6. Suominen H, Heikkinen E, Liesen H, Michel D, Hollman W. Effects of 8 weeks’ endurance training on skeletal muscle metabolism in 57-70 year-old sedentary men. Eur J Appl Physiol 1977;37:173-80. 7. deVries HA. Physiologic effects of an exercise training regimen upon men aged 52-88. J Gerontol 1970;25:325-36.
in CAD
589
8. Thomas SG, Cunningham DA, Rechnitzer PA, Donner AP, Howard JH. Determinants of the training response in elderly men. Med Sci Sports Exert 1985;17:667-72. 9. Seals DR, Hagberg JM, Hurley BF, Ehsani AA, Holloszy JO. Endurance training in older men and women. I. Cardiovascular response to exercise. J Appl Physiol 1984;57:1024-9. 10. Pomerance A. Pathology of the heart with and without cardiac failure in the aged. Br Heart J 1965;27:697-710. 11. Hellerstein HK, Franklin BA. Exercise testing and prescription. In: Wenger NK, Hellerstein HK, eds. Rehabilitation of the coronary patient. New York: John Wiley & Sons, 1984: 272-3. 12. Ades PA, Thomas JD, Hanson JS, Shapiro SM, LaMountain J. Effect of metoprolol on the submaximal stress test performed early after acute myocardial infarction. Am J Cardiol 1987;60:963-6. 13. Blood SM, Ades PA. Effects of beta-adrenergic blockade on exercise conditioning in coronary patients: a review. J Cardiopulmon Rehabilitation 1988;8:123-6. 14. Williams MA, Maresch CM, Esterbrooks DJ, Harbrecht JJ, Sketch MH. Early exercise training in patients older than age 65 years compared with that in younger patients after acute myocardial infarction or coronary artery bypass grafting. Am J Cardiol 1985;55:263-6. 15. Ades PA, Hanson JS, Gunther JGS, Tonino RP. Exercise conditioning in the elderly coronary patient. J Am Geriatr Sot 1987;35:121-4. 16. Sidney KH, Shephard RJ. Maximum and submaximum exercise tests in men and women in the seventh, eighth, and ninth decades of life. J Appl Physiol: Respir Environ Exert Physiol 1977;43:280-7. 17. May GS, Eberlein KA, Furberg CD, Passamani ER, DeMets DL. Secondary prevention after myocardial infarction: a review of long-term trials. Prog Cardiovasc Dis 1982;24,4:33152. 18. Oldridge NB, Guyall GH, Fischer ME, Rimm AA. Cardiac rehabilitation after myocardial infarction. Combined experience of randomized clinical trials. JAMA 1988;260:945-50. 19. O’Connor GT. Burine JE. Yusuf S. Goldhaber SZ. Olmstead EM, Paffenbarger RS, Hennekens’CH. An overview of randomized trials of rehabilitation with exercise after myocardial infarction. Circulation 1989;80:234-44. 20. Erdman RAM, Duivenvoorden HJ, Verhage F, Kazemier M, Hugenholtz PG. Predictability of beneficial effects in cardiac rehabilitation: a randomized clinical trial of psychosocial variables. J Cardiopulmon Rehabilitation 1986;6:206-13. 21. Ehsani AA, Biello DR, Schultz J, Sobel BE, Holloszy JO. Improvement of left ventricular contractile function by exercise training in patients with coronary artery disease. Circulation 1986;74:350-8. 22. Froelicher V, Jensen D, Genter F, Sullivan M, McKirnan MD, Witzum K, Scharg J, Strong ML, Ashburn W. A randomized trial of exercise training in patients with coronary heart disease. JAMA 1984;252:1291-7.
