Cardiac rehabilitation in the elderly: patient selection and outcomes

In Western countries, the aging and improving survival of patients with coronary heart disease are responsible for an increasing number of older adults (65 years of age and older) who are eligible for cardiac rehabilitation. The elderly with coronary heart disease represent a special population with changes induced by aging and lifestyle, comorbidity, cognitive dysfunction, and high risk of disability. Although the elderly account for the majority of cardiac admissions and procedures, studies on cardiac rehabilitation have traditionally focused on younger patients. In aged experimental animals, there is evidence that exercise training is able to improve hemodynamic parameters and biologic markers. Moreover, in older patients, exercise improves functional capacity and reduces myocardial work, similar to that seen in younger patients. As for younger patients, cardiac rehabilitation requires a multidisciplinary approach, including comprehensive assessment, treatment of risk factors and comorbidity, and psychosocial assessment. Cardiac rehabilitation is safe and helpful for elderly coronary patients. Physicians must be encouraged to prescribe cardiac rehabilitation programs for the elderly following major coronary events and coronary revascularization procedures.     

抗阻运动对老年心脏康复作用的研究进展

心血管疾病已成为我国居民致残致死的首要病因,心脏康复对心血管疾病患者十分重要,可以提高生活质量、运动能力和体力活动能力,降低再住院率和病死率。抗阻运动是心脏康复的重要组成部分,可以提高肌肉力量、耐力和身体活动能力。本综述旨在总结抗阻运动对老年人群心脏康复的作用,为更好的改善老年心血管病患者的预后提供帮助。     

Exercise therapy for older persons with cardiovascular disease

Cardiac rehabilitation with exercise training after myocardial infarction in persons younger than 70 years has been found to cause a significant decrease in all-cause mortality, cardiovascular mortality, and fatal reinfarction, but no significant difference in nonfatal reinfarction. After myocardial infarction or coronary revascularization in older individuals, such programs significantly improve physical work capacity, body mass index, percent body fat, serum lipids, behavioral characteristics, and quality of life. Exercise modalities should include aerobic, resistance, and flexibility exercises. Less intense exercise of longer duration should be performed by older persons with coronary artery disease. Exercise training programs in patients with congestive heart failure produce significant improvement in peak oxygen consumption, exercise duration, and power output. The benefits of exercise training in patients with congestive heart failure may be due to an increase in cardiac output, an improvement in skeletal muscle metabolism, and an increase in peak blood flow to the exercising limb caused by a reduction in vascular resistance.     

Exercise-based cardiac rehabilitation for very old patients (> or =75 years): focus on physical function

Older patients have high rates of physical function impairment and disability following a cardiac event. Exercise training has been shown to favorably affect such limitations, as well as cardiovascular risk factors, symptoms, and mortality post coronary event in middle-aged patients. Aerobic capacity, body strength, quality of life, and physical function are improved with exercise-based cardiac rehabilitation (CR) in patients older than 65 years. However, there have been relatively few studies of the effects of exercise-based CR on physical function recovery in the very old patients (> or =75 years), despite the continuous growth of this segment of the population. After hospitalization for a cardiac event, postacute inpatient CR serves as a bridge between acute care and independent home living for the most disabled older patients. It plays an important role in the physical recovery process, particularly after cardiac surgery. Exercise-based outpatient (phase II) CR, starting early after hospital discharge, is safe in very old patients and studies demonstrate that these patients derive similar benefits from CR, compared with younger patients, regarding physical function improvement. Older patients, however, are less likely than younger cardiac patients to participate in outpatient CR programs. There is a need to find protocols that could increase the referral and participation rates of the frailer and older cardiac patient to exercise-based CR.     

A controlled trial of cardiac rehabilitation in the home setting using electrocardiographic and voice transtelephonic monitoring

OBJECTIVE: The goal of this study was to compare the effectiveness of home-based, transtelephonically monitored cardiac rehabilitation with standard, on-site, supervised cardiac rehabilitation. BACKGROUND: Participation in cardiac rehabilitation has been demonstrated to increase exercise capacity, decrease cardiovascular symptoms, improve psychosocial status, and decrease total and cardiovascular mortality rates in patients with coronary heart disease. Because of multiple factors, national overall participation is only at 15% of eligible patients. METHODS: Effects of a 3-month home-based, transtelephonically monitored rehabilitation program (n = 83 patients) with simultaneous voice and electrocardiographic transmission to a centrally located nurse coordinator were compared with effects of a standard on-site rehabilitation program (n = 50 patients). The study design was a multicenter, controlled trial. Primary outcome variables were peak aerobic capacity and quality of life, as measured by the Health Status Questionnaire. RESULTS: Patients in the home-based monitoring program increased peak aerobic capacity to a similar degree as patients who exercised on site (18% vs 23%). Quality of life domains of physical functioning, social functioning, physical role limitations, emotional role limitations, bodily pain, and energy/fatigue improved similarly in both groups. There were no circulatory arrests or other major exercise-related medical events in either group. A total of 3100 hours of home exercise were transtelephonically monitored. CONCLUSIONS: Patients with coronary heart disease can effectively participate in home-based, monitored cardiac rehabilitation, with exercise and quality of life improvements comparable to those demonstrated at on-site programs.     

Reduction in C-reactive protein through cardiac rehabilitation and exercise training

OBJECTIVES: This study was designed to assess the effects of three-month formal phase II cardiac rehabilitation and exercise training programs on high-sensitivity C-reactive protein (HSCRP) levels in patients with coronary heart disease (CHD). BACKGROUND: High-sensitivity C-reactive protein is associated with abdominal adiposity and other CHD risk factors and is a potent independent predictor of CHD events. Although weight reduction and statin therapy reduce HSCRP levels, the independent effects of cardiac rehabilitation programs on HSCRP are not well established. METHODS: We analyzed plasma levels of HSCRP in 277 patients with CHD (235 consecutive patients before and after formal phase II cardiac rehabilitation and exercise training programs and 42 "control" patients who did not attend cardiac rehabilitation). Additionally, we determined the effects of cardiac rehabilitation on HSCRP independent of statin therapy and weight loss. RESULTS: Rehabilitation patients improved significantly in body fat, obesity indices, exercise capacity, and other cardiac risk factors. Mean (5.9 +/- 7.7 to 3.8 +/- 5.8 mg/l; -36%; p < 0.0001) and median levels of HSCRP (-41%; p = 0.002) decreased significantly in the rehabilitation group but not in the control population. Similar significant reductions in HSCRP occurred in the rehabilitation patients regardless of whether they received statin therapy or lost weight. CONCLUSIONS: Therapeutic lifestyle changes effected through a three-month cardiac rehabilitation program significantly improved numerous cardiac risk factors. Through this holistic approach to secondary prevention, we observed significant reductions in HSCRP levels. These findings identify another clinical modality of reducing HSCRP beyond use of statin drugs and suggest an additional benefit of formal phase II cardiac rehabilitation and exercise training programs.     

Determinants of physical functioning in coronary patients: response to cardiac rehabilitation.

BACKGRound: Coronary heart disease is a major cause of disability. There has been little study of the effect of cardiac rehabilitation on measures of self-reported physical functioning. METHODS: Physical functioning was measured using the Medical Outcomes Study-Short-Form Questionnaire. Determinants of physical function were analyzed in 303 patients with coronary heart disease. Response of physical function to a 3-month exercise rehabilitation program was then determined. RESULTS: At baseline, women had lower physical function scores than men, despite similar age and diagnostic distribution. Older patients had lower physical function than younger patients. Aerobic exercise capacity, leg and arm strength, and comorbidity and depression scores were all significant predictors of baseline physical function (r range, 0.46 to -0.22). Physical function score increased significantly after exercise conditioning, with a mean (+/- SD) overall score increase from 66 +/- 23 to 80 +/- 20 on a scale of 0 to 100. The best baseline determinant of a favorable physical function improvement after rehabilitation was a low baseline physical function score. The best training-related correlate of improved physical function score was a decrease in mental depression score. CONCLUSIONS: Self-reported physical function in coronary patients is related to age, sex, fitness, and mood state. Physical functioning improves after cardiac rehabilitation in all age, sex, and diagnostic groups, but particularly in patients with low baseline values. These data support the concept that cardiac rehabilitation effectively prevents and treats cardiac disability.     

Physical activity in the prevention of atherosclerotic coronary heart disease

Opinion statement There are compelling epidemiologic and clinical data demonstrating that regular physical activity reduces the incidence of atherosclerotic vascular disease. The hypothesis that exercise decreases atherosclerotic coronary heart disease has never been directly tested in a randomized, controlled clinical trial. Nevertheless, there are sufficient data to recommend that adults should routinely engage in moderately vigorous physical activity. Exercise training also improves multiple atherosclerotic cardiovascular risk factors, including low levels of high-density lipoprotein cholesterol, blood triglycerides, blood pressure, glucose intolerance, insulin resistance, and obesity. Some of this effect attributed to exercise training is actually an acute effect of recent exercise and not a chronic metabolic adaptation. There are multiple randomized controlled clinical trials of exercise training in patients with established coronary artery disease enrolled in cardiac rehabilitation programs. These results demonstrate that exercise training reduces total cardiovascular mortality in patients with established coronary heart disease. The evidence cited above supports the recommendation that all stable adults should participate daily in a minimum of 30 minutes of moderately vigorous physical activity. Less activity than this is probably beneficial, whereas more activity is probably more beneficial.     

Benefits of Cardiac Rehabilitation and Exercise Training in Older Persons

Despite the well-proved benefits of cardiac rehabilitation and exercise training, older persons are frequently not referred to or vigorously encouraged to pursue this therapy after major coronary heart disease (CHD) events. Therefore, we determined the effects of this therapy on plasma lipids, indices of obesity, and exercise capacity in older CHD patients compared with the benefits obtained in a younger cohort. At baseline, the older persons had lower body mass indices (BMI), triglycerides levels, and estimated metabolic equivalent (METs), and the elderly had higher levels of high-density lipoprotein cholesterol (HDL-C). Most other parameters were statistically similar in the older and younger patients. After cardiac rehabilitation, the elderly had significant improvements in METs, BMI, percent body fat, HDL-C, and low-density lipoprotein cholesterol (LDL-C)/HDL-C but not in total cholesterol or LDL-C. However, improvements in all of these parameters were statistically similar in older and younger patients. We conclude that despite baseline differences, improvements in exercise capacity, obesity indices, and lipid levels were statistically similar in older and younger patients enrolled in formal, phase II, cardiac rehabilitation and exercise training programs. Therefore, our data emphasized that the elderly should not be categorically denied the benefits of vigorous secondary CHD prevention, including formal cardiac rehabilitation and exercise training programs.     

Cardiac rehabilitation in the elderly]

Cardiac rehabilitation is an integral component of secondary prevention, and is indicated for patients with a wide variety of cardiac conditions, ranging from coronary artery disease to chronic heart failure. Best results are obtained with integrated, multicomponent cardiac rehabilitation programs, which include exercise training together with counseling and psychosocial measures that may help patients maintain sustained changes toward a more healthy lifestyle. Evidence from randomized controlled trials and meta-analyses supports the efficacy of cardiac rehabilitation on clinically relevant outcomes such as reduced long-term morbidity and mortality, enhanced functional profile and improved control of cardiovascular risk factors. However, the vast majority of this evidence derives from trials with only small numbers of patients > 70 years of age. In elderly patients the goal of cardiac rehabilitation may differ from those of younger patients, and include the preservation of mobility, self-sufficiency and mental function. Cardiac rehabilitation my represent an opportunity to provide effective health care and achieve a high quality of life for older patients. Future research programs should therefore be aimed at specifically investigating the efficacy and effectiveness of cardiac rehabilitation in older, frail cardiac patients.     

Cardiovascular exercise and wellness. Exercise training for cardiac rehabilitation patients: meeting the challenges of the millennium

Exercise training for cardiac rehabilitation has evolved over the past decades in response to a growing knowledge base in exercise physiology, an expanding understanding to the knowledge base of coronary disease, and a change in the patients presenting for cardiac rehabilitation. The patient population has changed from a post myocardial infarction patient group, to patients who have had coronary artery revascularization (coronary artery bypass surgery or percutaneous transluminal coronary angioplasty) with the implantation of intraarterial stents. Program goals have evolved from enhancing endurance fitness in deconditioned patients to initiating the long-term adoption of an active exercising lifestyle with the use of strength training to complement endurance training. An increased understanding of behavioral issues in the adoption of an active lifestyle will influence the evolution of cardiac rehabilitation exercise training. During the next several years, it is anticipated that the patient population will change to include patients with significant left ventricular systolic dysfunction and congestive heart failure. The exercise training programs will then further evolve to reflect the successful exercise training formats utilized in the multicenter trials of exercise training for patients with congestive heart failure. (c) 2000 by CHF, Inc.     

Individualized preventive care in cardiac rehabilitation: adapted from AACVPR Award of Excellence Lecture, Charleston, WVa, October, 2006

The benefits of individualizing risk factor therapies and exercise protocols in patients participating in early outpatient cardiac rehabilitation are reviewed. Risk factor intervention modules for modifications of lipid abnormalities and obesity are outlined. Specific individualized exercise regimens are described for patients characterized by the presence of obesity, older age, intermittent claudication, and chronic heart failure, which provide favorable outcomes related to risk factor measures and physical functioning. With adoption and application of an individualized approach for cardiac rehabilitation patients, programs are evolving to become secondary prevention centers for patients with established coronary heart disease.     

Physical exercise and peritoneal dialysis: An area yet to be explored

Health-related quality of life (HRQoL) of patients suffering from chronic kidney disease (CKD) is profoundly impaired by their frailty, disability and decreased physical capacity. Especially among older patients, a high prevalence of low physical activity levels and reduced functional performance has been reported. Physical exercise training has been shown to have a beneficial impact, counteracting these same hazardous consequences of inactivity and sedentarism both on CKD and end-stage kidney disease (ESKD) patients on hemodialysis (HD) treatment. The evidence-based knowledge on the effects of physical exercise on ESKD patients undergoing Peritoneal Dialysis (PD) treatment is scarce, even though this is a continually growing population that shares the same risk factors and desired clinical outcomes as the previously mentioned groups of patients. Further investigation will be necessary to clarify whether this exercise-based approach may be suitable for the PD population.This paper's purpose is to review the available literature, including randomized controlled trials, reviews and meta-analysis results that assessed the impact of physical exercise on patients under PD treatment bearing in mind their HRQoL, physical functioning and cardiovascular parameters. Furthermore, it aims to evaluate the perceived significant barriers and limitations of the PD population in what concerns physical exercise practice and how nephrologists should address them.     

Cardiac rehabilitation and exercise training in secondary coronary heart disease prevention

Substantial evidence indicates that increased levels of physical activity, exercise training, and overall cardiorespiratory fitness provide protection in primary and secondary coronary heart disease (CHD) prevention. Clearly, cardiac rehabilitation and exercise training (CRET) programs have been greatly underused in patients with CHD. We review the benefits of formal CRET programs on CHD risk factors including exercise capacity, obesity indices, plasma lipids, inflammation, and psychosocial stress as well as overall morbidity and mortality. These data support the fact that patients with CHD, especially after major CHD events, need routine referral to CRET programs; and patients should be vigorously encouraged to attend these valuable programs.     

Aerobic exercise and the post myocardial infarction patient: a review of the literature

Meta analyses of randomized controlled tests of cardiac rehabilitation after myocardial infarction demonstrate that regular exercise reduces the risk of overall mortality and cardiovascular mortality. In patients with established coronary artery disease, exercise is associated with improved activity tolerance, modification of risk factors, and improvement in quality of life. Randomized controlled tests demonstrate that whereas older patients after coronary events are substantially less fit than younger patients, they obtain a similar relative improvement of aerobic capacity with a graded conditioning program. However, older adults are enrolled in such programs at a lower rate than other age groups. Despite similar clinical profiles to men, women are less likely to participate in exercise rehabilitation. In this article we discuss the principles of program development, guidelines for monitoring of patients, and facilitation of exercise programs in the Australian context.     

Is brisk walking an adequate aerobic training stimulus for cardiac patients?

Walking is the most common aerobic training modality utilized in cardiac rehabilitation programs. However, it remains unclear whether or not brisk walking is of a sufficient intensity to improve aerobic fitness in this population. In this study, we investigated whether men and women with coronary artery disease can achieve an exercise intensity that is sufficient to induce a training effect, ie, a training heart rate (THR), defined as >/= 70% of measured maximal heart rate (HRmax), via brisk walking on a flat surface. One hundred forty-two outpatient volunteers from the William Beaumont Hospital Cardiac Rehabilitation Program (Royal Oak, MI) and the University of Wisconsin-La Crosse Exercise and Health Program (La Crosse, WI) were asked to walk one mile as briskly as possible on measured tracks. Heart rate was monitored throughout the walk via radiotelemetry. The percentage of patients within each gender and phase of rehabilitation who attained a THR were assessed using peak or symptom-limited exercise testing to determine the HRmax. All of the women and 90% of the men achieved a THR, averaging 85 +/- 8% and 79 +/- 10% of HRmax, respectively (mean +/- SD). There was no difference in the percentage of phase II or phase III cardiac rehabilitation program patients who achieved a THR. These findings suggest that brisk walking is of a sufficient intensity to elicit a THR in all but the most highly fit patients with coronary disease. Thus, physicians and allied health professionals can prescribe brisk walking on a flat surface to their cardiac patients with confidence that this intensity will achieve cardiorespiratory and health benefits.     

Cardiac rehabilitation after acute myocardial infarction

At the time of evidence-based medicine, while the proofs of the benefits of cardiac rehabilitation to the coronary multiply, a large number of patients are still managed without any form of rehabilitation. In particular, younger patients with myocardial infarction treated by early reperfusion and older subjects. The objective of in-hospital or ambulatory cardiac rehabilitation is a global coverage of the patient and his/her risk factors, that the short duration of hospitalization in the acute phase does not allow. Several randomized studies, metaanalyses, and registers show a decrease from 20 to 30% of the mortality after cardiac rehabilitation. The benefits of physical training on risk factors modification are demonstrated by numerous works: improvement of lipid parameters and arterial pressure, prevention of diabetes, increased smoking cessation, loss of weight, better overall well-being; besides the management of risk factors, physical training improves exercise capacity, a recognised prognostic factor. The efficiency of cardiac rehabilitation may be comparable with that of the key treatments of coronary artery disease, such as beta-blockers or coronary angioplasty. All these proofs give to the cardiac rehabilitation in post-myocardial infarction a high-level recommendation, grade IA.     

Physical activity in primary and secondary prevention of cardiovascular disease: Overview updated

Although the observed progress in the cardiovascular disease treatment, the incidence of new and recurrent coronary artery disease remains elevated and constitutes the leading cause of death in the developed countries. Three-quarters of deaths due to cardiovascular diseases could be prevented with adequate changes in lifestyle, including increased daily physical activity. New evidence confirms that there is an inverse dose-response relationship between physical activity and cardiovascular disease and mortality risk. However, participation in moderate to vigorous physical activity may not fully attenuate the independent effect of sedentary activities on increased risk for cardiovascular diseases. Physical activity also plays an important role in secondary prevention of cardiovascular diseases by reducing the impact of the disease, slowing its progress and preventing recurrence. Nonetheless, most of eligible cardiovascular patients still do not benefit from secondary prevention/cardiac rehabilitation programs. The present review draws attention to the importance of physical activity in the primary and secondary prevention of cardiovascular diseases. It also addresses the mechanisms by which physical activity and regular exercise can improve cardiovascular health and reduce the burden of the disease.     

Rehabilitation in Older Coronary Patients

Modern medicine dictates a more active therapeutic approach in the geriatric population. This review summarizes relevant data on cardiac rehabilitation in patients aged 65 years or older. The cardiovascular risk factors in the elderly are similar to those in younger people; thus, treating hypertension or hypercholesterolemia, cessation of smoking, and changing of life style and proper diet are recommended regardless of age. Cardiovascular function gradually declines with age, and the incidence of atherosclerotic heart disease increases. Rehabilitation programs for elderly patients with postmyocardial infarction should be specifically designed, particularly for exercise training. Special attention should be paid to warm-up and cool-down periods, upgrading the intensity of exercise, and programming the muscular conditioning component. On the whole, cardiac rehabilitation in the elderly is cost-effective. It should consider the individual's general health, risk factor profile, cardiac status, and mental response.     

Particular Utility of Cardiac Rehabilitation in Relation to Age

Considerable evidence indicates that physical activity, exercise training, and cardio-respiratory fitness provide protection in primary and secondary coronary heart disease (CHD) prevention, including in the elderly population. However, cardiac rehabilitation and exercise training (CRET) programs have been greatly under-utilized in patients with CHD, and this has been especially noted in populations of elderly patients, where CRET services have been covered by Medicare. We reviewed the benefits of formal CRET programs on CHD risk factors, including exercise capacity, indices of obesity, plasma lipids, inflammation, psychosocial stress, as well as overall morbidity and mortality, including recent studies in the elderly. These data support the routine referral of elderly CHD patients to formal CRET programs, and greater efforts are needed to vigorously encourage patients to attend these highly beneficial programs.