EXERCISE REHABILITATION OF OLDER PATIENTS WITH CARDIOVASCULAR DISEASE

EXERCISE IN SECONDARY PREVENTION AND CARDIAC REHABILITATION

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EXERCISE REHABILITATION OF OLDER PATIENTS WITH CARDIOVASCULAR DISEASE Atul Aggarwal, MD, and Philip A. Ades, MD

Older patients with coronary artery disease have very high rates of disability and recurrent coronary events.', 72 Disability rates are particularly high in women, the older-old (persons older than 75 years), and patients with angina pectoris or chronic heart fail67 Approximately one quarter of individuals above 65 years of age have symptoms of coronary artery disease (CAD), and this age group accounts for two thirds of all acute myocardial infarctions.60Furthermore, persons older than 65 years of age account for more than 50% of the patients undergoing revascularization proced~res.'~ Therefore, the rehabilitation of older patients with CAD is a major public health issue. Aerobic and resistance training have been shown to increase aerobic capacity, muscular strength, and endurance in older coronary patients with minimal risk of injury or coronary events?, 4, 9, 55, 92, 93 Despite the high levels of disability in older patients with CAD, physicians are less likely to refer these patients than younger individuals to cardiac rehabilitation programs.1° PATHOPHYSIOLOGY AND EPIDEMIOLOGY OF CORONARY ARTERY DISEASE IN OLDER PATIENTS

Older patients with CAD are characterized by a greater severity of angiographic dis-

ease,83 more severe left ventricular systolic dysfunction,56and a higher incidence of diastolic dysfunction than younger patients.87 There is a greater incidence of delayed and atypical presentations and non-Q wave infarcts.", 78 Furthermore, older patients with acute myocardial infarction may not be receiving widely proven therapies such as thrombolysis, contributing to increased morbidity and disability rates in this p o p ~ l a t i o n . ~ ~ Compared with younger CAD patients, older patients have decreased exercise capacity and higher rates of disability and mobility limitations.62,67 Exercise capacity has been demonstrated to diminish with aging in healthy older subjects in both cross-sectional and longitudinal st~dies.5~.The mechanism is multifactorial, with age-related changes in maximal heart rate, stroke volume, cardiac output, left ventricular wall thickness and padrenergic sensitivity variably implicated, along with peripheral factors such as muscle mass and vascularity. The limitation of exercise performance in older patients with left ventricular dysfunction is more complex. While the initial insult results in a reduction in left ventricular function, with a resultant decrease in rest and exercise cardiac output, secondary neurohormonal, peripheral muscular, and vascular abnormalities often predominate as the cause of exercise int0lerance.9~ Exercise capacity correlates poorly with he-

From the Cardiovascular Disease Program (AA); and The Department of Medicine (PAA), Cardiology Division, Medical Center Hospital of Vermont, Fletcher Allen Health Care and University of Vermont College of Medicine, Burlington, Vermont

CARDIOLOGY CLINICS VOLUME 19 NUMBER 3 AUGUST 2001

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modynamic variables such as left ventricular ejection fraction, cardiac output and left atrial filling The decline in mortality due to CAD during the last two decades has been attributed more to effects of prevention, rather than treatment of CAD.& As a result, the number of older patients with CAD is increasing, and this shift in the distribution in age in the US population can be expected to continue well into the twenty-first century.84It is expected that the number of individuals 65 years or older will more than double in the next 50 years. Determining what combination of interventions will produce the greatest health benefit will continue as the demographics and risk-factor epidemiology of the US population evolve.89An intervention such as cardiac rehabilitation, designed to reduce disability rates and prevent recurrent coronary events in older CAD patients, should play an increasingly important role as the number of the older CAD patients increases. CORONARY DISABILITY IN OLDER PATIENTS

Coronary artery disease is the leading cause of premature, permanent disability in the US labor force, accounting for 19% of disability allowances by the Social Security Admini~trati0n.l~ However, there are no guidelines or definitions put forth by the Social Security Administration for cardiac disability for patients older than 65 years of age.n Disability in older CAD patients is generally defined by limitations in mobility and strength and in the performance of activities of daily living. Self-reported questionnaires, physical performance testing and exercise testing are all used to assess the level of disabilty.30,73,76,81 The Framingham Disability Study describes the relationship of disability to specific CAD manifestations in older patients.67This study analyzed the relationship between patient-described disability and manifestations of angina and heart failure in 2576 individuals with and without CAD. Quantitative assessment of levels of physical and social disability was determined by self-reported information. The measure of disability included three questions drawn from the Rosow and Breslau Functional Health Scale? (1) Are you able to walk up and down stairs to the second floor without help? (2) Are you

able to walk half a mile without help? and (3) Are you able to do heavy work around the house, like shoveling snow or washing windows, walls, or floors without help? A greater percentage of women reported being disabled compared to men, and they also reported being disabled in more activities than men. In all gender and age strata, disability was more prevalent in persons with CAD than in persons free of CAD (Tables 1 and 2). This study provides important epidemiological support for the clinical observation that once a person develops angina pectoris, it chronically affects physical function, regardless of CAD risk factors, stroke or other physical debilities. Whether these higher rates of disability in older CAD patients are due to physiologically based symptoms of their heart disease, such as angina, dyspnea, or fatigue or to perceptual effects of their heart disease that lead them to choose to be less active in the absence of limiting symptoms was not determined by this study. Results of other studies on this topic are complementary to that of the Framingham Disability Study. In a study of 100 men 35 to 77 years old, Neil1 et a1 showed that exercise capacity based on treadmill time was strongly correlated with a physician’s independent assessment of symptomatic status (angina history).61 However, participation in many household activities bore no relationship to exercise capacity or to other measures of the severity of the underlying heart disease. The Table 1. FRAMINGHAM DISABILITY STUDY BY AGE AND CARDIOVASCULAR DISEASE STATUS (AGE 55-69 YEARS) Disability Status

No CAD or CHF Women Men Coronary disease Women Men Angina pectoris Women Men Chronic heart failure Women Men

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829 574

67 49

88 12

67 57

67 81

80 43

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CAD = Coronary artery disease; CHF = chronic heart failure. Dutu from Pinsky JL, Jette AM, Branch LG, et al: The Framingham Disability Study: Relationship of various coronary heart disease manifestations to disability in older patients living in the community. Am J Public Health 801363-1368, 1990; with permission.

EXERCISE REHABILITATION OF OLDER PATIENTS WITH CARDIOVASCULAR DISEASE Table 2. FRAMINGHAM DISABILITY STUDY BY AGE AND CARDIOVASCULAR DISEASE STATUS (AGE 70 to 88 YEARS) Disability Status

No CAD or CHF Women Men Coronary disease Women Men Angina pectoris Women Men Chronic heart failure Women Men

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49 27

471 273

79 49

121 103

84 56

83 59

88 57

25 14

CAD = Coronary artery disease; CHF = chronic heart failure. Data from Pinsky JL, Jette AM, Branch LG, et a1 The Framingham Disability Study: Relationship of various coronary heart disease manifestations to disability in older patients living in the community Am J Public Health 801363-1368, 1990; with permission.

patients' own perception of their cardiac limitation for different activities was determined as much by their own concerns and outside advice as by cardiac symptoms. This may explain, at least in part, why people with CAD choose not to be active. Chirikos and Nickel analyzed determinants of continuing functional disability after hospitalization for acute coronary syndromes among 976 subj e c t ~In . ~a~multivariate analysis, presence of chronic diseases, including angina, was a significant contributor to disability, as determined by telephone interview at 6,18 and 24 months. Furthermore, a significant contribution of increasing age was noted. In another analysis of a cohort of 1001 men and women, they found that female survivors with angina were at significantly higher risk for diminished functional capacity when compared to men with angina or women with other heart disease, mirroring the results of Framingham disability study.6zFinally, the Medical Outcomes Study, a data base of 9385 adults with average age of 46 years, analyzed the impact of various chronic disease, on functional status and found that heart disease, had the greatest impact on physical and role functioning.80 Data from our laboratory provide further insight into the determinants of disability in older CAD patients.lP8 Fifty-one men and women 65 to 88 years old with chronic CAD have undergone comprehensive evaluations with exercise echocardiography and measure-

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ment of peak aerobic capacity, strength, and body composition, along with detailed clinical histories and self-reported measures of physical function and mental depression. Univariate predictors of physical function score included age, gender, peak aerobic capacity, strength, percentage of body fat, and depression score. By multivariate analysis, the only predictors of physical function score were mental depression score, aerobic capacity and handgrip strength. Left ventricular systolic function, which varies inversely with infarct size, was not related to physical function score.sThese data show that both physiological and psychological factors are important determinants of functional status in older patients with CAD. Similar results were obtained by Marchionni et a1 in an assessment of 265 older post-myocardial infarction (MI) patients.57Marchionni found that increasing age, female gender, presence of depressive post-MI symptoms, a small body surface area and low levels of usual physical activity were all associated independently with a lower total work capacity. In summary, the presence of clinical CAD is a powerful predictor of disability and mobility limitations in older patients. Disability rates are highest in women, the older-old, and in the presence of angina pectoris, chronic heart failure, mental depression, and low exercise capacity. EXERCISE CONDITIONING IN OLDER CORONARY PATIENTS: AEROBIC TRAINING

Cardiac rehabilitation efforts in older coronary patients are focused on improving physical functioning and extending disease-free survival. Furthermore, exercise rehabilitation and counseling have a positive effect on multiple coronary risk factors, including hypertension, lipid abnormalities, and ~besity.'~, 75, 88 Exercise capacity is an independent predictor of all causes of cardiovascular mortality in all age groups, in both healthy and unhealthy men.2oIn CAD patients, exercise traininginduced changes in peak aerobic capacity are associated with lower mortality for patients with the greatest training effect.86Meta-analyses of randomized trials of cardiac rehabilitation including over 4000 patients document a 20% decrease in overall mortality through a 3-year follow-up.@,65 With regard to age, patients over 65 to 70 years old were generally

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excluded from these trials, and 80% of the enrollees were men. Thus, the applicability of these results to the geriatric population and to women is limited. These results, nonetheless, suggest that exercise training, even in the absence of other preventive and invasive interventions, lowers mortality in middle-aged CAD patients. A large volume of data has emerged in the past decade that documents the safety and efficacy of exercise training programs in older CAD patient^.^, 4, 9, 55, 92 Compared with younger patients with a recent coronary event, older patients had a lower peak exercise capacity on entry and on completion of an exercise training protocol.6,92 However, older patients obtained a similar relative training benefit as younger patients (Fig. l)? Maximum exercise intensity increased in the older patients by as much as 68%, along with a 27% decrease in the rate-pressure product? These benefits are notable in that the older patients are significantly more disabled at entry into a cardiac rehabilitation program, after experiencing a major coronary event, than the younger patient^.^ In addition, after exercise rehabilitation, reductions in fat and body mass index, as well as lipids, and improvement in quality of life measures have all been d e m ~ n s t r a t e dFormal .~~ exercise programs have been extended up to 12 months, resulting in maintenance of significantly greater increases in peak exercise capacity and in peak and submaximal exercise efficiency." 92 The effects of cardiac rehabilitation in older CAD patients on submaximal exercise re-

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Figure 1. Peak aerobic capacity, Vqmax before after conditioning in older and younger patient groups (P <0.001 compared with preconditioning). (Adapted from Ades PA, Grunwald MH: Cardiopulmonary exercise testing before and after conditioning in older coronary patients. Am Heart J 120585489, 1990; with permission.)

sponse are perhaps more relevant to the performance of activities of daily living than the maximal exercise response. Conditioning effects of a 12-week aerobic conditioning program were determined in 45 patients with a mean age of 69 2 6 years.'* Training effects were measured using an exhaustive submaxima1 exercise protocol, with patients exercising at a constant intensity of 80% of their peak preconditioning Vo2max.While maximal aerobic capacity increased by l6%, exhaustive submaximal exercise time increased by more than 40%. Furthermore, at the end of 3 months of conditioning, at every level of submaximal exercise, work was performed at a lower heart rate, serum lactate level, and perceived exertion score (Figs. 2 and 3). For most patients, activities that were exhaustive before training could be performed for extended periods of time. The mechanisms of physiological adaptations to aerobic exercise conditioning in older CAD patients are somewhat different than those seen in middle-aged (<65 years old) coronary patients. In younger coronary patients, physiological adaptations to training include both peripheral adaptations (skeletal muscle and vascular), which result in a widened arteriovenous oxygen difference at maximal exercise,26,33 and cardiac adaptations, which include increases in cardiac dimensions, stroke work, cardiac output, and afterload-corrected indices of left ventricular function.34,35, 46, 47 In older coronary patients, coronary and peripheral vascular disease are superimposed on age-related increases in left ventricular and arterial wall thickness and ~tiffness.~~, 65 These result in a limitation in cardiovascular adaptations to aerobic conditioning. The authors tested the hypothesis that conditioning-induced adaptations in older patients are localized to the peripheral circulation." The effects of a %month and a 1-year program of intense aerobic exercise were studied in 60 older coronary patients with a mean age of 68 k 5 years and compared with sedentary, age- and diagnosis-matched control groups. Peak aerobic capacity increased in the intervention group by 16% and 29% at 3 months and 1 year, respectively. This was almost entirely explained by the increased arteriovenous oxygen difference at peak exercise in the exercise group. There was no measurable increase in peak exercise cardiac output or in peripheral arterial blood flow. The increase in oxygen extraction ratio

EXERCISE REHABILITATION OF OLDER PATIENTS WITH CARDIOVASCULAR DISEASE

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Figure 2. Serum lactate levels during submaximal exercise before and after 3 months of conditioning. (Adapfed from Ades PA, Waldmann ML, Poehlman ET, et al: Exercise conditioning in older coronary patients: Submaximal lactate response and endurance capacity. Circulation 885724577,1993; with permission.)

was accompanied by skeletal muscle alterations consisting of increased oxidative enzyme activity and an increased capillary density after 3 months of conditioning and an increased muscle fiber cross-sectional area after 12 months of conditioning. The enddiastolic volume and stroke volume actually tended to decrease after 3 months of training, with no change at 12 months, in contrast to findings in younger coronary patients by other groups.35,47 Since cardiac adaptations were not prominent even after an intense and prolonged program of aerobic exercise, it appears that a greater emphasis should be directed to the training of skeletal muscle with the incorporation of resistance training for

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older coronary patients. These results have important clinical implications for the design of exercise training programs for older coronary patients. EXERCISE CONDITIONING IN OLDER CORONARY PATIENTS: RESISTANCE TRAINING

Prior to 1990, resistance training was not a component of the recommended guidelines for exercise training and rehabilitation by either the American Heart Association or the American College of Sports Medicine.69Resistance training has recently been advanced as

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Figure 3. Perceived exertion (Borg Scale 6 to 20)23during submaxima1 exercise before and after 3 months of conditioning. (Adapted from Ades PA, Waldmann ML, Poehlman ET, et al: Exercise conditioning in order coronary patients: Submaximal lactate and endurance capacity. Circulation 88:572-577,1993; with permission.)

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a useful intervention in older coronary patients.4O. 79 Normal aging is associated with loss of skeletal muscle mass and strength, a process known as su~copeniu.~~ Resistance training leads to greater development of muscular strength, endurance, and mass4 Thus, resistance training is particularly helpful for improving the function of frail and elderly patients, who benefit substantially from both upper- and lower-body exercise.68,70 In addition, both aerobic exercise and resistance exercise have favorable effects on bone mineral density, glucose tolerance, and insulin sensitivity?" Many older cardiac patients have concurrent morbidities, such as osteoporosis, low back pain, diabetes mellitus, and susceptibility to falls, that are all favorably influenced by resistance training. The evidence for benefits of adjunctive resistance training in cardiac rehabilitation programs is derived from several sources. Highintensity strength training has been shown to lead to significant gains in muscle strength and muscle mass in institutionalized nonagenarians over a time period of 2 In a randomized, controlled trial involving 24 healthy individuals 2 6 5 years old, resistance-training program increased submaximal walking endurance time by 38%.2A positive correlation was shown between improvement in leg strength and walking endurance. By the virtue of having greater leg strength, participants worked at lower percentages of their peak strength at a given workload.

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Older patients

Studies evaluating the safety and efficacy of resistance training in older patients with CAD have been limited. Resistance training in older CAD patients of both sexes, who had recently suffered an MI, was found to yield a similar relative increase in strength as in younger CAD patients (Fig. 4).40 The commonest side effect was mild muscle soreness. The safety of resistance exercise has been demonstrated as early as 3 weeks after an acute MI.91From a practical point of view, the onset of upper-body resistance training should be delayed until 3 months after coronary bypass surgery to allow full sternal healing but can commence as soon as 3 to 4 weeks after an MI after performance of a satisfactory baseline exercise tolerance test. The authors recently studied the effect of resistance training on self-reported physical function and on measured physical performance in 15 older women with CAD.7Female patients 2 6 5 years old were randomized to a 6-month program of resistance training or a control group that performed light flexibility exercises. The resistance training group had greater improvement in measured total physical performance score using the ContinuousScale Physical Functional Performance Test (CS-PFP)30,although the self-reported physical function score and aerobic capacity were not improved in either group. Thus, while measured physical performance during various activities in the laboratory setting improved markedly, this did not translate into an increase in self-reported physical function.

Younger patients

Figure 4. Changes in leg strength with conditioning in older and younger patient groups. P <.05 before (solid bar) and after (shaded bar) conditioning within groups. (Adapted from Fragnoli-Munn K, Savage P, Ades PA, et al: Combined resistance-aerobic training in order patients with coronary artery disease after myocardial infarction. J Cardiopulm Rehab 18:416420, 1998; with permission.)

EXERCISE REHABILrrATION OF OLDER PATIENTS WITH CARDIOVASCULAR DISEASE

A role for physical activity counseling in combination with resistance training is envisioned. EXERCISE CONDITIONING IN OLDER PATIENTS WITH HEART FAILURE

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A recent study demonstrated that progressive resistance could safely increase strength and function in older heart failure patients due to favorable modifications of skeletal muscle.39 Although benefits of exercise rehabilitation have been demonstrated in young cardiac allograft recipients, there is a dearth of data in the elderly, due to the fact that few older individuals are considered eligible candidates for transplantation?"

The prevalence of heart failure continues to increase in men and women of all ages, and it is the most common diagnosis-related group (DRG) at hospital discharge in Medicare paGENDER-RELATED ISSUES OF tients above 65 years old.@Despite the beneCARDIAC REHABILITATION IN fits of case management strategies, including OLDER PATIENTS angiotensin-converting enzyme inhibitors, which have helped in reduction of readmission to hospital and improvement in quality In patients above 65 years old, women and men have the same relative risks of coronary of life, the mortality and morbidity from heart Women suffer from higher rates of failure in the older population continue to be high.71 disability after an MI than men, especially in the older age group.62,67 In addition, older A number of studies from the last decade women with CAD are less likely to enter carshow that patients with heart failure can exerdiac rehabilitation programs than are older cise safely, and that regular exercise improves functional status and decreases symptoms.18, men, despite similar clinical pr0fi1es.l~The lower participation rate in older women is 28, 29 There is improvement in quality of life scores and reduction in overall m0rta1ity.l~ primarily due to a lower physician recommendation score. The lower physician recomThis is accompanied by impressive physiomendation score may be due to a bias that logical gains, including increased peak oxycardiac rehabilitation is less beneficial in older gen consumption,'8, 29 increased peak cardiac women. Despite being less fit before particioutp~t,2 and ~ improvement in autonomic balpation in exercise training, older women with a n ~ e , endothelial 2~ function, and skeletal muscle biochemistry and h i s t o m o r p h ~ m e t r y . ~ ~CAD derive similar improvements in functional capacity as their male co~nterparts.'~, The mean age of patients in these studies, 16, 54 They also derive improvement in multihowever, ranges from 54 to 64 years, and ple domains of measured physical perthere are relatively few studies showing the formance, as reported above.7 The different benefits of exercise training in older patients clinical profile of women in cardiac rehabilita(>65 years old) with heart failure. tion may require a program that is designed Wielenga et a1 showed that exercise trainto suit to their personal preferences, with eming is equally effective in increasing exercise phasis on joint goal setting, frequent encourcapacity in patients younger and older than agement from professionals, and a range of 65 years in terms of improvement in exercise time and quality of life.90The relative inexercises.59Not only are women less likely to participate in cardiac rehabilitation than men, creases in peak oxygen consumption and anthey are less likely to participate in other aerobic threshold were modest and did not preventive out-patient cardiology visits as differ by age group. In another study of older we11.31 patients with heart failure with a mean age of 81 k 4 years, exercise capacity increased after exercise training, and a majority of subjects reported subjective improvement in PSYCHOSOCIAL ISSUES RELATED TO CARDIAC REHABILITATION IN well-being. However, there was no improveOLDER PATIENTS ment in quality of life assessed by the Living With Heart Failure Questionnaire.66There is insufficient evidence to recommend a specific The psychosocial aspects of cardiac rehabiltype of training program for heart failure paitation are important due to a higher prevatients, although existing studies have focused lence of depressive symptoms in later life on aerobic exercises, such as cycling or treadthan in younger adults, especially in the mill walking, rather than resistance training. older-old.21Depression in patients hospital-

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ized following an MI is not only associated with poor physical function but is also an independent marker of short- and long-term mortality in patients followed-up to more than 20 years.17,43 The importance of depression in older cardiac patients also emanates from the fact that these subjects are less likely to follow behavior and lifestyle recommendations after MI.” After cardiac rehabilitation, older depressed patients have marked improvements in depression scores, functional status, exercise capacity and quality-of-life Conventional cardiac risk factors and aerobic capacity improve to a similar extent among the depressed and nondepressed older CAD patients. The effects of cardiac rehabilitation on physical functioning were studied in 303 patients with coronary heart disease undergoing cardiac rehabilitation in our hospital.‘j Physical functioning improved after cardiac rehabilitation, and the best predictor of an improvement in physical function was a decrease in depression score during program participation. Older patients with CAD who report low social support are also at increased risk of 51 Frasure-Smith et a1 recently m~rtality.’~, showed that very high levels of social support appear to buffer the impact of depression on cardiac mortality.42Cardiac rehabilitation stress management programs and psychological counseling are performed both in a group setting and in individualized sessi0ns.l The sessions and exercise program provide social support and social contacts for individuals who were often isolated after a coronary event. Counseling sessions focus on stress management and relaxation skills in addition to reintegration and socialization. Individuals who are at high risk for prolonged depression or maladaptive recovery patterns are identified and referred for more specific therapy, such as pharmacological antidepressant therapy or longer-term counseling. CARDIAC REHABILITATION PARTICIPATION

Despite the documented benefits of exercise training in older coronary patients, older patients are substantially less likely than the younger patients to participate in outpatient cardiac rehabilitation programs.l0An analysis of the demographic, medical and psychosocia1 factors that predict participation in older

patients was carried out.’O Factors associated with nonparticipation in eligible patients included lack of physician referral; distance from the rehabilitation center; female gender; lower level of education; psychosocial factors such as denial of illness and depression; and presence of comorbid medical conditions such as arthritis, diabetes, and obstructive lung disease. In a multivariate analysis, the most powerful predictor of physician participation was the strength of the primary physician’s recommendation. When the strength of the physician’s recommendation was perceived as weak by the patient, the entry rate was 2%, and when the recommendation was strong, the entry rate was 66% (Fig. 5). Accordingly, to maximize involvement of older CAD patients in cardiac rehabilitation, primary care physicians and cardiologists need to specifically recommend participation and to take into account the special needs of older patients. As mentioned above, female subjects, those with depression, and those with low function at baseline stand to gain the maximum benefit from cardiac rehabilitation, and the physicians should make these vulnerable subsets of patients a priority for participation. From a financial standpoint, Medicare has recognized the value of cardiac rehabilitation after a coronary event, and coverage is generally provided. HOME EXERCISE PROGRAMS FOR OLDER CORONARY PATIENTS

Several studies report on home exercise programs after a coronary event.24,32, 48 A

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Figure 5. Cardiac rehabilitation participation by physician’s recommendations score. The physician’s recommendation score was graded from 1 (not mentioned or recommended against) to 5 (strongly recommended). (Adapted from Ades PA, Waldmann ML, McCann WJ, et al: Predictors of cardiac rehabilitation participation in older coronary patients. Ann Intern Med 152:10331035, 1992; with permission.)

EXERCISE REHABILITATION OF OLDER PATIENTS WITH CARDIOVASCULAR DISEASE

home-based rehabilitation program can be especially advantageous for older patients who are unable to travel, because they can receive the services in their own environment, which facilitates incorporation of the exercises into their day-to-day activities. Visiting nurses can often initiate the elderly stages of walking at home and monitoring. In many cases, cardiac rehabilitation programs are not available geographically, and a home-based program can be devised for these patients. Only 15% of eligible patients in the United States actually receive on-site cardiac rehabilitation services.**There is a need to expand preventive cardiology services to include these high-risk patients in a cost-effective manner, and this necessitates a redefinition of this classical model, in which cardiac rehabilitation services have been delivered on-site at a welldefined exercise training facility. Older patients tend to require a more hands-on approach early after a coronary event, but can often transition to a home program with appropriate follow-up. Exercise programs can be individualized, with the high-risk patients referred to an on-site program for closer monit0ring.l SCREENING AND IMPLEMENTATION

Older coronary patients enter a cardiac rehabilitation program after careful screening that includes an exercise tolerance test; an assessment of physical strength; and a clinical review that includes an analysis of severity of residual coronary disease, measurement of risk factors, and a questionnaire- or interview-derived data assessment of physical functioning and psychosocial function. Diagnostic categories appropriate for cardiac rehabilitation include patients who have experienced: Myocardial infarction Coronary bypass surgery Percutaneous coronary revascularization Stable angina pectoris Valve replacement Chronic heart failure Exercise modalities should include options for aerobic exercise, resistance exercise, and flexibility. Aerobic choices include treadmills, a walking course, cycles, airdynes, rowers, and others. Aerobic exercise is often guided by an exercise heart rate range and/or scales of perceived exertion such as the Borg scale,

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which quantifies perception on a 6 to 20 scale.23A gradual increment of exercise heart rate from 60% to 65% of maximum attained heart rate attained at baseline stress testing to higher levels of up to 85% is balanced against the greater risk of injury at higher levels. Measurable benefits have been documented even with low levels of exercise. It has been observed that older coronary patients are less likely to exercise to a physiologic maximum at their baseline test than younger patients, and therefore, a strict adherence to an exercise heart rate range is often inappropriate? Duration of exercise stimulus can begin with very brief, intermittent bouts of exercise, gradually increasing to 20 to 25 minutes or longer. In older patients, training regimens often need to be adjusted to accommodate the frequent presence of medical comorbidities that alter the modality and intensity of exercise delivered. For example, patients with hip arthritis may do better with cycling or rowing exercise avoiding the weight bearing of treadmill walking. Longer-term exercise programs have been advocated for older people, related partly to their low baseline capacity.93Even people who use canes and walkers can be exercise-tested and trained on a treadmill with surround bars or on a cycle ergometer. Also important are social issues, such as transportation, which can have an important bearing on participation of elderly coronary patients in exercise programs. Resistance training should include training of leg extensor muscles to assist with walking, stair climbing, and prevention of falls, along with upper body training to aid in the lifting and pushing required to perform daily household activities. Resistance training often begins with the use of elastic tubing and stretching and progresses to include dumbbells and stationary weights. Resistance training protocols are often quantified by the measurement of the single repetition maximal lift (1-RM) for a given exerci~e.~’ Subjects then perform an 8- to 10-repetition set of a given exercise at 40% to 50% of the 1-RM, and then gradually increase exercise intensity, as tolerated, to 50% to 80% of updated 1-RMs. The presence of osteoarthritis does not contraindicate resistance exercise, unless a specific motion is limited by pain. Finally, for many people, flexibility, or lack thereof, can be an exercise-limiting factor. Flexibility exercises can range from a simple 5 to 10 minutes of stretching per day to the more complex protocols of yoga and tai-chi.

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SUMMARY

As the population of elderly patients with cardiovascular disease continues to increase, much research needs to be done with the goal of maintaining physical functioning and personal independence in this population. It is of particular importance to determine whether training programs can improve physical functioning in the most severely disabled older coronary patients. Effects of cardiac rehabilitation programs on other outcome measures, including psychosocial outcomes, lipid levels, insulin levels, and body composition require better study. Finally, the economic benefits of cardiac rehabilitation in the older coronary patients has received little attention, although early reports are promising.22,53 In summary, the older population with coronary disease is characterized by high rates of disability. Exercise training has been demonstrated to be safe and to improve strength, aerobic fitness capacity, endurance and physical function. It remains to be seen whether exercise training can reverse or prevent disability in a broad population of older patients with cardiovascular disease. If successful, cardiac rehabilitation programs will pay great medical, social, and economic dividends in this population. References 1. Ades PA Cardiac rehabilitation in older coronary patients. J Am Geriatr SOC4798-105, 1999 2. Ades PA, Ballor DL, Ashikaga T, et al: Weight training improves walking endurance in healthy elderly persons. Ann Intern Med 124568-572,1996 3. Ades PA, Grunwald MH: Cardiopulmonary exercise testing before and after conditioning in older coronary patients. Am Heart J 120585589,1990 4. Ades PA, Hanson JS, Gunther PG, et al: Exercise conditioning in the elderly coronary patient. J Am Geriatr SOC35:121-124, 1987 5. Ades PA, Huang D, Weaver SO: Cardiac rehabilitation participation predicts lower rehospitalization costs. Am Heart J 123:916-921, 1992 6. Ades PA, Maloney A, Savage P, et al: Determinants of physical functioning in coronary patients. Response to cardiac rehabilitation. Arch Intern Med 159:2357-2360,1999 7. Ades PA, Savage PD, Brochu M, et a1 Resistance training on physical function in older women with coronary heart disease (abstr). Circulation 102 Suppl II:II-679, 2000 8. Ades PA, Tischler MD, Savage P, et a1 Determinants of disability in older coronary patients (abstr). Circulation 94 Suppl 11-497, 1995 9. Ades PA, Waldmann ML, Gillespie C: A controlled

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Address reprint requests to Atul Aggarwal, MD Cardiology Division Medical Center Hospital of Vermont 111 Colchester Avenue Burlington, VT 05401 e-mail: [email protected]