Cardiac rehabilitation in older adults
- Nanette K Wenger, MD
Nanette K Wenger, MD
- Professor of Medicine (Cardiology)
- Emory University School of Medicine
- Section Editors
- Bernard J Gersh, MB, ChB, DPhil, FRCP, MACC
Bernard J Gersh, MB, ChB, DPhil, FRCP, MACC
- Editor-in-Chief — Cardiovascular Medicine
- Section Editor — Coronary Heart Disease; Myopericardial Disease
- Professor of Medicine
- Mayo Clinic College of Medicine
- Kenneth E Schmader, MD
Kenneth E Schmader, MD
- Editor in Chief — Geriatric Medicine
- Section Editor — Geriatrics
- Chief, Division of Geriatrics
- Duke University
- Director, Geriatric Research Education and Clinical Center
- Durham VA Medical Centers
Following hospitalization for a coronary event such as an acute coronary syndrome or heart failure, all patients, and in particular the elderly, are at increased risk of disability, including a repeat cardiovascular event. The efficacy and safety of cardiac rehabilitation have been demonstrated in all patients in which they have been studied, including the elderly (age >65 years) .
Cardiac rehabilitation programs are designed to enhance recovery from acute cardiovascular events and to improve both quality of life and survival [2-6]. In addition, patients with stable coronary heart disease treated medically or those who have undergone myocardial revascularization with percutaneous coronary intervention or coronary artery bypass graft surgery derive benefit. (See "Prevention of cardiovascular disease events in those with established disease or at high risk".)
In older patients with heart failure and a preserved ejection fraction, in whom exercise intolerance is the primary chronic symptom, exercise training improves both peak and submaximal exercise capacity . Accumulating evidence has shown comparable exercise training benefits in older and younger patients with heart failure . (See "Cardiac rehabilitation in patients with heart failure".)
The indications for cardiac rehabilitation in the elderly are the same as for the general population. (See "Cardiac rehabilitation: Indications, efficacy, and safety in patients with coronary heart disease" and "Cardiac rehabilitation: Indications, efficacy, and safety in patients with coronary heart disease", section on 'Evidence of benefit'.)
The use of cardiac rehabilitation programs in the elderly will be reviewed here. The details of these programs are discussed separately. (See "Cardiac rehabilitation programs".)
- Pasquali SK, Alexander KP, Peterson ED. Cardiac rehabilitation in the elderly. Am Heart J 2001; 142:748.
- Ades PA. Cardiac rehabilitation and secondary prevention of coronary heart disease. N Engl J Med 2001; 345:892.
- Smith SC Jr, Benjamin EJ, Bonow RO, et al. AHA/ACCF Secondary Prevention and Risk Reduction Therapy for Patients with Coronary and other Atherosclerotic Vascular Disease: 2011 update: a guideline from the American Heart Association and American College of Cardiology Foundation. Circulation 2011; 124:2458.
- Hillis LD, Smith PK, Anderson JL, et al. 2011 ACCF/AHA Guideline for Coronary Artery Bypass Graft Surgery: executive summary: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation 2011; 124:2610.
- Levine GN, Bates ER, Blankenship JC, et al. 2011 ACCF/AHA/SCAI Guideline for Percutaneous Coronary Intervention: executive summary: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines and the Society for Cardiovascular Angiography and Interventions. Circulation 2011; 124:2574.
- Kwan G, Balady GJ. Cardiac rehabilitation 2012: advancing the field through emerging science. Circulation 2012; 125:e369.
- Kitzman DW, Brubaker PH, Morgan TM, et al. Exercise training in older patients with heart failure and preserved ejection fraction: a randomized, controlled, single-blind trial. Circ Heart Fail 2010; 3:659.
- Fleg JL. Aerobic exercise in the elderly: a key to successful aging. Discov Med 2012; 13:223.
- Shephard RJ. The scientific basis of exercise prescribing for the very old. J Am Geriatr Soc 1990; 38:62.
- Fleg JL, Lakatta EG. Role of muscle loss in the age-associated reduction in VO2 max. J Appl Physiol (1985) 1988; 65:1147.
- McGuire DK, Levine BD, Williamson JW, et al. A 30-year follow-up of the Dallas Bedrest and Training Study: I. Effect of age on the cardiovascular response to exercise. Circulation 2001; 104:1350.
- Blumenthal JA, Emery CF, Madden DJ, et al. Cardiovascular and behavioral effects of aerobic exercise training in healthy older men and women. J Gerontol 1989; 44:M147.
- Shephard, RJ. Habitual physical activity levels and perception of exercise in the elderly. J Cardiopulm Rehabil 1989; 9:17.
- Jonsson PV, Lipsitz LA, Kelley M, Koestner J. Hypotensive responses to common daily activities in institutionalized elderly. A potential risk for recurrent falls. Arch Intern Med 1990; 150:1518.
- Exercise in Health and Disease: Evaluation and Prescription for Prevention and Rehabilitation, 2nd ed, Pollock M, Wilmore J (Eds), WB Saunders, Philadelphia 1990.
- Pollock ML, Carroll JF, Graves JE, et al. Injuries and adherence to walk/jog and resistance training programs in the elderly. Med Sci Sports Exerc 1991; 23:1194.
- Bruce RA, Larson EB, Stratton J, et al. Physical fitness, functional aerobic capacity, aging, and response to physical training or bypass surgery in coronary patients. J Cardiopulmonary Rehabil 1989; 9:24.
- Fiatarone MA, Marks EC, Ryan ND, et al. High-intensity strength training in nonagenarians. Effects on skeletal muscle. JAMA 1990; 263:3029.
- Nelson ME, Rejeski WJ, Blair SN, et al. Physical activity and public health in older adults: recommendation from the American College of Sports Medicine and the American Heart Association. Circulation 2007; 116:1094.
- Borg GA. Psychophysical bases of perceived exertion. Med Sci Sports Exerc 1982; 14:377.
- Lavie CJ, Milani RV, Littman AB. Benefits of cardiac rehabilitation and exercise training in secondary coronary prevention in the elderly. J Am Coll Cardiol 1993; 22:678.
- Taddei S, Galetta F, Virdis A, et al. Physical activity prevents age-related impairment in nitric oxide availability in elderly athletes. Circulation 2000; 101:2896.
- Wannamethee SG, Lowe GD, Whincup PH, et al. Physical activity and hemostatic and inflammatory variables in elderly men. Circulation 2002; 105:1785.
- Milani RV, Lavie CJ, Mehra MR. Reduction in C-reactive protein through cardiac rehabilitation and exercise training. J Am Coll Cardiol 2004; 43:1056.
- Tanaka H, Dinenno FA, Monahan KD, et al. Aging, habitual exercise, and dynamic arterial compliance. Circulation 2000; 102:1270.
- Abete P, Calabrese C, Ferrara N, et al. Exercise training restores ischemic preconditioning in the aging heart. J Am Coll Cardiol 2000; 36:643.
- Abete P, Ferrara N, Cacciatore F, et al. High level of physical activity preserves the cardioprotective effect of preinfarction angina in elderly patients. J Am Coll Cardiol 2001; 38:1357.
- Beere PA, Russell SD, Morey MC, et al. Aerobic exercise training can reverse age-related peripheral circulatory changes in healthy older men. Circulation 1999; 100:1085.
- Marchionni N, Fattirolli F, Fumagalli S, et al. Improved exercise tolerance and quality of life with cardiac rehabilitation of older patients after myocardial infarction: results of a randomized, controlled trial. Circulation 2003; 107:2201.
- Ståhle A, Mattsson E, Rydén L, et al. Improved physical fitness and quality of life following training of elderly patients after acute coronary events. A 1 year follow-up randomized controlled study. Eur Heart J 1999; 20:1475.
- Pocock NA, Eisman JA, Yeates MG, et al. Physical fitness is a major determinant of femoral neck and lumbar spine bone mineral density. J Clin Invest 1986; 78:618.
- Wenger NK. Cardiovascular disease in the elderly. Curr Probl Cardiol 1992; 17:609.
- Milani RV, Lavie CJ. Prevalence and effects of cardiac rehabilitation on depression in the elderly with coronary heart disease. Am J Cardiol 1998; 81:1233.
- Stanek KM, Gunstad J, Spitznagel MB, et al. Improvements in cognitive function following cardiac rehabilitation for older adults with cardiovascular disease. Int J Neurosci 2011; 121:86.
- Suaya JA, Stason WB, Ades PA, et al. Cardiac rehabilitation and survival in older coronary patients. J Am Coll Cardiol 2009; 54:25.
- Frengley JD, Sansone GR, Alba A, et al. Influence of age on rehabilitation outcomes and survival in post-acute inpatient cardiac rehabilitation. J Cardiopulm Rehabil Prev 2011; 31:230.
- Taylor RS, Brown A, Ebrahim S, et al. Exercise-based rehabilitation for patients with coronary heart disease: systematic review and meta-analysis of randomized controlled trials. Am J Med 2004; 116:682.
- de Vries H, Kemps HM, van Engen-Verheul MM, et al. Cardiac rehabilitation and survival in a large representative community cohort of Dutch patients. Eur Heart J 2015; 36:1519.
- Johnston M, MacDonald K, Manns P, et al. Impact of cardiac rehabilitation on the ability of elderly cardiac patients to perform common household tasks. J Cardiopulm Rehabil Prev 2011; 31:100.
- Lai FC, Tu ST, Huang CH, Jeng C. A home-based exercise program improves heart rate variability and functional capacity among postmenopausal women with coronary artery disease. J Cardiovasc Nurs 2011; 26:137.
- Mandic S, Stevens E, Hodge C, et al. Long-term effects of cardiac rehabilitation in elderly individuals with stable coronary artery disease. Disabil Rehabil 2016; 38:837.
- Wenger, NK, Froelicher, ES, Smith, LK, et al. Cardiac Rehabilitation. Clinical Practice Guideline No. 17, U.S. Department of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research and the National Heart, Lung, and Blood Institute, Rockville, MD, AHCPR Publication No. 96-0672, October, 1995.
- Cottin Y, Cambou JP, Casillas JM, et al. Specific profile and referral bias of rehabilitated patients after an acute coronary syndrome. J Cardiopulm Rehabil 2004; 24:38.
- Williams MA, Fleg JL, Ades PA, et al. Secondary prevention of coronary heart disease in the elderly (with emphasis on patients > or =75 years of age): an American Heart Association scientific statement from the Council on Clinical Cardiology Subcommittee on Exercise, Cardiac Rehabilitation, and Prevention. Circulation 2002; 105:1735.
- Lavie CJ, Milani RV. Effects of cardiac rehabilitation programs on exercise capacity, coronary risk factors, behavioral characteristics, and quality of life in a large elderly cohort. Am J Cardiol 1995; 76:177.
- Suaya JA, Shepard DS, Normand SL, et al. Use of cardiac rehabilitation by Medicare beneficiaries after myocardial infarction or coronary bypass surgery. Circulation 2007; 116:1653.
- Aragam KG, Dai D, Neely ML, et al. Gaps in referral to cardiac rehabilitation of patients undergoing percutaneous coronary intervention in the United States. J Am Coll Cardiol 2015; 65:2079.
- Doll JA, Hellkamp A, Ho PM, et al. Participation in Cardiac Rehabilitation Programs Among Older Patients After Acute Myocardial Infarction. JAMA Intern Med 2015; 175:1700.
- Buttery AK, Carr-White G, Martin FC, et al. Limited availability of cardiac rehabilitation for heart failure patients in the United Kingdom: findings from a national survey. Eur J Prev Cardiol 2014; 21:928.
- Rodrigues P, Santos M, Sousa MJ, et al. Cardiac Rehabilitation after an Acute Coronary Syndrome: The Impact in Elderly Patients. Cardiology 2015; 131:177.
- Forman DE, Rich MW, Alexander KP, et al. Cardiac care for older adults. Time for a new paradigm. J Am Coll Cardiol 2011; 57:1801.
- Brown TM, Hernandez AF, Bittner V, et al. Predictors of cardiac rehabilitation referral in coronary artery disease patients: findings from the American Heart Association's Get With The Guidelines Program. J Am Coll Cardiol 2009; 54:515.
- Grace SL, Russell KL, Reid RD, et al. Effect of cardiac rehabilitation referral strategies on utilization rates: a prospective, controlled study. Arch Intern Med 2011; 171:235.
- Hammill BG, Curtis LH, Schulman KA, Whellan DJ. Relationship between cardiac rehabilitation and long-term risks of death and myocardial infarction among elderly Medicare beneficiaries. Circulation 2010; 121:63.
- Thomas RJ, King M, Lui K, et al. AACVPR/ACC/AHA 2007 performance measures on cardiac rehabilitation for referral to and delivery of cardiac rehabilitation/secondary prevention services endorsed by the American College of Chest Physicians, American College of Sports Medicine, American Physical Therapy Association, Canadian Association of Cardiac Rehabilitation, European Association for Cardiovascular Prevention and Rehabilitation, Inter-American Heart Foundation, National Association of Clinical Nurse Specialists, Preventive Cardiovascular Nurses Association, and the Society of Thoracic Surgeons. J Am Coll Cardiol 2007; 50:1400.
- Taylor RS, Dalal H, Jolly K, et al. Home-based versus centre-based cardiac rehabilitation. Cochrane Database Syst Rev 2010; :CD007130.
- Beatty AL, Fukuoka Y, Whooley MA. Using mobile technology for cardiac rehabilitation: a review and framework for development and evaluation. J Am Heart Assoc 2013; 2:e000568.
- Varnfield M, Karunanithi M, Lee CK, et al. Smartphone-based home care model improved use of cardiac rehabilitation in postmyocardial infarction patients: results from a randomised controlled trial. Heart 2014; 100:1770.
- Ades PA, Waldmann ML, Polk DM, Coflesky JT. Referral patterns and exercise response in the rehabilitation of female coronary patients aged greater than or equal to 62 years. Am J Cardiol 1992; 69:1422.
- Thompson PD, Buchner D, Pina IL, et al. Exercise and physical activity in the prevention and treatment of atherosclerotic cardiovascular disease: a statement from the Council on Clinical Cardiology (Subcommittee on Exercise, Rehabilitation, and Prevention) and the Council on Nutrition, Physical Activity, and Metabolism (Subcommittee on Physical Activity). Circulation 2003; 107:e9053.
- Balady GJ, Ades PA, Bittner VA, et al. Referral, enrollment, and delivery of cardiac rehabilitation/secondary prevention programs at clinical centers and beyond: a presidential advisory from the American Heart Association. Circulation 2011; 124:2951.
- Fletcher GF, Balady GJ, Amsterdam EA, et al. Exercise standards for testing and training: a statement for healthcare professionals from the American Heart Association. Circulation 2001; 104:1694.