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New Orleans, LA
Drs. Lavie and Milani are from the Section of Cardiovascular Diseases, Ochsner Clinic Foundation.
Correspondence to: Carl J. Lavie, MD, Medical Co-Director, Cardiac Rehabilitation, Director, Exercise Laboratories, Ochsner Clinic Foundation, 1514 Jefferson Hwy, New Orleans, LA 70121-2483; e-mail: clavie{at}ochsner.org email
Despite the increasing prevalence of coronary artery disease (CAD) among older patients, there seems to be a strong age bias in the treatment of cardiovascular diseases, including various preventive strategies.123456 Data from Ades and colleagues789 as well as from our institution indicate that elderly patients are less likely to be referred to formal cardiac rehabilitation programs, and when referred, experience poor program compliance due to the lack of "strength" of the referring physicians’ recommendation.110 At our institution, elderly patients are routinely referred for cardiac rehabilitation, yet attend our program only half as frequently as do younger patients.1 However, we and others have reported the significant benefits of formal, phase II cardiac rehabilitation and exercise-training program on plasma lipids, obesity indexes, exercise capacity, behavioral characteristics, and quality of life (QOL), including subgroups of elderly patients > 75 years of age as well as older women.1011121314151617
We recently reported11 on the benefits of formal cardiac rehabilitation in 268 consecutive elderly patients 
65 years of age (mean age, 70 ± 4 years; 76% men). In this cohort, following rehabilitation, small, but statistically significant, improvements were noted in obesity indexes, including total weight (–1%; p < 0.05), body mass index (–1%; p < 0.05), and the percentage of body fat (–6%; p < 0.001). Although total cholesterol and triglyceride levels had nonsignificant minor improvements following rehabilitation, there were significant improvements in high-density lipoprotein (HDL) cholesterol (+3%; p < 0.01), total cholesterol/HDL ratio (–4%; p < 0.01), and fasting glucose level (–4%; p < 0.01). Estimated exercise capacity improved markedly (+34%) following cardiac rehabilitation. There were also demonstrable improvements in validated scores for anxiety, depression, and somatization by 40%, 40%, and 33%, respectively (all p < 0.0001), as well as for overall QOL score (+17%; p < 0.0001) following cardiac rehabilitation. Although elderly patients typically have significantly lower hostility scores and lower prevalence of hostility than the younger patients, hostility scores still improved modestly (–19%; p = 0.06) following cardiac rehabilitation, but elderly patients with high hostility scores at baseline had more marked improvements following rehabilitation (hostility score, –48% [p < 0.001]; QOL, + 23% [ p < 0.001]).
Depression remains a relatively common symptom in elderly patients following major CAD events, with a point prevalence rate of 18%.18 These patients have reduced exercise capacity, lower HDL levels, more anxiety, hostility, and somatization, and lower QOL scores than elderly patients without depression. Following cardiac rehabilitation, these patients had 57% reductions in their depression scores (p < 0.0001), > 50% reductions in the prevalence of depression, and 32% improvements in their QOL scores, as well as marked improvements in exercise capacity, HDL, and other CAD risk factors.
Although elderly is typically defined as > 65 years of age, most experts agree that the majority of patients 65 to 75 years of age are still "relatively" young, and limited data are available for "very" elderly patients (eg, those > 75 or 80 years of age). We previously analyzed a group of 54 patients who were 75 years of age (mean age, 78 ± 3 years) following cardiac rehabilitation.16 The very elderly had significant improvements in plasma lipid levels, including total cholesterol (–5%; p = 0.01), triglycerides (–16%; p < 0.001), HDL (+6%; p = 0.05), low-density lipoprotein (LDL) cholesterol (–6%; p = 0.04), and the LDL/HDL ratio (–8%; p = 0.02), as well as dramatic improvements in estimated exercise capacity (+39%; p < 0.0001), which was greater than the 31% improvement noted in the younger patients (p = 0.06 for the relative improvement between the two groups). The very elderly patients also had dramatic and statistically significant improvements in all behavioral characteristics, including scores of anxiety (–66%), somatization (–42%), depression (–56%), and hostility (–65%), and in the total QOL score (+20%) and its six evaluated components. Improvements in the hostility score (+65% vs + 18%; p = 0.03), well-being score (+18% vs + 15%; p < 0.05), and total QOL score (+20% vs + 14%; p = 0.09) were greater in very elderly patients compared with younger patients.
Elderly women are probably the fastest growing segment in society and in cardiovascular practices, and this group is the least likely to be referred to and to attend cardiac rehabilitation programs. We previously analyzed our results in 70 elderly women (mean age, 71 years).17 For most parameters, improvements following cardiac rehabilitation were statistically similar in the elderly women relative to the other patients. However, elderly women had significantly greater improvements in obesity indexes, including body mass index (–2% vs 0%; p < 0.03) and percentage of body fat (–10% vs –5%; p < 0.01), compared with the other patients. The improvements in body weight and percentage of body fat were particularly noteworthy, since obesity seems to be a stronger risk factor in women than in men.
In the current issue of CHEST (see page 1026), the results of the small study from Hung et al in 18 elderly women (average age, 70 to 71years) support the benefits of strength training as well as aerobic exercise training in improving overall physical fitness and QOL. One group of women performed treadmill and cycle exercise, whereas the other group also performed upper and lower extremity strength training. Both exercise regimens led to significant improvements in exercise capacity, lower extremity strength, and emotional and global QOL. However, only patients in the group that received specific strength training improved upper extremity strength, as well as physical and social QOL. Although this study was somewhat limited by the very small number of patients studied, the overall findings have considerable practical clinical impact. Since muscular strength declines significantly with age, especially in women, and since this significantly impacts overall QOL, these results further support the addition of strength training to further enhance the benefits of formal cardiac rehabilitation and exercise-training programs in older women. In addition, these data support the growing volume of data indicating the benefits of formal cardiac rehabilitation and exercise-training programs to not only improve CAD risk factors but also to improve functional capacity and overall QOL in older patients.192021 Greater emphasis is needed to ensure that a higher percentage of older cardiac patients are routinely referred to and vigorously encouraged to attend formal cardiac rehabilitation following major cardiac events.
References
75 years of age. Am J Cardiol 1995;76,177-179[CrossRef][ISI][Medline]
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