Cardiac rehabilitation expands into the elderly

More and more people are living longer. Since 1970, life expectancy in Western Europe has increased by between 6–8 years. Life expectancy at birth in the European Union was estimated to be 80.9 years in 2017, reaching 78.3 years for men and 83.5 years for women. The calculated life expectancy for those born in 2019 is 79 years for males and 84 years for females.1 Cardiovascular disease is the most frequent cause of death in people over 65 years of age, and most importantly it is responsible for considerable morbidity and a large burden of disease. In 2016, the European Union counted 1.83 m deaths from diseases of the circulatory system. In the high-income countries of Western Europe, the annual number of deaths from cardiovascular diseases declined between 1990–2013, but globally deaths increased by 41% despite a 39% decrease in age-specific death rates. This increase was driven by a 55% increase in mortality due to the aging of populations. The data provide a reminder that cardiovascular disease will remain a global threat as the world population gets older.2 Patients older than 70 years account for one-third to one-half of patients with acute myocardial infarction admitted to hospital, and 80% of deaths due to acute myocardial infarction occur in those aged over 65 years, 60% of them in people aged 75 years or more.3 From this it can be derived that, in cardiac rehabilitation, the proportion of patients over the age of 75 years is increasing and frailty is playing an increasing role. As a result, frailty has direct therapeutic implications that include endurance, strength and coordination training, as well as nutritional interventions. Evidence from randomised 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.4 Improvement of exercise capacity is one of the most important targets of a cardiac rehabilitation programme. Therefore, cardiac rehabilitation is an important component in the continuum of care for patients with cardiovascular diseases, including the older population. However, the vast majority of the 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 may represent an opportunity to provide effective healthcare to achieve a high quality of life for older patients. In the elderly population, the symptom complex of frailty represents physical, mental, psychological and social factors and is not only of social importance, but also of prognostic importance with regard to the hospitalization rate and mortality. The literature on improvement in exercise capacity during cardiac rehabilitation is sparse in the elderly population. Research programmes should therefore be aimed at specifically investigating the efficacy and effectiveness of cardiac rehabilitation in older, frail cardiac patients. In the current issue of the European Journal of Preventive Cardiology, Bierbauer et al. report how age and sex are associated with improvements in exercise capacity during a residential cardiac rehabilitation programme and the most important predictors of this change in exercise capacity.5 The authors demonstrated that clinically relevant improvements in exercise capacity were independent of patients’ age and sex. Although older patients improved their exercise capacity to a lesser degree than did younger patients, significant improvements could be observed up into octogenarian patients. In addition to these findings, the authors of the study report that heart failure and type 2 diabetes were important negative predictors of improvement in exercise capacity. However, patients with heart failure or diabetes still succeeded in reaching minimal clinically important improvement across all age groups up to 85 years of age. As indicated by these results, efforts need to be increased to refer eligible patients to structured rehabilitation programmes irrespective of patients’ age and sex. The overall referral rate of patients after a cardiovascular event to cardiac rehabilitation in Europe is less than 50%.6 Beyond that, referral to and participation in exercise-based cardiac rehabilitation is less frequent at an elderly age, especially for elderly females. Results of the Acute Myocardial Infarction in Switzerland (AMIS) plus registry show that the referral rate to cardiac rehabilitation continuously decreases with age.7 In contrast, elderly patients have exercise trainability comparable to that of younger patients participating in similar exercise programmes. Elderly patients show comparable improvement and no more complications or adverse outcomes of exercise training at an elderly age were described in any study.8 So elderly patients of both genders should be strongly encouraged to participate in exercise-based cardiac rehabilitation. Elderly and/or frail patients usually require individualised therapy. This takes place with particular attention to mobility, coordination and strength for fall prevention and maintenance/restoration of physical autonomy. Surgical procedures, cumulative comorbidities and cardiovascular risk factors were the factors with the strongest relationship to reduced exercise capacity in the elderly.9 Therefore, functional capacity is an important endpoint for therapies oriented to older adults with cardiovascular diseases. An exercise-based cardiac rehabilitation programme is associated with improvement in all domains of physical performance even in older adults after an acute coronary event or cardiac surgical intervention, particularly in those with poorer baseline performance. A relevant finding of the Cardiac Rehabilitation in Advanced aGE: Exercise TRaining and Active follow-up (CR-AGE EXTRA) randomised trial was that even a short (4 weeks) outpatient cardiac rehabilitation programme is effective in producing a sustained improvement in functional capacity measures in patients beyond the age of 75 years who are at increased risk of functional deterioration after hospitalisation.8 The process of cardiac rehabilitation in elderly patients must take into account the nature of the cardiac problem, concomitant illnesses and the physiological response to both exercise activity and the medical management of any underlying cardiac condition. Elderly patients usually show substantial functional improvement when participating in a cardiac rehabilitation programme and comply well with prescribed exercise. Poor compliance of elderly patients in participating in exercise activity is often associated with a lack of adequate information. Other factors associated with reduced compliance in the elderly include a lack of motivation, an extremely reduced exercise tolerance, socioeconomic problems and associated diseases. Therefore, early educational intervention may be crucial to reducing disability in these patients.10 Associated health problems and age-related deficits that adversely affect learning in these patients should also be viewed as handicaps that can be overcome. Further research to assist in tailoring an appropriate cardiac rehabilitation regimen for the older population will be necessary to provide not only a high quality but also a cost‐effective programme. In terms of cost-effectiveness, more research is required to assist with identifying and understanding which patient segments will produce greater cost-effectiveness and cost-utility from cardiac rehabilitation or alternative healthcare delivery models. The author(s) declared no potential conflicts of interests with respect to the research, authorship and/or publication of this article. The author(s) received no financial support for the research, authorship and/or publication of this article.