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Circulation. 2002;105:1735-1743
doi: 10.1161/01.CIR.0000013074.73995.6C
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(Circulation. 2002;105:1735.)
© 2002 American Heart Association, Inc.

AHA Scientific Statement

Secondary Prevention of Coronary Heart Disease in the Elderly (With Emphasis on Patients >=75 Years of Age)

An American Heart Association Scientific Statement From the Council on Clinical Cardiology Subcommittee on Exercise, Cardiac Rehabilitation, and Prevention

Mark A. Williams, PhD; Jerome L. Fleg, MD; Philip A. Ades, MD; Bernard R. Chaitman, MD; Nancy Houston Miller, RN BSN; Syed M. Mohiuddin, MD; Ira S. Ockene, MD; C. Barr Taylor, MD; Nanette K. Wenger, MD


Key Words: AHA Scientific Statements • aging • coronary disease • prevention


*    Introduction
up arrowTop
 *Introduction
down arrowOverview of Coronary Heart...
 down arrowSecondary Prevention
 down arrowConclusions
 down arrowReferences
 
The overall aging of the American population and improving survival of patients with coronary heart disease (CHD) has created a large population of older adults (>=65 years of age) eligible for secondary prevention. The prevalence of chronic ischemic heart disease in men and women >=65 years of age in the United States in 1995 was 83 per 1000 men and 90 per 1000 women. Among those >=75 years of age, the prevalences were 217 per 1000 for men and 129 per 1000 for women.1 Increasing evidence has accumulated over the past 2 decades that elderly individuals with CHD can benefit greatly from exercise training and other aspects of secondary prevention.2

Traditionally, components of secondary prevention programming (including exercise; smoking cessation; management of dyslipidemia, hypertension, diabetes, and weight; and interventions directed at depression, social isolation, return to work, and other psychosocial issues) have been provided by the clinician in the office setting or through cardiac rehabilitation programs. Cardiac rehabilitation programs are particularly well suited to the provision of secondary prevention services, but unfortunately, many older patients who would derive benefit from these interventions do not participate because of lack of referral or a variety of societal and other barriers.3 It is the purpose of this Scientific Statement to provide an update on the benefits of specific secondary prevention risk factor interventions in this age group and, where possible, to delineate benefits in the older elderly (>=75 years of age). An increased awareness on the part of physicians, nurses, third-party payers, and patients and their families of the benefits of secondary prevention programs to older adults will provide a basis for referral and aid in the implementation of such programming.


*    Overview of Coronary Heart Disease in the Elderly
up arrowTop
 up arrowIntroduction
 *Overview of Coronary Heart...
down arrowSecondary Prevention
 down arrowConclusions
 down arrowReferences
 
The clinical manifestations of CHD in older patients represent the effects of the disease superimposed on the physiological effects of age. The presence of obstructive coronary artery disease at autopsy approaches 50% in elderly women and 70% to 80% in elderly men. Although octogenarians comprise 5% of the US population, they represent 20% of all hospitalizations for myocardial infarction (MI) and 30% of all MI-related hospital deaths.4 At coronary arteriography, elderly individuals have more extensive coronary artery disease, more multivessel disease, more coronary artery calcification, and are more likely to have had a prior MI.

Angina
Whereas typical angina pectoris remains common at elderly age, an increased percentage of older versus younger patients have atypical manifestations of myocardial ischemia, including dyspnea and worsening heart failure, in addition to an excess occurrence of unstable angina and non–Q-wave MI.5,6 This "anginal equivalent" is thought to be mediated by an exaggerated rise in left ventricular (LV) end-diastolic pressure, resulting from the effect of ischemia superimposed on age-associated reduction in LV compliance in a moderately hypertrophied ventricle.7 Several studies have demonstrated that patients with CHD presenting with acute pulmonary edema are generally older than those manifesting typical anginal symptoms.8,9 The frequent symptomatic presentation of coronary ischemia as dyspnea is related to a number of factors, including significant mitral valvular regurgitation, which also may be responsible for those symptoms of left heart failure.9 An even more frequent substitution of dyspnea for chest discomfort also occurs in elderly patients with acute MI. This atypical presentation of acute MI, particularly in women, may partially explain the high rate of unrecognized MI in this age group.10

Reductions in physical activity and aerobic exercise capacity often seen with "normative" aging also affect the older CHD patient. The frequent coexistence of chronic lung disease, peripheral arterial disease, arthritis, and neuromuscular disorders may make ambulation difficult. A lack of anginal symptoms in an elderly patient with suspected CHD may merely reflect the patient’s lack of significant activity.

Myocardial Infarction
Contributions to increased MI mortality at an elderly age include an increased incidence of comorbid conditions, more extensive CHD, and a lesser use of beneficial therapies, including substantial underuse of medications shown to improve MI survival (eg, aspirin, ß-blocking drugs, and angiotensin-converting enzyme [ACE] inhibitors).11–16 Furthermore, in the Myocardial Infarction Triage and Intervention Registry, which compared patients >75 years of age to younger patients, the rates of coronary thrombolysis were 5% versus 39%, percutaneous transluminal coronary angioplasty (PTCA) 7% versus 29%, coronary artery bypass grafting (CABG) 5% versus 11%, and aspirin use 57% versus 82%.11

Although the benefit of coronary thrombolysis is evident to age 75, this is not the case at very elderly age. Primary PTCA seems to offer an advantage over coronary thrombolysis in the very elderly, although both strategies have significantly better outcomes than conservative care.17 The American Heart Association/American College of Cardiology (AHA/ACC) Guidelines for Preventing Heart Attack and Death in Patients With Atherosclerotic Cardiovascular Disease recommend that all patients who have had an MI should be treated with ACE inhibitors and that these should be started early in stable, high-risk patients.18 Long-term ACE therapy should be considered for all other patients with coronary or other vascular disease unless contraindicated. ß-Blocker therapy should be started and continued indefinitely in all post-MI and acute ischemic syndrome patients, dependent on contraindications.18

Interventional Therapy
Because many older patients tolerate antianginal therapy poorly, and because octogenarians with unstable angina treated medically have an event-free one-year survival rate of only 55% with a high rate of persistent symptoms and recurrent hospitalizations, major interest has focused on the value of interventional therapy.19 Although angiographic success is comparable to that seen in younger patients, elderly patients who undergo PTCA are more likely to be women and to have multivessel high-grade stenoses and an excess of hospital death and postprocedural MI.20–23 The newer transcatheter procedures, including intracoronary stenting, have shown similar success rates in patients >=70 years of age compared with younger patients in the Newer Approaches To Coronary Interventions (NACI) Registry, although other studies have described an excess of non–Q-wave MI and vascular complications in this older patient group.24

Coronary Artery Bypass Graft Surgery
An increasing number of octogenarians undergo CABG surgery, many of them reoperations.25 Elderly patients are more likely to have unstable and severe angina, to be women, and to have hypertension, heart failure (HF), and other vascular diseases. Nonrandomized comparisons show a 3-year survival rate of 77% with elective CABG versus 54% for medical therapy.26 Five-year survival is improved with CABG versus PTCA (66% versus 55%).27 In the database of the Society of Thoracic Surgeons (1995 to 1996), a 4.7% CABG mortality rate is described for octogenarians.28 However, there is an excess of postoperative arrhythmias (particularly atrial fibrillation), stroke, and protracted hospital stay, despite subsequent excellent anginal relief and improved functional status. One series showed the survival after CABG in octogenarians to be comparable to that for the US octogenarian population as a whole.

Arrhythmias
Frequency of complex cardiac arrhythmias, both atrial and ventricular, increases markedly with age in clinically healthy populations and may also be a sign of acute myocardial ischemia in the elderly.29 Sudden death as the initial manifestation of CHD is more common in this age group. Atrial fibrillation affects {approx}10% of individuals older than 80 years of age, with CHD, hypertension, and valvular disease the most common causes, often in association with HF.30,31 The development of atrial fibrillation during an episode of myocardial ischemia often presents as acute HF, which may rapidly resolve with restoration of sinus rhythm.


*    Secondary Prevention
up arrowTop
 up arrowIntroduction
 up arrowOverview of Coronary Heart...
 *Secondary Prevention
down arrowConclusions
 down arrowReferences
 
Strategies for impacting risk factors associated with secondary events in patients with CHD have been used frequently, although relatively few data have been reported about the effectiveness of these interventions in older patients. Benefits for these patients, including those >=75 years of age where possible, are described here.

Smoking Cessation
Continued smoking after acute cardiac events such as an MI or CABG surgery is associated with significant deleterious effects on the cardiovascular system. These effects include an increase in blood pressure, heart rate, and peripheral vascular resistance, especially in older individuals; an increase in catecholamines; an impairment in flow-mediated dilation of coronary arteries; increased susceptibility to clotting; and metabolic changes, including a reduction in high-density lipoprotein (HDL)-cholesterol.32 The cumulative deleterious effects are often angina pectoris, MI, stroke, and death.

For individuals with cardiovascular disease, the benefits of quitting smoking are numerous. Moreover, these benefits accrue within the first year of quitting. Cessation reduces overall mortality by 25% to 50% in those who have suffered an MI, and at least 50% of this decline is seen in the first year.33 Data from the Coronary Artery Surgery Study (CASS) indicate that smoking cessation reduces both morbidity and mortality rates in those over the age of 70 who have undergone CABG surgery.34 The reduction in relative risk of MI and death in those over age 70 is similar to that seen in younger individuals. Thus, advanced age does not attenuate the benefits of quitting.

Smoking cessation rates in middle-aged and older individuals with cardiovascular disease range from 20% to 70% at the end of one year.35 In response to high rates of relapse, the US Public Health Service Guideline, Treating Tobacco Use and Dependence, has classified tobacco dependence as a chronic condition requiring repeated intervention.36 Interventions noted to be effective in younger individuals have also proved effective in elderly cardiovascular patients.37,38 These interventions include strong physician advice, behavioral counseling, buddy support programs, self-help materials, telephone counseling, and the use of pharmacological therapies. Multi-component programs that combine strong physician advice, behavioral counseling at the bedside, nicotine replacement therapy, and telephone follow-up by nurse case managers after hospital discharge have been shown to be highly effective in helping cardiovascular patients to quit smoking.35,39

Management
Both nicotine replacement therapy and other pharmacological agents are safe in patients with cardiovascular disease, including the elderly.36 Cardiac rehabilitation programs offer a unique opportunity to provide smoking cessation counseling for older cardiovascular patients. These programs enable healthcare professionals to provide the behavioral and pharmacological interventions that are needed to help smokers succeed in quitting.

Hypertension
Hypertension is common among elderly patients of both sexes and is a major risk factor for CHD, cerebrovascular disease, and peripheral arterial disease. It is the most common antecedent of HF and chronic renal failure. According to Joint National Commission (JNC) VI criteria, >50% of people over the age of 60 years, especially women, are hypertensive.40 Treatment and control of hypertension are suboptimal in the elderly, inasmuch as nearly two thirds of those >=75 years of age have uncontrolled hypertension, defined as systolic blood pressure >=140 mm Hg and/or diastolic blood pressure >=90 mm Hg.41 Isolated systolic hypertension (systolic blood pressure >=140 mm Hg with diastolic blood pressure <90 mm Hg) is the most common type of hypertension in the elderly, and a wide pulse pressure (>=50 mm Hg) in this age group may be a better marker for cerebrovascular disease and HF than mean or diastolic blood pressure.42

Meta-analysis has demonstrated that the benefits of antihypertensive therapy are particularly high in patients 60 to 80 years of age.43 In the older population, treatment prevents strokes and HF more than coronary events, but overall mortality also is reduced. The target for lowering blood pressure should be the same as in younger patients, <140/90 mm Hg, with a lower target (<130/80 mm Hg) in patients with heart failure, renal insufficiency, and type 2 diabetes mellitus.40

Large, randomized hypertension treatment studies have not included a sufficient number of older patients to draw conclusions for patients aged >=80 years. Results from both the recent Systolic Hypertension Europe (SYST-EUR) study and a subgroup meta-analysis of randomized controlled antihypertensive drug trials support benefits of therapy.44,45 Both studies demonstrated the benefits of active treatment in patients >=80 years of age, including a significant reduction in the risk for stroke, major cardiovascular events, and HF. However, there was no reduction in cardiovascular death or total mortality. A large international trial evaluating the effect of antihypertensive therapy on incidence of stroke and cognitive function (HYpertension in the Very Elderly Trial [HYVET]) in patients >=80 years of age, may provide definitive information regarding the risk and benefits in this population.

Management
Treatment of hypertension in the elderly should follow the JNC VI guidelines.40 Nonpharmacological therapy, a cornerstone of management, including weight reduction, decreased sodium and alcohol intake, and exercise, is more effective in older populations when compared with the younger age group.46 Selection of pharmacological therapy should be based on the severity of hypertension, presence of risk factors, and target organ damage. Selection of a specific drug therapy also depends on the presence of comorbidities, particularly HF and type 2 diabetes mellitus, for which ACE inhibitors are particularly appropriate. Control of hypertension and, specifically, isolated systolic hypertension has been clearly associated with reduction in morbidity and mortality due to stroke, CHD, HF, and chronic renal failure.47

Abnormal Lipid Levels
Multiple studies have demonstrated the value of lipid-lowering therapy for both the primary and secondary prevention of CHD. Because these studies have not been specifically oriented toward the elderly, the value of such therapy in older individuals has been questioned. However, substantial data from subanalyses of older subjects within existing studies are available, and in addition, there are now several studies in progress that are specifically oriented toward this patient group.

The Scandinavian Simvastatin Survival Study (4S) demonstrated important reductions in coronary event–related morbidity and mortality in patients with known CHD.48 In a post hoc analysis from this study, it was demonstrated that cholesterol lowering with simvastatin produced similar reductions in relative risk for major coronary events in patients >=65 years of age compared with younger patients. Thus, CHD mortality was reduced 42% in subjects <65 years of age and 43% in those >=65 years of age. Likewise, hospitalization for CHD was reduced by 31.8% in those under age 65, and by 33.1% in those >=65 years of age. Because mortality rates increase substantially with age, the absolute risk reduction for both all-cause and CHD mortality in simvastatin-treated subjects was approximately twice as great in the older patients.

A similar analysis from the Cholesterol and Recurrent Events (CARE) trial conducted in patients whose total cholesterol was <=240 mg/dL demonstrated that statin therapy in the elderly was equally effective when applied to older patients with known CHD whose total cholesterol was not above 240 mg/dL.49 Major coronary event rates were reduced 19% in those <65 years of age but 32% in those >=65 years of age. For CHD deaths, the differential was even more striking. CHD mortality was decreased by 11% in subjects <65 years of age but decreased by 45% in those >=65 years of age. Again, because of the greater absolute risk to which the elderly are subject, they derived a greater absolute benefit. Thus, for every 1000 older patients treated, 225 cardiovascular hospitalizations would be prevented compared with 121 hospitalizations in 1000 younger patients.

Finally, the Pravastatin Pooling Project, which compared subjects with CHD who were younger versus those >=65 years of age, also demonstrated identical benefits in the elderly.50 The relative risk reduction for the combined end point of CHD death/nonfatal MI was 32% in those <55 years of age, 21% in the 55- to 64-year age group, and 26% in those between 65 and 75 years of age.

Each of these studies described the greater absolute risk to which elderly patients are subject and thus demonstrated that a relative risk reduction similar to that seen in younger individuals produces a greater absolute benefit in the older group. Statin therapy in the elderly has been projected to be cost-effective. On the basis of present costs for statin therapy, the incremental cost for quality-adjusted life-year in the elderly was $18 800.51 Decreasing statin costs by increasing the availability of generic preparations would produce a further favorable effect.

To date, all of the available lipid-lowering studies have included individuals up to 75 years of age but very few subjects >=75 years of age. Consequently, there are few actual data available to guide us in recommending lipid-lowering therapy for patients >=75 years of age. However, examination of the studies done so far demonstrates no evidence of a diminishing effect with age. In fact, the elderly derive greater benefits from therapy because of their greater absolute risk. Thus, there is reason to believe that lipid-lowering therapy should be extended to the very elderly coronary patient. Nonetheless, the clinician should not overlook quality-of-life issues, concomitant illness, and remaining life expectancy in these patients. Most studies to date have shown a one- to two-year lag time before any benefit is demonstrable. In order for lipid-lowering therapy to be reasonable, such a lag time should not represent too large a proportion of remaining life expectancy.

At present, there are two ongoing studies specifically oriented toward the value of statin therapy in the elderly. These are the Prospective Study of Pravastatin in the Elderly (PROSPER), which will study patients with vascular disease or high risk of vascular disease, and the Fluvastatin Assessment of Morbidity/Mortality in the Elderly (FAME), another primary-care study of subjects. These studies should provide more specific information on which to base therapeutic decisions in the elderly.

Management
In conclusion, data suggest that older patients with CHD will benefit from having abnormal lipid levels treated, and that the benefit they derive is likely to be even greater than that which is seen in younger patients. The National Cholesterol Education Program Adult Treatment Panel III guidelines should be followed, bringing low-density lipoprotein (LDL)-cholesterol levels down to <100 mg/dL and, if at all possible, increasing HDL-cholesterol levels to >40 mg/dL.52 Recommendations for appropriate levels of triglycerides in the elderly are not specifically addressed here because few data relative to this age group are available. However, the AHA/ACC guidelines for secondary prevention suggest that, in general, when triglyceride level is >=200 mg/dL, then non–HDL-cholesterol (total cholesterol minus HDL-cholesterol) should be <130 mg/dL.18

Obesity
Obesity is a risk factor for second coronary events in older men and women with CHD, according to data from the Framingham Study.53 This is due primarily to the prominent clustering of dyslipidemia, hypertension, and insulin resistance in older overweight individuals and particularly in individuals with preferential abdominal obesity.54 Weight loss, therefore, has the potential to act as a multifactorial risk reduction intervention in this population. Unfortunately, few data are available that describe the effect of either increased physical activity or hypocaloric diets as means to impact obesity in older patients with CHD.

The effect of exercise training alone, without a nutritional intervention, on measures of obesity and abdominal adiposity in older coronary patients has been only minimal.55,56 Body weight, body fat percentage, fat mass, and waist circumference have been shown to improve only slightly. However, significant correlations between changes in body mass and fat mass with risk factors such as lipid subfractions, glucose, and insulin measures have been observed. The relatively minimal effect of exercise alone on body weight is probably due to the low exercise-related energy expenditure accomplished by patients with CHD in general and particularly by older patients.57 An alteration of the exercise prescription to include more frequent and more prolonged bouts of walking as a means to increase exercise-related energy expenditure is promising as an adjunct to dietary therapy in older obese patients with CHD.58

Likewise, little attention has been paid to the use of hypocaloric diets in the management of weight in these patients. One study of obese patients with CHD with a mean age of 60 years demonstrated a mean weight loss of 11 kg, a 10% decrease in both total cholesterol and LDL-cholesterol levels, a 24% reduction in triglycerides, and an 8% increase in HDL-cholesterol on such a diet.59

Management
Results from a behaviorally based weight reduction program and nutritional counseling for older obese patients in a clinical setting are not yet available.60 Nonetheless, although older CHD patients have a lower rate of obesity than do their younger counterparts, weight loss induced by exercise or hypocaloric diets in older patients is associated with similar improvements in cardiac risk factors such as lipid subfractions and measures of insulin resistance. Thus, there is reason to expect a reduction in secondary coronary events.

Diabetes
The presence of diabetes mellitus is a powerful predictor for the occurrence of secondary coronary events in older CHD patients.61 The prevalence of insulin resistance and diabetes mellitus increases with age, particularly in the presence of abdominal obesity.62 Exercise training is well known to improve insulin resistance and diabetic control in healthy older persons.63,64 In middle-aged CHD patients, even short-term exercise training improves hyperinsulinemia.65 In older coronary patients, glucose and insulin levels are more closely related to total body fat mass rather than to measures of fitness or exercise training response.55 This suggests that the effect of exercise programming on glycemic control in older diabetic patients may relate more to its favorable effects on fat mass or body fat distribution than to its effect on fitness per se.55,56 Thus, the treatment of obesity in overweight, older diabetic patients assumes a particularly prominent role.

Management
The management of diabetes mellitus in older CHD patients should extend beyond exercise programming and weight management programs to include blood glucose screening for undiagnosed patients and surveillance of individuals already on treatment.66 The intake assessment should include measurement of fasting glucose as well as glycosylated hemoglobin at the time when lipid and other risk factors are being assessed. Patients with diabetes need to be informed about the short-term hypoglycemic effects of exercise. Frequent fingerstick measurements before and after exercise can help guide therapy. Appropriate hypoglycemic therapy to achieve near-normal fasting plasma glucose with the goal of a glycosylated hemoglobin level <7% is recommended.18 Treatment of other risk factors is also essential. Nutritional counseling, particularly as it relates to the treatment of obesity, should be provided, and treatment plans should be coordinated with primary care physicians. Affiliation with a diabetic treatment center is useful, particularly as it relates to educational issues and comprehensive care of newly diagnosed individuals.

Psychosocial Interventions
Few studies have examined the particular psychosocial needs of elderly patients with CHD who are participating in secondary prevention and cardiac rehabilitation programs. However, research from younger populations and elderly populations with noncardiac illnesses helps to define those psychosocial issues important to older cardiac patients.67 Although there are many psychosocial problems that could be addressed, general domains that need assessment or intervention include socioeconomic status, depression, social support/isolation, cognitive functioning, and issues related to work, sexual activity, and well-being.

Income and education may have a profound effect on morbidity and mortality. Low socioeconomic status is not only a risk factor for CHD mortality in both men and women, but it also influences participation in secondary prevention/rehabilitation programs.67 Therefore, assessing a patient’s educational and economic resources, and making adjustments/recommendations as needed, are important when designing secondary prevention programs.

Studies indicate that depression has a major impact on morbidity, mortality, and functional recovery in patients with cardiovascular disease; 10% to 15% of older patients are depressed, with as many as 20% showing significant signs of anxiety.68 Because safe and effective treatments for reducing depression are available, all elderly patients should be evaluated for depression and offered treatment as appropriate. Elderly individuals, especially those >=75 years of age, suffer significant personal, financial, and other types of losses. For instance, among those over the age of 65 years, 51% of women and 13% of men are widowed.69 These losses may lead to depression, isolation, and other problems. Lack of social support and social isolation have been associated with increased morbidity and mortality in elderly men and women after MI.70 Of note, social support/isolation is a complex phenomenon involving emotional and social aspects, mediated through family, friends, and religious networks. The National Heart, Lung, and Blood Institute (NHLBI) Enhancing Recovery in Coronary Heart Disease trial (ENRICHD), which is evaluating the effects of interventions to reduce depression and social isolation in a large sample of post-MI patients, half of whom are >=65 years of age, should help to clarify the roles of social support and reducing depression in elderly patients with heart disease.68

Changes in sensory function make it difficult for many elderly patients to read health information or hear instructions. In addition, significant cognitive impairment is likely to be present in elderly people.69 Dementia, for example, is prevalent in 15% to 20% of those over the age of 85 years.71 Finally, whereas the rates of alcohol and substance abuse seem to diminish with age, they are still common in older patients and may go unrecognized if not assessed.72

The level of interest that elderly cardiovascular patients exhibit in working or participating in physical and social activities, including remaining sexually active, is an important consideration in assessing and maintaining quality of life. To the degree possible, elderly patients should be encouraged to remain active, not just for the physiological benefit, but for psychosocial well-being as well. As for intimacy, up to 30% of married couples >=75 years continue to have sex, and at least 7% of elderly individuals without spouses are sexually active.73

Management
Assessing desires for physical functioning, including helping individuals continue to remain sexually active, is an important part of the psychosocial assessment and intervention. A general psychosocial assessment may be helpful in routine evaluation of participants.74 Simple screening tools can help identify most major problems and can be followed up with more sophisticated instruments or assessments as required and referral for treatment as needed.75 Finally, healthcare providers need to be familiar with and address end-of-life issues in patients with terminal CVD illness, including determination of patients’ advanced directives.76

Physical Activity
The prescription of exercise for increasing physical activity and fitness for elderly patients with heart disease has been an essential component of secondary prevention for at least two decades.77 The basis for an exercise intervention in these patients includes improved functional capacity with reduced activity-related abnormal signs or symptoms. Increases of 10% to 60% in functional capacity and 10% to 25% reduction of myocardial work at standardized exercise workloads have been observed after 12 weeks of early exercise training after hospitalization.56,78–82 Extended periods of training have resulted in further gains, although modest, in these parameters.81,83 Expected outcomes are similar to those for younger patients, although absolute levels of functional capacity in the elderly are less, and results may require longer program participation in this age group, particularly for those patients >=75 years of age.77–79 As with younger patients, a multidisciplinary approach to secondary prevention that includes exercise may positively impact other heart disease risk factors, including hypertension, obesity, elevated blood glucose level, and various psychosocial parameters, particularly quality of life, while combating feelings of isolation and depression.2,56,82

Whether exercise training as a part of secondary prevention is associated with a reduction of events of morbidity or mortality as in younger patients has yet to be established. However, one study of older patients with heart disease and several others of older persons without known heart disease have suggested a positive impact of physical activity on mortality. In the British Regional Heart Study (5934 men with established CHD; mean age, 63 years), results suggested that light-to-moderate activity is associated with a significantly lower risk of all-cause mortality over the 5-year follow-up.84 In recent studies of subjects without diagnosed heart disease at protocol entry, several have demonstrated the relationship of physical activity to mortality. Hakim and colleagues85 studied a cohort of 707 men, mean age 69 years, from the Honolulu Heart Program, finding that regular walking was associated with a lower overall mortality rate over the 12-year follow-up. Results from the Iowa Women’s Health Study found similar results (40 417 women; mean age, 62 years), concluding that there was an inverse association between physical activity and all-cause mortality in postmenopausal women over the 7-year follow-up.86 Lastly, results from the Cardiovascular Health Study (5201 men and women; mean age, 73 years) suggested that level of physical activity was an independent predictor of 5-year mortality.87

Management
The recommendations for increasing participation in programs of physical activity should not be limited to structured exercise but should also include a broader interpretation of exercise programming, including consideration of differences in needs between women and men, occupational and leisure activities and simple acts of daily living, the importance of socialization, and diversity of exercise activities.88 It is incumbent on clinicians to strongly and repeatedly encourage exercise participation, while carefully considering the appropriate and individualized recommendations for the exercise prescription.

Methods for prescribing exercise for cardiac patients have been published and generally do not require significant modification for elderly patients.89 The exercise prescription should define individual patient guidelines for activity while allowing for, and encouraging, variation in the exercise regimen. The exercise program should promote all aspects of physical conditioning, including aerobic capacity and muscular endurance, range of motion and flexibility, and muscular strength.

Modification of the components of the exercise prescription should be considered for elderly patients, particularly those >=75 years of age and those with significant comorbidities that limit mobility, eg, arthritis, pulmonary disease, and peripheral arterial disease. Increasing caloric expenditure and enhancement of functional mobility should be emphasized, as well as participation in activities that increase socialization with others. The latter is paramount to combating feelings of isolation and depression. Increasing frequency and duration of exercise sessions should supersede increases in intensity and progression to reduce the potential for overuse injuries.

Strength training for elderly patients as a component of the overall exercise prescription should improve neuromuscular function, muscular strength, and endurance. Such training is essential to improving responses to the various physical demands of daily living as well as occupational and recreational activities.90 Furthermore, it is likely to improve functional independence and self-esteem, while reducing the risk of injury associated with musculoskeletal overuse and falls.

Cardiac Rehabilitation Participation and Adherence
The provision of education, counseling, and behavior interventions are critical elements of secondary prevention programming, and because of a variety of resources, particularly the availability of trained personnel, the cardiac rehabilitation program is often the optimal setting for their implementation. Specialists in disease management, smoking cessation, diet, and exercise provide initial interventions and reinforce appropriate behavior. On the basis of a comprehensive review of the scientific literature, the Agency for Health Care Policy and Research concluded that "cardiac rehabilitation services are an essential component of the contemporary management of patients with multiple presentations of CHD and heart failure." Unfortunately, utilization of cardiac rehabilitation by older patients with CHD historically has been poor, especially in women. Participation in secondary prevention programs has been estimated at {approx}20% for eligible patients, and long-term adherence is even more dismal.3,91–93 This low rate of participation and adherence is problematic given the benefits associated with cardiac rehabilitation and exercise training in the elderly.78,82,94 Barriers to patient referral and subsequent program entry and adherence include (1) lack of recognition by healthcare providers as well as their patients and families of the value of secondary prevention in this age group; (2) economic and logistic considerations for those wishing to participate; and (3) limited opportunities for safe and effective, reduced-cost programming, such as home-based or community center programs.

Nonetheless, it seems that the strength of the primary care physician’s referral to cardiac rehabilitation is the most powerful predictor of subsequent participation.3 Providing the opportunity for the patient and family to participate in the design of the intervention, underscoring the importance of specific interests and concerns, and overcoming potential limitations to active participation are essential to long-term adherence.77


*    Conclusions
up arrowTop
 up arrowIntroduction
 up arrowOverview of Coronary Heart...
 up arrowSecondary Prevention
 *Conclusions
down arrowReferences
 
Secondary prevention interventions to impact and control risk factors in older patients with CHD, including habitual cigarette smoking, hypertension, abnormal blood lipids, elevated blood glucose, obesity, various psychological concerns, and physical inactivity, appear effective to an extent similar to that observed in younger patients. Greater involvement of the elderly in these programs is needed to fully realize the therapeutic and secondary preventive potential.


*    Footnotes
 
The American Heart Association makes every effort to avoid any actual or potential conflicts of interest that may arise as a result of an outside relationship or a personal, professional, or business interest of a member of the writing panel. Specifically, all members of the writing group are required to complete and submit a Disclosure Questionnaire showing all such relationships that might be perceived as real or potential conflicts of interest.

This statement was approved by the American Heart Association Science Advisory and Coordinating Committee in January 2002. A single reprint is available by calling 800-242-8721 (US only) or writing the American Heart Association, Public Information, 7272 Greenville Ave, Dallas, TX 75231-4596. Ask for reprint No. 71-0224. To purchase additional reprints: up to 999 copies, call 800-611-6083 (US only) or fax 413-665-2671; 1000 or more copies, call 410-528-8521, fax 410-528-4264, or e-mail mrayfiel@lww.com. To make photocopies for personal or educational use, call the Copyright Clearance Center, 978-750-8400.


*    References
up arrowTop
 up arrowIntroduction
 up arrowOverview of Coronary Heart...
 up arrowSecondary Prevention
 up arrowConclusions
 *References
 

  1. National Center for Health Statistics. Current Estimates from the National Health Interview Survey, 1995. Hyattsville, Md: US Department of Health and Human Services, CDC; 1998. DHS publication No. (PHS) 98-1527.
  2. Wenger NK, Froelicher ES, Smith LK, et al. Clinical Practice Guideline No. 17: Cardiac Rehabilitation. US Department of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research, National Heart, Lung, and Blood Institute; 1995. AHCPR Publication No. 96-0672.
  3. Ades PA, Waldmann ML, McCann WJ, et al. Predictors of cardiac rehabilitation participation in older coronary patients. Arch Intern Med. 1992; 152: 1033–1035.[Abstract]
  4. Wenger NK, ed. Cardiovascular Disease in the Octogenarian and Beyond. London: Martin Dunitz, Ltd; 1999.
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