Cardiac Rehabilitation in Very Old Adults: Effect of Baseline Functional Capacity on Treatment Effectiveness

Editor's Note: Commentary based on Baldasseroni S, Pratesi A, Francini S, et al. Cardiac rehabilitation in very old adults: effect of baseline functional capacity on treatment effectiveness. J Am Geriatr Soc 2016;64:1640-5.

Study Questions:

  • Is outpatient cardiac rehabilitation (CR) safe, sustainable, and effective in older adults (aged 75 years and older) referred after an acute coronary event (unstable angina pectoris, acute myocardial infarction) or cardiac surgery (coronary artery bypass grafting, heart valve replacement or repair)?
  • Does the baseline functional capacity of patients at entry into CR have bearing on their likely benefits from the program?

Methods:

Observational study of 160 adults, aged ≥75 years (mean age 80 ±4) referred to outpatient CR with an aerobic and strength training regimen. Enrollment, adherence and safety of a 4-week supervised CR program were evaluated as were the functional changes that occurred. Changes in physical function were assessed as: 1) Peak oxygen consumption (VO2) measured with symptom-limited bicycle cardiopulmonary exercise testing; 2) Distance walked during a 6-minute walk test (6MWT); 3) Peak torque (strength) measured with an isokinetic dynamometer.

Results:

Over two-thirds of patients referred to CR were enrolled with high adherence (100% completed the whole program, including 90% who completed >80% of the sessions while enrolled) and low rate of adverse events (no participant had to abandon the program permanently and no severe cardiac or non-cardiac complication occurred).

Indexes of physical performance improved from baseline to discharge (peak VO2 peak, 10.9%; 6MWT, 11.0%; peak torque, 11.5%).

Baseline performance was independently associated with changes in all three indexes, with higher baseline values predicting less improvement (peak VO2 peak: OR = 0.86, 95% confidence interval (CI): 0.77–0.97; 6MWT: OR = 0.99, 95% CI: 0.99–1.00; peak torque: OR 0.96, 95% CI: 0.94–0.98).

Conclusions:

An exercise-based cardiac rehabilitation program was effective in terms of enrollment and safety in older adults after an acute coronary event or cardiac surgical intervention. Gains in physical function were significant, particularly among patients with poorer performance at the onset.

Perspective:

Older adults referred to CR had high enrollment, adherence, and safety, with improved aerobic, strength, and balance functional domains, especially for those who were the most functionally impaired at baseline. Whereas many clinicians tend to refer older cardiac patients to CR who are relatively more robust, this study implies that older candidates who are enfeebled may derive the most benefits from participation. Benefits include reduced risks of disability for patients who are particularly vulnerable. This study is consistent with an earlier randomized trial which showed improvements in exercise tolerance and self-reported physical function from CR after myocardial infarction in adults aged ≥75 years that were similar to and/or larger than improvements in younger adults.1

References

  1. 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;107:2201-6.

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