This post was authored by Alfred A. Bove, MD, PhD, MACC, member of ACC’s Sports and Exercise Cardiology Section.

For those of us who are lifelong runners, each year that goes by raises a concern about whether to continue to run and compete. Community-sponsored running events have accommodated the older athletes by age grouping the competitors so that we compete with our age group peers for finishing position. Most competitive or professional athletes are considered to be older athletes when they approach 40 years of age. There is clear data that indicates that strength and aerobic capacity decline with age, and even with similar training, older athletes usually don’t compete with their younger counterparts.

The Ironman triathlon was recently held in Hawaii, and there were 25 male and five female finishers over age 70. In Philadelphia in spring 2015 there were 40,000 participants in the city’s signature 10 mile race of whom 960 were over age 60, and 22 were over age 75. If you are a runner in Philly, it is a required event, regardless of your age. The older athletes don’t compete with the front runners, but remain committed to participating and competing among their peers or just improving their “personal best.”

Similar statistics can be found in published data on race participation. The report by Sumeet S. Chugh, MD, FACC, and Joseph B. Weiss, MD, published earlier this year in the Journal of the American Cardiology (JACC), showed that our older population is not sitting still. Many are not just walking for health, but are participating in competitive amateur races. Some data demonstrate a continuing increase in the number of participants in amateur running races to nearly 20 million in 2013. Organizers now understand that local races need to be designed to accommodate not only the fastest runners, but also the slower runners who will finish the race at a pace of 15 minutes a mile. Support systems for community-sponsored races are now routinely kept open for these slower older runners, and medical-support facilities established to support the runners expect to handle medical needs of runners of all ages.

A study by Duck-chul Lee, PhD, et al., published last year in JACC, evaluated the health status of 15,000 runners and showed that runners of all ages benefit from the exercise even at a slow running pace and for as little as 50 minutes a week. Many dedicated runners continue to run as they age, and will not use age alone as a reason to stop exercising. Often orthopedic problems limit exercise activity, or result in cessation of running activity. Runners sometimes revert to cycling, swimming or walking to maintain condition when joint problems limit running activity.

Safety of exercise has been an ongoing discussion. As athletes age, the etiology of sudden death converges on coronary disease as the principle cause. Yet there are ample data showing that risk of sudden death with exercise is greatly diminished in those individuals who exercise regularly. We have seen current literature indicate that marathon runners may be at increased risk for cardiac disease. It is clear that runners can have abnormal calcium scores, some degree of myocardial scarring, and enlarged left and right cardiac chambers. These findings are reported along with studies demonstrating a substantial reduction in risk for cardiac death in those who exercise. The article by James H. Currens, MD, and Paul D. White, MD, published in 1961 in the New England Journal of Medicine, describing the heart of lifelong marathoner Clarence DeMar also showed significant coronary atherosclerosis, myocardial fibrosis and cardiac enlargement. Yet, DeMar continued to compete until age 68 when he died of colon cancer. His coronary arteries were larger than average and the atherosclerosis resulted in no significant obstructions.

How should we approach the older man or woman who wants to exercise, or to continue exercising as a part of their daily life, with atherosclerotic risk and ischemia the major concern? If that person is exercising frequently without symptoms, and wants to continue with their same level of activity, an evaluation of usual cardiovascular risk factors should inform the process of evaluation. Most chronic exercisers follow a healthy lifestyle, so you won’t find smokers, body mass index should be normal, diet should be reasonably healthy. Usual age-related disorders will be found like hypertension, hyperlipidemia, often glucose intolerance rather than frank diabetes. If risk is high, a functional test is the best way to assure safety with exercise. If risk is low and the individual is exercising and participating in races without symptoms, they are likely to be at low risk for an event. If they are interested in increasing exercise intensity, or have significant risk factors, then a functional test is needed to assure safety.

For older individuals who take the advice of their physician and want to start exercising, risk assessment is essential, and a functional test is needed if risk is high. Occult ischemia might not be evident in a sedentary individual, but will be quite evident when activity is undertaken. Modest activity goals are essential for a new exerciser, with consideration of recovery time between activities. For those who want to participate in an organized event, I usually suggest planning for participation in six to 12 months with the interim time devoted to gradually increasing exercise intensity, smoking cessation, losing weight, changing dietary habits and aiming for a permanent change in lifestyle. Guideline-directed use of statins and antihypertensive medications should be part of the program, but for those over 70 years of age, it is not clear whether aspirin provides any benefit.

We are recommending exercise for all of our patients, and in many healthy patients over age 65, the lure of an organized race will get some older individuals to participate. Our part is to assure safety and provide some guidelines for continuing or starting exercise as our patients get older. Prohibition of competitive participation however should not be the advice, rather a careful consideration of goals, risk and prior health should produce a tailored exercise program for all of our patients regardless of their age.

This post is part of a series of posts from ACC’s Sports and Exercise Cardiology Section. For more information about the Section, click here. Follow the sports and exercise cardiology conversation on Twitter with the hashtag #SportsCardio.

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