Exercise rehabilitation of older patients with cardiovascular disease

Cardiac Rehabilitation in German Speaking Countries of Europe-Evidence-Based Guidelines from Germany, Austria and Switzerland LLKardReha-DACH-Part 2

Background: Scientific guidelines have been developed to update and harmonize exercise based cardiac rehabilitation (ebCR) in German speaking countries. Key recommendations for ebCR indications have recently been published in part 1 of this journal. The present part 2 updates the evidence with respect to contents and delivery of ebCR in clinical practice, focusing on exercise training (ET), psychological interventions (PI), patient education (PE). In addition, special patients’ groups and new developments, such as telemedical (Tele) or home-based ebCR, are discussed as well. Methods: Generation of evidence and search of literature have been described in part 1. Results: Well documented evidence confirms the prognostic significance of ET in patients with coronary artery disease. Positive clinical effects of ET are described in patients with congestive heart failure, heart valve surgery or intervention, adults with congenital heart disease, and peripheral arterial disease. Specific recommendations for risk stratification and adequate exercise prescription for continuous-, interval-, and strength training are given in detail. PI when added to ebCR did not show significant positive effects in general. There was a positive trend towards reduction in depressive symptoms for “distress management” and “lifestyle changes”. PE is able to increase patients’ knowledge and motivation, as well as behavior changes, regarding physical activity, dietary habits, and smoking cessation. The evidence for distinct ebCR programs in special patients’ groups is less clear. Studies on Tele-CR predominantly included low-risk patients. Hence, it is questionable, whether clinical results derived from studies in conventional ebCR may be transferred to Tele-CR. Conclusions: ET is the cornerstone of ebCR. Additional PI should be included, adjusted to the needs of the individual patient. PE is able to promote patients self-management, empowerment, and motivation. Diversity-sensitive structures should be established to interact with the needs of special patient groups and gender issues. Tele-CR should be further investigated as a valuable tool to implement ebCR more widely and effectively.

Dose-Response Relationship between Endurance Training Prescription Variables and Increases in Aerobic Performance of Healthy and Unhealthy Middle and Very Old Individuals Aged 70 Years and Older: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Background: The objectives of this systematic review and meta-analysis were to quantify the effectiveness of endurance training (ET) on aerobic performance (i.e., peak oxygen uptake (VO_2peak)) in healthy and unhealthy middle and very old adults aged 70 years and older, and to provide dose–response relationships of training prescription variables (in terms of frequency, and volume). Methods: Several scholarly databases (i.e., PubMed/MEDLINE, SpringerLink, ScienceDirect Journals, and Taylor & Francis Online—Journals) were searched, identifying randomized controlled studies that investigated the effectiveness of ET on VO_2peak in older adults. Standardized mean differences (SMD) were calculated. Results: In terms of changes differences between experimental and control group, ET produced significant large effects on VO_2peak performance (SMD = 2.64 (95%CI 0.97–4.31)). The moderator analysis revealed that “health status” variable moderated ET effect onVO_2peak performance. More specifically, ET produced larger SMD magnitudes on VO_2peak performance in healthy compared with unhealthy individuals. With regard to the dose–response relationships, findings from the meta-regression showed that none of the included training prescription variables predicted ET effects on VO_2peak performance. Conclusions: ET is an effective mean for improving aerobic performance in healthy older adults when compared with their unhealthy counterparts.

Gender-specific issues in cardiac rehabilitation: do women with ischaemic heart disease need specially tailored programmes?

Ischaemic heart disease (IHD) has changed from a disease of middle-aged men in the late 1970s to a disease of elderly women in the 2000s. Most clinical studies during the past three decades have been conducted with men. Cardiac rehabilitation programmes were also developed with special regard to improving the rate of return to work in middle-aged men. The rehabilitation needs of older patients and women in particular have been largely neglected. The aim of this review is briefly to outline our present knowledge on gender issues in cardiac rehabilitation, and to specify barriers with regard to physical activities especially in (older) women. Coping with a cardiac event, women tend to minimize or play down the impact of their health situation and avoid burdening their social contacts. After a first cardiac event, women report greater psychological distress and lower self-efficacy and self-esteem. In addition, older age, lower exercise levels and reduced functional capacity or co-morbid conditions such as osteoporosis and urinary incontinence are barriers to physical activities in women with IHD. Recent studies on psychosocial intervention revealed less favourable results in women compared with men. These findings have not yet been well explained. This emphasizes our current lack of knowledge about the processes and determinants of successful psychosocial interventions in men and women with IHD. A large (European) trial on gender-specific coping styles, needs, and preferences of older women, and the effects of psychosocial intervention is proposed.

Performance-based functional assessment of patients undergoing transcatheter aortic valve implantation

BACKGROUND

Very few data exist on the functional evaluation of patients with severe symptomatic aortic stenosis undergoing transcatheter aortic valve implantation (TAVI). The aims of this prospective study were (1) to evaluate the Duke Activity Status Index (DASI) as a measure of functional status pre-TAVI and post-TAVI, (2) to determine the clinical parameters associated with DASI changes after TAVI, and (3) to compare functional status as evaluated by DASI and the New York Heart Association (NYHA) class with exercise capacity as evaluated by the 6-minute walk test (6MWT) in such patients.

METHODS

A total of 76 patients (80 ± 8 years old) who underwent successful TAVI were included. All patients completed the DASI self-questionnaire at baseline and at 6 months after TAVI, and 46 patients also performed a 6MWT.

RESULTS

The mean DASI increased from 10.3 ± 5.4 to 16.3 ± 8.3 at 6 months after TAVI (P < .0001). However, the DASI did not change or even decreased to some extent in 30% of patients after TAVI. Renal dysfunction as evaluated by the estimated glomerular filtration rate was identified as the independent predictor of DASI impairment after TAVI (OR 1.7 for each decrease in estimated glomerular filtration rate of 10 mL/min/1.73 m(2), 95% CI 1.3-2.3, P = .005). The mean distance walked increased from 165.9 ± 77.6 to 211.8 ± 78.7 m (P = .0001) at follow-up. The DASI showed a good correlation with the distance walked at baseline (r = 0.55, P < .0001) and at follow-up (r = 0.66, P < .0001). The NYHA class improved to some degree in all but 5 patients; however, the NYHA class did not correlate with the results of DASI and the 6MWT.

CONCLUSIONS

Transcatheter aortic valve implantation was associated with a significant increase in functional status at 6-month follow-up as evaluated by the DASI, although no improvement was observed in about one third of patients. The presence of baseline renal dysfunction better determined this lack of improvement in functional status. The DASI, but not the NYHA class, correlated with distance walked in the 6MWT. These results suggest that the DASI might become a useful tool for evaluating both candidates for and the impact of TAVI procedures.

Cardiac rehabilitation – Past to Present

Abstract

Cardiac rehabilitation and secondary prevention can promote recovery, reduce coronary events and improve quality of life in many people with heart disease. Traditionally provided for people with coronary heart disease, there is scope to have provision for a range of people, both young and old, and including those with heart failure, valve disease or with an internal cardiac defibrillator. At its best, cardiac rehabilitation spans the whole pathway of care, beginning before admission to hospital and continuing long after, with ongoing management of lifestyle changes. Guidelines are available based on best evidence, and programmes focus on the whole person and address physical, psychological and social well-being. They incorporate health education, risk factor modification, social support and exercise. Programmes can be run in the community, home or hospital. To ensure effective cardiac rehabilitation for each patient, members of the multi-disciplinary team are challenged to work together to meet the individual needs of patients and their family. The standard of care should be monitored through audit so that improvements can be made.

Influence of an early recovery telehealth intervention on physical activity and functioning after coronary artery bypass surgery among older adults with high disease burden

OBJECTIVE

Older adults with poor functioning preoperatively are at risk for delayed recovery and more impaired outcomes after coronary artery bypass surgery (CABS). The study objective was to determine whether a 6-week early recovery telehealth intervention, designed to improve self-efficacy and management related to symptoms after CABS, was effective in improving outcomes (physical activity, physiologic, and psychologic functioning) for older adults (aged > 65 years) with higher disease burden.

METHODS

A descriptive, repeated-measures experimental design was used. Follow-up data were collected at 3 and 6 weeks and 3 months after CABS. Subjects were drawn from a larger randomized clinical trial. Parent study subjects who had high disease burden preoperatively (physical component score of < 50 on the Medical Outcome Study Short Form-36 and RISKO score of > 6) were included (N = 55), with 23 subjects in the early recovery intervention group and 31 subjects in the usual care group (n = 31). Subjects ranged in age from 65 to 85 years (M = 71.6 + 5.1 years).

RESULTS

There was a significant main effect by group (F[1,209] = 4.66, P < .05). The intervention group had a least square means of 27.9 kcal/kg/d of energy expenditure compared with the usual care group of 26.6 kcal/kg/d per the RT3 accelerometer (Stayhealthy, Inc, Monrovia, CA). Both groups had significantly improved physical (F[2,171] = 3.26, P < .05) and role-physical (F[2,171] = 6.64, P < .005) functioning over time.

CONCLUSION

The subgroup of subjects undergoing CABS with high disease burden were responsive to an early recovery telehealth intervention. Improving patients' physical activity and functioning can reduce morbidity and mortality associated with poor functioning after cardiac events.

Effects of Long‐Term and Ongoing Cardiac Rehabilitation in Elderly Patients With Coronary Heart Disease

The authors assessed the effect of very long-term cardiac rehabilitation (over 1 year) on exercise tolerance and coronary heart disease risk factors in patients older than 80 years with coronary heart disease relative to an elderly cohort without coronary heart disease. Included in this retrospective analysis were patients older than 80 at the time of their last evaluation who had completed at least 1 year of a cardiac prevention and exercise training program. A total of 43 coronary heart disease patients and 15 age-matched healthy subjects were included in this study. Long-term cardiac rehabilitation in very elderly coronary heart disease patients was shown to be feasible and effective in improving functional capacity (+5.4% after 1 year; P< .05) and risk factor control, and slowing the decline in exercise tolerance that occurs with normal aging.

Exercise Self-Efficacy in Older Women with Diastolic Heart Failure: Results of a Walking Program and Education Intervention

The purpose of this study was to evaluate exercise self-efficacy in older women with stable New York Heart Association Functional Class II and III heart failure who were enrolled in a 12-week, home-based, low- to moderate-intensity combined walking and education program. Findings indicate that participation in a 12-week, home-based walking program improved self-efficacy for exercise adherence and workload physical function. Women in the program also improved in 6-minute walk distance, depressive symptoms, and quality of life at 12 weeks, while control participants had no change on any measures. These results support that an exercise intervention that progresses gradually has potential to improve exercise self-efficacy, physical function, depressive symptoms, and quality of life in women with heart failure compared to education alone.

Aging with cardiopulmonary disease: the rehab perspective

Cardiac disease is a leading cause of disability. This article reviews the epidemiology, pathophysiology, and risk factors for coronary heart disease. We explore the latest research in risk stratification, exercise training, and screening for cardiac rehabilitation in the elderly patient. The rehabilitation specialist will see how this select population differs in their medical and rehabilitative needs.

Geriatric rehabilitation. 3. Physical medicine and rehabilitation interventions for common disabling disorders1∗1No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit upon the authors(s) or upon any organization with which the author(s) is/are associated.∗Key references

This self-directed learning module highlights physical medicine and rehabilitation (PM and R) interventions for common disorders that cause disability in older adults. It is part of the study guide on geriatric rehabilitation in the Self-Directed Physiatric Education Program for practitioners and trainees in PM and R and geriatric medicine. This article specifically focuses on PM and R interventions for arthritides, fractures, cardiovascular disorders, peripheral vascular disease, amputations, pulmonary disorders, cancer, stroke, traumatic brain injury, Parkinson's disease, spinal cord injury, peripheral neuropathies, and diabetic complications.

OVERALL ARTICLE OBJECTIVE

To summarize the physical medicine and rehabilitation interventions for commonly disabling conditions of older adults.