The population older than 80 years is increasing but data on prevention of coronary disease in this age group are sparse. The present study compared the improvement in quality of life, lipid profile, blood pressure, weight, and physical performance after cardiac rehabilitation in patients <80 versus ≥80 years of age. A total of 1,112 patients, of whom 79 were older than 80 years, entered a 36-session outpatient cardiac rehabilitation program after interventions for coronary heart disease. The program consisted of physical exercise, lifestyle modification, and pharmacotherapy. Quality of life improved by 1.3 (95% confidence interval [CI] 0.6 to 2.0) in octogenarians and 1.8 (95% CI 1.5 to 2.1) in younger patients (p = 0.21), whereas weight decreased by 1.7 lbs (95% CI −2.9 to −0.4) and 3.1 lbs (95% CI −3.6 to −2.5, p = 0.04), respectively. In hypertensive patients, systolic blood pressure decreased from 155 ± 11 to 133 ± 20 mm Hg in octogenarians versus 155 ± 13 to 130 ± 20 mm Hg in younger patients, reducing the prevalence of hypertension to approximately 10% in both groups. Low-density lipoprotein cholesterol decreased by 16 mg/dl (95% CI −27 to −5) versus 19 mg/dl (95% CI −22 to −16), increasing the percentage of patients at recommended goals from 32% to 46% in the elderly (p = 0.04) and from 18% to 30% in younger patients (p <0.001). Metabolic equivalent levels increased by 1.0 (95% CI 0.7 to 1.3) in octogenarians versus 2.4 (95% CI 2.2 to 2.5) in younger patients (p <0.001). In conclusion, patients ≥80 years of age in an active secondary prevention program derive a significant benefit in well being, risk factors, and exercise capacity and should not be denied such treatment because of age.
The elderly are the fastest growing population segment in the United States. By 2025, those >80 years of age will make up 4.6% of North America, 6.4% of Europe, and 1.8% of the population of Asia and will be the fastest growing population segment in the world. Despite their growing number, data are sparse on the benefits of secondary prevention and cardiac rehabilitation (CR) in advanced age. In one meta-analysis of studies of CR, the mean age of the patients was 56 years and most had an upper age limit of 65 years. In another of >4,300 elderly patients undergoing CR, all were aged <71 years. Furthermore, outcome data in this population are needed because potentially beneficial treatment or recommendation may even be excluded on the basis of age alone. Accordingly, we investigated the hypothesis that elderly patients would improve their quality of life (QOL), lipid profile, blood pressure (BP), weight, and physical performance from secondary prevention measures in the setting of an outpatient CR program.
Methods
A total of 1,447 patients were enrolled from October 2004 to May 2012 into the outpatient CR program at Wake Forest Baptist Medical Center after interventions for coronary artery disease, including coronary artery bypass graft surgery and/or valvular disease defined by cardiac catheterization or echocardiography. Patients attending CR for valvular disease indications (n = 201) and patients who did not continue past the first session (n = 134) were excluded from analysis. The final study cohort included 1,033 patients aged <80 years and 79 patients aged ≥80 years. All data were taken from patient records at this institution, and this study was approved by our Institutional Review Board.
The CR program consisted of 3 sessions/week for 12 weeks for a total of 36 sessions. The average number of sessions attended per patient was 26 ± 12. Participation rates defined as attending at least 27 (75%) of CR sessions were 61% for ages <80% and 66% for ages ≥80 (p = 0.39). Each session consisted of physical exercise and health and nutrition education. Exercise lasted 30 to 40 minutes and consisted of 5 minutes of warm-up and cool-down activity. An individualized plan was constructed by an exercise physiologist beginning at an exercise intensity on the basis of history, co-morbidities, orthopedic limitations, previous fitness, and clinical status according to the American College of Sports Medicine Guidelines for Exercise Testing and Prescription. Exercise level was gradually increased in increments of 0.5 to 1.0 metabolic equivalents (METs) as tolerated to a rating of perceived exertion of 11 to 14 on a 6 to 20 Borg scale. Heart rates were obtained at peak exercise during each method by telemetry. In our program, exercise comprises upper and lower body training methods including walking laps on a track, cycle ergometry, treadmills, and stair climbers as well as light resistance exercises.
At each visit, baseline vital signs were recorded for all patients and included height, weight, systolic and diastolic pressures, heart rate at rest, and MET level. Steady-state MET levels were recorded at each session and were obtained either automatically from exercise devices or using a standardized MET formula. MET levels represent the highest level of exertion for the patient for that specific session. This information was documented by the supervising exercise physiologist or nurse. Baseline MET level was recorded during the first CR session and at each subsequent visit in the same manner.
BP was measured in the sitting position after a 5-minute rest by a trained registered nurse using a standardized cuff. Stages of hypertension were classified according to the guidelines from the JNC 7 report. Normal BP was defined as a systolic BP (SBP) <120 mm Hg and diastolic BP (DBP) <80 mm Hg; prehypertension as an SBP from 120 to 139 mm Hg or DBP from 80 mm Hg and 89 mm Hg; hypertension as an SBP >140 mm Hg or DBP >90 mm Hg. Baseline BP represents the first, and post-BP the last, measurement for that specific patient.
Adult Treatment Panel III guidelines were used to define lipid goals in our patients. Optimal levels in patients with coronary heart disease are considered to be low-density lipoprotein (LDL) of <100 mg/dl, high-density lipoprotein (HDL) of >40 mg/dl, and a triglyceride level of <150 mg/dl. Pre- and postlipid profiles were checked, respectively, within 1 month of starting and finishing the CR.
QOL score was calculated at the beginning and end of the program using the Ferrans and Powers Quality of Life Index Cardiac Version IV Questionnaire. Additional initial blood measurements included a lipid profile and hemoglobin A1C. Left ventricular function was measured by standard echocardiographic techniques. The presence of diabetes and chronic obstructive pulmonary disease was documented by chart review; these diagnoses having previously been made using standard criteria.
Descriptive statistics (frequency and percent for categorical factors, mean and SD for continuous factors) were calculated and compared for statistical significance using chi-square or Fisher’s exact testing for categorical variables and Student’s t test for continuous variables. Baseline and postrehabilitation CR metric levels were compared using paired t tests, and delta values were calculated as mean (95% confidence interval) of postrehabilitation minus baseline levels. Peak MET levels, defined as the maximal MET level attained at any point during the CR program, were measured in all patients, whereas data availability for other post-CR metrics ranged from 40% (QOL) to 87% (BP). A p value of 0.05 was considered statistically significant. SAS version 9.2 statistical software package (SAS Institute, Cary, North Carolina) was used for all statistical analysis.
Results
At baseline, elderly patients (age ≥80 years) were more likely to be women and Caucasian ( Table 1 ). Compared with younger patients, the elderly had significantly higher mean QOL scores, were leaner in terms of weight and body mass index (BMI), and had significantly better lipid profiles. SBP was significantly elevated but DBP was significantly lower in the elderly compared with younger patients. Ejection fraction was similar across age groups as was the use of β-blocking agents, angiotensin-converting enzyme inhibitors, and statins.
| Characteristic | Age <80 Yrs (n = 1,033) | Age ≥80 Yrs (n = 79) | p |
|---|---|---|---|
| Age (yrs) | 61 ± 10 | 82 ± 2 | <0.001 |
| Men | 756 (73) | 46 (58) | 0.004 |
| Caucasians | 854 (83) | 73 (92) | 0.03 |
| Body mass index (kg/m 2 ) | 29 ± 6 | 25 ± 4 | <0.001 |
| Weight (lbs) | 197 ± 43 | 160 ± 26 | <0.001 |
| Waist circumference (inches) | 41 ± 5 | 38 ± 4 | <0.001 |
| QOL | 22 ± 5 | 24 ± 3 | <0.001 |
| Baseline MET level | 2.7 ± 0.9 | 2.2 ± 0.6 | <0.001 |
| Hypertension | 826 (80) | 65 (82) | 0.64 |
| SBP (mm Hg) | 122 ± 18 | 129 ± 23 | 0.008 |
| DBP (mm Hg) | 71 ± 10 | 67 ± 12 | 0.02 |
| Heart rate at rest (beats/min) | 76 ± 14 | 71 ± 12 | 0.005 |
| LDL (mg/dl) | 100 ± 41 | 89 ± 31 | 0.004 |
| HDL (mg/dl) | 40 ± 15 | 43 ± 14 | 0.06 |
| Triglycerides (mg/dl) | 151 ± 118 | 143 ± 152 | 0.66 |
| Current smoker | 105 (10) | 1 (1) | 0.009 |
| Lung disease | 333 (32) | 27 (34) | 0.72 |
| Diabetes mellitus | 326 (32) | 16 (20) | 0.04 |
| Ejection fraction (%) | 49 ± 12 | 50 ± 12 | 0.46 |
| Multivessel coronary disease | 722 (70) | 60 (76) | 0.26 |
| Medications | |||
| β blocker | 939 (91) | 67 (85) | 0.08 |
| ACE inhibitor | 682 (66) | 50 (63) | 0.62 |
| Statin | 932 (90) | 68 (86) | 0.24 |
Overall changes in CR metrics from baseline to program completion are listed in Table 2 . Significant improvements were observed in peak exercise capacity, QOL, weight measures, SBP, LDL, and triglycerides across all age groups. Figure 1 displays absolute mean MET levels for patients attending each session. All patients were included regardless of participation level to minimize intersession variability and to avoid a subgroup plot of high attenders. All age groups had continuous improvement in MET levels during the course of the program, corresponding to a relative increase from baseline of 36% in the elderly and >100% in their younger counterparts.
| Metric | Age <80 Yrs (n = 1,033) | Age ≥80 Yrs (n = 79) | Age ≥80 vs Age <80 Yrs, p | ||||
|---|---|---|---|---|---|---|---|
| n | Mean Difference (95% CI) | p ∗ | n | Mean Difference (95% CI) | p ∗ | ||
| Peak MET level attained | 1,033 | 2.4 (2.2 to 2.5) | <0.001 | 79 | 1.0 (0.7 to 1.3) | <0.001 | <0.001 |
| QOL | 414 | 1.8 (1.5 to 2.1) | <0.001 | 34 | 1.3 (0.6 to 2.0) | <0.001 | 0.21 |
| Weight (lbs) | 866 | −3.1 (−3.6 to −2.5) | <0.001 | 69 | −1.7 (−2.9 to −0.4) | 0.008 | 0.04 |
| Body mass index (kg/m 2 ) | 819 | −0.5 (−0.6 to −0.4) | <0.001 | 68 | −0.4 (−0.6 to −0.1) | 0.008 | 0.23 |
| SBP (mm Hg) | 899 | −3.8 (−4.9 to −2.6) | <0.001 | 69 | −5.5 (−10.5 to −0.4) | 0.03 | 0.51 |
| DBP (mm Hg) | 895 | −1.7 (−2.4 to −0.9) | <0.001 | 69 | −0.8 (−3.8 to 2.1) | 0.57 | 0.55 |
| LDL (mg/dl) | 624 | −19 (−22 to −16) | <0.001 | 53 | −16 (−27 to −5) | 0.004 | 0.62 |
| HDL (mg/dl) | 648 | 1.8 (1.0 to 2.6) | <0.001 | 56 | 0.9 (−2.6 to 4.4) | 0.61 | 0.61 |
| Triglycerides (mg/dl) | 646 | −20 (−29 to −11) | <0.001 | 56 | −33 (−68 to 2) | 0.07 | 0.43 |
∗ Paired t test comparing pre- to postrehabilitation levels.
Changes in BP in hypertension and lipid status in relation to goals are detailed in Table 3 . Overall, significant mean decreases were observed for both SBP and DBP across both age groups, resulting in significant decreases in the prevalence of systolic and diastolic hypertension after CR. Similarly, in those patients with suboptimal lipid levels, significant improvements were observed in mean LDL, HDL, and triglyceride levels, resulting in significant increases in the prevalence of patients at goal lipid levels after CR.
| Age <80 | Age ≥80 | |||||||
|---|---|---|---|---|---|---|---|---|
| n | Before CR, Mean ± SD | After CR, Mean ± SD | Pre- to Postdelta, p value | n | Before CR, Mean ± SD | After CR, Mean ± SD | Pre- to Postdelta, p Value | |
| SBP >140 (mm Hg) | 119 | 155 ± 13 | 130 ± 20 | <0.001 | 18 | 155 ± 11 | 133 ± 20 | 0.001 |
| SBP 120–140 (mm Hg) | 332 | 128 ± 6 | 120 ± 14 | <0.001 | 21 | 131 ± 6 | 121 ± 15 | 0.006 |
| SBP <120 (mm Hg) | 448 | 108 ± 8 | 112 ± 12 | <0.001 | 30 | 107 ± 8 | 115 ± 12 | <0.001 |
| DBP >90 (mm Hg) | 27 | 98 ± 8 | 74 ± 14 | <0.001 | 1 | ∗ | ∗ | ∗ |
| DBP 80–90 (mm Hg) | 135 | 84 ± 3 | 73 ± 9 | <0.001 | 8 | 86 ± 3 | 69 ± 9 | 0.001 |
| DBP <80 (mm Hg) | 733 | 67 ± 7 | 68 ± 8 | 0.03 | 60 | 64 ± 8 | 66 ± 9 | 0.06 |
| LDL ≤100 (mg/dl) | 364 | 74 ± 18 | 73 ± 23 | 0.42 | 38 | 74 ± 18 | 71 ± 23 | 0.53 |
| LDL >100 (mg/dl) | 260 | 135 ± 28 | 91 ± 37 | <0.001 | 15 | 130 ± 31 | 80 ± 42 | <0.001 |
| HDL ≥40 (mg/dl) | 267 | 51 ± 21 | 50 ± 17 | 0.25 | 29 | 53 ± 13 | 52 ± 17 | 0.71 |
| HDL <40 (mg/dl) | 381 | 32 ± 5 | 35 ± 9 | <0.001 | 27 | 31 ± 6 | 34 ± 9 | 0.08 |
| TRG ≤150 (mg/dl) | 425 | 97 ± 30 | 106 ± 57 | 0.001 | 39 | 85 ± 28 | 93 ± 32 | 0.20 |
| TRG >150 (mg/dl) | 221 | 257 ± 169 | 181 ± 101 | <0.001 | 17 | 315 ± 260 | 188 ± 125 | 0.02 |
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