Editorial comment
The elderly are priority candidates for cardiac rehabilitation
Mendes Miguel
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METs: metabolic equivalents.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Marta Braga, Helena Nascimento, Roberto Pinto, Paulo Araújo, Alzira Nunes, Joana Rodrigues, Vítor Araújo, Fernando Parada-Pereira, Maria Júlia Maciel, Afonso Rocha" "autores" => array:10 [ 0 => array:2 [ "nombre" => "Marta" "apellidos" => "Braga" ] 1 => array:2 [ "nombre" => "Helena" "apellidos" => "Nascimento" ] 2 => array:2 [ "nombre" => "Roberto" "apellidos" => "Pinto" ] 3 => array:2 [ "nombre" => "Paulo" "apellidos" => "Araújo" ] 4 => array:2 [ "nombre" => "Alzira" "apellidos" => "Nunes" ] 5 => array:2 [ "nombre" => "Joana" "apellidos" => "Rodrigues" ] 6 => array:2 [ "nombre" => "Vítor" "apellidos" => "Araújo" ] 7 => array:2 [ "nombre" => "Fernando" "apellidos" => "Parada-Pereira" ] 8 => array:2 [ "nombre" => "Maria Júlia" "apellidos" => "Maciel" ] 9 => array:2 [ "nombre" => "Afonso" "apellidos" => "Rocha" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "en" => array:9 [ "pii" => "S0870255120304467" "doi" => "10.1016/j.repc.2020.04.009" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0870255120304467?idApp=UINPBA00004E" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2174204921000052?idApp=UINPBA00004E" "url" => "/21742049/0000004000000001/v1_202102241115/S2174204921000052/v1_202102241115/en/main.assets" ] "en" => array:12 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Editorial comment</span>" "titulo" => "The elderly are priority candidates for cardiac rehabilitation" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "21" "paginaFinal" => "23" ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Mendes Miguel" "autores" => array:1 [ 0 => array:3 [ "nombre" => "Mendes" "apellidos" => "Miguel" "email" => array:1 [ 0 => "mfmendes@chlo.min-saude.pt" ] ] ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">In their article published in this issue of the <span class="elsevierStyleItalic">Journal</span>,<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Marta Braga and colleagues studied a population of 731 coronary patients who completed phase 2 of a cardiac rehabilitation (CR) program in a Portuguese center between January 2009 and December 2016. They aimed to compare the gains resulting from participation in the program in older patients (aged ≥65 years), who accounted for 15.9% of the overall cohort, with those of younger patients (aged <65 years).</p><p id="par0010" class="elsevierStylePara elsevierViewall">Compared to younger patients, the older group were more likely to be male, hypertensive and diabetic and to have a greater waist circumference, while the younger group included more smokers and had higher low-density lipoprotein (LDL) cholesterol and triglyceride levels on admission.</p><p id="par0015" class="elsevierStylePara elsevierViewall">Older patients were more likely to have suffered non-ST-elevation myocardial infarction and to have multivessel disease. There was no significant difference between the groups in severity of left ventricular dysfunction.</p><p id="par0020" class="elsevierStylePara elsevierViewall">Metabolic profile, functional capacity, parameters of cardiac autonomic regulation and quality of life were assessed. The authors found no significant differences between the two groups in the gains obtained and therefore concluded that older patients benefited to a similar extent to younger individuals in these four aspects.</p><p id="par0025" class="elsevierStylePara elsevierViewall">Attesting to the excellence of the program, a reduction of 2-3 cm in waist circumference was observed, which was more marked in older than in younger women (-3.5 ± 3.1% vs. -0.6 ± 6.1%, p = 0.031). This reduction was not accompanied by significant reductions in body weight, which suggests that there had been a positive change in body composition, with an increase in lean mass and decrease in fat mass. This is rarely seen, particularly in elderly age-groups, in CR programs with biweekly sessions lasting less than three months such as those described in this study.</p><p id="par0030" class="elsevierStylePara elsevierViewall">With regard to changes in lipid profile, mean decreases of 37.5 mg/dl and 17 mg/dl, respectively, were seen in LDL cholesterol and triglycerides. The latter may be explained solely by exercise and dietary modification, but the magnitude of the falls in LDL cholesterol could only have been achieved by beginning or increasing lipid-lowering medication, again demonstrating the good quality of cardiological management in this program.</p><p id="par0035" class="elsevierStylePara elsevierViewall">The study has several limitations, which are pointed out by the authors, including those inherent to its retrospective design and the possibility of referral and selection bias, the fact that cardiopulmonary stress testing<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> was not used to obtain a more accurate quantification of functional capacity, and the lack of data on the study parameters after phase 2 of the CR program, which meant that its long-term impact could not be assessed. Two more limitations should be borne in mind: no direct analysis of body composition was carried out, and a questionnaire specific to coronary patients was not used to assess health-related quality of life.</p><p id="par0040" class="elsevierStylePara elsevierViewall">The aim of the study has considerable merit, since elderly patients,<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> particularly older women,<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> who accounted for only 20.7% of the older group, are rarely referred for CR, due to the erroneous but widespread belief that advanced age, whether accompanied by frailty or not, leads to increased risk and fewer benefits. Further evidence for this perception is that only 15.9% of participants in the CR programs in this study, which reflects seven years of activity in a hospital with some of the highest numbers of CR participants in the country, were aged ≥65 years, whereas according to the most recent data from the Portuguese Registry of Acute Coronary Syndromes (ProACS),<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> the mean age of individuals suffering myocardial infarction in Portugal is 66 ± 13 years and 26% of them are aged over 75 years.</p><p id="par0045" class="elsevierStylePara elsevierViewall">Contradicting this belief, the study by Braga et al. demonstrates yet again<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> that the elderly derive similar benefit from CR to younger individuals. This is an important finding and is further evidence that older as well as younger patients should be referred for CR programs after an acute event such as acute coronary syndrome (ACS) or cardiac surgery or in chronic conditions such as heart failure.</p><p id="par0050" class="elsevierStylePara elsevierViewall">The elderly usually present higher clinical risk due to more severe cardiovascular and metabolic risk factors and a range of associated comorbidities,<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> including frailty, cerebrovascular disease, cognitive decline, heart failure, chronic obstructive pulmonary disease, peripheral arterial disease and locomotor system disorders. They therefore stand to benefit significantly from the reduction in risk derived from participation in a CR program that provides them with regular and individualized exercise, improved disease knowledge and psychosocial support.</p><p id="par0055" class="elsevierStylePara elsevierViewall">However, including older patients in a CR program is a challenge for any center, which will need to make concerted efforts to overcome a variety of barriers.<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8,9</span></a> These may be related to physicians (reluctance to refer patients for CR and failure to support their participation in a CR program), patients (inconvenience, lack of familiarity with sports, embarrassment at having to wear sports clothes and shoes, the feeling that the program is not designed for them, presence of comorbidities, financial constraints and difficulties with transport), and centers (unevenly distributed and hence unavailable in many parts of the country, inconvenient timetables, and lack of home-based programs with telemonitoring).</p><p id="par0060" class="elsevierStylePara elsevierViewall">The main issue with CR in elderly patients (as also in younger individuals) is how to change behaviors and maintain the healthy lifestyles instilled during the program in the following years.</p><p id="par0065" class="elsevierStylePara elsevierViewall">The study by Braga et al. demonstrates that significant benefits were achieved in soft endpoints (functional capacity, metabolic profile, autonomic nervous system activity and quality of life) after a CR program lasting 2-3 months, but not in reductions in hard endpoints such as reinfarction, hospitalization for heart failure and mortality, which would require a longer study with more patients.</p><p id="par0070" class="elsevierStylePara elsevierViewall">To reduce the risk of these hard endpoints, patients’ adherence to a healthy lifestyle and prognosis-changing medication must be sustained for many years.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> This will be easier to achieve if patients are included in a phase 3 (maintenance) program of indefinite duration, in order to consolidate and maintain the gains obtained in phase 2.</p><p id="par0075" class="elsevierStylePara elsevierViewall">The limitations in Braga et al.’s study pointed out above do not weaken its many valid and interesting conclusions, which are in my opinion valuable due to its appropriate methodology, the quality of the comprehensive analysis they performed, and the large population sample of real-world patients in a high-quality Portuguese CR program.</p><p id="par0080" class="elsevierStylePara elsevierViewall">In the 2013-2014 national survey of CR in Portugal by Conceição Silveira and colleagues,<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> a total of 1927 patients were included in phase 2 programs in 2013, 51.8% of them following ACS. It was estimated that only 8% of Portuguese ACS patients were enrolled in CR programs. This survey, like previous ones, does not provide demographic information on participants, including age or gender, and so it is difficult to determine whether the patient population of Braga et al.’s study is representative of the country as a whole. However, this information will be available in the National Registry of Cardiac Rehabilitation, soon to be launched by the Working Group on Exercise Physiology and Cardiac Rehabilitation (GEFERC) and that will be housed in the National Center for Data Collection in Cardiology (CNCDC).</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of interest</span><p id="par0085" class="elsevierStylePara elsevierViewall">The author has no conflicts of interest to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Conflicts of interest" ] 1 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Miguel M. The elderly are priority candidates for cardiac rehabilitation. Rev Port Cardiol. 2021;40:21–23.</p>" ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:10 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Cardiac rehabilitation in older patients: indication or limitation?" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "M. Braga" 1 => "H. Nascimento" 2 => "R. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 11 | 4 | 15 |
| 2024 October | 91 | 31 | 122 |
| 2024 September | 51 | 25 | 76 |
| 2024 August | 46 | 24 | 70 |
| 2024 July | 34 | 35 | 69 |
| 2024 June | 28 | 22 | 50 |
| 2024 May | 35 | 17 | 52 |
| 2024 April | 25 | 25 | 50 |
| 2024 March | 30 | 24 | 54 |
| 2024 February | 29 | 20 | 49 |
| 2024 January | 28 | 28 | 56 |
| 2023 December | 19 | 26 | 45 |
| 2023 November | 41 | 39 | 80 |
| 2023 October | 19 | 25 | 44 |
| 2023 September | 25 | 22 | 47 |
| 2023 August | 21 | 14 | 35 |
| 2023 July | 18 | 10 | 28 |
| 2023 June | 19 | 16 | 35 |
| 2023 May | 37 | 32 | 69 |
| 2023 April | 27 | 11 | 38 |
| 2023 March | 42 | 19 | 61 |
| 2023 February | 34 | 25 | 59 |
| 2023 January | 19 | 18 | 37 |
| 2022 December | 30 | 41 | 71 |
| 2022 November | 49 | 40 | 89 |
| 2022 October | 34 | 31 | 65 |
| 2022 September | 29 | 38 | 67 |
| 2022 August | 26 | 39 | 65 |
| 2022 July | 28 | 46 | 74 |
| 2022 June | 32 | 30 | 62 |
| 2022 May | 22 | 30 | 52 |
| 2022 April | 32 | 39 | 71 |
| 2022 March | 30 | 52 | 82 |
| 2022 February | 29 | 47 | 76 |
| 2022 January | 23 | 35 | 58 |
| 2021 December | 41 | 45 | 86 |
| 2021 November | 28 | 30 | 58 |
| 2021 October | 48 | 60 | 108 |
| 2021 September | 29 | 30 | 59 |
| 2021 August | 52 | 33 | 85 |
| 2021 July | 20 | 17 | 37 |
| 2021 June | 39 | 31 | 70 |
| 2021 May | 31 | 33 | 64 |
| 2021 April | 66 | 72 | 138 |
| 2021 March | 78 | 42 | 120 |
| 2021 February | 46 | 16 | 62 |
| 2021 January | 17 | 4 | 21 |
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