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Exercise in Older Adults


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A presentation on Exercise in Older Adults by Dr Jason Kaplan.

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Exercise in Older Adults

  1. 1. Dr Jason Kaplan June 2013 Exercise in Older Adults
  2. 2. The benefits of middle age fitness • Arch Int Med 2012 University of Texas • Age 49 EST / 5 categories /1970– Most to least ( majority ) Cooper Clinic • RV records from 1999-2009 • Adults least fit at Middle age checkup most likely to develop chronic disease at earlier age heart diabetes, cancer
  3. 3. • Most fit – some still developed but later in life – ie lived with chronic disease later in life for shorter time periods • “ lenghthening of Morbidity “ • “ The Fit live well ! “
  4. 4. Invasion of the MAMILS !
  5. 5. METS Activity METS Slow walk 2-3 Golf 3-5 Fast walk / tennis doubles 4-5 Hiking 6-7 Dancing, rowing 6-7 Bicycle, swimming 6-10 Singles Tennis 7-12 Running 10 km /hr 10 Running 15 km/hr 16 MET- 3.5 mL O2 uptake /kg/min = resting oxygen uptake in sitting position
  6. 6. Myers J et al. N Engl J Med 2002;346:793-801 Relative Risks of Death from Any Cause among Subjects with Various Risk Factors Who Achieved an Exercise Capacity of Less Than 5 MET or 5 to 8 MET, as Compared with Subjects Whose Exercise Capacity Was More Than 8 METS
  7. 7. Myers J et al. N Engl J Med 2002;346:793-801 Age-Adjusted Relative Risks of Death from Any Cause According to Quintile of Exercise Capacity among Normal Subjects and Subjects with Cardiovascular Disease
  8. 8. CAD in older athletes • Routine physical exercise is associated with reduced morbidity and mortality from CAD, but vigorous physical exertion also transiently increases the risk of both acute myocardial infarction (MI) and SCD. • In most cases, the risk to asymptomatic individuals without prior atherosclerotic disease is small.
  9. 9. CAD older athletes • athletes with established CAD remain at some increased risk for SCD or MI, and any CAD risk factors should be vigorously treated. • Regular physical exercise improves an individual’s CV risk profile and reduces CVD morbidity and mortality. • vigorous exercise also increases the short- term risk of coronary events and sudden death by 5- to 7-fold compared to rest.
  10. 10. Who Needs An EST prior to vigorous Exercise • The American College of Cardiology and American Heart Association recommend exercise treadmill testing for asymptomatic patients with diabetes mellitus, men older than 45 years of age, and women older than 55 years of age before they undertake vigorous exercise, with the decision to incorporate myocardial imaging based on the baseline ECG and pre-test probability of CAD • Level of evidence B
  11. 11. 2010 ACCF/AHA Guideline for Assessment of Cardiovascular Risk in Asymptomatic Adults • 1. An exercise ECG may be considered for cardiovascular risk assessment in intermediate-risk asymptomatic adults (including sedentary adults considering starting a vigorous exercise program), par- ticularly when attention is paid to non-ECG markers such as exercise capacity.
  12. 12. The EST – Key points • - doesn’t predict SCD or MI ( CACS better ) – rupture non stenotic plaque • Useful in risk after event/ revasc ie BP/ He, rythym • HR and BP response important • Exercise not hand grip • Exercise duration predicts survival • Talk test vs age regression ( 220 – age X 70- 80%)
  13. 13. Watch these People • Uncontrolled SBP > 160 at rest ( BP will to rise with exercise ) • Active Symptoms( CP, SOB, Palp, Syncope) • Strong Family History – those over age 50 • Poorly controlled lipids • Any exercise induced symptom is significant
  14. 14. Cardiovascular risk stratification for exercise • AHA ( prob outdated ) • Class A- healthy,no clinical evidence of inc CVS Risk • Class B - established CHD- LOW RISK • Class C- mod/high risk/ previous events • Class D- contraindicated • MET- 3.5 mL O2 uptake /kg/min = resting oxygen uptake in sitting position.
  15. 15. Class A • Lets talk about it !
  16. 16. Older Athletes • Masters Athletes • Age varies by sport – Generally over 40 years of age • Organized sports that require systematic training for competition • General use – synonym for “older athlete”
  17. 17. • Masters Athletes – Aging Well • Declines in athletic performance inevitable with aging • Peak endurance performance maintained to age 35 • Modest decreases to age 50-60 Progressively steeper declines > age 60 • Tanaka H, Seals DR. Endurance exercise performance in Masters athletes. J Physiol. 2008 Jan 1;586(1):55-63.
  18. 18. • Masters Athletes – Aging Well • 3 main physiological determinants of reduction – Lactate threshold reduced – Exercise economy stable – Maximal oxygen consumption • Decreases in maximal stroke volume, heart rate, & AV O2 difference • Reduced intensity & volume in training sessions
  19. 19. • Prolonged Endurance Exercise • 25 healthy 51-59 yo volunteers (21 males) from 2010 & 11 Manitoba Marathons • Assessed Cardiac biomarkers & TTE assessed 1 wk prior to, immediately after & 1 wk after the marathon – CMR was performed at baseline & within 24 hrs of marathon completion CCT within 3 months of marathon – Karlstedt E, et al. The impact of repeated marathon running on cardiovascular function in the aging population. J Cardiovasc Magn Reson. 2012;14(1):58.
  20. 20. • Prolonged Endurance Exercise – All participants demonstrated an elevated cTnT, RA & RV volumes post marathon – RV systolic function decreased significantly immediately post marathon • Returned to baseline 1 week later – Marathon associated with transient, reversible increase in cardiac biomarkers & RV systolic dysfunction
  21. 21. • Long Term Marathon Running • 26 women ≥ 10 annual marathons (n=26) – Less coronary plaque prevalence (19 vs. 50%) – Less calcific plaque volume (43 vs. 77 mm3) • 50 men ≥ 25 annual marathons (n=50) – Similar plaque prevalence – Increased total plaque volume (200 vs. 126 mm3, – p<0.01), calcified plaque volume (84 vs. 44 mm3, p<0.0001), & non-calcified plaque volume (116 vs. 82, p=0.04) • All significantly lower resting HR, body mass, BMI, & TG levels & higher HDL cholesterol levels
  22. 22. • Long Term Marathon Running – Compared to a control population • Men running marathons for longer time – Paradoxically increased coronary plaque volume & prevalence – Women had lower coronary artery plaque prevalence & less calcified plaque volume • Schwartz RS, et al. Coronary Artery Plaque in Long Term Marathon Runners Assessed by High Resolution CCTa. (unpublished data)
  23. 23. Why Inc Risks • Arterial stiffness ( PWA- Sphygmacor) higher in marathon runners • Atrial remodelling and atrial arrhythmias • Increased pro- inflammatory markers – Il 6 , TNF, Chromagraffin A, CRP • Marathon Study • Statins also seem to increase risks muscle related injury
  24. 24. Older age/ Endurance Key Points • Marathon running is associated with a small increased incidence of SCD, which is dependent on age, sex, and training status. (The risk from a half-marathon is significantly less.) • Myocardial hypertrophy and coronary ischemia are the fundamental pathophysiologic entities, with the former more likely to be fatal.
  25. 25. • Despite a significantly more favorable CV risk profile in marathon runners, coronary calcification and myocardial injury are relatively common and seen more frequently than in a control population of non-runners.
  26. 26. Take HOME POINTS CAD older athletes • It is important to know how important exercise is to the individual patient: “Some people are hooked on it and it is very important to their lives.” • we know their risk of coronary events increases during intense activity. It’s not possible to precisely determine this increased risk, but it is greater than at rest.
  27. 27. • “Treat risk factors aggresively especially their lipids.” Hopefully, intensive lipid-lowering will stabilize their plaques and permit them to continue their chosen activity. • Warning: some patients think that because they are in good shape and run marathons, they do not have to take cholesterol-lowering therapy. You are most likely to see this in people with risk factors who want to ignore them.
  28. 28. Message from British Heart Foundation