Background: Cardiovascular disease is the leading cause of morbidity and mortality in the elderly population. Coronary artery disease, heart failure, and peripheral artery disease constitute the prevailing conditions. Cardiac rehabilitation (CR) represents a cornerstone in the secondary prevention of cardiovascular disease, since it has been associated with significant cardiovascular benefits in the above-mentioned conditions, by significantly reducing cardiovascular outcomes and improving functional independence and quality of life. Besides, CR offers the background for optimizing the control of cardiovascular risk factors and implementing physical exercise, also providing psychological and social support. Summary: The prevalence of cardiovascular disease increases with age, associating high morbidity and mortality. In addition, comorbidities, frailty, and other geriatric conditions, entities that also entail poor prognosis, are often present in elderly patients. Indeed, frailty is recommended to be systematically addressed in elderly patients with cardiovascular disease, and there is growing evidence regarding the benefits of CR programs in this setting, also associated with lower adverse events during follow-up. However, elderly patients are less often referred to CR after a cardiovascular event when compared to their younger counterparts. In this review, we summarized the benefits of CR programs in the elderly population with established cardiovascular disease, proposing a comprehensive framework that integrates personalized care strategies. Key Messages: Cardiovascular disease is the leading cause of morbimortality, especially in the elderly. The management of cardiovascular disease in elderly patients poses unique challenges, since they represent a heterogeneous group and evidence is low. CR can provide significant benefits in older patients, encompassing physical training and specific management of geriatric syndromes.

Cardiovascular disease (CVD) is the leading cause of mortality worldwide, and it is responsible for high morbidity and dependency [1]. The prevalence of CVD also increases with aging, which has been associated with several factors such as inflammation, oxidative stress, or vascular and myocardial stiffness [2]. However, the elderly population represent a heterogeneous group, and despite scientific advancements, the management of CVD in the elderly poses unique challenges [1]. Therefore, any intervention performed in the elderly aimed to reduce the CVD burden must be individualized, since the possible benefit of cardiovascular interventions should always be weighted considering life expectancy, comorbidities, competing mortality risks, and patient preferences [3].

Cardiac rehabilitation (CR) constitutes a multidisciplinary approach including exercise training, lifestyle modification, and psychological support. CR programs play a crucial role in cardiovascular care, especially in patients with coronary artery disease (CAD) or heart failure (HF) [4]. Significant benefits, such as lower hospitalizations, better functional capacity, and better quality of life, which are consistent and independent of age have been demonstrated [5] CR is a Class IA recommendation in patients with CAD or HF, regardless of age [6, 7]. Besides, frequent conditions in elderly patients, including frailty and other geriatric syndromes, can also be addressed in CR programs, given their potential reversibility [8] (Fig. 1 and Graphical Abstract; for Graphical Abstract, see https://doi.org/10.1159/000539766). However, elderly patients are usually not referred to CR programs or, when done, evidence shows a higher risk of rejection and lower completion rates [4, 9].

Fig. 1.

Benefit of CR programs in elderly patients with CVD.

Fig. 1.

Benefit of CR programs in elderly patients with CVD.

Close modal

Older patients have been traditionally underrepresented in major clinical trials, leading to a lack of robust scientific data [10]. Increasing use of real-world studies or registries has improved our scientific knowledge about this population. In this review, we summarize the benefits of CR in elderly patients with CVD (in three specific clinical scenarios: CAD, peripheral artery disease [PAD], and HF), specifically addressing potential barriers such as frailty or cognitive impairment.

Physical Exercise in the Elderly Population

Physical exercise in the elderly population reduces cardiovascular events, improves control of traditional risk factors, and reduces the prevalence of obesity, osteoporosis, anxiety, and depression. It counteracts both central and peripheral functional limitations [11]. Besides, physical exercise has been associated with a reduction in the risk of falls or sarcopenia. Altogether, it allows the maintenance of functional independence, even in frail patients [12].

A real-world study specifically including the older population, the Leisure World Cohort Study (>13,000 people, mean age 74 years), reported a 35% decrease in total mortality with physical activity [13]. Few data are available in those even older, although healthy lifestyles are encouraged. The European Society of Cardiology and American Heart Association guidelines recommend exercise adapted to comorbidity and baseline functional capacity, avoiding exercise with abrupt postural changes [14, 15].

The characteristics of physical exercise based on frequency-intensity-duration model are summarized in Table 1. The patient needs formation on the intensity of physical exercise with a preference on subjective exertion scales, such as the Borg scale or adapted scales, easier for the elderly [16]. Traditionally CR has been based on aerobic training (AT). In the last years, there has been a movement to wider forms of physical activity, including resistance training (RT), balance, and respiratory training. Aerobic exercise combined with strength and balance exercises are recommended in order to maintain functional independence. The American College of Sports Medicine (ACSM) position recommends adapted RT in older adults to improve performance and muscle strength [17]. Exercise has to be progressive and tailored to each patient’s capabilities and preferences, to avoid injuries and not decrease further adherence. RT has been proven to be safe and helps to perform daily activities [18].

Table 1.

Characteristics of physical exercise in the older population [19]

FrequencyIntensityDuration
Aerobic >5 days/week Moderatea >30 min/session 
Strength training 2 days/week Moderateb 1–2 setsc 
Flexibility/balance >5 days/week Moderated >10 min/sessione 
FrequencyIntensityDuration
Aerobic >5 days/week Moderatea >30 min/session 
Strength training 2 days/week Moderateb 1–2 setsc 
Flexibility/balance >5 days/week Moderated >10 min/sessione 

a40–69% of VO2 max or 55–74% of heart rate reserve.

b40% of 1 RM (maximum load you are able to lift in a single repetition).

c10–15 reps/8–10 muscle groups.

d20–40% of heart rate reserve.

e20 s per static stretch with 3–4 repetitions.

CR in Elderly Patients with CAD

Referral to a CR program with structured physical exercise constitutes a Class IA recommendation in current clinical practice guidelines [20]. Not only it has been associated with lower mortality and cardiovascular events but also improvements in quality of life [21]. Those benefits extend independently of age, with a reduction in mortality rates reported to be up to 50% at 12 months and 32% at 48 months [22]. Elderly patients admitted to CR programs exhibit a worse baseline functional status and clinical profile than their younger counterparts, with higher comorbidities. However, they also achieve great benefits, especially with longer programs, including improvements in functional capacity and quality of life, with no issues about safety.

CR in HF Patients

CR programs in HF have been shown to significantly decrease hospitalization rates, improving exercise performance and quality of life. The impact on survival is less certain, with no clear benefit during the first year and only one trial showing an increase in the mid-term (>1 year). The evidence in the elderly population is less robust due to the usual underrepresentation in main clinical trials. Besides this, older patients are referred less often to CR and their adherence is also lower [23]. There are several reasons behind this fact, including clinician and/or patient perceptions as lack of benefit, misperceptions of safety, or logistic difficulties in transport to medical centers. However, the benefits seem to be similar to those achieved in younger patients [24]. CR in HF is highly recommended by both the European Society of Cardiology and the American Heart Association current guidelines [7, 25]. The multimodal approach of these programs offers the possibility to address usual problems related to HF and also special problems, more prevalent in older patients, such as frailty, nutritional deficits, and sarcopenia, as well as psychological and cognitive impairment [26].

Of note, inspiratory muscle training should be specifically prescribed in HF patients. It can improve respiratory comfort, increase walking distance, and improve quality of life. A trial conducted in older patients with acute HF concluded that an early exercise program with multiple physical-function domains, with an initial focus on mobility, balance, and RT before aerobic performance, resulted in greater improvement in physical function than usual care [27].

CR and Geriatric Syndromes

Frailty and pre-frailty are very common in older patients with CAD or HF, entailing a worse prognosis [28‒30]. Importantly, frailty is potentially reversible. Thus, it is essential to correctly evaluate and identify frailty, in order to specifically include it in the treatment and care plan that best suits each patient [28]. The pathophysiology is complex, including the sum of nutritional deficits, hospitalization-related sarcopenia, or chronic inflammation, all of which lead to a vulnerable situation to stressors [31]. Modern CR programs are compelled to seek frailty, although the optimal tools for the assessment in this area are not well determined yet. Easier-to-implement scales, especially those including physical assessment, can be useful, such as the modified Fried scale or the short physical performance battery [32, 33]. Although frailty is a factor related to lower referral to CR, these programs have shown potential in reverting both frailty and pre-frailty [34]. In fact, the sub-analysis of the REHAB-HF trial hints a greater benefit in more frail patients [35]. The approach to frailty in CR has to be coordinated. The design of the exercise program in more frail patients has to focus, first, on improving balance [36] and strength over stamina. This approach improves quality of life and reduces the risk of falls [37]. Interval training can be useful in this scenario [38]. As the program evolves and both the patient’s balance and strength improve, AT can gain more importance, more similar to a non-frail patient program.

Sarcopenia and nutritional deficits are very common in older patients with HF. Muscle wasting, impaired nutritional status, and HF share common pathophysiological mechanisms that lead to an inflammatory and catabolic state. The prevalence of sarcopenia and cachexia is estimated at around 20 and 10%, respectively [39]. Several questionnaires can help to diagnose sarcopenia such as MNA or SARC-F [40, 41] along with laboratory and physical tests (i.e., total proteins, pre-albumin, retinol binding protein-4, hand-grip, SPPB…), and image tests (muscle echography). Nutrition specialist or endocrinology support may be advised. The PICNIC trial (Nutritional Intervention Program in Malnourished Patients Admitted for HF) established that individualized nutritional intervention (diet optimization, specific recommendations, and nutritional supplement prescriptions if necessary) during and after admission due to acute HF may have a prognostic benefit [42]. The sum of effective therapies for HF, nutritional supplements, and exercise (especially AT plus RT) have been shown to decrease the level of frailty [43].

The educational benefits of CR can be tampered by psychological and social factors surrounding the patient. Table 2 summarizes those specific issues. Depression and anxiety are common in the elderly with HF, and both can mask incipient dementia. Exercise, along with cognitive training can improve mental status and cognitive function. Lack of social support is also related to lower physical activity, worse self-care, and greater risk of future disability, but interventions on this issue showed mixed results. However, in a small trial, CR proved to enhance not only physical performance but also the cognitive, emotional, and social networking parameters [44].

Table 2.

Specific issues to be addressed in CR programs in the older population

Frailty Frailty measure is highly recommended through a scale including physical performance variables 
Exercise program In frail patients, balance and resistance should be prioritized in the beginning. Interval training can be beneficial in this setting. AT should gain progressive importance later in the program 
Nutritional status Addressing nutritional deficits would complement the exercise program to improve the patient's physical performance, both in pre-frailty and established frailty. Sarcopenia demands adequate protein intake plus aerobic and RT 
Psychological state Depression and anxiety may mask incipient cognitive impairment, physical exercise can improve cognitive abilities in older patients 
Cognitive status Cognitive impairment may make it difficult to learn heart-healthy habits and may limit the beneficial effect of programs in this population 
Social situation Lack of social support may complicate the continuation of measures implemented during the program. It is important to involve family and carers, and in some cases, an assessment by a social worker may be necessary 
Frailty Frailty measure is highly recommended through a scale including physical performance variables 
Exercise program In frail patients, balance and resistance should be prioritized in the beginning. Interval training can be beneficial in this setting. AT should gain progressive importance later in the program 
Nutritional status Addressing nutritional deficits would complement the exercise program to improve the patient's physical performance, both in pre-frailty and established frailty. Sarcopenia demands adequate protein intake plus aerobic and RT 
Psychological state Depression and anxiety may mask incipient cognitive impairment, physical exercise can improve cognitive abilities in older patients 
Cognitive status Cognitive impairment may make it difficult to learn heart-healthy habits and may limit the beneficial effect of programs in this population 
Social situation Lack of social support may complicate the continuation of measures implemented during the program. It is important to involve family and carers, and in some cases, an assessment by a social worker may be necessary 

PAD is part of the ischemic continuum of atherosclerotic CVD. Supervised exercise therapy (SET) should be offered to all patients with symptomatic PAD who are not at risk of acute limb ischemia, with a Class IA guideline endorsement [19, 45‒48].

There are no different recommendations in older patients, although individual comorbidities should be considered [47, 48]. Among Medicare beneficiaries between 2017 and 2018, those enrolled in SET for symptomatic PAD were slightly older (73.6 ± 8.0 years vs. 73.1 ± 9.1 years) compared with those not enrolled [49].

For optimal results, SET should be implemented several times per week and in a progressive process to increase exercise intensity as tolerated. Patients should supplement SET with home exercise. Unsupervised exercise training is recommended when supervised exercise training is not feasible or available [47].

The treadmill should be considered the primary exercise training modality. Relative contraindications for treadmill are poor walking capacity, presence of a foot wound, unstable gait, and fall risk on the treadmill, like in patients with neurological (i.e., Parkinson’s disease, dementias, stroke) and non-neurological (i.e., orthopedic, amputation) comorbidities, and in those who require a walking assist device. No treadmill training modalities are also used and sometimes better tolerated. They include lower-extremity cycling, like in CR units, or recumbent total-body stepping, a seated mode of aerobic exercise that engages both upper and lower extremities or upper-body training [50]. Any training is better than none.

Recently, recommendations for training patients with PAD with claudication have been published [48]. Table 3 comprises the main recommendations. The inclusion of elderly patients with PAD in CR programs is increasing. These programs are recommended to patients with PAD in order to improve their prognosis, since PAD is closely related to CVD. Moreover, in the latest consensus document published, attendance to CR program is strongly recommended for patients with PAD [48].Finally, the most important message is an individualized exercise prescription for each patient, especially older ones, regarding comorbidities, session duration, training modality, frequency, claudication intensity, work-to-rest ratio, and the planned progression.

Table 3.

Recommendations for training in patients with PAD [45]

Modality supervised treadmill walking 
• Intensity 40–60% maximal workload based on baseline treadmill test 
• Frequency 3 times/week supervised, supplemented with home walking 
• Duration ≥12 weeks and 36 sessions, consider more sessions as indicated by individual patient 
• Until mild to moderate pain/discomfort 
• Begin with 30–50 min intermittent exercise with the goal of accumulating 30–50 min of total walking exercise 
• Lifelong maintenance preferably 6–7 days/week 
• How to start each session? 
  • 1. Begin walking comfortably

  • 2. If leg pain occurs <8–10 min stop and rest

  • 3. Restart at the same intensity

  • 4. When walking longer than 8 min increases speed or grade

  • 5. Start next session at previous final speed or grade

  • 6. Try at least 30 min of walking time

 
Modality supervised treadmill walking 
• Intensity 40–60% maximal workload based on baseline treadmill test 
• Frequency 3 times/week supervised, supplemented with home walking 
• Duration ≥12 weeks and 36 sessions, consider more sessions as indicated by individual patient 
• Until mild to moderate pain/discomfort 
• Begin with 30–50 min intermittent exercise with the goal of accumulating 30–50 min of total walking exercise 
• Lifelong maintenance preferably 6–7 days/week 
• How to start each session? 
  • 1. Begin walking comfortably

  • 2. If leg pain occurs <8–10 min stop and rest

  • 3. Restart at the same intensity

  • 4. When walking longer than 8 min increases speed or grade

  • 5. Start next session at previous final speed or grade

  • 6. Try at least 30 min of walking time

 

Interventions aimed at controlling traditional cardiovascular risk factors such as hypertension or diabetes represent a key aspect of CR. As a general rule, the management of traditional cardiovascular risk factors should be adapted considering patient’s specific comorbidities and geriatric conditions, regardless of age. Thus, an individualized and careful approach is of great importance. Table 4 summarizes the foremost measures regarding the control of these risk factors.

Table 4.

Summary of measures control of traditional cardiovascular risk factors

Guidelines recommendationsSpecific recommendations for the older population
Hypertension Target blood pressure of <140/80 mm Hg, down to 130 mm Hg if well tolerated Avoid postural hypotension 
Reduce salt intake Less strict targets are recommended in frailty or ≥80 years patients 
Single-pill with two-drug combination if tolerated 
Diabetes Reduce glycosylate hemoglobin to 7% Frailty patients: lenient glycemic control with target glycosylate hemoglobin <8% 
In terminate-ill or severe cognitive impairment patients: avoid hypoglyemia or symptomatic hyperglycemia 
Dyslipidemia Very high cardiovascular risk: LDL cholesterol <55 mg/dL and reduction >50% from baseline Treatment with statins is recommended in older people with CVD 
Statins are the preferred agent of choice Starting low-dose statins if higher risk of renal impairment and/or potential drug interaction or adverse effects 
Starting low-dose statins if higher risk of drug interaction or adverse effects Up titrated upwards to achieve LDL-cholesterol treatment goals 
Obesity Target body mass index 25–34 kg/m2 Lose weight programs based exclusively on diet should be avoided in order to prevent loss of skeletal muscle 
Tobacco Smoke cessation Elderly patients should be encouraged to quit smoking 
Diet Adherence to Mediterranean diet Special attention to taste disorders 
Avoid low levels of vitamin B12, B1, thiamine 
Intravenous iron when indicated 
Protein supplementation in frail patients 
Guidelines recommendationsSpecific recommendations for the older population
Hypertension Target blood pressure of <140/80 mm Hg, down to 130 mm Hg if well tolerated Avoid postural hypotension 
Reduce salt intake Less strict targets are recommended in frailty or ≥80 years patients 
Single-pill with two-drug combination if tolerated 
Diabetes Reduce glycosylate hemoglobin to 7% Frailty patients: lenient glycemic control with target glycosylate hemoglobin <8% 
In terminate-ill or severe cognitive impairment patients: avoid hypoglyemia or symptomatic hyperglycemia 
Dyslipidemia Very high cardiovascular risk: LDL cholesterol <55 mg/dL and reduction >50% from baseline Treatment with statins is recommended in older people with CVD 
Statins are the preferred agent of choice Starting low-dose statins if higher risk of renal impairment and/or potential drug interaction or adverse effects 
Starting low-dose statins if higher risk of drug interaction or adverse effects Up titrated upwards to achieve LDL-cholesterol treatment goals 
Obesity Target body mass index 25–34 kg/m2 Lose weight programs based exclusively on diet should be avoided in order to prevent loss of skeletal muscle 
Tobacco Smoke cessation Elderly patients should be encouraged to quit smoking 
Diet Adherence to Mediterranean diet Special attention to taste disorders 
Avoid low levels of vitamin B12, B1, thiamine 
Intravenous iron when indicated 
Protein supplementation in frail patients 

Hypertension

Hypertension is a common medical condition among the elderly population. Its prevalence has been estimated as high as 77% in patients ≥65 years [51]. Any reduction in blood pressure is beneficial, in both fit and frail people [52]. However, potential risks such as hypotensive episodes, postural hypotension, or drug interactions should be taken into account, especially in those elderly patients with frailty or high comorbidity burden [53]. Current ESC guidelines recommend a target blood pressure of <140/80 mm Hg independently of age and systolic blood pressure down to 130 mm Hg if well tolerated. Of note, less strict targets are advisable in frailty or very old (≥80 years) patients [20]. Lifestyle interventions such as reducing salt intake or increasing physical exercise are recommended in all patients regardless of age. When pharmacological treatment is needed, it is preferable to start with a two-drug combination, ideally as a single-pill combination. However, in frail older patients, monotherapy may be used instead from the beginning [20].

Diabetes

The prevalence of type 2 diabetes also increases with age [52]. Current pharmacologic agents can achieve metabolic control and reduce cardiovascular risk and events while avoiding hypoglycemia. Sodium-glucose-linked transporter-2 inhibitors and glucagon-like peptide-1 receptor agonists have consistently demonstrated important clinical benefits and high safety profile in specific sub-analysis by age from main pivotal trials [54]. Regarding metabolic target, it should be tailored individually, taking into consideration patients’ status, frailty, and life expectancy. Intensive glycemic control has been shown not to reduce mortality but also to increase the risk of hypoglycemia. Generally, the metabolic target should be to reduce glycosylate hemoglobin to 7–7.5%, although in frailty patients or those with high comorbidity, a lenient control is recommended (glycosylate hemoglobin <8%), even less strict in case of terminate-ill patients or with severe cognitive impairment. Instead, avoiding hypoglycemic and symptomatic hyperglycemic should be prioritized [54, 55]. All patients should receive nutritional counselor avoiding low-calorie diets due to their association with a higher risk of malnutrition and sarcopenia [55].

Dyslipidemia

Aging plays an important role in lipid metabolic pathways, with a reduced degradation of low-density lipoprotein (LDL) cholesterol and triglycerides, which in turn associates a progressive increase in cholesterol level until 70 years, when it slightly falls [56]. Dyslipidemia affects as much as 40% of the population over 65 years. Adequate control of LDL-cholesterol levels improves cardiovascular and adverse events-free survival in patients with CVD [57]. In this setting, the current management of dyslipidemia in the elderly does not differ from younger patients: achieving an LDL-c ≤55 mg/dL and >50% baseline reduction [57, 58]. Elderly patients also benefit from lipid-lowering therapies, with a significant decrease in all-cause mortality and cardiovascular outcomes [59]. Despite this information, registries still show low prescription rates of lipid-lowering agents in elderly patients [60]. Statins are still the first agent of choice as they have shown multiple benefits in this scenario, although prescription should be individualized, especially in patients with short life expectancy. ESC guidelines specifically recommend starting with low-dose statins in those patients with a higher risk of drug interactions or muscular symptoms such as those with frailty [20]. Second-line eligible agents such as ezetimibe or proprotein convertase subtilisin/kexin type 9 inhibitors have also shown, to be both safe and effective in older patients [56]. More recently, bempedoic acid and inclisiran have successfully been demonstrated to reduce LDL-cholesterol levels in patients up to 75 years with no safety concerns [61, 62].

Obesity

Although obesity has been associated with a higher risk of CVD, elderly patients with CVD seem to have a better prognosis with slightly higher body mass index (BMI). This obesity paradox is particularly evident in HF patients. However, BMI could not be appropriate as a marker of obesity in this group as it could underestimate visceral adiposity or sarcopenic obesity [52]. The approach to treat overweight and obesity in the elderly demands a delicate balance. A restrictive diet can lead to a loss of skeletal muscle over fat mass, with the risk of worsening functional capacities [63]. A plan to lose weight in these patients cannot rely just on diet, but it also needs an exercise program including both aerobic and RT to minimize the loss of lean mass [64].

Tobacco Consumption

Tobacco abstinence is the single most effective measure to prevent CVD, irrespective of age. Then, smoking cessation is considered a priority, as benefits are tangible within a few years of quitting. Elderly patients should be encouraged to quit smoking [65].

Diet

Mediterranean diet has proved to reduce cardiovascular risk in high-risk population including patients up to 80 years old. DASH diet, similar to the former in many components, can be beneficial too [66]. In general, a diet based on a high intake of vegetables, whole grains, fruit, nuts, and fish, low intake of saturated fat, and reduction of red meat and alcohol is advisable in all age groups [20]. Nevertheless, elder people have special features that require attention. Taste disorders are common in the elderly, especially under polypharmacy [67], and this can lead to a greater difficulty to maintain salt restriction or to a loss of appetite that can lead to sarcopenia [68]. Vitamin supplementation has not proved to reduce cardiovascular events [69] although vitamin B12 deficit (common with concomitant metformin and proton pump inhibitors) and low levels of vitamin B1, thiamine (seen under long-time diuretic treatment), should be addressed [70]. Intravenous iron is safe and effective, and there are no age-dependant recommendations for use in HF [71]. Protein supplementation, along with an adapted exercise program can be useful in frail patients [72].

CR programs provide important benefits irrespective of age, acknowledging the unique challenges posed by geriatric conditions, common in elderly patients with CVD. Although CR has significant benefits in the older population, a significant degree of uncertainty currently exists in this field. An integrative approach should be considered, integrating personalized interventions and current scientific data, ultimately contributing to improving cardiovascular outcomes and enhanced quality of life in these patients.

The authors have no conflicts of interest to declare.

No funding has been received for this work.

Dr. Pablo Díez-Villanueva: conception and design. All authors were involved in the literature review, critical revision of the manuscript, and completed, read, and approved the final manuscript.

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