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

2. Dr Jason Kaplan
June 2013
Exercise in Older
Adults

3. 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

4. • 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 ! “

5. Invasion of the MAMILS !

9. 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

10. 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

11. 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

13. 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.

14. 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.

15. 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

16. 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.

17. 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%)

18. 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

19. 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.

21. Class A
• Lets talk about it !

25. 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”

26. • 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.

27. • 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

28. • 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.

29. • 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

30. • 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

31. • 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)

32. 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

33. 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.

34. • 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.

35. 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.

36. • “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.

37. Message from British Heart Foundation