Cardiac rehabilitation in older adults

INTRODUCTION — Following hospitalization for a cardiac event such as an acute coronary syndrome or heart failure (HF), all patients, and in particular older adults, are at increased risk of disability, including a repeat cardiovascular event. Because functional capacity declines with aging, there is often a decreased ability to perform activities of daily living, with progressive disability and dependency, all of which are exacerbated by acute cardiovascular illness and hospitalization. The efficacy and safety of cardiac rehabilitation have been demonstrated in all patients in which they have been studied, including older adults (age >65 years) [1].

Cardiac rehabilitation programs have several medically supervised components including medical evaluation, exercise training, physical activity counseling, coronary artery disease risk factor reduction, nutritional counseling and weight management, psychosocial support, and medication adherence education. (See "Cardiac rehabilitation programs", section on 'Components'.)

The indications for cardiac rehabilitation in older adults are the same as for the general population. (See "Cardiac rehabilitation: Indications, efficacy, and safety in patients with coronary heart disease", section on 'Evidence of benefit'.)

The use of cardiac rehabilitation programs in older adults will be reviewed here. The details of these programs are discussed separately. (See "Cardiac rehabilitation programs".)

OVERVIEW OF BENEFITS — Cardiac rehabilitation promotes physical function, helps overcome disease, deconditioning, and vulnerabilities such as disability, frailty [2], and falls. Cardiac rehabilitation facilitates education, monitoring, and guidance to reduce iatrogenesis and promote adherence. It fosters cognition, socialization, and independence in older adults [3]. Additionally, it provides an opportunity to treat other geriatric-specific issues such as balance retraining, fall reduction, sarcopenia, polypharmacy, depression, and cognitive decline [4]. Exercise rehabilitation is associated with improvement in exercise tolerance regardless of age and sex [5].

SPECIFIC PATIENT GROUPS — Cardiac rehabilitation in older adults has been shown to be beneficial in several patient groups with cardiac disease.

Cardiovascular events — Cardiac rehabilitation programs are designed to enhance recovery from acute cardiovascular events (eg, myocardial infarction or acute coronary syndrome) and to improve both quality of life and survival [6-10]. After a cardiac event or hospitalization, cardiac rehabilitation can reintroduce older adults to exercise in a safe and monitored setting.

In a pilot randomized controlled trial of 63 older patients after an acute coronary syndrome, complementary resistance and balance training did not provide greater benefit for the resultant physical performance compared with usual cardiac rehabilitation programs. However, all three rehabilitation programs were safe and well tolerated by older patients and improved capacity and physical performance [11].

Stable coronary heart disease — Patients with stable coronary heart disease treated medically or those who have undergone myocardial revascularization with percutaneous coronary intervention or coronary artery bypass graft surgery derive benefit. Older frail patients are now being referred for cardiac surgery, and cardiac rehabilitation may improve the postoperative outcome following cardiac procedures [12]. (See "Prevention of cardiovascular disease events in those with established disease (secondary prevention) or at very high risk".)

The ongoing RESILIENT randomized controlled trial, which uses mobile health for older adults with ischemic heart disease in the home setting, is designed to generate evidence about the efficacy of mobile health cardiac rehabilitation among older adults and to understand the parameters that suggest sustained engagement, declining engagement, and/or persistent low engagement. These findings will help design precision approaches to mobile health cardiac rehabilitation implementation [13].

Transcatheter aortic valve replacement — Cardiac rehabilitation may improve disability, frailty, quality of life, anxiety, exercise capacity, and survival in patients with transcatheter aortic valve replacement (TAVR). This is a potentially important intervention, as TAVR patients are often very old, disabled, frail, and have low exercise capacity [14]. (See "Transcatheter aortic valve implantation: Periprocedural and postprocedural management".)

Heart failure — Cardiac rehabilitation can play a decisive role in improving function, quality of life, symptoms, morbidity, and mortality in older adults with HF [15]. Specific improvements are:

●Cardiac rehabilitation offers the opportunity to optimize medication regimens in HF [16].

●Accumulating evidence has shown comparable exercise training benefits in older and younger patients with HF [17]. In older patients with heart failure and preserved ejection fraction (HFpEF), and in whom exercise intolerance is the primary chronic symptom, exercise training improves both peak and submaximal exercise capacity [18]. (See "Cardiac rehabilitation in patients with heart failure".)

A study of the response to endurance exercise training in older adults with HF showed that the training-related improvement was higher in patients with HFpEF than in those with HF with reduced ejection fraction (HFrEF) [19].

●Cardiac rehabilitation can improve physical functioning, mortality, and quality of life in older adults with HF regardless of ejection fraction if geriatric-related complexities are addressed [20]. Persons with HFpEF (who are more likely female) may benefit more from cardiac rehabilitation. Despite this, they are referred less and are less likely to participate in rehabilitation than males [21,22].

In the REHAB-HF trial of a tailored rehabilitation program for adults >60, 349 patients with HF were randomly assigned cardiac rehabilitation during or early after hospitalization versus usual care [23]. The intervention focused on four domains relevant to an older population: strength, balance, mobility, and endurance. All patients had markedly impaired physical function, and nearly all were frail or prefrail. Severe leg weakness prevented nearly one-third of the patients from standing even once from a seated position without the use of their arms.

•There were both high retention (82 percent) and adherence to the program (67 percent).

•Patients in the intervention group had higher physical function scores at three months.

•Patients in the intervention group experienced symptoms of chest pain, hypertension, hypoglycemia, and hyperglycemia, whereas patients in the control group experienced more falls and HF.

•Rates of secondary outcomes of death and rehospitalization did not differ between treatment groups.

•In a post-hoc analysis of REHAB-HF, there was a trend toward a greater benefit among patients with HFpEF versus HFrEF on some outcomes including the Short Physical Performance Battery, six-minute walk distance, and six-month all-cause rehospitalization, and death. This was despite the fact that HFpEF participants had significantly worse baseline physical function, frailty, quality of life, and depression [24].

It is important to acknowledge that cardiac rehabilitation was administered early and was specially tailored to a frail and older population, but may not be widely available.

Among older adults, a combined high-intensity interval and resistance training program was shown to improve systolic blood pressure, body fat percentage, waist circumference, physical activity, functional capacity, and quality of life [25].

Older patients who had outpatient cardiac rehabilitation interrupted by COVID-19 restrictions had a deterioration in their frailty status [26].

EXERCISE IN OLDER ADULTS — Cardiac rehabilitation programs include an exercise component as well as the provision of information and skills to help lower the risk of subsequent events from diabetes, hypertension, smoking, dyslipidemia, and adverse psychosocial factors. The benefits from cardiac rehabilitation programs are attributable to all components of the program. This section focuses on the ways in which exercise is beneficial in this population.

All patients being considered for an exercise program should be evaluated to determine their potential risk with physical activity and to determine whether any contraindications to exercise are present. Implementation of exercise training in older coronary patients requires only modest modifications in the exercise prescription, training techniques, and standard program components that are used in younger coronary patients [27]. (See "Cardiac rehabilitation programs", section on 'Exercise training'.)

Program adaptations — The specific recommendations for activity levels and energy expenditure in older patients must include:

●Consideration of the cardiovascular changes associated with aging [28]. These include a decrease in maximal oxygen consumption due to a loss of muscle mass [28], an impaired efficiency of maximal peripheral oxygen extraction, and a decline in maximal heart rate, which is compensated for by an increase in stroke volume in order to maintain cardiac output [29].

•A study in octogenarians suggests that the cardiovascular and hemodynamic responses to physical activity do not differ significantly from those in younger adults [30].

●Changes related to physical inactivity [31-33].

●Changes reflecting the cardiac dysfunction resulting from coronary heart disease or other cardiovascular disease.

●Consideration of comorbidities, including arthritis and peripheral artery disease (PAD), that may impair mobility. PAD occurs in 10 to 20 percent of individuals older than 65 years of age, with only one-third demonstrating classic intermittent claudication. There is strong evidence for the routine use of supervised exercise therapy for PAD patients [34].

Several distinctive features of the response to physical activity in older coronary patients must be appreciated to attain improvement in physical work capacity. (See "Cardiac rehabilitation programs".)

●A greater emphasis and more time must be devoted to warm-up activities, including flexibility and range-of-motion exercises, which enable musculoskeletal and cardiorespiratory readiness for exercise [35].

●Cool-down activities are of equal importance to allow gradual dissipation of the heat load of exercise and subsidence of exercise-induced peripheral vasodilatation, which can lead to hypotension. Older subjects are at greater risk for the latter problem because of the delayed baroreceptor responsiveness with aging.

●The exercise heart rate returns more gradually to resting values in the older adult patient, necessitating a longer period of rest between various components of exercise or for higher-intensity activity when it is alternated with periods of low-intensity exercise.

●Aging is associated with a decrease in skin blood flow, which lowers the efficiency of sweating and temperature regulation during exercise. This warrants a reduction in the intensity of exercise for older patients in hot or humid environments.

Exercise prescription — Aerobic training is initially begun at low intensity (eg, 2 to 3 METs), with a gradual increase in both exercise intensity and duration to limit discomfort and injury. Only mild fatigue should be engendered by an exercise training session. The older patient who remains asymptomatic at lower intensities of exercise and who has no contraindications to more strenuous exercise, based on the results of pretraining exercise testing, may be progressed gradually to higher (albeit still moderate) activity intensity.

Even in previously physically active older individuals, musculoskeletal complications can be substantially lessened by avoidance of running, jumping, and other high-impact aerobics [36]. Older females are more liable to experience musculoskeletal complications of high-impact activities than older men.

Although the ideal exercise regimen for older adult coronary patients has not yet been determined, the exercise undertaken should be dynamic, enjoyable, easily accessible, and without adverse sequelae. Brisk regular walking is an excellent prototype of a readily accessible form of exercise designed to achieve aerobic fitness; gradual increases are recommended in both the pace and distance of walking. Further advantages are that no special equipment, facilities, exercise skills, or training are required, and walking permits socialization with exercising companions. Brisk walking constitutes a substantial percentage of the lower maximal oxygen uptake of older patients and is therefore an effective and safe physical conditioning stimulus [37]. In comparison, brisk walking is usually insufficient to stimulate a training effect in younger individuals, except for those who are extremely sedentary.

Arm exercise should be added to the walking regimen since training of arm muscles is needed to affect improvement in the exercise response to arm work. Strength training, designed to improve muscle function and increase muscle mass, also enhances aerobic capacity, and it is an additional component of value in the exercise rehabilitation of the older coronary patient [35,38].

One study suggests that frailty, increasingly common in older cardiovascular patients referred for cardiac rehabilitation, may influence the onset, type, and intensity of the exercise training program and identified a need for tailored rehabilitative interventions for these patients [39].

A narrative review of cardiac rehabilitation in older patients with frailty and heart failure highlights that three domains, including not only physical frailty but cognitive psychological, spiritual, and social aspects should be understood. Nutritional and pharmacologic interventions are also important. All of these interventions must be incorporated in the cardiac rehabilitation program [40].

The American College of Sports Medicine has specific recommendations for physical activity and exercise in older adults [41]. These include:

●Aerobic activities – Moderate-intensity aerobic physical activity (30 minutes on five days/week) or vigorous-intensity aerobic activity (20 minutes on two days/week).

●Muscle strengthening activity – A resistance (weight) that allows 10 to 15 repetitions for each exercise using major muscle groups.

●Flexibility activities – Activities that improve flexibility (at least two days/week for 10 minutes/day).

●Balance exercise – To reduce the risk of injury from falls, older adults should perform exercises that maintain or improve balance.

Patients have been traditionally taught to control the intensity of their exercise by pulse counting or by use of the Rating of Perceived Exertion [42]. (See "Exercise assessment and measurement of exercise capacity in patients with coronary heart disease".)

However, our preference for older patients is for the "talk test." Patients are instructed to exercise only to an intensity that permits them to continue talking to an exercising companion.

Enclosed shopping malls are present in many communities and they provide ideal sites for walking for older coronary patients who can exercise in an unsupervised setting. These venues offer a level surface in a temperature- and humidity-controlled environment.

Silent ischemia — The absence of exercise-related angina does not exclude the presence of exercise-induced myocardial ischemia; many older patients have non-chest pain myocardial ischemia, and exercise-induced dyspnea is often an anginal equivalent. (See "Silent myocardial ischemia: Epidemiology, diagnosis, treatment, and prognosis".)

Silent ischemia at pretraining exercise testing indicates what level of exercise may prove hazardous during exercise training. The intensity range recommended for exercise training should be 60 to 75 percent of the highest heart rate safely achieved at exercise testing. This exercise intensity is still an effective stimulus for aerobic metabolism and improved endurance and is associated with greater comfort and enjoyment and fewer musculoskeletal complications than those encountered at the previously recommended 70 to 85 percent heart rate range [36]. Lower exercise intensity for training in older adults, undertaken for a longer period of time, is also characterized by greater safety during unsupervised exercise and improved adherence to long-term exercise training.

Potential benefits of exercise — There are potential and proven benefits anticipated from exercise training in older adults [5]:

●Laboratory and physiologic measures – The following improvements are seen:

•Prevention of age-related endothelial dysfunction due to preservation or restoration of nitric oxide availability [43]. (See "Coronary endothelial dysfunction: Clinical aspects".)

•A reduction in hemostatic factors (fibrinogen, plasma and blood viscosity, platelet count, coagulation factors VIII and IX, von Willebrand factor, fibrin D-dimer, tissue plasminogen activator antigen) [44]. (See "Effects of exercise on lipoproteins and hemostatic factors".)

•A decrease in the inflammatory biomarker serum C-reactive protein concentration [44,45]. (See "C-reactive protein in cardiovascular disease".)

•Attenuation of age-related reductions in central arterial compliance and restoration of arterial compliance in previously sedentary, healthy middle-aged and older men [46].

•Restoration of ischemic preconditioning, which is reduced in the aging heart [47]. Physical activity reduced in-hospital mortality after a myocardial infarction among persons with angina (a clinical equivalent of ischemic preconditioning) [48]. (See "Myocardial ischemic conditioning: Clinical implications".)

•A reversal of age-related decline in maximal oxygen consumption in the peripheral circulation [29,49].

●Physical fitness – An improvement in physical fitness, physical work capacity, and endurance [50,51]. This can prolong the duration of an active lifestyle, and may hinder or obviate disability and dependency [31] and the need for costly custodial care. Resistance training can increase muscle strength, endurance, exercise performance, and physical function in older adults with coronary disease and HF. Combining aerobic exercise with resistance training is more effective than isolated aerobic and resistance training [52]. High-intensity interval training for older adults with low exercise capacity may be considered [53].

●Falls – An enhancement in flexibility, joint mobility, balance, stability, muscle strength and tone, and neuromuscular coordination, which may lessen the propensity for falling and permit increased participation in the activities of daily living [54,55].

●Bone density – Objectively measured physical fitness appears to be a major determinant of bone mass and bone density in older adults [56]. Moderate-intensity exercise can hinder the demineralization of bone and resultant osteoporotic fractures, a particularly important consideration for older females for whom osteoporosis is often a prominent problem in the absence of appropriate therapy. (See "Overview of the management of low bone mass and osteoporosis in postmenopausal women".)

●Coronary artery disease risk factors – Coronary risk factors are highly prevalent and tend to cluster at older age [57]. The absolute risk attributable to each of these factors increases with age because of the excess occurrence of coronary events in an older population. As a result, the potential benefit of risk reduction may be even greater for older than for younger patients.

Participation in an exercise regimen at any age often encourages coronary risk reduction [5]; the increased energy expenditure of exercise can aid in weight control and serve as an adjunct to dietary therapy, especially when smoking cessation is undertaken. Exercise also exerts a beneficial effect on coronary heart disease risk factors, including obesity, hypertension, and insulin resistance. (See "Prevention of cardiovascular disease events in those with established disease (secondary prevention) or at very high risk".)

●Self-confidence – Exercise training may be associated with improvement in self-confidence and self-image, a sense of well-being, and a lessening of anxiety, depression, and loss of motivation [58]. Although some studies describe an exercise-related improvement in cognitive function and psychomotor speed, the lessened depression associated with exercise and physical fitness may simply enable better completion of the cognitive testing modalities used in these assessments.

●Cognitive function – Cardiac rehabilitation may improve cognitive function [59]. In 66 patients >70 years of age with cardiovascular diseases, cardiac rehabilitation improved temporal orientation, attention, and calculation on the Mini-Mental Status Examination [60].

●Preconditioning – Although cardiac rehabilitation has traditionally been focused on secondary prevention after cardiovascular diseases, new models of preconditioning rehabilitation (with exercise and nutrition components) are being offered to frail older people before surgery to improve functional outcomes and reduce hospital stay [61]. 

●Reversing function decline – A randomized study of exercise in 370 older patients who were hospitalized for acute illness showed an exercise intervention to be effective in preventing the functional decline associated with hospitalization [62].

CLINICAL OUTCOMES — The following clinical outcomes are improved by cardiac rehabilitation in older adults.

Survival — The following studies of cardiac rehabilitation provide evidence for an improvement in survival in older adults:

•In a study assessing cardiac rehabilitation and survival in over 600,000 older adults (United States Medicare beneficiaries) hospitalized for coronary conditions or cardiac revascularization procedures, mortality rates were 21 to 34 percent lower in cardiac rehabilitation users than in nonusers [63].

•One study of post-acute, inpatient cardiac rehabilitation showed equal benefit (eg, survival, hospital days, and physical function) for patients younger than 65 years of age, those 65 to 74, and those older than 75 years of age [64]. These data reflect benefit in the population with substantial comorbidity and impaired functional status.

•A systematic review meta-analysis of randomized controlled trials of exercise-based rehabilitation for patients with coronary heart disease, including older patients, showed improved cardiac and all-cause mortality and demonstrated improvement in a number of coronary risk factors [65].

•Survival was evaluated in a community cohort of nearly 36,000 individuals with an average age of about 65 years who sustained an acute coronary syndrome or who underwent cardiac surgery between 2007 and 2010. The adjusted hazard ratio for survival was 0.65 (95% CI 0.56-0.77) comparing those who received cardiac rehabilitation with those who had not [66]. The benefit was similar among those ≤70 years of age and those >70 years.

Coronary risk reduction — Despite the absence of large clinical trials evaluating secondary prevention of coronary heart disease specifically in older adults, many trials of secondary prevention included a reasonable proportion of older patients; there were few patients >age 85 years of age. Older participants in multifactorial cardiac rehabilitation had significant reductions in coronary risk factors [5,17,67,68]. Comparable findings were reported in the French Nationwide PREVENIR survey [68]. (See "Prevention of cardiovascular disease events in those with established disease (secondary prevention) or at very high risk".)

Other outcomes

●Weight loss – Weight loss in overweight (ie, body mass index >25 kg/m²) subjects produces favorable changes in a number of coronary risk factors, including hyperlipidemia, hyperglycemia, and hypertension; control of obesity also encourages the maintenance of an active lifestyle. (See "Overweight and obesity in adults: Health consequences" and "Obesity in adults: Overview of management".)

Among older patients, the benefit of exercise training without nutritional intervention is limited [69,70]. The minimal effect of exercise alone on body weight is probably due to the low energy expenditure with exercise achieved in older adults. As a result, it is advisable to recommend more frequent and prolonged-duration walking as an adjunct to dietary modification in obese (ie, body mass index >30 kg/m²) older patients with coronary heart disease.

●Independent living – Cardiac rehabilitation significantly enhanced the capability of older patients to live independently by improving their ability to perform common household tasks [71].

●Functional capacity – Improvements in both functional capacity and heart rate variability have been demonstrated [72]. Older coronary patients participating in maintenance cardiac rehabilitation have similar exercise capacity and cardiorespiratory response to exercise as their age/sex-matched, less active healthy peers [73].

●Physical performance domains – An observational study assessed the effect of cardiac rehabilitation in a consecutive series of older adults (age 75 and older) referred to an outpatient cardiac rehabilitation unit after an acute coronary event. There was improvement in all domains of physical performance, particularly in those with poorer baseline performance. The parameters measured were peak oxygen consumption during a symptom-limited cardiopulmonary stress test, distance walked during a six-minute walk test, and peak strength using an isokinetic dynamometer [74].

●Quality of life – Older patients who participate in exercise training also report an increase in their leisure activities, an increase in sexual interest and function, improved sleep status, and enhanced optimism. These multifaceted benefits can enhance the quality of life of older patients [50,51].

●Work capacity – Substantial data support the role of physical activity in maintaining physical work capacity into old age. Exercise training results in a relative improvement in aerobic capacity among older adults that is comparable to that seen in younger subjects [67]. Significant increases in total work capacity may occur even in patients over the age of 75, although in these individuals, the relative improvement is smaller [50].

The major components of secondary prevention in older adults are discussed separately:

●Treatment of hypertension. (See "Treatment of hypertension in older adults, particularly isolated systolic hypertension".)

●Treatment of dyslipidemia. (See "Low-density lipoprotein cholesterol-lowering therapy in the primary prevention of cardiovascular disease" and "Management of low density lipoprotein cholesterol (LDL-C) in the secondary prevention of cardiovascular disease".)

●Treatment of diabetes mellitus. (See "Treatment of type 2 diabetes mellitus in the older patient".)

●Cessation of smoking. (See "Cardiovascular risk of smoking and benefits of smoking cessation", section on 'Effect of age'.)

●Psychosocial intervention. (See "Psychosocial factors in acute coronary syndrome".)

UNDERUTILIZATION — Despite the evidence in support of cardiac rehabilitation in older adults, utilization rates are low. In an analysis of Medicare claims for hospitalizations during 1997 in over 250,000 individuals over the age of 65, cardiac rehabilitation use was 13.9 percent in patients hospitalized for acute myocardial infarction and 31 percent in those who underwent coronary artery bypass graft surgery [75]. Similar low referral rates were reported after percutaneous coronary intervention [76]. Another study found that about 37 percent of older patients with recent myocardial infarction were not referred and that about two-thirds who were referred did not attend [77]. In a study of 169 older patients with HF, only 21 percent were referred for any cardiac rehabilitation service [78], although at interview, most wanted to attend. After an acute coronary syndrome hospitalization, patients older and younger than age 65 had comparable and maintained improvements in functional capacity, metabolic profile, and other prognostic parameters due to cardiac rehabilitation [79].

A 2011 review of cardiac care for older adults highlights that cardiac rehabilitation can be better utilized to reduce morbidity and mortality, improve quality of life, increase functional capacity, reduce readmissions, and reduce healthcare costs for older patients [80]. The multiple comorbidities and complex medication regimens are often specifically addressed within a cardiac rehabilitation setting.

Although many older patients are not referred because they are deemed too frail, these are the patients that often achieve the greatest benefits. Frailty and sarcopenia are not contraindications to cardiac rehabilitation exercise prescription but indeed represent the most important reasons to promote it [81]. Cardiac rehabilitation affords unique opportunities to measure and treat frailty, with an individualized exercise prescription aiming to improve cardiopulmonary fitness concurrent with sarcopenia and overall frailty [82].

Patients with slow gait speed may be less likely to be referred and if referred, less likely to finish cardiac rehabilitation compared with those with normal gait speed. Nevertheless, cardiac rehabilitation was equally beneficial in those with normal and slow gait speed [83].

The American Heart Association's Get With the Guidelines Program identified older adults and individuals with the most comorbidities as those with decreased odds of referral for cardiac rehabilitation and advocated more emphasis on increasing referral to cardiac rehabilitation to overcome the underutilization of this modality in the secondary prevention of cardiovascular disease [84].

The Centers for Medicare and Medicaid Services track referral to cardiac rehabilitation after hospitalization for myocardial infarction or HF, percutaneous coronary intervention, and coronary artery bypass graft surgery as a performance measure [85]. The success of non-center or hospital-based rehabilitation programs requires application to older patients [86] such as home-based exercise programs supported by smartphone applications to track relevant data, smartphone-based interactive tools, and computer- or mobile-phone-based coaching and motivational strategies [87,88].

Despite its documented benefits, older adults underuse cardiac rehabilitation; older females underutilize it disproportionately to men [89]. Alternate models of cardiac rehabilitation may help attract older females, such as home-, mobile-, and community-based cardiac rehabilitation programs, where benefits are similar to traditional programs [22].

Despite these benefits, both referral to and participation in exercise rehabilitation have been less frequent in older adults [5], especially older females [21,22].

Strategies to increase utilization

●An automatic referral strategy combined with patient discussion was shown to achieve the highest rates of cardiac rehabilitation referral [90]. Institutions were encouraged to adopt such quality-improvement initiatives to promote the dissemination and implementation of cardiac rehabilitation referral. Among Medicare beneficiaries, a strong dose-response relationship was shown among the number of cardiac rehabilitation sessions attended and long-term outcomes [91]. Attending all 36 sessions was associated with lower risk of death and myocardial infarction at four years.

●In-person synchronous, remote, and virtual cardiac rehabilitation may decrease barriers to utilization for older adults; however, further studies are needed to test the efficacy of these methods in older adults [92,93]. Home-based cardiac rehabilitation can extend the breadth and depth of education, counselling, and monitoring modalities for older adults and has been shown to be as efficacious as center-based cardiac rehabilitation [94]. In an international multicenter randomized clinical trial of 179 patients in Europe, six months of home-based mobile cardiac rehabilitation was associated with a greater increase in physical fitness compared with no cardiac rehabilitation. Beneficial adaptations were sustained at one-year follow-up [95].

Although remote cardiac rehabilitation offers the opportunity to increase access and effectiveness of cardiac rehabilitation in older adults, refinements are needed to best enable remote cardiac rehabilitation to be safe and effective for the wide range of older adults, including those who are frail, sedentary, and fearful [96]. Educating the referring clinician regarding the safety and efficacy of cardiac rehabilitation in older adults may increase referral rates. Hybrid and remote cardiac rehabilitation may enable older adults to access cardiac rehabilitation services who would not otherwise participate in center-based cardiac rehabilitation. The telemedicine infrastructure developed during the COVID-19 pandemic will aid in the implementation of hybrid and remote-based cardiac rehabilitation of older adults.

●Smart devices, wearables, and other digital health options may enhance access to and effectiveness of cardiac rehabilitation, although more robust research is needed [97].

RECOMMENDATIONS OF OTHERS — We agree with the recommendations of multiple societies or guideline groups, which recommend cardiac rehabilitation in older patients [5,21,22,31,32,67-69,98-100].

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Primary prevention of cardiovascular disease" and "Society guideline links: Secondary prevention of cardiovascular disease" and "Society guideline links: Lifestyle management and cardiac rehabilitation".)

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Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on “patient info” and the keyword(s) of interest.)

●Basics topics (see "Patient education: Heart attack recovery (The Basics)" and "Patient education: Recovery after coronary artery bypass graft surgery (The Basics)")

●Beyond the Basics topics (see "Patient education: Heart attack recovery (Beyond the Basics)" and "Patient education: Recovery after coronary artery bypass graft surgery (CABG) (Beyond the Basics)")

SUMMARY AND RECOMMENDATIONS

●Background – Older adults (age greater than 65 years) are at high risk of disability following a cardiovascular event or hospitalization for heart failure (HF). Complications of myocardial infarction and revascularization procedures are more frequent at older age with prolongation of hospitalization predisposing to deconditioning. (See 'Introduction' above.)

●Benefits – Patients with acute coronary syndrome, stable coronary heart disease, transcatheter aortic valve replacement (TAVR), and HF (regardless of ejection fraction) benefit from cardiac rehabilitation. (See 'Specific Patient Groups' above.)

•Among older patients hospitalized with HF, an early, tailored cardiac rehabilitation program can improve physical function. (See 'Heart failure' above.)

•The available data suggest a benefit in cardiovascular risk reduction similar to that observed in younger individuals, including a reduction in mortality. (See 'Clinical outcomes' above.)

•The benefits of cardiac rehabilitation in older adults extend beyond the cardiovascular system and include an improvement in physical fitness and work capacity as well as enhancement in flexibility, joint mobility, balance, stability, muscle strength, and tone. (See 'Potential benefits of exercise' above.)

●Program adaptations – Several program adaptations can increase the safety, adherence, and efficacy of cardiac rehabilitation in older adults. (See 'Program adaptations' above.)

●Indications – For all older adults with coronary artery disease (including those with an acute coronary syndrome, recent myocardial revascularization, or stable angina pectoris) and older patients with HF, we recommend referral to a cardiac rehabilitation program (Grade 1B). (See "Cardiac rehabilitation: Indications, efficacy, and safety in patients with coronary heart disease", section on 'Indications'.)