EXERCISE TESTING IN THE ELDERLY:

SAME SETUP – DIFFERENT APPROACH ?

A. Mezzani

S. Maugeri Foundation

Veruno Scientific Institute – Rehabilitative Cardiology Division

Veruno (NO) - Italy

64

65

66

67

68

70

Veruno Scientific Institute - Rehabilitative Cardiology Division

Patients’ mean age

2005 2006 2007 2008 2009

65,2

66,1

67,668,1

69,9

Yea

rs

IRCCS Veruno

IRCCS Veruno

Functionalcapacityevaluation

Trainingprescription

Prognosticstratification

Diagnosis ofmyocardialischemia

EXERCISE TESTINGIN THE ELDERLY

IRCCS Veruno

≥65<75 years ≥75 years

n. 793 154

Age (yrs) 69±3 77±2

BMI (kg/m2) 25.44±4 24.65±3

Peak VO2 (ml/kg/min) 14.3±4 13.5±3

Peak W 84±24 77±19

VE/VCO2 slope 33±7 34±6

NYHA 1.9±0.7 1.9±0.6

EF (%) 28±8 30±8

EDV (ml/m2) 112±45 98±29

β-B (%) 50 54

Cardiopulmonary ET in CHF patientsVeruno 2000 - 2009

IRCCS Veruno

Cardiopulmonary ET in CHF patientsRepeatability in elderly patients

Marburger CT, Am J Cardiol 1998

n. = 9

Age = 70.6 ± 2 years

IRCCS Veruno

First ventilatory threshold identificationin elderly CHF patients

VO2 (l/min)

VCO

2(l/m

in)

S1 = 0.86S2 = 1.28

1st

VT

n. = 395Mean age = 76 yrs

1st VT identified = 80%

Scardovi AB, J Cardiovasc Med 2007

IRCCS Veruno

Cicoira M, Int J Cardiol 2008

IRCCS Veruno

0

20

40

60

80

100

120

140

0 1 2 3 4 5 6 7 8 9 10 0 1 2 3 4 5 6 7 8 9 10

W

T (min) T (min)

160

Ramp

15 W/min

Ramp

10 W/min20 W

X 2 min

30 W

X 2 min

Incremental exercise testingCycle ergometer protocols

IRCCS Veruno

Main noncardiac causes of ineligibility

for exercise testing in the elderly

1) COPD

2) Peripheral arterial disease

3) Degenerative arthritis

4) Unfamiliarity with vigorous exercise and/or

exercise testing equipment

5) Clinician’s unwillingness to allow patients to

exercise

IRCCS VerunoDeckers JW, Eur Heart J 1984

IRCCS VerunoVolpi A, Circulation 1993

IRCCS Veruno

Volpi A, Circulation 1993

IRCCS Veruno

Stevenson LW, Circulation 1995

IRCCS Veruno

‘Thus, exclusion from the exercise test

appears to be an empiric index that

incorporates the cumulative risk resulting

from overlapping of known adverse prognostic

factors and their detrimental interactions.’

Volpi A, Circulation 1993

IRCCS Veruno

Y1 =

VO

2 (b

lue)

y2 =

Wor

k(red)

Constant-power exercise testing

T

Rest Exercise Recovery

O2 deficit

O2 debt

IRCCS Veruno

0

PhI-PhIItr

-40 80 160 240 320 400 480

Time (s)

0

500

750

1000

Residual

VO

2(m

l/m

in)

RE

R

0.75

0.9

Exercise

Rest VO2

PhI

amplitude

Steady-state VO2

IRCCS VerunoAlexander NB, J Gerontol 2003

1 mph – 0% grade – 6 minutes

IRCCS VerunoRickli H, J Am Coll Cardiol 2003

1 mph – 6% grade – 6 minutes

IRCCS Veruno

6-min walking test

Faggiano P, Am Heart J 1997

90% 79% 87%

IRCCS Veruno

6-min walking test in CHF patientsRepeatability in elderly patients

n. = 24Age (median) = 81 years

ICC = 0.91

IRCCS Veruno

O’Keeffe ST, Heart 1998

IRCCS Veruno

De Feo S, Eur J Cardiovasc Prev Rehabil 2009

Distance walked at 6-min WT soon after cardiac surgery

IRCCS Veruno

Ingle L, Eur Heart J 2007

IRCCS Veruno

Passantino A, J Am Coll Cardiol 2006

IRCCS Veruno

1) The indications and safety of exercise testing in

the elderly are similar to those in younger patients.

2) The frequent presence of both cardiovascular and

noncardiovascular comorbid conditions requires

concerted efforts to match the older patient with

an appropriate exercise testing protocol.

Conclusions - 1

IRCCS Veruno

3) Ineligibility for symptom-limited incremental

exercise testing due to clinical reasons bears per

se a negative prognostic value, irrespective of the

cause of functional limitation.

4) Patients unable to undergo incremental, maximal

effort can be offered alternative methods of

ergometric evaluation, that provide an adequate

functional and prognostic stratification.

Conclusions - 2

IRCCS Veruno

Thank you !