Addressing the paradox of age and participation in cardiac rehabilitation

A paradoxical situation exists in cardiac rehabilitation. People are living longer and the prevalence of cardiovascular disease increases with age. In 2016 average life expectancy was over 80 years in the European Union. However, older patients are underrepresented in cardiac rehabilitation (CR) programmes despite their disease prevalence, and the evidence for the effectiveness of CR in decreasing mortality and morbidity after cardiovascular events and surgery is primarily based on younger patients. The median age of participants in systematic reviews of clinical trials of exercise-based rehabilitation for coronary artery disease or heart failure is 60 years or less. Data from national cohorts and audits show slightly older participants, with mean ages in the mid-60 s. Consistent with other reports, the EUROASPIRE IV survey determined that older age was a predictor of non-participation in CR, and an analysis of 601,099 patients aged 65 years and older potentially eligible for CR in the United States found that only 12.2% participated. Nonetheless, older patients experience the same benefits from CR, and their engagement needs to be increased. The reasons for lack of referral to and uptake of CR among older patients are multifactorial. Concomitant conditions such as frailty, poor functional status and multiple comorbidities may make clinicians reluctant to refer, programmes reluctant to enrol, and patients consider themselves too ill for participation. Conversely, patients with the lowest physical activity and poorest function are most likely to benefit from exercise training components. A retrospective analysis of 5641 patients undergoing CR found the greatest gain in mean peak metabolic equivalents (METs) in those with the poorest level of fitness (<5 METs), which was associated with a greater reduction in mortality compared to the participants overall. The multicomponent nature of comprehensive CR provides the opportunity to address issues associated with ageing such as deconditioning, frailty, fall risk, cognitive impairment, management of comorbid conditions and psychosocial issues as well as facilitating risk factor control and medication adherence. Into this paradoxical situation the EU-CaRE project has been designed to obtain the evidence base to improve, tailor and optimise CR programmes regarding sustainable effectiveness, cost-effectiveness and participation level for patients aged 65 years and above. In this issue of the journal, the investigators present baseline data from 1633 older patients enrolled in CR programmes in eight countries. The patients’ mean age was 73 5.4 years, and 408 patients (25%) were over the age of 76 years. The majority were enrolled following an acute coronary syndrome (54%) or with stable coronary artery disease (33%), and only 16% had not received a revascularisation procedure. The need for CR was evident as patients had multiple risk factors, with 58% having three or more risk factors. Control of risk factors was suboptimal for many despite a high proportion of patients being on appropriate medications. Cardiorespiratory fitness was low with a mean peak oxygen consumption of 16ml/kg/minute, 56% reported less than 4 days per week of moderate exercise, and almost half had a body mass index greater than 27 kg/m. Depressive symptoms were screened using the PHQ9 and 18% of patients had moderate to severe depression. A strength of this paper is that it provides an analysis of the characteristics and baseline treatment of older patients attending CR in eight European countries. Data were collected in a prescribed and uniform manner and reviewed for quality. However, some limitations are inevitable. The study is only being conducted in countries in western Europe, there is a