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Università degli Studi di Salerno

Amelia Filippelli Dipartimento di Medicina e Chirurgia, Università degli Studi di Salerno

Servizio Farmacologia Clinica - AOU S. Giovanni di Dio e Ruggi d'Aragona amelia.filippelli@sangiovannieruggi.it - afilippelli@unisa.it

Riabilitazione cardiorespiratoria nell’anziano

Cardiopulmonary rehabilitation in elderly

http://www.who.int/mediacentre/factsheets/fs310/en/index1.html

CARDIOVASCULAR AND RESPIRATORY DISEASES ARE

THE LEADING CAUSES OF DEATH

ASSOCIATIONS BETWEEN CARDIOVASCULAR DISEASE AND

RESPIRATORY DISEASE :

common risk factors and common symptoms/signs

Early-life risk factors for chronic non respiratory diseases.

Chacko A, Carpenter DO, Callaway L, Sly PD.

Eur Respir J. 2015 Jan;45(1):244-59.

dyspnea

fatigue

exercise tollerance

cognitive and daily

activities impairment

SYMTOMS/SIGNS

RISK FACTORS Obstructive Diseases*

Restrictive Diseases

Interstitial

Chest Wall

Neuromuscular

Other Diseases (lung cancer,

pulmonary, before and after

thoracic and abdominal surgery,

obesity-related respiratory

disease…)

*COPD, persistent asthma, cystic fibrosis,

bronchiolitis obliterans

Recent myocardial infarction

Coronary bypass

Valvular heart disease

Heart failure

Valve surgery

Percutaneous coronary

Intervention

Cardiac transplantation

Stable angina

INTERNATIONAL GUIDELINES: INDICATIONS FOR

REHABILITATION GOLD Guidelines AHA/ACC Guidelines

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http://www.burke.org/rehab/inpatient/cardiopulmonary

CARDIOPULMONARY REHABILITATION

TEAM: THE AIMS

CARDIOPULMONARY

REHABILITATION

TEAM

Lessening limitations of

activities by focusing on

the individual’s capabilities

and utilizing compensatory

strategies and devices

Removing or lessening

restrictions to participation in

life situations to the extent

possible

Providing counseling to the

individual and family and/or

caregiver on alternative

possibilities for life

participation when necessary

Preparing the individual, family

and/or caregiver to make the

transition to the next stage of

the rehabilitation process

Providing rehabilitation through

an interdisciplinary approach

that emphasizes

communication, collaboration

and cooperation

Providing the highest

quality, patient

focused rehabilitation

CARDIOPULMONARY REHABILITATION: FUNDAMENTAL PART OF THE

CONTINUUM OF CARE OF BOTH CHRONIC CARDIOVASCULAR AND

RESPIRATORY DISEASES

“EXERCISE TRAINING IS AN INTEGRAL PART OF

CARDIAC REHABILITATION, A COMPLEX

THERAPEUTIC APPROACH, EFFECTIVE BOTH IN

YOUNG AND ELDERLY PATIENTS.”

Exercise Training in Aging and Diseases.

Conti V, Russomanno G, Corbi G and Filippelli A.

Transl Med UniSa. 2012 May-Aug; 3: 74–80.

“EXERCISE TRAINING, THE MAIN COMPONENT IN

CARDIOPULMONARY REHABILITATION IN ELDERLY,

CAN BE CONSIDERED AS AN ANTIOXIDANT… THE

ADHERENCE TO INDIVIDUALLY TAILORED

MULTICOMPONENT EXERCISE PROGRAMMES OF

GERIATRIC REHABILITATION IS AN EXCELLENT WAY

TO DELAY AND EVEN TREAT AGE-ASSOCIATED

FRAILTY.”

Exercise training as a drug to treat age associated

frailty.

Viñaa J, Salvador-Pascuala A, Tarazona-Santabalbinab

FS, Leocadio Rodriguez-Mañasd L, Gomez-Cabreraa MC.

Free Radical Biology and Medicine. Vol 98, 2016, Pag159–

164.1

CARDIOPULMONARY REHABILITATION

Exercise training

Nutritional therapy

Behaviour intervention

Education

Outcome assessment

Promotion of long-term adherence

PHYSIOPATHOGENESIS OF CVD/

RESPIRATORY DISEASES

Exercise training

COMPONENTS

• Lower extremity exercises

• Arm exercises

• Ventilatory muscle training

TYPES OF EXERCISE

• Endurance or aerobic

• Strength or resistance

EXERCISE TRAINING

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INTERNATIONAL GUIDELINES:

CONTRAINDICATIONS FOR REHABILITATION

GOLD Guidelines AHA/ACC Guidelines

Patients with severe orthopedic

or neurological disorders limiting

their mobility

Severe pulmonary arterial

hypertension

Exercise induced syncope

Unstable angina or recent MI

Refractory fatigue

Inability to learn, psychiatric

instability and disruptive behavior

Unstable angina

Uncompensated heart failure

Uncontrolled arrhythmias

Severe ischemia, LV disfunction

during exercise testing

Poorly controlled hypertension

Acute thrombophlebitis

Pulmonary or sistemic embolism

Myocarditis

Severe psychological disorders

Severe mobility limitations

• Improved exercise capacity

• Reduced the perceived intensity of

breathlessness

• Improved health-related quality of life

• Reduced the number of hospitalizations and

days in the hospital

• Reduced anxiety and depression associated with

COPD

• Strength and endurance training of the upper

limbs improves arm function

• Benefits extend well beyond the immediate period

of training

• Improved survival

• Respiratory muscle training can be beneficial,

especially when combined with general exercise

training

• Improved recovery after hospitalization for an

exacerbation

• Enhanced the effect of long-acting bronchodilators

• Decreased mortality at up to 5 years post

participation

• Decreased cardiovascular events

• Reduced symptoms (angina, dyspnea,

fatigue)

• Improved Modifiable Risk Factors

• Improved function and exercise capacity

• Improved health-related quality of life

• Improved health factors like lipids and blood

pressure

• Enhanced ability to perform activities of

daily living

• Improved psychosocial symptoms

• Reduced hospitalizations and use of

medical resources

• Increased ability to return to work or engage

in leisure activities

INTERNATIONAL GUIDELINES: OUTCOMES

GOLD (Global Initiative for Chronic Obstructive Lung

Disease) Guidelines

AHA/ACC (American Heart Association/American College

of Cardiology) Guidelines

COPD and CHF coexistence

The risk ratio of developing HF in COPD pts is 4.5

The rate-adjusted hospital prevalence of CHF is 3 times greater among pts. discharged with a diagnosis of COPD compared with patients discharged without mentioned of COPD

• Up to 1/3 of elderly pts. with CHF have COPD

• Up to 1/5 of elderly pts. with COPD have CHF

14 million

Americans

have

COPD

And

5 million

have

CHF

Pier Luigi Temporelli. Monaldi Archives for Chest Disease Cardiac Series 2015:

«Cardiopulmonary rehabilitation in patient with heart failure and chronic pulmonary

disease»

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ISWT = Incremental Shuttle Walk Test

ESWT= Endurance Shuttle Walk Test

Symptom-directed, exercise training programs are

feasible and effective for COPD and CHF and training

can be progressed similarly for both categories, based

on symptoms rather than diagnosis.

Shortness of breath associated with cardiorespiratory abnormalities

and peripheral muscle discomfort are the major factors that limit

exercise capacity in patients with chronic obstructive pulmonary

disease (COPD) and those with congestive heart failure (CHF). Both of

these symptoms negatively impact on patients' daily physical activity levels.

In turn, poor daily physical activity is commonly associated with increased

rates of morbidity and mortality. Cardiopulmonary rehabilitation

programmes partially reverse muscle weakness and dysfunction and

increase functional capacity in both COPD and CHF. However, benefits

gained from participation in cardiopulmonary rehabilitation

programmes are regressing soon after the completion of these

programmes.

CARDIOPULMONARY REHABILITATION IN PATIENTS WITH

LUNG OR HEART DISEASE

Should all patients with COPD be exercise trained? What is the right rehabilitation program in COPD?

”...Accumulating evidence demonstrates the general benefits of exercise training,

an essential component of pulmonary rehabilitation.

In fact, exercise training is the most powerful intervention that is currently

available to provide symptomatic relief in COPD.

Despite such proven efficacy, one current challenge is to find ways of

optimizing exercise training benefits.

Various exercise training strategies will be outlined,

along with their beneficial effects and potential limitations.

Whether exercise training may exert deleterious effects in some patients has to

be determined…”

CARDIOVASCULAR AND RESPIRATORY DISEASES SHARE ALSO PATHOPHYSIOLOGICAL MECHANISMS

Eur Heart J. 2013.Sep;34(36):2795-803.

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CARDIOVASCULAR AND RESPIRATORY DISEASES ARE

age-related diseases

Inflammaging Free radicals hypothesis

Genetic hypothesis Telomeres Why do we age?

AGING

Proteins Lipids

Membrane damage

Enzymatic activity loss

Inert complex formation

Transcriptional and traslocation defects

Nucleic acids

Ox Anti-Ox

OXIDATIVE STRESS IN AGING

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Guarente L. Franklin H. Epstein Lecture: Sirtuins, aging, and medicine.

N Engl J Med. 2011;364(23):2235-44.

Sirtuins, aging and aging-associated diseases

Corbi et al. Int J Mol Sci. 2013 Jun

17;14(6):12696-713..

+

CHF COPD

SIRT1 LEVELS ARE DECREASED IN BOTH CARDIOVASCULAR AND

RESPIRATORY DISEASES EXERCISE BENEFITS…OUR RESULTS

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Cardiac rehabilitation in CHF patients:

Study design

30-minute sessions of aerobic exercise + respiratory exercises

5 days /week for 4 weeks

cardiopulmonary

stress test

ECG and

echocardiographic

examinations Comorbility and risk factors

Clinical and demographic features

blood chemistry tests

cardiopulmonary

stress test

blood chemistry tests

Subjects with post-ischemic

HF in clinically stable

conditions

In vivo and in

vitro experiments

Antioxidative and antisenescent

effects of cardiac rehabilitation:

Role for Sirt1

Unpublished data

Antioxidative and antisenescent effects of cardiac

rehabilitation: Role for Sirt1

Unpublished data

Sirt 1 and catalase as indicator of rehabilitation program

efficacy: role in exercise tolerance

Unpublished data

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SIRT1 AND «THE AGING THEORY OF COPD»

Conti et al. Anal Cell Pathol (Amst). 2015;2015:897327.

.Conti et al. .Anal Cell Pathol (Amst). 2015;2015:897327.

Ito K et al. COPD as a disease of accelerated lung aging.

Chest. 2009 Jan;135(1):173-80.

Sirtuins

AGING HYPOTHESIS FOR COPD

• Total oxidative status (TOS) • Trolox equivalent antioxidant capacity

(TEAC) • Oxidative stress index (OSI) • IL-6 expression

LYMPHOCYTES • Sirt1 expression • Sirt1 activity

FICOLL

GEL

ERYTHROCIYTES AND NEUTROPHYLS

PLASMA

Sirt 1 as predictive and prognostic marker for COPD: study disegn

HS, Healthy smokers HnS ,Healthy non smokers COPD, patients

ng

/ml

Sirt1 expression

P=0,04

Sirt1 activity

P<0,001

AU

Sirt 1 activity as predictive and prognostic marker for

COPD: preliminary data

=

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Association between Tiffeneau index (FEV1/FVC) and Sirt1 activity

P<0,01

CONCLUSIONS Accumulating evidence demonstrates the general benefits of exercise

training, an essential component of cardiopulmonary rehabilitation, in

both CVD and respiratory diseases

There is a large variability in the response of cardiopulmonary

rehabilitation programmes

There are no molecular markers to assess programmes’ efficacy and

safety

It is necessary to study molecular pathways underlying physiopathology

of cardiovascular and respiratory diseases and identify indicators to

optimize the exercise-based rehabilitative process.

THANKS FOR ATTENTION