05/11/2016. Riabilitazione cardiorespiratoria nell anziano INTERNATIONAL GUIDELINES: INDICATIONS FOR REHABILITATION

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1 Università degli Studi di Salerno CARDIOVASCULAR AND RESPIRATORY DISEASES ARE THE LEADING CAUSES OF DEATH Riabilitazione cardiorespiratoria nell anziano Cardiopulmonary rehabilitation in elderly 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 ASSOCIATIONS BETWEEN CARDIOVASCULAR DISEASE AND RESPIRATORY DISEASE : common risk factors and common symptoms/signs INTERNATIONAL GUIDELINES: INDICATIONS FOR REHABILITATION GOLD Guidelines AHA/ACC Guidelines RISK FACTORS SYMTOMS/SIGNS dyspnea fatigue exercise tollerance cognitive and daily activities impairment Early-life risk factors for chronic non respiratory diseases. Chacko A, Carpenter DO, Callaway L, Sly PD. Eur Respir J Jan;45(1): 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 1

2 CARDIOPULMONARY REHABILITATION TEAM: THE AIMS CARDIOPULMONARY REHABILITATION: FUNDAMENTAL PART OF THE CONTINUUM OF CARE OF BOTH CHRONIC CARDIOVASCULAR AND RESPIRATORY DISEASES 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 rehabilitation through an interdisciplinary approach that emphasizes communication, collaboration and cooperation CARDIOPULMONARY REHABILITATION TEAM Providing the highest quality, patient focused rehabilitation 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 Promotion of long-term adherence Outcome assessment Exercise training CARDIOPULMONARY REHABILITATION Education Nutritional therapy Behaviour intervention 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 May-Aug; 3: 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, Pag Exercise training 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 2

3 INTERNATIONAL GUIDELINES: CONTRAINDICATIONS FOR REHABILITATION GOLD 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 AHA/ACC Guidelines 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 INTERNATIONAL GUIDELINES: OUTCOMES GOLD (Global Initiative for Chronic Obstructive Lung Disease) Guidelines 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 AHA/ACC (American Heart Association/American College of Cardiology) Guidelines 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 COPD and CHF coexistence 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 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 Pier Luigi Temporelli. Monaldi Archives for Chest Disease Cardiac Series 2015: «Cardiopulmonary rehabilitation in patient with heart failure and chronic pulmonary disease» 3

4 CARDIOPULMONARY REHABILITATION IN PATIENTS WITH LUNG OR HEART DISEASE 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. Should all patients with COPD be exercise trained? What is the right rehabilitation program in COPD? CARDIOVASCULAR AND RESPIRATORY DISEASES SHARE ALSO PATHOPHYSIOLOGICAL MECHANISMS...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 Eur Heart J Sep;34(36):

5 Genetic hypothesis Why do we age? Telomeres CARDIOVASCULAR AND RESPIRATORY DISEASES ARE age-related diseases Inflammaging Free radicals hypothesis Enzymatic activity loss Inert complex formation AGING Membrane damage Transcriptional and traslocation defects OXIDATIVE STRESS IN AGING Proteins Lipids Nucleic acids Anti-Ox Ox 5

6 Sirtuins, aging and aging-associated diseases Guarente L. Franklin H. Epstein Lecture: Sirtuins, aging, and medicine. N Engl J Med. 2011;364(23): SIRT1 LEVELS ARE DECREASED IN BOTH CARDIOVASCULAR AND RESPIRATORY DISEASES EXERCISE BENEFITS OUR RESULTS + CHF COPD Corbi et al. Int J Mol Sci Jun 17;14(6):

7 Cardiac rehabilitation in CHF patients: Study design Subjects with post-ischemic HF in clinically stable conditions Clinical and demographic features Comorbility and risk factors blood chemistry tests ECG and echocardiographic examinations cardiopulmonary stress test Antioxidative and antisenescent effects of cardiac rehabilitation: Role for Sirt1 30-minute sessions of aerobic exercise + respiratory exercises 5 days /week for 4 weeks cardiopulmonary stress test In vivo and in vitro experiments blood chemistry tests Unpublished data Antioxidative and antisenescent effects of cardiac rehabilitation: Role for Sirt1 Sirt 1 and catalase as indicator of rehabilitation program efficacy: role in exercise tolerance Unpublished data Unpublished data 7

8 ng/ml AU 05/11/2016 SIRT1 AND «THE AGING THEORY OF COPD» AGING HYPOTHESIS FOR COPD Sirtuins Conti et al. Anal Cell Pathol (Amst). 2015;2015: Ito K et al. COPD as a disease of accelerated lung aging. Chest Jan;135(1): Sirt 1 as predictive and prognostic marker for COPD: study disegn HS, Healthy smokers HnS,Healthy non smokers COPD, patients PLASMA Total oxidative status (TOS) Trolox equivalent antioxidant capacity (TEAC) Oxidative stress index (OSI) IL-6 expression LYMPHOCYTES Sirt1 expression Sirt1 activity FICOLL Sirt 1 activity as predictive and prognostic marker for COPD: preliminary data P=0,04 Sirt1 activity GEL P<0,001 ERYTHROCIYTES AND NEUTROPHYLS Sirt1 expression = 8

9 Association between Tiffeneau index (FEV1/FVC) and Sirt1 activity 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 P<0,01 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 9