Predictors of physical frailty improvement in older patients enrolled in a multidisciplinary cardiac rehabilitation program.

Cardiac rehabilitation (CR) improves clinical and functional recovery in older patients after acute cardiac syndromes, whose outcome is influenced by cardiac disease severity, but also by comorbidity and frailty. The aim of the study was to analyze the predictors of physical frailty improvement during the CR program. Data were collected in all patients aged > 75 years consecutively admitted from 1 January to December 2017 to our CR, consisting of 5-day-per-week of 30-min session of biking or calisthenics on alternate days for 4 weeks. Physical frailty was measured with short physical performance battery (SPPB) at the entry and the end of CR. Outcome was represented by an increase of at least 1 point in the SPPB score from baseline to the end of the CR program. In our study population of 100 patients, mean age 81 years, we demonstrated that a strong predictor of improvement in SPPB score was the poorer performance in the test at baseline; for Δ-1 point of score, we registered an OR 2.50 (95% CI = 1.64-3.85; p = 0.001) of probability to improve the physical performance at the end of CR. Interestingly those patients with worse performance at SPPB balance and chair standing task showed greater probability of ameliorating their physical frailty profile at the end of CR. Our data strongly suggest that CR program after acute cardiac syndrome produces a significant physical frailty improvement in those patients with worse frailty phenotype with an impairment in chair standing or balance at entry.

Cardiac Rehabilitation in Advanced aGE after PCI for acute coronary syndromes: predictors of exercise capacity improvement in the CR-AGE ACS study.

BACKGROUND: The positive effect of cardiac rehabilitation (CR) on outcomes after acute coronary syndromes (ACS) is established. Nevertheless, enrollment rates into CR programs remain low, although ACS carry a high risk of functional decline particularly in the elderly. AIM: We aimed to determine if a multidisciplinary CR improves exercise capacity in an older population discharged after ACS systematically treated with PCI. METHODS: CR-AGE ACS is a prospective, single-center, cohort study. All patients aged 75+ years consecutively referred to Cardiac Rehabilitation outpatient Unit at Careggi University Hospital, were screened for eligibility. Moderate/severe cognitive impairment, disability in 2+ basic activities of daily living, musculoskeletal diseases, contraindication to Cardiopulmonary Exercise Test, and diseases with an expected survival < 6 months, were exclusion criteria. Participants attended a CR program, based on 5-day-per-week aerobic training sessions for 4 weeks. RESULTS: We enrolled 253 post-ACS patients with a mean age 80.6 ± 4.4 years. After CR, 136 (56.2%) 77 (31.3%) patients obtained, respectively, at least a moderate (∆+5%) or an optimal (∆+15%) increase in VO2peak. Baseline VO2peak (- 1 ml/kg/min: OR 1.18; 95% CI 1.09-1.28), the number of training sessions (+1 session: OR 1.07; 95% CI 1.01-1.15), and mild-to-moderate baseline disability (yes vs. no: OR 0.22; 95% CI 0.01-0.57) were the predictors of VO2peak changes. CONCLUSIONS: A CR program started early after discharge from ACS produces a significant increase in exercise capacity in very old patients with mild-to-moderate post-acute physical impairment. Baseline VO2peak, the number of training sessions, and the level of baseline disability are the independent predictors of improvement.

Serial Changes in Cardiopulmonary Exercise Testing Parameters in Untreated Patients With Transthyretin Cardiac Amyloidosis.

BACKGROUND: Transthyretin amyloid cardiomyopathy (ATTR-CM) is associated with a progressive reduction of functional capacity. The progression of cardiopulmonary exercise testing (CPET) parameters over time is still unknown. METHODS: In this study, 55 patients with ATTR-CM underwent 2 serial cardiologic evaluations and CPETs in a national referral center for cardiac amyloidosis (Careggi University Hospital, Florence). RESULTS: Forty-three patients (78%) had wild-type ATTR. Median age was 80 years (interquartile range [IQR] 76-83 years), and 50 of the patients (91%) were men. At baseline, median peak oxygen consumption (pVO2) was 15 mL/kg/min (IQR 12-18 mL/kg/min), percentage of predicted pVO2 (%ppVO2) was 71% (IQR 60%-83%) and VE/VCO2 slope was 31 (IQR 26-34). After a median follow-up of 14 months (IQR 13-16 months), pVO2, %ppVO2 and VE/VCO2 slope were significantly worsened (-1.29 mL/kg/min [95% confidence interval (CI): -1.85 to -0.74; P < 0.01], -4.5% [95% CI: -6.9 to -2.02; P < 0.01], and 8.6 [95% CI 6-11; P < 0.01], respectively). Furthermore, exercise time (-39 s, 95% CI: -59 to -19; P < 0.01), exercise tolerance (-0.47 metabolic equivalents, 95% CI: -0.69 to -0.2; P < 0.01), and peak systolic pressure (-10.8 mm Hg, 95% CI: -16.2 to -5.4; P < 0.01) were significantly reduced. The worsening in CPET variables did not correspond with a significant change in echocardiographic parameters. CONCLUSIONS: Cardiorespiratory response to exercise significantly worsened over a short period of time in patients with ATTR-CM. Serial CPET may be useful to identify early disease progression.

Prognostic value of cardiopulmonary exercise testing in patients with transthyretin cardiac amyloidosis.

The aim of this study is to evaluate the prognostic value of cardiopulmonary testing (CPET) in a cohort of patients with transthyretin cardiac amyloidosis (ATTR-CA). ATTR-CA is associated with a progressive reduction in functional capacity. The prognostic role of CPET parameters and in particular of normalized peak VO2 (%ppVO2) remains to be thoroughly evaluated. In this study, 75 patients with ATTR-CA underwent cardiological evaluation and CPET in a National Referral Center for cardiac amyloidosis (Careggi University Hospital, Florence). Fifty-seven patients (76%) had wild-type ATTR. Median age was 80 (75-83) years, 68 patients (91%) were men. Peak oxygen consumption (14.1 ± 4.1 ml/kg/min) and %ppVO2 (68.4 ± 18.8%) were blunted. Twenty-seven (36%) patients had an abnormal pressure response to exercise. After a median follow-up of 25 (12-31) months, the composite outcome of death or heart failure hospitalization was registered in 19 (25.3%) patients. At univariate analysis %ppVO2 was a stronger predictor for the composite outcome than peak VO2. %ppVO2 and NT-proBNP remained associated with the composite outcome at multivariate analysis. The optimal predictive threshold for %ppVO2 was 62% (sensitivity: 71%; specificity: 68%; AUC: 0.77, CI 0.65-0.88). Patients with %ppVO2 ≤ 62%and NT-proBNP > 3000 pg had a worse prognosis with 1- and 2-year survival of 69 ± 9% and 50 ± 10%, respectively. CPET is a safe and useful prognostic tool in patients with ATTR-CA. CPET may help to identify patients with advanced disease that may benefit from targeted therapy.

[The complexity of risk stratification in older patient candidate to non-cardiac surgery]. / La complessità della stratificazione del rischio nel paziente anziano cardiopatico candidato a chirurgia non cardiaca.

During the last decades the older patients who are candidates for surgery have grown exponentially due to the increase in life expectancy and the surgery technique improvement. Despite this, the mortality remains high and our ability to predict the surgery outcomes continues to be low in the elderly. The main reason is related to different difficulties; we are unable to differentiate properly the chronological from the biological age, and the current surgery and cardiology risk scores are poorly geriatric-oriented. We must underline how the measure of comorbidity during the preoperative evaluation is often limited to a simple count of comorbid conditions, without a more detailed assessment of their severity. On the other hand different comorbidity scores have been validated in geriatric populations showing a good correlation with prognosis, such as the Index of Coexisting Disease-ICED or the Geriatric Index of Comorbidity-GIC. Our predictive deficiency about the outcomes is linked to poor attention for identifying the frail patients that are already at high risk of disability. Recently, the evaluation of frailty is a key target for geriatric medicine, and geriatricians have developed various methods for measuring this parameter and suggesting the physical performance indexes as a reliable surrogate of frailty. Surrogate frailty measures, such as the "gait speed" or the "Short Physical Performance Battery-SPPB" seem to be the valid tools for evaluating older surgery patients due to their simplicity and short administration time. We think that the future challenge will be their widespread use in this specific clinical setting.

Type D personality impairs quality of life, coping and short-term psychological outcome in patients attending an outpatient intensive program of cardiac rehabilitation.

BACKGROUND: Type D personality represents a risk factor for adverse outcome and impaired Quality of Life (QoL) in CHD patients. Only few studies investigated Type D patients following cardiac rehabilitation (CR). No study investigated Type D personality in Italian patients attending a CR program of 4 weeks. The aims of the study were a) to verify the presence of Type D personality among patients attending an Italian CR program; b) to investigate psychological health status, QoL and coping style of CR patients and c) to test the influence of Type D personality on CR patients outcome. METHODS: Data from 59 patients attending an outpatient intensive program of 4 weeks of CR were collected at admission, and 1 month after discharge, using a set of self-report questionnaires. Variables were measured using CBA-H, DS-14, Q-LES-Q and Brief COPE Scale. RESULTS: The percentage of Type D personality found in the study sample was 39%. At admission Type D patients showed a significant lower level of psychological health status and QoL satisfaction compared to non Type D patients (p<0.05). After CR a significant percentage of Type D patients, despite an overall improvement, continued to show a clinically relevant psychological impairment in terms of anxiety (p=0.003), depressive mood (p=0.001), impairment in psychophysical well-being (p=0.002), perceived psychophysical stress (p=0.002), interpersonal difficulties (p<0.001), and social anxiety (p=0.045). Type D personality was also found to be associated with a significant greater use of maladaptive coping strategies (p<0.05). CONCLUSIONS: Type D personality played a significant clinically relevant role on psychological health outcome in CR. Type D personality patients reported a significant higher level of psychological impairment, in terms of anxiety, depressive mood, impairment in psychophysical wellbeing, perceived psychophysical stress, interpersonal difficulties, social anxiety, and a significant lower QoL, prior and after CR. Type D personality seemed also to be associated with maladaptive coping strategies. Importance of assessment for Type D personality is warranted in CR setting, as additional interventions seem required to enhance the outcome of these patients defined in letterature at high-risk.

Prognostic value of exercise stress test and dobutamine stress echo in patients with known coronary artery disease.

BACKGROUND: The aim of this study was to compare the feasibility of dobutamine stress echocardiography (DSE) and exercise stress test (EST) between patients in different age groups and to evaluate their proportional prognostic value in a population with established coronary artery disease (CAD). METHODS: The study sample included 323 subjects, subdivided in group 1 (G1), comprising 246 patients aged <75 years, and group 2 (G2), with 77 subjects aged >or=75 years. DSE and EST were performed before enrollment in a cardiac rehabilitation program; for prognostic assessment, end points were all-cause mortality and hard cardiac events (cardiac death or nonfatal myocardial infarction). RESULTS: During DSE, G2 patients showed worse wall motion score index (WMSI), but the test was stopped for complications in a comparable proportion of cases (54 G1 and 19 G2 patients, P = NS). EST was inconclusive in similarly high proportion of patients in both groups (76% in G1 vs. 84% in G2, P = NS); G2 patients reached a significantly lower total workload (6 +/- 1.6 METs in G1 vs. 5 +/- 1.2 METs in G2, P < 0.001). At multivariate analysis, a lower peak exercise capacity (HR 0.566, CI 0.351-0.914, P = 0.020) was associated with higher mortality, while a high-dose WMSI >2 (HR 5.123, CI 1.559-16.833, P = 0.007), viability (HR 3.354, CI 1.162-9.678, P = 0.025), and nonprescription of beta-blockers (HR 0.328, CI 0.114-0.945, P = 0.039) predicted hard cardiac events. CONCLUSION: In patients with known CAD, EST and DSE maintain a significant prognostic role in terms of peak exercise capacity for EST and of presence of viability and an extensive wall motion abnormalities at peak DSE.

[Cardiac rehabilitation of patients with left ventricular assist device as "destination therapy"]. / Riabilitazione cardiologica di pazienti con supporto circolatorio mediante dispositivo di assistenza ventricolare sinistra. Esperienza preliminare dopo impianto di sistema a flusso continuo come "destination therapy" in tre pazienti con scompenso cardiaco avanzato.

"End stage" heart failure is unresponsive to conventional pharmacological and non pharmacological treatments and has a bad prognosis either regarding survival or quality-of-life; besides cardiac transplantation is limited by organ shortage. Therefore mechanical devices have been developed, initially as "bridge to transplantation" and, more recently, as "destination therapy": definitive treatment for non-transplantable patients. In these patients instrumental evaluation, treatment and rehabilitation are not yet defined and standardized. This paper reports the initial experience realized, as a part of a regional cooperation project within Florence and Siena University Hospitals activities, with the first three male patients, aged 45 to 70 years, affected by end-stage heart failure (NYHA class IV), non-eligible to transplantation, and implanted with Jarvik Flowmaker 2000, an intraventricular axial-flow VAD generating a continuous blood flow. After clinical stabilization, patients underwent a specific evaluation and treatment purposely designed for these subjects during ICU and post-ICU stay and, subsequently, a formal cardiac rehabilitation program. Hemodynamic, bioumoral and functional parameters were recorded at the beginning, during and at the end of intensive rehabilitation program. All patients completed the program, achieving a remarkable and meaningful functional recovery, such to allow them going home, continuing with a self-activity with weekly follow-up in the Rehabilitation Center. The experience acquired by following these patients longitudinally--from the VAD implantation to hospital discharge--allowed us to develop a flow-chart divided in five phases, identifying the main clinical problems, the rehabilitative treatment goals and the useful indicators to define criteria for shift from every phase to the following one.

Long-term functional outcomes after cardiac rehabilitation in older patients. Data from the Cardiac Rehabilitation in Advanced aGE: EXercise TRaining and Active follow-up (CR-AGE EXTRA) randomised study.

AIM: Cardiac rehabilitation promotes functional recovery after cardiac events. Our study aimed at evaluating whether, compared to usual care, a home-based exercise programme with monthly reinforcement sessions adds long-term functional benefits to those obtained with cardiac rehabilitation in the elderly. METHODS: After a 4-week outpatient cardiac rehabilitation, 160 of 197 patients aged 75 years and older screened for eligibility with different indications for cardiac rehabilitation, were randomly assigned to a control (C) or an active treatment (T) group. During a 12-month follow-up, C patients received usual care, while T patients were prescribed a standardised set of home-based exercises with centre-based monthly reinforcements for the first 6 months. The main (peak oxygen consumption) and three secondary outcome measures (distance walked in 6 minutes, inferior limbs peak 90° Torque strength, health-related quality of life) were assessed at baseline, at random assignment and at 6 and 12-month follow-ups with the cardiopulmonary exercise test, 6-minute walking test, isokinetic dynamometer and the Short Form-36 questionnaire, respectively. RESULTS: Both C and T groups obtained a significant and similar improvement from baseline to the end of the 4-week cardiac rehabilitation programme in the three functional outcome measures. However, at univariable and age and gender-adjusted analysis of variance for repeated measures, changes from random assignment to 6 or 12-month follow-up in any outcome measure were similar in the C and T groups. CONCLUSION: Results from this randomised study suggest that a home-based exercise programme with monthly reinforcements does not add any long-term functional benefit beyond those offered by a conventional, 4-week outpatient cardiac rehabilitation programme. TRIAL REGISTRATION: ClinicalTrial.gov Identifier: NCT00641134.

Cardiac Rehabilitation in Very Old Adults: Effect of Baseline Functional Capacity on Treatment Effectiveness.

OBJECTIVES: To assess the effect of cardiac rehabilitation (CR) and identify predictors of changes in functional capacity with CR in a consecutive series of older adults with a recent cardiac event. DESIGN: Observational. SETTING: In-hospital CR unit. PARTICIPANTS: Individuals aged 75 and older referred to an outpatient CR Unit after an acute coronary event (unstable angina pectoris, acute myocardial infarction) or cardiac surgery (coronary artery bypass grafting, heart valve replacement or repair) (N = 160, mean age 80 ± 4). MEASUREMENTS: Peak oxygen consumption (VO2 peak, power) during a symptom-limited cardiopulmonary stress test, distance walked in a 6-minute walk test (6MWT, resistance), and peak torque (strength) using an isokinetic dynamometer, were assessed at baseline and at discharge from a 4-week supervised training program. RESULTS: Indexes of physical performance improved from baseline to discharge (VO2 peak, 10.9%; 6MWT, 11.0%; peak torque, 11.5%). Baseline performance was independently associated with changes in all three indexes, with higher baseline values predicting less improvement (VO2 peak: OR=0.86, 95% confidence interval (CI)=0.77-0.97; 6MWT: OR= 0.99, 95% CI=0.99-1.00; peak torque: OR=0.96, 95% CI=0.94-0.98). CONCLUSION: An exercise-based CR program was associated with improvement in all domains of physical performance even in older adults after an acute coronary event or cardiac surgical intervention, particularly in those with poorer baseline performance.

Improved exercise tolerance and quality of life with cardiac rehabilitation of older patients after myocardial infarction: results of a randomized, controlled trial.

BACKGROUND: Whether cardiac rehabilitation (CR) is effective in patients older than 75 years, who have been excluded from most trials, remains unclear. We enrolled patients 46 to 86 years old in a randomized trial and assessed the effects of 2 months of post-myocardial infarction (MI) CR on total work capacity (TWC, in kilograms per meter) and health-related quality of life (HRQL). METHODS AND RESULTS: Of 773 screened patients, 270 without cardiac failure, dementia, disability, or contraindications to exercise were randomized to outpatient, hospital-based CR (Hosp-CR), home-based CR (Home-CR), or no CR within 3 predefined age groups (middle-aged, 45 to 65 years; old, 66 to 75 years; and very old, >75 years) of 90 patients each. TWC and HRQL were determined with cycle ergometry and Sickness Impact Profile at baseline, after CR, and 6 and 12 months later. Within each age group, TWC improved with Hosp-CR and Home-CR and was unchanged with no CR. The improvement was similar in middle-aged and old persons but smaller, although still significant, in very old patients. TWC reverted toward baseline by 12 months with Hosp-CR but not with Home-CR. HRQL improved in middle-aged and old CR and control patients but only with CR in very old patients. Complications were similar across treatment and age groups. Costs were lower for Home-CR than for Hosp-CR. CONCLUSIONS: Post-MI Hosp-CR and Home-CR are similarly effective in the short term and improve TWC and HRQL in each age group. However, with lower costs and more prolonged positive effects, Home-CR may be the treatment of choice in low-risk older patients.

[Cardiac rehabilitation in the elderly]. / Riabilitazione cardiologica nell'anziano.

Cardiac rehabilitation is an integral component of secondary prevention, and is indicated for patients with a wide variety of cardiac conditions, ranging from coronary artery disease to chronic heart failure. Best results are obtained with integrated, multicomponent cardiac rehabilitation programs, which include exercise training together with counseling and psychosocial measures that may help patients maintain sustained changes toward a more healthy lifestyle. Evidence from randomized controlled trials and meta-analyses supports the efficacy of cardiac rehabilitation on clinically relevant outcomes such as reduced long-term morbidity and mortality, enhanced functional profile and improved control of cardiovascular risk factors. However, the vast majority of this evidence derives from trials with only small numbers of patients > 70 years of age. In elderly patients the goal of cardiac rehabilitation may differ from those of younger patients, and include the preservation of mobility, self-sufficiency and mental function. Cardiac rehabilitation my represent an opportunity to provide effective health care and achieve a high quality of life for older patients. Future research programs should therefore be aimed at specifically investigating the efficacy and effectiveness of cardiac rehabilitation in older, frail cardiac patients.

[Physical activity and cardiovascular health a close link]. / Esercizio fisico e stato di salute: un legame inscindibile.

A sedentary lifestyle has definitively demonstrated to be one of the major risk factors for cardiovascular events as outlined by the American Heart Association. There is mounting evidence in the scientific literature that physical activity and physical fitness have a powerful influence on preventing coronary heart disease. Moreover, protective effects of physical activity have been demonstrated for non-insulin-dependent diabetes, hypertension, obesity. A continued, moderate exercise improves muscular function and strength, the body's ability to take and use oxygen (maximal oxygen consumption or aerobic capacity) and improves the capacity of blood vessel to dilate in response to exercise or hormones. Also muscular strength and flexibility improve after exercise program as well as the ability to perform daily activities, preventing disability particularly in aged people. Cardiac Rehabilitation programs including formal exercise improve quality of life reducing stress and anxiety after an acute coronary event and reduce long-term mortality by 20-25%. Recently published recommendation of Expert panels defined exercise as a key component to health promotion and disease prevention and delineated the intensity of exercise desired.

Impact of a cardiac rehabilitation program and inflammatory state on endothelial progenitor cells in acute coronary syndrome patients.

BACKGROUND: Among the benefits of a cardiac rehabilitation (CR) program for patients after an acute coronary syndrome (ACS) is the mobilization of endothelial progenitor cells (EPCs). However not all patients respond to CR with an increase of EPC. We performed this study to identify the characteristics of patients who will not benefit from an increase of EPCs at the end of a CR program. METHODS: 112 ACS patients were admitted to a four-week CR program. EPCs, high sensitivity C-reactive protein (hsCRP) and NT-ProBNP levels were determined at the beginning (T1) and at the end (T2) of the CR program. All patients performed a cardiopulmonary exercise test at T1 and at T2. EPCs were defined as CD34+KDR+, CD133+KDR+ and CD34+CD133+KDR+. hsCRP and NT-ProBNP were measured by nephelometric and immunometric method, respectively. RESULTS: At T2, we observed a significant increase of EPCs (p=0.001), VO2 peak, Watt max HDL-cholesterol (p<0.0001) and a significant decrease (p<0.001) of hsCRP and NT-ProBNP, triglycerides, HbA1c, systolic blood pressure and waist circumference. Variations of VO2 peak were significantly correlated with the variations of EPCs. Patients with increased EPCs showed significantly (p=0.01) lower baseline levels of CRP and higher basal Watt max (p=0.04). In a multivariate logistic regression analysis, the lowest tertile of baseline hsCRP significantly affected the likelihood of having an increase of EPCs at the end of the CR program. CONCLUSIONS: A CR program determines an increase of EPCs with a decrease of CRP and NT-ProBNP. A different trend for EPCs can be detected among patients correlated to CRP levels and exercise tolerance.

Prognostic value of dobutamine stress echocardiography in octogenarians.

The prognostic value of dobutamine stress echocardiography (DSE) for risk stratification of patients aged ≥ 80 years is not clearly defined. A follow-up of 3 ± 2 years for major cardiac events and all-cause mortality was obtained in 227 patients, age ≥ 80 years, who underwent DSE for known or suspected coronary artery disease. Stress function index (SFI), calculated as the ratio of peak wall motion score index to left ventricular ejection fraction, was analyzed both as continuous variable and categorized using the mean value of 5 as the cut-off. Only 95 patients (42%) of this group underwent a cycloergometer exercise stress test (EST). During DSE 118 patients developed inducible ischemia; SFI was 4.9 ± 2.6 and 60 subjects showed a value higher than 5. EST gave a positive result in 12 patients and a negative result in 8 patients; it was inconclusive for inadequate increase in heart rate in 75 (79%) subjects. Advanced age (HR: 1.184/year, 95% CI: 1.073-1.306, p = 0.001) and SFI ≥ 5 (HR: 2.682, 95% CI: 1.429-5.035, p = 0.002) were independent predictors of all-cause mortality; advanced age (HR: 1.252/year, 95% CI: 1.064-1.473, p = 0.007), SFI ≥ 5 (HR: 3.181, 95% CI: 1.174-8.621, p = 0.02) and presence of left bundle branch block (HR: 3.060, 95% CI: 1.057-8.862, p = 0.039) independently predicted an increased occurrence of major cardiac events. No parameter derived from EST showed an independent prognostic role. DSE showed a significant prognostic value in octogenarians, both for all-cause mortality and major cardiac events.

Early and late rehabilitation and physical training in elderly patients after cardiac surgery.

OBJECTIVE: Few randomized trials have enrolled patients who have undergone cardiac surgery, and even fewer have included patients aged 75 yrs or more. Furthermore, the optimal timing of cardiac rehabilitation for postsurgical patients has not yet been codified. The aim of this study was to verify whether rehabilitation outcomes are also favorable in postsurgical patients aged 75 yrs or more and whether an early rehabilitation program is as effective and safe as a late one. DESIGN: Three hundred patients who underwent cardiac surgery, 27.7% of whom were at least 75 yrs old, were randomly assigned to a rehabilitation program starting within the second week after operation or within the fourth week. All events occurring during the rehabilitation program or in the following year were recorded. RESULTS: During the rehabilitation program, new-onset atrial fibrillation was significantly more frequent in the early rehabilitation group, independent of age class, and anemia was significantly more frequent in older patients, independent of rehabilitation timing. At the end of the rehabilitation program, more than 90% of patients showed significant increases in walking distance, and during the follow-up, no significant difference was found with regard to mortality, nonfatal events, functional ability, or control of cardiovascular risk factors, independent of rehabilitation timing and age class. CONCLUSIONS: This study provides evidence that in selected patients who have undergone cardiac surgery, rehabilitation outcomes are also favorable in patients aged 75 yrs or more, and an early rehabilitation program is as effective and safe as a traditionally late one.