Elderly and physical activity: cardiological screening

In the elderly subject, even latent pathological conditions are more likely, which can contraindicate physical activity or limit it. For this reason, a more careful examination should be carried out before allowing any physical activity.
In addition to a careful objective examination aimed at establishing the current clinical conditions, enriched with a "careful medical history, it will often be necessary to perform instrumental tests for a more precise definition of the patient's health conditions. The doctor and the cardiologist must pay particular attention to the subjects with:

positive cardiac history of recent ischemic heart disease with residual ischemia;
suffering from chronic heart failure;
threatening arrhythmias that need treatment;
arterial hypertension difficult to treat with evidence of organ damage.

In principle, however, the vast majority of elderly people who intend to play sports should undergo some diagnostic investigation. For this reason we believe it is useful to provide very simple advice on how to interpret the various diagnostic investigations in the elderly subject.

ELECTROCARDIOGRAPHIC PANELS

In the elderly, the anomalies of the electrocardiogram (ECG) are quite frequent and there are numerous studies that report variable percentages depending on the interpretation criteria used. In practice, it can be considered that about 50% of the elderly have a surface ECG. anomalous and at least one third of the subjects over 70 years old have some cardiac arrhythmia. It is good to say immediately that, even if these anomalies may cause concern, they do not necessarily have to contraindicate motor activity in themselves.
The elderly may have some degree of sinus bradycardia, a finding that may be the natural consequence of the aging of the sinus node pacemaker cells, although it can sometimes conceal a sinus node disease. The PR interval is sometimes at the upper limits, but under stress it normalizes. As well as conduction disturbances such as right or left branch block or anterior or more rarely posterior hemiblock. All these anomalies, present in a percentage from 3- 5% of elderly subjects in good health, in the absence of other signs of heart disease may simply be the result of the degeneration of the conduction pathways, and still allow physical activity.
Chronic atrial fibrillation can be present in about 2 to 3% of healthy elderly people, with no other signs of heart disease. As mentioned, in fact, the degeneration of the conduction pathways is quite common starting with the sinus node, which becomes unable to maintain its pacemaker function, contributing to the onset of atrial fibrillation, which may not even be felt since it is not necessarily the heart significantly decreases its efficiency. It has been demonstrated, by stress test on the conveyor belt with Bruce protocol, that chronic atrial fibrillation involves only a modest decline in cardiovascular performance estimated at about 7%. This modest deficit would be attributable to the loss of atrioventricular synchronism and atrial systole, which, as we have already mentioned, is fundamental for ventricular filling and for maintaining a good systolic flow in the heart of the elderly even in the presence of a normal left ventricle.
A non-repetitive supraventricular or even ventricular ectopic beats can be observed with relative frequency. Such arrhythmias can be favored by the presence of wall hypertrophy frequently present in the senile heart.
These arrhythmias do not justify a priori absolute vetoes against sporting activity, but must be examined by other investigations.
The ECG of the elderly can also present anomalies of the P wave, in particular a negative deflection of the P usually in VI, expression of left atrial dilatation due to reduced compliance of the left ventricle.
As for the QRS complex, the electrical axis tends to shift to the left with advancing age and does not necessarily imply an underlying heart disease. In 10-40% of subjects, signs of ventricular hypertrophy may be present. In the absence of hypertension they must not take on a pathological significance.
The case of the presence of ST-segment modifications is different: in fact, the picture of hypertrophy and overload is associated with a higher morbidity and mortality.

ECHOCARDIOGRAPHIC PICTURES

The echocardiogram (ECHO) of an elderly person who does not have a heart disease may present a series of alterations that deserve to be reported, because they are solely due to the aging process.
The myocardium undergoes a partial replacement with fibrous tissue, while the heart valves and the fibroelastic tissue can undergo partial calcification. The resulting picture will be of a frequently thickened myocardium, in particular the interventricular septum, with ventricular diameters within normal limits.
The measurements of the global systolic efficiency, such as the shortening fraction and the ejection fraction are within normal limits. Conversely, the E / A ratio of the mitral flow velocitogram, ie the ratio between the E wave (the rapid in prothiastole) and the A wave (the atrial contraction wave), reverses due to the increase in stiffness of the left ventricle with age.
The aortic valve can undergo fibrosis and more or less extensive calcification creating the conditions for an aortic stenosis. Even the mitral ring can undergo extensive calcifications that can extend up to the mitral flaps, reducing their mobility and creating the conditions for a stenosis and / or mítral insufficiency. Mitral prolapse can also be a consequence of a degenerative process resulting from age. . It is estimated that 5 to 10% of elderly patients are carriers of this disease.
For these same reasons, it is quite common to find valve regurgitation on a degenerative basis in ECOColor Doppler often of mild or moderate entity. Thus the most common echo pictures will be: mitral and aortic insufficiency, aortic valve sclerosis with modest stenosis. All these conditions in themselves do not contraindicate physical activity, as they are part of the normal aging process, even if they must be evaluated in the overall clinical picture of the subject.

THE ERGOMETRIC EVALUATION

The stress test (ergometric test) remains the "fundamental exam for those who wish to carry out a" sporting activity of a certain commitment, as it reproduces in the laboratory those conditions of physical stress which, albeit with some differences, are then carried out on the " field".
This type of test can be performed on different equipment (ergometers), usually on the cycle ergometer, with different work protocols. The choice of the type of effort to perform must be made on the basis of the characteristics of the subject and his preferences. Certainly the cycle ergometer poses fewer stability problems, but it often induces a slower rise in the HR than the conveyor belt.
Performing an exercise test under electrocardiographic monitoring (exercise ECG) is essential in the search for a possible ischemic heart disease. "ECG. The stress test is nevertheless useful to verify the possible occurrence of arrhythmias and above all the behavior of the PA."
It is known that in the elderly population, over 70 years, the prevalence of coronary heart disease at autopsy is quite high (about 54%), but that largely remains undiagnosed for various reasons. This discrepancy between the prevalence of autopsy ischemic heart disease and the ante-mortem clinical one is due to the fact that in this age group the intensity of the work performed is lower. It should also be considered that in the elderly ischemic heart disease can manifest itself with atypical symptoms, such as dyspnea or asthenia, instead of the classic anginal chest pain. While taking into account these limitations we can say that in the elderly subject, able to reach at least 85% of his maximum HR, the stress test has an "excellent diagnostic capacity against ischemic heart disease even if the specificity is reduced, that is, the test can be" positive "even in healthy subjects. It should be emphasized that the elderly who practice regular physical activity is more suitable than the sedentary peer to carry out an exercise test with even more reliable results.

Curated by: Lorenzo Boscariol