Cardiovascular prevention and rehabilitation in the elderly: evidence for cardiac rehabilitation after myocardial infarction or chronic heart failure.

Cardiac rehabilitation in the elderly today often represents a utopia. The international scientific literature takes little into account this type of prescription for old people, although they represent a large and growing proportion of cardiac patients, with acute coronary syndrome or heart failure, which we have to manage in everyday life. Furthermore, interventions of health education, clinical follow up, rehospitalisation prevention and prescription of tailored exercise, are sometimes more necessary in this kind of patients, given the presence of multimorbidity, functional dependence, frailty, sarcopenia, social neglect. Most of the data on the feasibility, safety and efficacy of cardiac rehabilitation are favourable, but they are few and apparently not strong enough to convince the medical community. Therefore is necessary to join efforts to identify the geriatric patient's peculiarities and plan a suitable program of cardiac rehabilitation, which takes into account the multi-dimensionality and complexity of typical problems of the elderly, for which the classical cardiac outcomes can be limited.RiassuntoLa riabilitazione cardiologica nel paziente anziano rappresenta ad oggi in molte realtà una utopia. La letteratura scientifica internazionale prende poco in considerazione questo tipo di prescrizione nei soggetti in età avanzata, per quanto essi rappresentino una grande e crescente quota dei pazienti cardiopatici con sindrome coronarica acuta o scompenso cardiaco. Inoltre proprio su questa tipologia di pazienti interventi di educazione sanitaria, monitoraggio clinico e prescrizione di esercizio fisico personalizzato, risultano più necessari, data la presenza di multimorbilità, dipendenza funzionale, fragilità, sarcopenia, isolamento sociale. La maggior parte dei dati su fattibilità, sicurezza ed efficacia della riabilitazione cardiologica dopo infarto miocardico e nello scompenso sono favorevoli, ma risultano limitati nella numerosità delle casistiche e non condotti su pazienti assimilabili a quelli del mondo reale. E' necessario dunque identificare le peculiarità del paziente geriatrico e pianificare e personalizzare un programma di riabilitazione cardiologica che tenga in considerazione la multidimensionalità e la complessità dei problemi tipici del soggetto anziano, per il quale gli outcome cardiologici abituali possono risultare limitati o non significativi.</p

IL-10–Producing Infliximab-Specific T Cells Regulate the Antidrug T Cell Response in Exposed Patients

Abstract Infliximab (IFX) is a chimeric mAb that can lead to the appearance of anti-drug Abs. Recent research has identified the presence of circulating IFX-specific T cells in treated patients. The aim of the study was to analyze the functional characteristics of IFX-specific T cells, in particular their capability to produce biologically active regulatory cytokines. Drug-stimulated PBMCs or coculture systems were used to detect memory T cells in treated patients. The cytokines produced by IFX-specific T cells, T cell lines, and T cell clones were evaluated at the mRNA and protein levels. Drug infusion induced an increase in IL-10 serum levels in vivo, whereas other cytokines were unchanged. IL-10 mRNA was higher in IFX-stimulated PBMCs from treated patients compared with untreated patients. When analyzed longitudinally, an early IL-10 mRNA expression was observed. HLA class II–restricted IL-10 production by drug-specific T cells from exposed patients was observed in different experimental settings, such as a coculture system, sorted CD154+ T cells, IFX peptide–stimulated PBMCs, and IFX-specific T cell clones. Finally, IL-10–producing drug-specific T cell clones downregulated the response of autologous effector T cells to IFX. Overall, these findings identify IFX-specific T cells as a source of biologically active IL-10 and suggest interference by IL-10–producing cells in the detection of drug-specific T cells

Cardiac rehabilitation protocols in the elderly.

Cardiac rehabilitation (CR) is a comprehensive multidisciplinary program individually tailored to the needs of patients with cardiovascular disease. Cardiovascular disease is prevalent in older adults and is the leading cause of death and major disability in adults ≥75 years of age. The mean age of patients eligible for CR is increasing, with greater complexity and specific geriatric features, such as multimorbidity, frailty, and disability. In this population, CR interventions should be aimed to prevent disability and preserve the residual functional capacity. Every patient should be assessed with a multidimensional evaluation that includes clinical, functional, emotional, cognitive and social domains. Exercise-based CR programs have shown to be effective in improving function and quality of life, by reducing disability and age-related deconditioning and contributing favorably to improved health outcomes in an aged population. Very old and frail patients seem to get an even greater potential benefit, and an early start after an acute event can prevent the post-hospital syndrome. Despite these proven benefits, CR is often underused in this population and a great effort should be done to encourage them to attend these programs. There are just a few studies about CR programs in very old and frail patients, therefore a future goal should be to fill this gap

Effects of a physical activity program on functional fitness, oxidative stress and salivary cortisol levels in older adults

Quality of life into later life is influenced by multiple factors. The physical ability to perform common everyday activities represents a key factor to maintain a healthy and independent lifestyle. Moreover, aging is a process characterized by physiological alterations resulting in a progressive decline in biological functions, decreased resistance to stress, and increased susceptibility to diseases. Especially in elderly people, alterations such as imbalance between pro and antioxidant activity and/or hormonal dysregulation negatively affect the physical capacity, the emotional status and the overall general health and quality of life [1]. On the other hand, regular physical activity is considered an effective strategy for older adults to prevent and reduce the risk of developing those negative conditions arising from aging. A 24-week regular physical activity program (twice weekly, 1 hour per session) focused on functional fitness exercises was performed by 20 older adults (aged 55 years or more). A set of anthropometric (height, weight, BMI and body fat percentage) and physical measurements (grip strength, chair sit to stand, sit and reach and back scratch) assessing the functional fitness performance [2] were evaluated. Moreover, biochemical markers (d-ROMs and BAP tests as assessment of oxidative stress and antioxidant potential; salivary cortisol levels) were measured before and after the intervention program. The results confirm the benefits of a regular physical activity in older adults resulting in improved physical strength and flexibility in the functional fitness parameters, and in regulating pro and antioxidant activity and cortisol levels

Cardiac surgery in the elderly: What goals of care?

At present, the majority of cardiac surgery interventions have been performed in the elderly with successful short-term mortality and morbidity, however significant difficulties must to be underlined about our capacity to predict long-term outcomes such as disability, worsening quality of life and loss of functional capacity.The reason probably resides on inability to capture preoperative frailty phenotype with current cardiac surgery risk scores and consequently we are unable to outline the postoperative trajectory of an important patients' centered outcome such as disability free survival. In this perspective, more than one geriatric statements have stressed the systematic underuse of patient reported outcomes in cardiovascular trials even after taking account of their relevance to older feel and wishes. Thus, in the next future is mandatory for geriatric cardiology community closes this gap of evidences through planning of trials in which patients' centered outcomes are considered as primary goals of therapies as well as cardiovascular ones.</p

Treatment of very old patients with non valvular atrial fibrillation. The valuable opportunity offered by New Oral Anticoagulants, to be cautiously used

Atrial Fibrillation (AF) is the most frequent cardiac arrhythmia and its incidence increases with age reaching a 10% prevalence in the oldest old. Patients with AF have a five-fold increase in the risk of stroke. Current guidelines on AF management recommend the prescription of oral anticoagulant therapy in patients at medium and high risk of thromboembolic events. Advanced age is a risk factor for stroke in AF, but despite clear evidences a high rate of OAT under prescription is reported and particularly in the oldest old. Among the main causes of this phenomenon an enhanced risk of bleeding is often reported: this due to several factors: risk of falls, the presence of comorbidity and polifarmacy and a reduction in compliance and adherence that are common in the elderly. In recent years the international scenario in the management of OAT has significantly changed since the introduction of the new oral anticoagulants (NOA): Dabigatran, a direct thrombin inhibitor, and two oral factor Xa inhibitors Rivaroxaban and Apixaban, which have all been tested in randomized clinical trial (RELY, ROCKET-AF e ARISTOTLE) which have demonstrated non inferiority compared to warfarin in the prevention of thromboembolic events with an optimal safety profile. NOA could be an important therapeutic opportunity for stroke prevention in elderly patients with AF even if the substantial differences in mean age, anthropometric measures and comorbidity of the patients enrolled in these trials compared with those of the real world setting, oblige some caution and discussion

Effect of Functional Fitness on Plasma Oxidation Level in Elders: Reduction of the Plasma Oxidants and Improvement of the Antioxidant Barrier

Aging is characterized by a progressive decline in the physiological function due to the gradual alteration of molecules, cells and tissues. Reactive oxygen species (ROS) are the by-product of aerobic metabolism, and their increase is physiologically counteracted by the activation of the antioxidant machinery. A typical hallmark of aging is the imbalance of such equilibrium, due to either an increase of the amount of radicals or a failure of the antioxidant system. Literature reports that physical exercise is able to restore and maintain the homeostasis of oxidants and antioxidants during aging. Recently, growing interest has been turned to functional fitness, a special physical activity aimed to enhance the ability to perform everyday tasks, such as dressing, climbing stairs and preparing meals. The aim of this work was to assess whether a 24 weeksfunctional fitness program carried out on 28 elderly participants (57-86 years old) could be able to improve their oxidative status. For this purpose, dROMs (diacron Reactive Oxygen Metabolites) and BAP (Biological Antioxidant Potential) were analysed at the beginning and at the end of the study. Furthermore, both plasma and saliva protein carbonylation levels were explored through proteomics analysi

DAPT plus anticoagulant therapy: The difficult coexistence post-ACS in older patients with atrial fibrillation

Atrial fibrillation (AF) and coronary artery disease requiring percutaneous coronary intervention (PCI) and stenting often coexist in older patients. This poses the difficult problem of concurrent anticoagulant and double antiplatelet therapy (triple therapy). Current treatment guidelines do recommend triple therapy, especially in the course of acute coronary syndrome (ACS), with limitations due to an excessive risk of bleeding associated with this therapeutic regimen. This review summarizes randomized clinical trials and observational studies that compared triple therapy with a variety of different therapeutic options. Although the available evidence is not completely satisfactory and other studies are urgently needed, alternative regimens to triple therapy in AF patients undergoing PCI and stenting are promising, at least in terms of safety