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Sarcopenia is the loss of muscle strength, mass, and function, which is often exacerbated by chronic comorbidities including cardiovascular diseases, chronic kidney disease, and cancer. Sarcopenia is associated with faster progression of cardiovascular diseases and higher risk of mortality, falls, and reduced quality of life, particularly among older adults. Although the pathophysiologic mechanisms are complex, the broad underlying cause of sarcopenia includes an imbalance between anabolic and catabolic muscle homeostasis with or without neuronal degeneration. The intrinsic molecular mechanisms of aging, chronic illness, malnutrition, and immobility are associated with the development of sarcopenia. Screening and testing for sarcopenia may be particularly important among those with chronic disease states. Early recognition of sarcopenia is important because it can provide an opportunity for interventions to reverse or delay the progression of muscle disorder, which may ultimately impact cardiovascular outcomes. Relying on body mass index is not useful for screening because many patients will have sarcopenic obesity, a particularly important phenotype among older cardiac patients. In this review, we aimed to: (1) provide a definition of sarcopenia within the context of muscle wasting disorders; (2) summarize the associations between sarcopenia and different cardiovascular diseases; (3) highlight an approach for a diagnostic evaluation; (4) discuss management strategies for sarcopenia; and (5) outline key gaps in knowledge with implications for the future of the field.

Little is known about the prevalence and prognostic impact of preexisting frailty on acute care and in-hospital outcomes in older adults in the setting of acute myocardial infarction (AMI).Preexisting frailty was assessed at baseline in consecutive AMI patients ≥65 years of age treated at 778 hospitals participating in the NCDR ACTION Registry between January 1, 2015 to December 31, 2016. Three domains of preexisting frailty (cognition, ambulation, and functional independence) were abstracted from chart review and summed in 2 ways: an ACTION Frailty Scale based on responses to 6 groups adapted from the Canadian Study of Health and Aging Clinical Frailty Scale and an ACTION Frailty Score derived by summing a rank score of 0-2 assigned for each grade (total ranged between 0 to 6). Multivariable logistic regression examined the association between assigned frailty by score or scale and in-hospital mortality.Among 143,722 older AMI patients, 108,059 (75.2%) were fit and/or well and 6,484 (4.5%) were vulnerable to frailty, while 7,527 (5.2%) had mild, 3,913 (2.7%) had moderate, 2,715 had (1.9%) severe, and 632 (0.4%) had very severe frailty according to the ACTION Frailty Scale, while 14,392 (10.0%) could not be categorized due to incomplete ascertainment. Frail patients were older, more frequently female, of non-white race and/or ethnicity, and less likely to be treated with guideline-recommended therapies. Increasing severity of frailty by this scale was associated with a step-wise higher risk for in-hospital mortality (P-trend.001). Patient categories of the ACTION Frailty Score provided similar results. After adjustment, each 1-unit increase in Frailty Score was associated with a 12% higher mortality risk (OR 1.12, 95% CI 1.10-1.15).Among older patients with acute myocardial infarction, frailty is common and independently associated with in-hospital mortality. These findings show the importance of pragmatic evaluation of frailty in hospital-level quality scores, guideline recommendations, and incorporation into other registry data collection efforts.

This report summarizes the presentations, discussions, and recommendations of the most recent American Geriatrics Society and National Institute on Aging research conference, "Cancer and Cardiovascular Disease," on October 18-19, 2021. The purpose of this virtual meeting was to address the interface between cancer and heart disease, which are the two leading causes of death among older Americans. Age-related physiologic changes are implicated in the pathogenesis of both conditions. Emerging data suggest that cancer-related cardiovascular disease (CVD) involves disrupted cell signaling and cellular senescence. The risk factors for CVD are also risk factors for cancer and an increased likelihood of cancer death, and people who have both cancer and CVD do more poorly than those who have only cancer or only CVD. Issues addressed in this bench-to-bedside conference include mechanisms of cancer and CVD co-development in older adults, cardiotoxic effects of cancer therapy, and management of comorbid cancer and CVD. Presenters discussed approaches to ensure equitable access to clinical trials and health care for diverse populations of adults with CVD and cancer, mechanisms of cancer therapy cardiotoxicity, and management of comorbid CVD and cancer, including the role of patient values and preferences in treatment decisions. Workshop participants identified many research gaps and questions that could lead to an enhanced understanding of comorbid CVD and cancer and to better and more equitable management strategies.

Background and Aims Randomized clinical trials of hypertension treatment intensity evaluate effects on incident major adverse cardiovascular events (MACE) and serious adverse events (SAE). Occurrences after a non-fatal index event have not been rigorously evaluated. The current aim was to evaluate the association of intensive ( Methods Logistic regression and causal mediation modeling to obtain direct and mediated effects of intensive BP treatment. Primary outcome was all-cause mortality (ACM). Secondary outcomes were cardiovascular (CVM) and non-CV mortality (non-CVM). Results The direct effect of intensive treatment was a lowering of ACM [OR 0.75, 0.60-0.94]. The MACE-mediated effect substantially attenuated [OR 0.96, 0.92-0.99] ACM; while the SAE-mediated effect was associated with increased [OR 1.03, 1.01-1.05] ACM. Similar patterns were noted for intensive BP treatment on CVM and non-CVM. We also noted the SAE incidence was 3.9-fold higher than MACE incidence (13.7% vs 3.5%), and there was a total of 365 (3.9%) ACM with non-CVM 2.6-fold higher than CVM [2.81% (263/9,361) vs 1.09% (102/9,361)]. The SAE to MACE and non-CVM to CVM preponderance was across all age-groups with the ≥ 80-year age group having the highest differences. Conclusion The current analytic techniques demonstrated that intensive BP treatment was associated with an attenuated mortality benefit when MACE-mediated and possibly harmful when SAE-mediated. Current cardiovascular trial reporting of treatment effects does not allow expansion of the lens to focus on important occurrences after the index event.

Introduction: Cardiac rehabilitation (CR) participation reduces the likelihood of major adverse cardiovascular events (MACE), but is limited by structural factors, including race or ethnicity and annual income. We investigated (1) associations between CR participation and MACE, and (2) how structural disadvantage modifies this association, focusing on the intersection between race or ethnicity and household income. Hypotheses: We hypothesized that (1) CR participation would be inversely associated with MACE, and (2) this association would attenuate differences in MACE by race or ethnicity, as well as by household income. Methods: We identified 212,744 individuals with a CR-qualifying event between 1/1/16 and 12/31/20 in Optum’s de-identified Clinformatics® Data Mart database. We evaluated associations between CR sessions attended (0 to 36) and MACE (cardiac arrest, heart failure, myocardial infarction, or stroke hospitalizations) using a proportional hazards model for recurrent events, and assessed the three-way interaction between CR participation, race or ethnicity, and household income. Results: We included 212,744 individuals (age 70.8±11.3 years; 37.8% female sex; 71.9% White race) of whom 26.0% attended ≥1 CR sessions. Overall, we observed a dose-response association between CR participation and MACE. After adjustment, those who did not attend CR were 2.9 times as likely to experience MACE as those who attended ≥36 sessions (95% CI: 2.71, 3.03, P Figure ). Associations between CR participation and MACE were similar both across race or ethnicity and by household income ( P , interaction=0.28). Conclusion: Greater CR participation is associated with lower risk of MACE, regardless of (1) race or ethnicity and (2) household income. Because participation in CR remains low, particularly in socially disadvantaged populations, interventions to promote use of CR are critical to reduce disparities in cardiovascular outcomes.

INTRODUCTION: Growth of the older adult demographic has resulted in an increased number of older patients with cardiovascular disease (CVD) in combination with comorbid diseases and geriatric syndromes. Cardiac rehabilitation (CR) is utilized to promote recovery and improve outcomes, but remains underutilized, particularly by older adults. CR provides an opportunity to address the distinctive needs of older adults, with focus on CVD as well as geriatric domains that often dominate management and outcomes. AREAS COVERED: Utility of CR for CVD in older adults as well as pertinent geriatric syndromes (e.g., multimorbidity, frailty, polypharmacy, cognitive decline, psychosocial stress, and diminished function) that affect CVD management. EXPERT OPINION: Mounting data substantiate the importance of CR as part of recovery for older adults with CVD. The application of CR as a standard therapy is especially important as the combination of CVD and geriatric syndromes catalyzes functional decline and can trigger progressive clinical deterioration and dependency. While benefits of CR for older adults with CVD are already evident, further reengineering of CR is necessary to better address the needs of older candidates who may be frail, especially as remote and hybrid formats of CR are becoming more widespread.

Background Peripheral artery disease (PAD) affects over 230 million people worldwide and is due to systemic atherosclerosis with etiology linked to chronic inflammation, hypertension, and smoking status. PAD is associated with walking impairment and mobility loss as well as a high prevalence of coronary and cerebrovascular disease. Intermittent claudication (IC) is the classic presenting symptom for PAD, although many patients are asymptomatic or have atypical presentations. Few effective medical therapies are available, while surgical and exercise therapies lack durability. Metformin, the most frequently prescribed oral medication for Type 2 diabetes, has salient anti-inflammatory and promitochondrial properties. We hypothesize that metformin will improve function, retard the progression of PAD, and improve systemic inflammation and mitochondrial function in non-diabetic patients with IC. Methods 200 non-diabetic Veterans with IC will be randomized 1:1 to 180-day treatment with metformin extended release (1000 mg/day) or placebo to evaluate the effect of metformin on functional status, PAD progression, cardiovascular disease events, and systemic inflammation. The primary outcome is 180-day maximum walking distance on the 6-min walk test (6MWT). Secondary outcomes include additional assessments of functional status (cardiopulmonary exercise testing, grip strength, Walking Impairment Questionnaires), health related quality of life (SF-36, VascuQoL), macro- and micro-vascular assessment of lower extremity blood flow (ankle brachial indices, pulse volume recording, EndoPAT), cardiovascular events (amputations, interventions, major adverse cardiac events, all-cause mortality), and measures of systemic inflammation. All outcomes will be assessed at baseline, 90 and 180 days of study drug exposure, and 180 days following cessation of study drug. We will evaluate the primary outcome with linear mixed-effects model analysis with covariate adjustment for baseline 6MWT, age, baseline ankle brachial indices, and smoking status following an intention to treat protocol. Discussion MOBILE IC is uniquely suited to evaluate the use of metformin to improve both systematic inflammatory responses, cellular energetics, and functional outcomes in patients with PAD and IC. Trial Registration: The prospective MOBILE IC trial was publicly registered (NCT05132439) November 24, 2021.

Introduction The social and behavioral effects of the COVID-19 pandemic have impacted the health and physiology of most people, including those never diagnosed with COVID-19. While the impact of the pandemic has been felt across the lifespan, its effects on cardiorespiratory fitness (commonly considered a reflection of total body health) of older adults and children may be particularly profound due to social distancing and stay-at-home advisories, as well as the closure of sport facilities and non-essential businesses. The objective of this investigation was to leverage baseline data from two ongoing clinical trials to determine if cardiorespiratory fitness and body mass index were different during COVID-19 relative to before COVID-19 in older adults and children.Methods Healthy older individuals (N = 593; 65-80 years) and 200 typically developing children (8-10 years) completed a graded maximal exercise test and had their height and weight measured.Results Results revealed that older adults and children tested during COVID-19 had significantly lower cardiorespiratory fitness levels than those tested before COVID-19 shutdowns (older adults: 30% lower; children: 53% lower; p's & LE; 0.001). In addition, older adults and children tested during COVID-19 had significantly higher BMI (older adults: 31.34 +/- 0.57 kg/m(2), p = 0.004; children: 19.27 +/- 0.44 kg/m(2), p = 0.05) than those tested before COVID-19 shutdowns (older adults: 29.51 +/- 0.26 kg/m(2), children: 18.13 +/- 0.35 kg/m(2)). However, these differences in BMI did not remain significant when controlling for cardiorespiratory fitness.Discussion Results from this investigation indicate that the COVID-19 pandemic, and behavior changes taken to reduce potential exposure, may have led to lower cardiorespiratory fitness levels in older adults and children, as well as higher body mass index. These findings provide relevant public health information as lower cardiorespiratory fitness levels and higher body mass indexes recorded during the pandemic could have far-reaching and protracted health consequences. Public health guidance is needed to encourage physical activity to maintain cardiorespiratory fitness and healthy body composition., United States Department of Health & Human Services National Institutes of Health (NIH) - USA NIH National Institute on Aging (NIA) R01AG053952 United States Department of Health & Human Services National Institutes of Health (NIH) - USA, NIH Eunice Kennedy Shriver National Institute of Child Health & Human Development (NICHD) R01HD094054

Exercise intolerance (EI) is the primary manifestation of chronic heart failure with preserved ejection fraction (HFpEF), the most common form of heart failure among older individuals. The recent recognition that HFpEF is likely a systemic, multiorgan disorder that shares characteristics with other common, difficult-to-treat, aging-related disorders suggests that novel insights may be gained from combining knowledge and concepts from aging and cardiovascular disease disciplines. This state-of-the-art review is based on the outcomes of a National Institute of Aging-sponsored working group meeting on aging and EI in HFpEF. We discuss aging-related and extracardiac contributors to EI in HFpEF and provide the rationale for a transdisciplinary, "gero-centric" approach to advance our understanding of EI in HFpEF and identify promising new therapeutic targets. We also provide a framework for prioritizing future research, including developing a uniform, comprehensive approach to phenotypic characterization of HFpEF, elucidating key geroscience targets for treatment, and conducting proof-of-concept trials to modify these targets.

Home blood pressure monitoring (HBPM) can improve hypertension management. Digital tools to facilitate routinized HBPM and patient self-care are underutilized and lack evidence of effectiveness. MyBP provides video-based education and automated text messaging to support continuous BP self-monitoring with recurring feedback. In this pragmatic trial, we sought to generate preliminary evidence of feasibility and efficacy in community-dwelling adults ≥55 y/o with hypertension recruited from primary care offices. Enrollees were provided a standard automatic BP cuff and randomized 2:1 to MyBP vs treatment-as-usual (control). Engagement with MyBP was defined as the proportion of BP reading prompts for which a reading was submitted, tracked over successive 2-week monitoring periods. Preliminary measures of efficacy included BP readings from phone-supervised home measurements and a self-efficacy questionnaire. Sixty-two participants (40 women, 33 Blacks, mean age 66, mean office BP 164/91) were randomized to MyBP (n = 41) or a control group (n = 21). Median follow-up was 22.9 (SD = 6.7) weeks. In the MyBP group, median engagement with HBPM was 82.7% (Q1 = 52.5, Q3 = 89.6) and sustained over time. The decline in systolic [12 mm Hg (SD = 17)] and diastolic BP [5 mm Hg (SD = 7)] did not differ between the two treatment groups. However, participants with higher baseline systolic BP assigned to MyBP had a greater decline compared to controls [interaction effect estimate −0.56 (−0.96, −0.17)]. Overall hypertension self-efficacy improved in the MyBP group. In conclusion, trial results show that older hypertensive adults with substantial minority representation had sustained engagement with this digital self-monitoring program and may benefit clinically.

OBJECTIVE Evaluate the association between prefrailty and the risk of heart failure (HF) among older adults. DESIGN, SETTING, AND PARTICIPANTS This prospective, community-based cohort study included participants from the Atherosclerotic Risk in Communities study who underwent detailed frailty assessment using Fried Criteria and physical function assessment using the Short Performance Physical Battery (SPPB) score. Individuals with prevalent HF and frailty were excluded. MAIN OUTCOMES AND MEASURES Adjusted association between prefrailty (vs robust), physical function measures (SPPB score, grip strength, and gait speed), and incident HF (overall and HF subtypes, HF with reduced [HFrEF, EF

Cardiac rehabilitation is defined as a multidisciplinary program that includes exercise training, cardiac risk factor modification, psychosocial assessment, and outcomes assessment. Exercise training and other components of cardiac rehabilitation (CR) are safe and beneficial and result in significant improvements in quality of life, functional capacity, exercise performance, and heart failure (HF)-related hospitalizations in patients with HF. Despite outcome benefits, cost-effectiveness, and strong practice guideline recommendations, CR remains underused. Clinicians, health care leaders, and payers should prioritize incorporating CR as part of the standard of care for patients with HF.

Background In people with peripheral artery disease, post hoc analyses of the LITE (Low Intensity Exercise Intervention in Peripheral Artery Disease) randomized trial were conducted to evaluate the effects of walking exercise at a pace inducing ischemic leg symptoms on walking velocity and the Short Physical Performance Battery, compared with walking exercise without ischemic leg symptoms and compared with a nonexercising control group. Methods and Results Participants with peripheral artery disease were randomized to: home‐based walking exercise that induced ischemic leg symptoms; home‐based walking exercise conducted without ischemic leg symptoms; or a nonexercising control group for 12 months. Outcomes were change of walking velocity over 4 m and change of the Short Physical Performance Battery (0–12, with 12=best) at 6‐ and 12‐month follow‐up. A total of 264 participants (48% women, 61% Black race) were included. Compared with walking exercise without ischemic symptoms, walking exercise that induced ischemic symptoms improved change in usual‐paced walking velocity over 4 m at 6‐month (0.056 m/s [95% CI, 0.019–0.094 m/s]; P P P =0.03), and change in the Short Physical Performance Battery at 12‐month follow‐up (0.821 [95% CI, 0.309–1.334]; P P Conclusions In people with peripheral artery disease, those who walked for exercise at a comfortable pace without ischemic leg symptoms slowed their walking speed during daily life and worsened the Short Physical Performance Battery score, a potentially harmful effect, compared with people who walked for exercise at a pace inducing ischemic leg symptoms. Compared with a control group who did not exercise, home‐based walking exercise at a pace inducing ischemic leg symptoms significantly improved change of walking velocity over 4 m at 6‐month follow‐up, but this benefit did not persist at 12‐month follow‐up. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT02538900.

Background Cardiac rehabilitation (CR) is associated with improved cardiovascular outcomes. Racial and ethnic differences in CR have been identified, but whether income may attenuate these disparities remains unknown. We evaluated (1) racial/ethnic differences in CR participation in a contemporary sample of insured US adults, and (2) assessed how household income modifies associations between race or ethnicity and CR participation. Methods and Results We identified 107 199 individuals with a CR‐qualifying diagnosis between January 1, 2016 and December 31, 2018 in Optum’s de‐identified Clinformatics database. We evaluated associations between race or ethnicity and participation in CR, and assessed interaction between race or ethnicity and annual household income. The mean±SD age of all participants was 70.4±11.6 years; 37.4% were female and 76.0% were White race. Overall, 28 443 (26.5%) attended ≥1 CR sessions. After adjustment, compared with White individuals, the probability of attending CR was 31% lower for Asian individuals (95% CI, 27%–36%), 19% lower for Black individuals (95% CI, 16%–22%), and 43% lower for Hispanic individuals (95% CI, 40%–45%), all P P interaction=0.0005); however, Asian, Black, and Hispanic individuals were less likely to attend CR at all incomes. Conclusions In a geographically and racially diverse cohort, participation in CR was low overall, and was lowest among Asian, Black, and Hispanic candidates. Household income may impact the link between race or ethnicity and attendance at CR, but substantial racial and ethnic disparities exist across incomes.

Background Management of aortic stenosis (AS) relies on symptoms. Exercise testing is recommended for asymptomatic patients with significant AS but is often experienced as forbidding and/or technically unrealistic for patients who are often frail, deconditioned, and intimidated by the exercise test. We compared the physiological burden assessed with gas exchange assessments to gauge and respiratory exchange ratio (RER) of a 6-minute walk test (6MWT) to a cardiopulmonary exercise stress test (CPET) in patients with severe AS. peak oxygen utilization Methods Adults with equivocal symptoms and severe AS (1-aortic valve area [AVA] ≤ 1.0 cm2 or AVA index ≤ 0.6 cm2/m2, 2-peak aortic jet velocity ≥ 4.0 m/sec, 3-mean transvalvular pressure gradient ≥ 40 mm Hg by rest or dobutamine stress echocardiography, or 4-aortic valve calcification ≥ 1200 in women or ≥ 2000 AU in men) were studied. All participants completed both a 6MWT and symptom-limited progressive bicycle exercise testing. Breath-by-breath gas analysis and 12-lead electrocardiography were completed during 6MWT and CPET. Results: Eleven patients were studied. Patients walked on average 330 ± 75 m during the 6MWT and achieved a maximal workload of 48 ± 14 watts during the CPET. During the 6MWT, peak maximal oxygen uptake ( V ˙ O2peak) was 12.8 ± 2.5 vs 10.8 ± 4.2 mL/kg/min during the CPET. Respiratory exchange ratio exceeded 1.1 in both the 6MWT and CPET indicating similarly high exertion. Compared with the CPET, a larger proportion of the 6MWT was performed at a high intensity level (78% ± 28% vs 33% ± 24% at > 85% VO2peak; P = 0.004). Conclusions The 6MWT with breath-by-breath gas analysis was well tolerated and able to achieve a physiological intense RER and V ˙ O2peak that are similar to symptom-limited CPET in patients with severe AS.

The growing population of older adults (age ≥65 years) is expected to lead to higher rates of cardiovascular disease. The expansion of digital health (encompassing telehealth, telemedicine, mobile health, and remote patient monitoring), Internet access, and cellular technologies provides an opportunity to enhance patient care and improve health outcomes—opportunities that are particularly relevant during the current coronavirus disease-2019 pandemic. Insufficient dexterity, visual impairment, and cognitive dysfunction, found commonly in older adults should be taken into consideration in the development and utilization of existing technologies. If not implemented strategically and appropriately, these can lead to inequities propagating digital divides among older adults, across disease severities and socioeconomic distributions. A systematic approach, therefore, is needed to study and implement digital health strategies in older adults. This review will focus on current knowledge of the benefits, barriers, and use of digital health in older adults for cardiovascular disease management.

Function and the independent performance of daily activities are of critical importance to older adults. Although function was once a domain of interest primarily limited to geriatricians, transdisciplinary research has demonstrated its value across the spectrum of medical and surgical care. Nonetheless, integrating a functional perspective into medical and surgical therapeutics has yet to be implemented consistently into clinical practice. This article summarizes the presentations and discussions from a workshop, "Embedding/Sustaining a Focus on Function in Specialty Research and Care," held on January 31 to February 1, 2019. The third in a series supported by the National Institute on Aging and the John A. Hartford Foundation, the workshop aimed to identify scientific gaps and recommend research strategies to advance the implementation of function in care of older adults. Transdisciplinary leaders discussed implementation of mobility programs and functional assessments, including comprehensive geriatric assessment; integrating cognitive and sensory functional assessments; the role of culture, environment, and community in incorporating function into research; innovative methods to better identify functional limitations, techniques, and interventions to facilitate functional gains; and the role of the health system in fostering integration of function. Workshop participants emphasized the importance of aligning goals and assessments and adopting a team science approach that includes clinicians and frontline staff in the planning, development, testing, and implementation of tools and initiatives. This article summarizes those discussions.

In the United States, cardiac rehabilitation (CR) is vastly underutilized with only 19-34% of eligible patients participate. Lack of physician endorsement and referral to CR is a significant modifiable barrier that often stems from lack of CR knowledge. Studies show that physicians, of varying specialties, lack the necessary knowledge of CR and referral processes significantly limiting their endorsement but none have isolated cardiology fellows. Cardiology fellows spend a significant amount of time treating eligible patients, making them critically important to increasing participation at teaching hospitals where referral is lowest. University of Pittsburgh Department of Medicine (DOM) Cardiology Fellows were surveyed and interviewed to assess cardiology fellows’ knowledge (what they know about CR) and attitudes (what they think about CR), and their perceived facilitators and barriers to CR endorsement and referral. The fellows had low knowledge scores regarding eligibility, benefits and what CR entails. In regards to attitudes, the fellows believe in the benefits of CR, local CR programs and cost-effectiveness. Furthermore, fellows state they do not refer patients to CR because they forget or are unaware how to refer. Barriers to endorsement and referral included: logistics of CR operations, limited communication, limited time with patients, presumed patient barriers, intrinsic fellow barriers, understanding referral processes, and multiple hospital rotations. Facilitators to endorsement and referral included: evidence-based outcomes, patient-centered outcomes, ease of access to order-sets, and reminders. The findings of this study present in-depth thought processes regarding lack of CR knowledge, and barriers to CR endorsement and referral that were previously unknown in cardiology fellows. Addressing these specific barriers through fellowship education programming may increase endorsement and referrals. Additionally, targeting the specific thought processes that lead to these perceived fellow barriers could ultimately lead to improved CR participation.

Whereas the burgeoning population of older adults is intrinsically vulnerable to cardiovascular disease, the utility of many management precepts that were validated in younger adults is often unclear. Whereas biomarker- and imaging-based tests are a major part of cardiovascular disease care, basic assumptions about their use and efficacy cannot be simply extrapolated to many older adults. Biology, physiology, and body composition change with aging, with important influences on cardiovascular disease testing procedures and their interpretation. Furthermore, clinical priorities of older adults are more heterogeneous, potentially undercutting the utility of testing data that are collected. The American College of Cardiology and the National Institutes on Aging, in collaboration with the American Geriatrics Society, convened, at the American College of Cardiology Heart House, a 2-day multidisciplinary workshop, "Diagnostic Testing in Older Adults with Cardiovascular Disease," to address these issues. This review summarizes key concepts, clinical limitations, and important opportunities for research.

Older adults with cardiovascular disease (CVD) pose challenges to cardiac rehabilitation (CR) clinicians because their disease is often coupled to physical frailty. Older patients with CVD and frailty may be less likely to tolerate conventional CR exercise training due to multidimensional (ie, strength, mobility, and balance) physical impairments. Furthermore, conventional CR typically emphasizes endurance training without addressing the intrinsic skeletal muscle impairments of frail patients that often manifest as deficits in strength, mobility, and balance, undercutting feasibility and any likely benefits. However, if appropriately modified to meet the needs of frail older adults, CR may be a powerful tool for this challenging population. To best serve frail, older adults with CVD, CR programs can incorporate well-validated strategies to assess frailty and physical function that also fit within the workflows and patient populations of individual programs. Such frailty assessments provide opportunities to identify specific targets (eg, weakness) that need to be addressed before a subsequent aerobic training program can be successfully implemented and sustained. The current review focuses on the use of physical frailty measures in older adults with CVD, with practical considerations for their clinical use in contemporary CR, as well as directions for future research.

Falls and fear of falling are a major health issue and associated with high injury rates, high medical care costs, and significant negative impact on quality of life. Adults with cardiovascular disease are at high risk of falling. However, the prevalence and specific risks for falls among adults with cardiovascular disease are not well understood, and falls are likely underestimated in clinical practice. Data from surveys of patient-reported and medical record–based analyses identify falls or risks for falling in 40% to 60% of adults with cardiovascular disease. Increased fall risk is associated with medications, structural heart disease, orthostatic hypotension, and arrhythmias, as well as with abnormal gait and balance, physical frailty, sensory impairment, and environmental hazards. These risks are particularly important among the growing population of older adults with cardiovascular disease. All clinicians who care for patients with cardiovascular disease have the opportunity to recognize falls and to mitigate risks for falling. This scientific statement provides consensus on the interdisciplinary evaluation, prevention, and management of falls among adults with cardiac disease and the management of cardiovascular care when patients are at risk of falling. We outline research that is needed to clarify prevalence and factors associated with falls and to identify interventions that will prevent falls among adults with cardiovascular disease.

Introduction: Frailty, an increased vulnerability to stressors, is associated with adverse health outcomes. Cardiovascular disease (CVD) is associated with frailty, but whether circulating cardiac biomarkers of subclinical myocardial injury and strain (e.g., high-sensitivity cardiac troponin T [hs-cTnT] and natriuretic peptide [NT-proBNP]) are associated with frailty is unknown. Methods: We conducted a cross-sectional analysis of levels of hs-cTnT and NT-proBNP assessed among participants of the ARIC study at visit 5 (2011-2013, mean age: 75.5 years, 42% male, 21% Black). We used the Fried frailty phenotype that counts the presence of each component (weight loss, low physical activity, slow gait, exhaustion, and low grip strength) to classify participants as frail (≥3), pre-frail (1-2), or robust (0 components). Participants without prevalent CVD (stroke, myocardial infarction, or heart failure) were classified into hs-cTnT and NT-proBNP quartiles; those with prevalent CVD were considered in a separate group. Using adjusted multinomial logistic regression models, we tested the hypothesis that hs-cTnT and NT-proBNP are positively associated with odds of being pre-frail and frail, vs. robust. Results: Among 5,162 participants, 1,039 had prevalent CVD (20%), 2,447 (48%) were pre-frail, and 358 (7%) frail. Biomarker concentrations had graded associations with frailty and pre-frailty, vs. robust. Estimates comparing the 4 th vs. 1 st quartile, (e.g., hs-cTnT frail vs. robust OR=4.37 [95% CI: 2.69-7.09]) were similar to those observed for prevalent CVD vs. 1 st quartile (e.g., hs-cTnT frail vs. robust OR=5.11 [3.19-8.17]). All frailty components were positively associated with cardiac biomarker concentrations and CVD (Table), except exhaustion with NT-proBNP. Conclusions: Cardiac biomarker concentrations, even in the absence of CVD, may help identify people at greater risk for frailty. Future research should examine the role of changes in biomarkers from mid-life on the risk of frailty

This study updates cardiac rehabilitation (CR) utilization data in a cohort of Medicare beneficiaries hospitalized for CR-eligible events in 2017, including stratification by select patient demographics and state of residence.We identified Medicare fee-for-service beneficiaries who experienced a CR-eligible event and assessed their CR participation (≥1 CR sessions in 365 d), engagement, and completion (≥36 sessions) rates through September 7, 2019. Measures were assessed overall, by beneficiary characteristics and state of residence, and by primary (myocardial infarction; coronary artery bypass surgery; heart valve repair/replacement; percutaneous coronary intervention; or heart/heart-lung transplant) and secondary (angina; heart failure) qualifying event type.In 2017, 412 080 Medicare beneficiaries had a primary CR-eligible event and 28.6% completed ≥1 session of CR within 365 d after discharge from a qualifying event. Among beneficiaries who completed ≥1 CR session, the mean total number of sessions was 25 ± 12 and 27.6% completed ≥36 sessions. Nebraska had the highest enrollment rate (56.1%), with four other states also achieving an enrollment rate50% and 23 states falling below the overall rate for the United States.The absolute enrollment, engagement, and program completion rates remain low among Medicare beneficiaries, indicating that many patients did not benefit or fully benefit from a class I guideline-recommended therapy. Additional research and continued widespread adoption of successful enrollment and engagement initiatives are needed, especially among identified populations.

Cardiac Rehabilitation (CR) is a comprehensive disease management program that utilizes exercise training, behavioral modification, education, and psychosocial counseling to optimize outcomes and functionality in patients with cardiovascular disease (CVD)(1). While CR was initially designed as an exercise training and fitness program for younger patients, usually men, after debilitating hospitalizations for myocardial infarction or cardiac surgery, evidence has expanded to also include other types of CVD in women as well as men, including heart failure, valvular disease, and peripheral arterial disease(2–4). As the population of older adults continues to expand, age-related CVD is endemic and is commonly associated with exercise decline, diminished quality of life, and dependence. CR has the potential to counterbalance these patterns, and therefore stands out as a particularly important consideration for older adults with CVD. Nevertheless, CR remains highly underutilized(5,6). Novel approaches to CR including home-based and hybrid CR programs show promise for enhanced outreach to patients who may not otherwise participate. This review summarizes the current data available regarding CR in older adults with CVD with a focus on geriatric-specific complexities, current barriers to utilization, and approaches to enhance participation and effectiveness.

Background Aging is associated with central fat redistribution and skeletal muscle decline, yet the relationships of tissue compartments with heart failure (HF) remain incompletely characterized. We assessed the contribution of body composition to incident HF in elders. Methods and Results Participants from 2 older cohorts who completed dual‐energy X‐ray absorptiometry (DEXA) and, in one cohort, computed tomography were included. We evaluated associations with incident HF for DEXA principal components (PCs) and total lean, appendicular lean, total fat and trunk fat mass; and for computed tomography measures of abdominal visceral and subcutaneous fat, thigh muscle, intermuscular fat area and thigh muscle density. DEXA analysis included 3621, and computed tomography analysis 2332 participants. During median follow‐up of 11.8 years, 927 participants developed HF. DEXA principal components showed no relationship with HF. After adjustment for height, weight, and cardiovascular risk factors, total lean mass was near significantly associated with higher HF (hazard ratio [HR], 1.25 per SD [1.00–1.56]), whereas total fat mass and thigh muscle density were significantly related to lower HF (HR, 0.82 [0.68–0.99] and HR, 0.87 [0.78–0.97], respectively). Patterns were similar for HF subtypes. The relationships with HF for total lean and fat mass were attenuated after adjusting for intercurrent atrial fibrillation or excluding high natriuretic peptide levels. Conclusions Total lean mass was positively associated, while total fat mass and thigh muscle density were inversely associated, with incident HF. These findings highlight the limitations of DEXA for assessment of HF risk in elders and support the preeminence of computed tomography–measured skeletal muscle quality over mass as a determinant of HF incidence.

Introduction: Recent evidence showed that among people with peripheral artery disease (PAD), walking exercise conducted at a pace inducing ischemic leg symptoms improved six-minute walk distance (6MW), while walking exercise conducted at a pace without ischemic leg symptoms had no effect on 6MW. This report describes associations of walking exercise intensity and minutes walked for exercise among participants with PAD with the change in 6MW. Method & Results: In the LITE clinical trial, 305 participants with PAD (69±4 years, 181 (59%) Black, 146 (48%) female) were randomized to: 1) walking exercise conducted at a pace without ischemic leg symptoms (low-intensity: LI), 2) walking exercise conducted at a pace eliciting ischemic leg symptoms (high-intensity: HI), or 3) an attention-control group for 12-months. Participants in both exercise groups were asked to walk in or around the home for up to five days/week for up to 50 minutes/session. Measurements of walking intensity and exercise minutes per week were determined individually for each participant in each exercise group using an Accelerometer. Participants in each exercise group were categorized into quartiles according to exercise minutes per week and exercise intensity, respectively (4 th quartile indicated greatest minutes or intensity). Within the LI and HI groups, more minutes of exercise per week were associated with greater 6MW improvement [(LI: 4 th vs 1 st Q: +54 m, 95%CI:16, 92; P=0.018), (HI: 4 th vs 1 st Q: +54 m, 95% CI: 12, 96; P=0.010), Table 1]. Within the LI group, but not the HI group, greater exercise intensity was associated with greater 6MW improvement [(LI: 4 th vs 1 st Q: +80 m, 95% CI: 31, 128; P=0.002), Table 1]. Conclusion: While high intensity exercise improves 6MW in PAD, exercising for a greater duration offers greater benefit. Additionally, there is benefit in exercising at low intensity, focusing on increased duration of exercise, if patients are unable to exercise at high intensity.

Introduction: By 2030, it is projected that 20% of the population will be 65 or older. Older adults aged 85 and over (the oldest old) are the fastest growing segment of the US population and globally. As the population ages, cardiovascular disease is becoming a major public health challenge. Providing optimal care to older adults with CVD is challenging due to their complexity, competing vulnerabilities and a lack of evidence-based knowledge to bridge the existing gap between guidelines and real-world clinical practice. Hypothesis: Exposure to geriatric education during training will associate with attitudes toward treatment of older adult patients. Objective: Evaluate current cardiologists’ knowledge and attitude toward geriatric care. Methods: IRB-approved, quantitative cross-sectional study using an online survey distributed to all cardiologists and cardiology fellows within a large academic medical system. Result: Of the 98 physicians invited, 26 responded (26.5% response rate) of which 19.2% were female; 45% cardiology fellows, 5% early career (< 5 years) and 50% experienced cardiologists (>10 years). Of those surveyed, 77% reported more than half of their patients were over age 65. While 87% believed it was very important for cardiologists to have knowledge about geriatric syndromes, 70% reported little to moderate levels of knowledge about their impact on CV care. Only 20% reported a deep fund of knowledge. Most knowledge was gained through experience rather than formal education. None of the participants were aware of the “Essentials of Cardiovascular Care in Older Adults (ECCOA)” curriculum within the Geriatric Cardiology section of ACC. Two thirds were concerned about potential overtreatment for older adults, whereas 41% were concerned for potential undertreatment. Conclusion: Academic-affiliated cardiologists surveyed reported unmet educational needs regarding care of older adults. Efforts to equip cardiologists with the requisite up- to -date knowledge of geriatric cardiology are needed to formulate a balanced and holistic therapeutic plan of care for our most vulnerable patients.

Background: Pulmonary hypertension in the context of heart failure with preserved ejection fraction (PH-HFpEF) is the most common cause of PH worldwide. However, major pathways involved in the regulation of PH-HFpEF are still not well understood. We have recently reported on a role of skeletal muscle sirtuin-3 (SIRT3) in modulating PH-HFpEF. In this study, we attempted to define the processes by which skeletal muscle SIRT3 defects affect pulmonary vascular health in PH-HFpEF. Methods and Results: Skeletal muscle-specific Sirt3 knockout mice ( Sirt3 skm-/- ) exhibited drastically reduced pulmonary vascular density accompanied by pulmonary vascular proliferative remodeling and elevated pulmonary pressures. Using global mass spectrometry-based comparative secretome analysis, we found elevated secretion of lysyl oxidase homolog 2 (LOXL2) in SIRT3-deficeint skeletal muscle cells. Elevated circulation and protein expression levels of LOXL2 were also observed in plasma and skeletal muscle of Sirt3 skm-/- mice, rats with experimental PH-HFpEF (SU5416/Obese ZSF1, Ob-Su), and patients with PH-HFpEF. Interestingly, expression levels of the tumor suppressor WW domain-containing oxidoreductase (WWOX), which plays a housekeeping role in repressing cellular proliferation, were decreased in PASMCs from Sirt3 skm-/- mice. Reduced WWOX expression levels were also detected in PASMCs from Ob-Su rats and human subjects with obesity and diabetes. Treatment with LOXL2 recombinant protein resulted in reduced WWOX expression ex vivo in precision-cut lung slices (PCLS) and in vitro in PASMCs. Media conditioned by SIRT3-deficient skeletal muscle cells reduced WWOX expression in PASMCs, concomitant with increased PCNA levels and cellular proliferation. Finally, knockdown of both SIRT3 and LOXL2 in skeletal muscle cells or suppression of LOXL2 with β-aminopropionitrile (BAPN) restored WWOX and PCNA levels in PASMCs. Conclusions: These studies indicate a systemic pathogenic impact of skeletal muscle SIRT3 deficiency in remote pulmonary vascular remodeling and PH-HFpEF. These studies also reveal a new endocrine signaling axis that links skeletal muscle SIRT3 deficiency to remote WWOX regulation in the pulmonary vasculature through myokine LOXL2.

Objective: In a randomized clinical trial of people with lower extremity peripheral artery disease (PAD), to test whether walking exercise conducted at a pace without ischemic leg symptoms improved physical activity more than walking exercise conducted at a pace that induced ischemic leg symptoms and more than an attention control group. Methods & Results: In the LITE multi-centered clinical trial, 305 participants with PAD (69±40 years, 181 (59%) black, 146 (48%) female) were randomized to: 1) walking exercise conducted at a comfortable pace without ischemic leg symptoms (low-intensity), 2) walking exercise conducted at a pace eliciting ischemic leg symptoms (high-intensity), or 3) an attention-control group for 12-months. Physical activity (i.e., activity counts per minute) was a pre-specified secondary outcome. Both exercise groups were asked to walk for exercise in an unsupervised setting for up to 5 times/week for up 50 minutes/session. Physical activity was measured for up to 10 days using an ActiGraph accelerometer at baseline, 6-month, and 12-month follow-up. Low intensity exercise increased physical activity significantly less than high intensity exercise at 6-month follow-up (-74 counts per minute, 95% CI: -123, -26, P=0.003; Table 1) and 12-month follow-up (-47 counts per minute, 95% CI: -79, -15, P=0.004; Table 1). High intensity exercise increased physical activity significantly more than control at 6-month follow-up (+104 counts per minute, 95% CI: 48, 162, P Conclusion: These results support home-based walking exercise conducted at a pace that induces ischemic leg symptoms, but not walking exercise conducted at a comfortable pace without ischemic leg symptoms, to improve physical activity in people with PAD.