ABC | Volume 112, Nº5, May 2019

Updated Updated Geriatric Cardiology Guidelines of the Brazilian Society of Cardiology – 2019 Arq Bras Cardiol. 2019; 112(5):649-705 Table 6 – Centers for Disease Control and Prevention exercise guidelines for adults over age 65 Substantial health benefits 2 hours and 30 minutes (150 minutes) of moderate-intensity aerobic activity per week Muscle strengthening activities 2 or more days per week 1 hour and 15 minutes (75 minutes) of vigorous-intensity aerobic activity Additional health benefits 5 hours (300 minutes) of moderate-intensity aerobic activity per week Muscle strengthening activities 2 or more days per week 2 hours and 30 minutes (150 minutes) of vigorous-intensity aerobic activity Adapted from: Centers for Disease Control and Prevention (CDC). Physical activities for older adults. Available at: www.cdc.gov/features/activity-older-adults/ index.html. Accessed: 18/02/2016. which would be better than BMI at evaluating risk, given its association with visceral adiposity. 69,70 Another study indicates that the presence or absence of metabolic syndrome is more important than BMI in obese elderly patients, thus dividing this population into “healthy obese” (without metabolic syndrome) and obese with metabolic syndrome. The latter group has been strongly associated with increased risk of CVD regardless of BMI. 71 More studies are necessary to clarify the interrelation between aging, obesity, and cardiovascular risk and what the best measures parameter(s) would be. Weight management in the elderly and efforts to promote healthy aging should be based on an individual approach, taking into consideration the maintenance of muscle mass and strength, comorbidities, functional and social status, physical activity, and quality of life. Intentional weight loss in obese elderly patients improves their cardiovascular risk profile, reduces chronic inflammation, and is correlated with improved quality of life. Unintentional weight loss requires careful clinical assessment of the underlying cause. Furthermore, the identification of elderly patients with sarcopenic obesity is relevant to prognosis. Sarcopenia and sarcopenic obesity have been associated with a higher risk of CVD, especially in elderly men with this type of obesity. 1.8. Sedentarism Regular physical activity is essential to healthy aging. Considering that aging in inevitable, the rhythm and magnitude of decline in physiological function may be influenced by an intervention comprising exercise/physical activity (Table 6). 72,73 Aging is associated with skeletal muscle mass loss; reduced muscle strength, flexibility, cardiac output, and pulmonary function; changes in hormonal and immune system regulation; reduced bone density, and higher prevalence and incidence of sedentarism. 74 In sedentary elderly patients, walking may be a practical solution, evaluating heart rate (HR) before and after exercise. It is necessary to recognize that elderly people do not represent a uniform group of patients and chronological age in itself does not identify this special group. 75 Sedentarism is an important risk factor for CAD in elderly individuals. Some studies demonstrate that the relative risk of CAD attributable to sedentarism is comparable to that of hypertension, hyperlipidemia, and tobacco use. Sedentarism, as an important risk factor, is, in most cases, directly or indirectly associated with the causes or aggravation of various diseases, such as obesity, diabetes, arterial hypertension, anxiety, depression, dyslipidemia, atherosclerosis, respiratory disease, osteoporosis, and cancer. 76,77 Systematic physical exercise helps control systemic arterial hypertension (SAH), by reducing peripheral arterial resistance, increasing HDL-c, reducing obesity and triglycerides, improving blood glucose control, preventing coronary disease, and decreasing mortality. 77,78 Furthermore, it improves sleep quality, cognitive function, and short-term memory; decreases degree of depression; reduces or slows the onset of dementia; reduces the risk of colon, breast, prostate, and rectal cancer; increases bone density; and decreases the incidence of femur and vertebrae fractures. 77 In elderly patients, pre-exercise clinical evaluation is very important. The goal of exercise and cardiovascular rehabilitation in elderly patients is to improve their functional capacity as much as possible. These objectives are reached through programs that aim to increase aerobic capacity, muscle strength, and flexibility. 72,79-82 The amount of physical activity should be individualized, considering each patient’s comorbidities and peculiarities. 73,74,79 Elderly individuals should spend more time warming up before and cooling down after activity. The warm-up phase includes flexibility and movement exercises, which facilitate musculoskeletal biomechanics. The post-exercise cool- down phase allows for the gradual dissipation of body heat and consequent peripheral vasodilatation. Musculoskeletal injuries may be decreased by avoiding high impact activities, such as running and jumping. Extreme care is necessary for activities using free weights, given the risk of accidents, especially in less skilled or more frail elderly patients. 72,80 Walking briskly is an excellent way to obtain physical conditioning, with gradual increases in pace and distance covered. 81 Elderly patients should be instructed to reduce exercise intensity on humid or hot days, given that skin blood flow decreases with age, consequently lowering the efficiency of sweating and thermal regulation. 77 Practicing resistance exercise twice weekly is also recommended. Pre-participation assessment should begin with patient history and clinical exam, focusing on the particularities of this population, which often has silent atherosclerotic disease. Complementary investigation should be oriented by clinical data, avoiding high costs, which are sometimes prohibitive and may discourage physical exercise. Resting electrocardiogram 659