Cardiovascular and coronary heart disease are the chief contributors to the disease burden.1 National figures show that rates increase markedly with age for both males and females (Australian Institute of Health and Welfare 2004). In 2001, almost two-thirds of people with coronary heart disease (CHD) were aged 65 years and over (Figure 4.2). The age-standardised prevalence of CHD is higher among males than females (2.4% of males and 1.6% of females). In 2004–05, 18% of the population reported one or more long term conditions of the circulatory system (heart attack, to angina, stroke, varicose veins and high blood pressure) (Australian Bureau of Statistics 2006). High blood pressure was the commonest (11%) and increased in prevalence from14% in the 45 to 54 age group to 41% of those aged 75 years and over. Circulatory conditions were chiefly reported by people in middle and older age groups. Almost a quarter (23%) of those aged 45 to 54 years had a long term circulatory condition, increasing to 63% of those aged 75 years and over.
In Europe, heart disease is also the primary cause of ill-health burden, accounting for over 10% of the total (World Health Organisation 2004). In Australia, possibly due to the ‘healthy migrant’ phenomenon, people from CLDB groups have lower mortality rates for cardiovascular disease than Australian born people, but generally report lower levels of physical activity, increasing their morbidity risk (Australian Institute of Health and Welfare 2004). In contrast, cardiovascular disease is high in Indigenous Australians: the standardised mortality rate is 2.6 times higher than in the non-Indigenous population (Australian Institute of Health and Welfare 2004).
Figure 4.2 Age-specific prevalence of coronary heart disease, Australia, 2001
Source: Heart, stroke and vascular diseases - Australian facts (Australian Institute of Health and Welfare 2004)
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Physical activity is inversely related to the incidence of ischaemic heart disease and stroke (at least the ischaemic type), as indicated in the Harvard Alumini cohort study and other populations (Lee and Paffenbarger 1998; Batty 2002; Batty and Lee 2002), including older women (Ellekjaer, Holmen et al. 2000). An integrative literature review reported equivocal findings on the relationship between physical activity and two other CVD risk factors, plasma lipid levels and blood pressure (Houde and Melillo 2002).
1 For ease of reading, the term cardiovascular disease (CVD) will be used throughout this document to relate to cardiovascular conditions, coronary heart disease, stroke, heart failure and peripheral vascular disease. An exception will be made where the information pertains to a specific condition.
The risk of coronary heart disease (CHD) is highest in older people, particularly in older women, where the risk increases threefold post menopause (Kannell and Wilson 1995). Whilst there is some observational study evidence that suggests mortality rates are only improved by physical activity for males (Stessman, Maaravi et al. 2000), the Iowa study of postmenopausal women confirmed the risk reduction impact of physical activity on mortality in females (Kushi, Fee et al. 1997). Risk reduction may have been underestimated even in this gender specific study. The researchers, like many others, focused solely on leisure time activity. Non-leisure time activities are often not accounted for, yet older women may derive their total activity from a number of sources, not least incidental activities in the home.
Cardiovascular disease risk is particularly higher in certain culturally and linguistically diverse (CLDB) groups, such as those from the African subcontinent (Briffa, Maiorana et al. 2006). There are few studies that assess the influence of physical activity on health outcomes in CLDB groups. A large prospective study of an ethnically diverse sample of postmenopausal American women highlights the impact of physical activity on cardiovascular risk reduction (Manson, Greenland et al. 2002). There was an inverse association between physical activity and coronary heart disease and overall cardiovascular events. For example, the adjusted relative risk ratios for cardiovascular events across quintiles of brisk walking were 1.0, 0.89, 0.81, 0.78 and 0.72 respectively (Rho for trend <0.001). The findings did not vary significantly according to race, age or body mass index (BMI). In the American Women’s Health Initiative study, reduced incidence of coronary events was strongly related to baseline physical activity behaviour in both black and white women (Manson, Greenland et al. 2002). The relative risk of CVD in the highest quintile of energy expenditure (metabolic equivalent MET score) compared to the lowest was 0.55 (95% CI 0.47-0.65) for white women and 0.48 (95% CI 0.25-0.93) for black women.
Cardiovascular disease prevention and managementPhysical activity is beneficial in the prevention and treatment of CVD. Although physical activity appears to influence CVD mortality rates in older people, the amount and type of activity to prescribe cannot be unequivocally specified from the available evidence. There is level II evidence that moderate physical activity has cardiovascular protective effects (Bauman 2004) and recent evidence supports the use of walking to reduce the risk of CVD (Lee, Rexrode et al. 2001; Manson, Greenland et al. 2002).
In general, health benefits have been observed for both older men and women. However, there have been concerns that since physical activity recommendations are based on studies largely involving male populations, they may not be generalisable to females. Im (2001) conducted an extensive review of the physical activity literature between 1980 and 1999 and noted that only 13% of the reports included females. Whilst this trend may be changing, it has implications for the generalisability of findings.
Physical activity has been used extensively in the management of people with CVD. Recommendations for people with CVD have been produced by the National Heart Foundation of Australia (Briffa, Maiorana et al. 2006). The recommendations provide clinical guidance to practitioners when advising older people with pre-existing CVD. Chapter 9 provides details of the secondary and tertiary prevention evidence base as it applies to older people.
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