Stress Testing May Not Be Necessary for Most Older Persons Starting an Exercise Program

Yale School of Medicine
Tuesday, 18 July 2000

Commonly recommended exercise stress testing for older persons may deter many of them from participating in highly beneficial exercise programs, Yale researchers report.

After weighing the benefits and risks of exercise among older persons, Thomas Gill, M.D. and colleagues concluded that current guidelines for exercise stress testing are not applicable for the vast majority of older persons who are interested in starting an exercise program.

These guidelines, Gill said, were designed primarily to address the role of exercise for developing and maintaining cardiovascular fitness in young and middle-aged adults, rather than for restoring or enhancing physical function in older persons. Gill's report appears in the July 19 issue of The Journal of the American Medical Association (JAMA).

"Based on a rigorous review of the available evidence, we found that the risk of myocardial infarction (MI) related to exercise among older persons may be overstated," said Gill, associate professor of internal medicine and geriatrics at the Yale School of Medicine.

Gill said vigorous exercise such as slow jogging, speed walking, tennis, and shoveling snow three days a week throughout the year would only increase the annual risk of a heart attack from 1.3 to 1.6 percent in a 79-year-old woman, and from 3.9 to 4.8 percent in a 90-year-old man. Less strenuous exercise such as walking, muscle strengthening and balance training would increase the risk of MI even less.

"Regular exercise and physical activity may actually reduce the overall risk of MI and death among older persons, possibly through improvements in cardiac risk factors and overall fitness," Gill said.

Current guidelines from the American Heart Association and American College of Sports Medicine suggest that exercise stress tests should be done routinely among older persons prior to the start of a moderately intense exercise program in an attempt to detect asymptomatic blockages to the heart's arteries.

Because most older persons are unable to complete a treadmill exercise test satisfactorily, more expensive tests are usually required to detect asymptomatic blockages to arteries. Gill said there is no evidence that detecting these asymptomatic blockages is beneficial.

Instead, Gill and his colleagues recommend that older persons starting an exercise program should have complete physical examinations and histories to identify potential risks to exercise outside of a monitored environment. And all previously sedentary older persons without symptomatic cardiovascular disease should start with a low intensity exercise program such as balance exercises, tai chi, self-paced walking, and lower extremity muscle strengthening.

"The intensity and amount of exercise should be gradually increased as the person's capacity increases, and each exercise session should include a warm-up and cool-down period," Gill said. "If chest pain, shortness of breath or dizziness develops, older persons should be instructed to rest and to see their physician if these symptoms persist or recur with further exercise."

Gill adds, "Although additional research is needed in several areas, our recommendations can be used by physicians to advise their older patients about precautions that should be taken to minimize the risk of adverse cardiac events from exercise programs."

Gill's research team at Yale School of Medicine included Harlan Krumholz, M.D., associate professor of medicine and in the Department of Epidemiology and Public Health, and Loretta DiPietro, associate professor in the Department of Epidemiology and Public Health and Associate Fellow at the John B. Pierce Laboratory.

For more information, or to contact Yale School of Medicine, see their website at: info.med.yale.edu/ysm/