A Breif Review of the Effects of Physical Activity in Subjects with Cardiovascular Disease: An Interpretative Key

Today is consolidated the importance of physical activity to health, so it is important to know the eff ects of exercise for primary prevention and secondary. A regular physical activity of mild intensity results in signifi cant benefi ts in term of health, while a sedentary lifestyle and otherrisk factors contributeto development of chronic degenerative diseases, in particular cardiovascular. The advanced age does not contraindicate physical activity and exercise can prevent cardiovascular and disability diseases in the elderly. In the elderly person physical exerciseis able toimprove muscular tone and movement skills, of reduce the risk of sudden death caused by cardiovascular diseases, of reduce the development of tumors and metabolic disorders, as well as of delay the decline of cognitive function. The aim of this literature review is to clarify the link and the eff ects between physical activity, aging and cardiovascular diseases, providing practical indications for a useful physical activity for elderly subjects with cardiovascular problems;adapting to the skills of the elderly person, prescribed after careful assessment of the environmental conditions in which it must take place. In conclusion, a physical activity program fi nds a sure indication both in elderly subjects without and with pathologies and in the elderly with high risk of disability.


Introduction
Th e evolution of lifestyles, along with the possibility of access to physical education from the social groups such as the elderly and children, have initiated a modifi cation of perception and social meaning of the movement and physical activity, emphasizing the educational and social value and decreasing the competitive component (D'Isanto & Di Tore, 2016). Practicing regular physical activity off ers several physical and mental benefi ts for elderly (Gaetano, 2016), including slowing the aging process, promoting psychological and cognitive well-being, reductionof the risk of physical disability,increasing longevity and greater functional independence (American College of Sports Medicine, 2009). Th e education to the physical activity, motor and sports should be the center of the teaching-learning processes and help the process of construction of knowledge and skills within the school (Raiola, 2013). And how much this knowledge and skills system can be conditioned by social and cultural aspects (D'Isanto, Altavilla, & Tafuri, 2017).Tod ay is consolidated the importance of physical activity to health, so it is important to know the eff ects of exercise for primary prevention and secondary (Tiziana, Antonetta, & Gaetano, 2017). It is not easy to separate the eff ects of aging from the decrease in physical activity linked to age. Regular physical activity of moderate intensity leads to signifi cant health benefi ts in all age groups; moreover, a sedentary lifestyle contributes, together with other risk factors, to the development of numerous diseases, in particular those of the cardiovascular apparatus. Several studies reinforce the view that physical activity has favorable eff ects on the state of health (Paff enbarger & Lee, 1997). In old age, physical activity is not contraindicated; on the contrary, it can prevent cardiovascular diseases and the disability of the elderly (Rengo, Leosco, & Iacovoni, 2004). Th ere are EFFECTS OF PHYSICAL ACTIVITY IN SUBJECTS WITH CARDIOVASCULAR DISEASE | G. ALTAVILLA ET AL. many positive aspects of regular physical activity in the elderly (Shekelle, Maglione, & Mojica, 2003): -reduction the risk of sudden death, heart attack or heart disease; -reduction of up to 50% risk of developing colon cancer; -the reduction of the risk of up to 50% of the development of type 2 diabetes; -prevention or reduction of hypertension; -reduction of the risk of developing cognitive impairment and dementia; -the reduction of symptoms of anxiety, stress and depression; -weight loss and decreased risk of obesity, with benefi ts of 50% compared to those with a sedentary lifestyle. A sedentary lifestyle can contribute together with other risk factors to the development of various chronic diseases, particularly those aff ecting the cardiovascular system. Th erefore, the primary objective of public health should be the development of strategies to promote the spread of physical activity in all environments and in all age groups. Th e promotion of physical activity is becoming a priority public health action, oft en included in health plans and programs all over the world. In Italy, in the National Health Plan of 2011-2013, the aim was to increase on average 10% physical-sport activity in free time among the elderly, starting from the consideration that physical activity has a protective eff ect not only for cardio-respiratory and cardio-vascular pathologies, but also for osteoarticular and metabolic diseases. In the USA, the Healthy People 2010 program identifi es physical activity as one of the main health objectives, such as the European Union in the Public Health Program (2003)(2004)(2005)(2006)(2007)(2008) indicates programs that support and promote physical activity. Th e perform of regular physical activity can therefore play a fundamental role in improving the functional abilities of the elderly and their quality of life.
Th e aim of this literature review is to clarify the link and the eff ects between physical activity, aging and cardiovascular diseases, providing practical indications for a useful physical activity for elderly subjects with cardiovascular problems.

Methods
Th e review of the literature and scientifi c documents was conducted through the use of several databases: PubMed, MedLine, Google Scholar. Relevant bibliographies were sought to identify the eff ects of physical exercise in individuals with cardiovascular disease.

Sedentary lifestyle is a cardiovascular risk factor
Th ere are numerous evidences of the benefi cial eff ects of physical activity in countering the reduction of cardiocirculatory performance (Hakim et al., 1999;Hambrecht et al., 2000;Donal et al, 2011). In sedentary subjects, in fact, there is a more marked reduction in systolic function and cardiac output, accompanied by an increase in heart rate; subjects who have undergone long-term sickness, develop a hypokinetic syndrome overlapping that of aging. It is widely known that a lifestyle characterized by physical inactivity is a cardiovascular risk factor. A sedentary lifestyle is responsible for a signifi cant increase in cardiac morbidity and mortality. Physical exercise has benefi cial eff ects on cardiovascular disease, as demonstrated by Paff enbarger et al. (1997), in a study conducted on Harvard college students. Th is work has shown that a reduction in the risk of death in physically active subjects compared to sedentary ones. Furthermore, the authors showed that in the group of subjects who developed arterial hypertension and who carried out physical activity there was a reduction in mortality of 50%. Th e benefi ts of the exercise were also evident in the assessment of the incidence of coronary heart disease independently of other factors and suggesting that moderate sporting activity is associated with the reduction of the mortality. Th e study showed that in order to achieve a reduction in mortality of 20%, an exercise intensity is required that leads to an energy consumption of about 4200 KJules a week (equivalent to 30 minutes of exercise a day, for at least 4-5 days at week). An Inferior intensity were not suffi cient to guarantee signifi cant improvements in the prognosis. Physical activity of mild to moderate intensity has also shown benefi ts in elderly subjects (Wannamethee, Shaper, & Walker, 1998), indicating the need for a specifi c public health program that encourages physical exercise in this increasingly prevalent age group.

Eff ects of the physical exercise on the diseases cardiovasculary and suggestions
In the Longitudinal Study of Aging, conducted on subjects over seventy years old, the importance of maintaining a good level of physical activity in old age is further confi rmed, demonstrating an inverse relationship between physical activity and mortality (R akowski & Mor, 1992). Th e improvement of cardiac function is possible thanks to an increase in oxygen consumption and contractile capacity of the heart. Hasbeen shown that in elderly subjects with acute myocardial infarction, routine physical activity prior to the ischemic event favors both short-term and long-term survival (Rengo, Galasso, & Piscione, 2007).Sig nifi cant eff ects of exercise on the blood pressure have been reported in patients with mild or initial hypertension, where it is possible through physical activity to prevent or slow down the evolution towards stable arterial hypertension. Some studies (Kokkinos, Narayan, & Colleran, 1995;Kokkinos& Myers, 2010) have shown that regular exercise in subjects with mild or moderate arterial hypertension induces a mean reduction in blood pressure in the following measure: 8-10 mmHg for maximum pressure and 7-8 mmHg for the minimum pressure. Th erefore, it is advisable to use only aerobic running, favoring long distances, while avoiding repetitions (especially short ones), fartlek or training with net changes of pace (for example, of cross-country races). Aerobic training of moderate intensity, as well as the total duration of physical activity, play an important role in improving the HDL cholesterol and the elimination of the sedentariness could lead to a reduction of 15-39% of cardiovascular diseases, 33% of strokes and 22-33% of tumors (Sunami, Motoyama, & Kinoshita, 1999). A review of primary prevention in women shows that even walking an hour a week has a protective effect on the risk of death from cardiovascular disease (Oguma, Sesso, Paff enbarger, & Lee, 2002). Other reviews have shown that patients with cardiovascular disease benefi t from a physical activity that consumes 1600 kcal per week to counter the progression of coronary heart disease and 2200 kcal per week for heart disease (Franklin & Swain, 2003). It is important to remember that a physical exercise, preferably aerobic, must be mild-moderate: 30 minutes of movement (walking, swimming, cycling, etc.) are suffi cient a day, at least fi ve times a week, to obtain benefi ts. Th e screening should be planned for all seniors who wish to undertake a regular physical activity, both to identify subjects with chronic illnesses, symptoms linked at some diseases or to prescribe a program of appropriate and personalized exercises. Th e training must be practiced for several days a week and continued with a certain periodicity until becoming permanent. In general, the success of a program depends not only on the functional possibilities of the various interested parties, but also on the characteristics, intensity, duration of the exercise, its continuity and the repetition of the movements (Carlson, Ostir, & Black, 1999). In order to maximize these benefi ts and reduce possible risks, we recommend monitoring the heart rate by increasing the intensity of resistance exercises, using 60-70% of the maximum heart rate for that subject as a goal. Th e maximal heart rate defi ned by the equation is considered: HRmax=208-0.7×age, HRmax is predicted, primarily, by age alone and is independent of sex and physical activity (Tanaka, Monahan, & Seals, 2001).Th e decrease in resting heart rate is usually signifi cant in the trained subjects and indicates the improvement of cardiovascular conditions. For a better and personalized defi nition of the maximal heart rate and to rule out any latent cardiovascular pathologies, it is always advisable, in the elderly subject, to perform an exercise electrocardiogram before planning a physical activity. Aging alters body composition and reduces its functionality and, consequently, increases the risk of disability and chronic diseases such as cardiovascular diseases, type 2 diabetes, obesity and certain types of cancer (Singh, 2004). Scientifi c evidence (Spirduso, Francis, & MacRae, 2005) confi rm that regular physical activity can reduce the physio-logical eff ects of aging and a sedentary lifestyle amplifi es the eff ects of aging, while an active lifestyle prolongs the expectation of life and limiting the progression of chronic diseases and disabling conditions.

Suggested physical activity for healthy subjects and with cardiovascular diseases
Wal king is the most used activity, but for those who have orthopedic and/or excess weight problems, water or bike activities are more recommended. For healthy elderly there are no contraindications to the cardiovascular effi ciency training, which can lead to improvements even higher than 20% (Huang, Shi, Davis-Brezette, & Osness, 2005) and in any case sensitive improvements already aft er the fi rst three months of training. Many of the people suff er of problems at the cardiovascular system, naturally before being able to training subjects with these particular types of pathologies it is essential that the doctor gives the authorization and directives for the workouts. Regular aerobic activity is able to lower the heart rate and resting blood pressure, this allows the heart to reduce the workload and be less exposed to risks of overload diseases. Increasing the aerobic capacity of a person, improves the standard of living by providing more energy for everyday activities (American Association of Cardiovascular and Pulmonary Rehabilitation, 2004). In order to see the benefi ts, the training must at least have a duration of 12 weeks and must be practiced for at least two to three sessions a week. Th e duration of a single workout is at least 30 minutes of continuous exercise or accumulated with a heart rate at the beginning of the program of at least 10 beats below that recommended by the cardiologist (ACSM's, 2013).Th e training of people with stable cardiovascular diseases must be authorized by a doctor, the role of the coach is to develop a program in line with the guidelines of the cardiologist without compromising the basic cardio-circulatory functions. Tables 1 and 2 compares and illustrates two training protocols for heart patients and healthy people; while in Tables 3 and 4 two diff erent activities are suggested for two subjects with diff erent cardiovascular pathologies.
In Tables 3 and 4 two diff erent activities are suggested for two subjects with diff erent cardiovascular pathologies.

Discussion
Th e evolution of lifestyles, along with the possibility of access to physical education from the social groups such as the elderly and children, have initiated a modifi cation of perception and social meaning of the movement and physical activity. Performing regular physical activity has benefi cial eff ects on most organs and systems and is therefore essential for the primary prevention of a large number of diseases. From the evidences in the literature, contained in the present review, the physical exercise in older people produces three main benefi ts: -improves functional capacity both in the healthy subject and in the patient with illness; -is of supportive in widespread diseases such as arterial hypertension, diabetes and obesity; -reduces the risk of developing chronic disabling diseases. Although the benefi cial eff ects of physical exercise increase with increasing frequency and intensity of activity, it is important to remember that the greatest benefi ts are due to moderate physical activity, as can be deduced from the various works mentioned in this document of review. A complete program, which integrates aerobic and anti-resistance activities, fi nds a sure indication in elderly subjects with and without pathologies or at high risk of disability. In conclusion, we can affi rm that physical activity must be adequate to the subject's ability (organic, psychic, functional, etc.); be prescribed aft er correctly establishing intensity, duration and rhythm of repetition of the exercises and be congenial and suitable for the cultural, creative and emotional possibilities of the elderly person.