ageing represents one of the biggest challenges to public health worldwide . according to 
 the world health organization ( who ) , currently , there are 650 million elderly ( over 60  years 
 of age ) . of these
, nearly 66% live in developing countries and this percentage may reach 75% 
 in 20251 . this marked increase in life 
 expectancy increases the morbidity from chronic diseases2 , depression3 , and 
 worsens physical performance and quality of life4 . besides , ageing may affect physical performance of older adults , 
 evoking negative impacts on their behavior and consequent changes in lifestyle , causing them 
 to become dependent5 .
several studies have 
 reported that the loss of functional capacity in elderly people is usually related to the 
 presence and complexity of comorbidities6 . 

although several mechanisms may be related to this impairment of physical function in this 
 population , the gradual loss of muscle mass and strength is often associated with the onset 
 and establishment of disabilities7 . the 
 relation between angiotensin converting enzyme ( ace ) gene polymorphism and differences in 
 physical performance phenotypes
have been explored during the last few years , being 
 described as a positive association between polymorphism insertion / deletion ( i / d ) of the ace 
 gene and exercise performance8 . according 
 to the literature , individuals with ace insertion ( i allele ) present lower ace plasma 
 levels9 and an increase in slow - twitch 
 rather than fast - twitch muscle fibers10 , 11 which , in turn , confers better 
 cardiovascular and skeletal muscle strength after training11 , 12 with a positive effect 
 in endurance sporting events13 , 14 .
there are few reports about the effectiveness of 
 pharmacological interventions that can prevent the decline in functional capacity in older 
 adults . however , a cross - sectional study in healthy elderly individuals showed a positive 
 correlation between the use of angiotensin - converting enzyme inhibitors ( aceis ) and skeletal 
 muscle mass in these hypertensive patients15 .
it was also noticed that the increase in physical performance 
 observed after treatment with perindopril is similar to that after a six - month training 
 program16 .
in addition to acei , 
 angiotensin receptor blockers ( arbs ) may also modulate the effects of angiotensin ii , as 
 they block the angiotensin-1 ( t-1 ) receptor , regardless of the amount of angiotensin ii 
 circulating levels17 . although some reports claim that the use of aceis can prevent the decline in ageing - related 
 muscle strength , further studies are necessary to confirm this hypothesis , especially 
 because many studies have evaluated this effect in patients with congestive heart failure 
 ( chf ) only and not in the elder population in general .
thus , this study aimed to evaluate if 
 older adults treated with aceis or arbs may have a better functional exercise capacity and 
 muscle strength .
the study 
 was approved by the ethics committee of the university of northern parana ( pp070/09 ) .
the convenience sample consisted of older adults ( age 
 over 60  years ) , according to the recommendations of the world health organization ( who ) for 
 developing countries19 who participated 
 in an interdisciplinary project - the eelo project - study on ageing and longevity .
the eelo 
 project is a thematic project developed at the university of northern parana ( unopar ) , which 
 aims to evaluate the socio - demographic factors and indicators of health conditions of older 
 adults in londrina , a city in northern paran , brazil .
further information can be found at 
 http://www2.unopar.br / sites / eelo/. this study was developed in londrina as the elder 
 population of the city represents 12% of the total population - a percentage similar to that 
 reported for other developed countries20 , 21 .
the total sample of the eelo project 
 consisted of 508 individuals , corresponding to the 43,610 citizens over 60  years old living 
 in londrina .
of those , 101 individuals did not match the inclusion criteria , and therefore 
 were excluded from the study .
therefore , the convenience sample of the present study 
 consisted of 407 physically independent elderly people capable of performing basic and 
 instrumental activities of daily life .
the included subjects were divided into three experimental groups ( according to the 
 medication used ) : the control group ( cg ) : physically independent elderly people with 
 exercise capacity and muscle strength exceeding 80% of the predicted value ; the acei group : 
 patients who used aceis for at least six months ; and the arb group : patients who used arbs 
 for at least six months .
older adults using other antihypertensive drugs that may influence 
 muscle strength or exercise capacity ( e.g. , calcium channel blockers ) or individuals 
 performing less than 80% of the predicted value of the tests were excluded from this study . 

questions concerning height and weight were also included in 
 order to determine the anthropometric characteristics .
this test was performed in accordance with 
 the guidelines established by the american thoracic society ( ats)22 and the reference values used were those described by 
 troosters23 .
data were expressed as 
 walking distance ( in meters ) and as the percentage of the predicted value .
blood pressure , heart rate ( hr ) , respiratory rate , symptoms of dyspnea and fatigue as well 
 as oxygen saturation were measured before , immediately after , and 2 minutes after test 
 recovery .
a 
 dynamometer was used to assess muscle strength that was calibrated according to the 
 methodology described by vianna24 .
the 
 individuals were placed in the standing position and after hand size adjustment , the device 
 was held comfortably aligned with the forearm , running parallel to the longitudinal axis of 
 the body .
the proximal inter - phalangeal joint of the hand was adjusted under the support 
 bar , which was then pressed between the fingers and thenar region . during handgrip ,
the arm 
 remained still with flexion of the interphalangeal and metacarpophalangeal joints only . 
 considering standardization , the movement of the elbow or wrist during the act of handling 
 was not allowed .
handgrip strength was measured in both the hands and the best result was 
 considered .
the values obtained were compared to the reference values described by 
 mathiowetz et al25 .
data were analyzed 
 using the graphpad prism 5.0 statistical program ( graphpad software inc . , san diego , ca , 
 usa ) and the significance level was set at p<0.05 .
since data 
 were regularly distributed , parametric tests were used and descriptive data were expressed 
 as mean and standard deviation . one - way analysis of variance ( anova ) was used to compare the groups regarding muscle 
 strength and functional exercise capacity .
no differences concerning sex ( p=0.99 ) , age ( p=0.46 ) , height ( p=0.11 ) , weight ( p=0.06 ) , and 
 body mass index ( p=0.07 ) were observed among the experimental groups .
therefore , it may be 
 assumed that the groups were similar regarding anthropometric data ; results are shown in 
 table 1table 1.anthropometric data of subjects in the experimental groupsanthropometric datacg ( n=235)aceig ( n=140)arbg ( n=32)genderm80 ( 34.04%)48 ( 34.29%)11 ( 34.38%)f155 ( 65.96%)92 ( 65.71%)21 ( 65.62%)age ( yrs)69.0  6.369.5  6.470.3  5.6 height ( cm)156.8  8.6157.5  10.0153.8  5.8weight ( kg)68.2 
11.771.4  12.469.6  12.5bmi ( kg / m)27.6  4.128.5  3.928.6  3.8 m : male , f : female , bmi : body mass index , cg : control group , aceig : angiotensin 
 converting enzyme inhibitor group , arbg : angiotensin - ii receptor blockers group .
values are expressed as mean and standard deviation ( mean  sd ) . a longer walking distance performed by men from the aceig
however , the individuals from the arbg were similar 
 to individuals from the aceig and the cg , according to one - way anova ( p=0.04 , table 2table 2.comparison of the walking distance ( by the 6-minute - walking test [ 6mwt ] ) and 
 muscle strength in men from the cg , aceig , arbgvariablescgaceigarbg6mwt ( m)499.9  76.4538.1  73.3 * 516.8  84.5muscle strength ( kgf)33.7  5.936.9  7.1 * 32.2  5.9cg : control group , aceig : angiotensin converting enzyme inhibitor group , arbg : 
 angiotensin - ii receptor blockers group .
* statistically different from control group , one - way anova followed by bonferroni 
 test ) .
m : male , f : female , bmi : body mass index , cg : control group , aceig : angiotensin 
 converting enzyme inhibitor group , arbg : angiotensin - ii receptor blockers group .
cg : control group , aceig : angiotensin converting enzyme inhibitor group , arbg : 
 angiotensin - ii receptor blockers group .
* statistically different from control group , one - way anova followed by bonferroni 
 test similar data were observed concerning women ( p=0.04 , table 3table 3.comparison of the walking distance ( by the 6-minute - walking test [ 6mwt ] ) and 
 muscle strength in women from the cg , aceig , and arbgvariablescgaceig arbg6mwt ( m)504.4  73.9529  82.2 * 525.1  62.1muscle strength ( kgf)23.3  4.524.7  4.6 * 23.5  4.7cg : control group , aceig : angiotensin converting enzyme inhibitor group , arbg : 
 angiotensin - ii receptor blockers group . * statistically different from control group , one - way anova followed by bonferroni 
 test ) .
however , when the percentage of predicted value was considered , it was 
 observed that individuals from both the aceig and the arbg had better performance than 
 individuals from the cg ( table 4table 4.comparison of the walking distance ( by the 6-minute - walking test [ 6mwt ] ) and 
 muscle strength in individuals from the cg , aceig , and arbgvariablescgaceig arbg6mwt ( % predicted value)95.6  9.999.2  12.1 * 100.9  13.6*muscle strength ( % predicted value)98.1  17.7104.8  18.8 * 105.1  18.7*cg : control group , aceig : angiotensin converting enzyme inhibitor group , arbg : 
 angiotensin - ii receptor blockers group .
* statistically different from control group , one - way anova followed by bonferroni 
 test ) .
regarding muscle strength , men from the aceig had higher values when 
 compared to those of men from the cg .
however , the individuals from the arbg were similar to 
 individuals from the aceig and the cg , according to one - way anova ( p=0.04 , table 2 ) .
similar data were observed concerning 
 women ( p=0.04 , table 3 ) . by contrast ,
when the 
 percentage of the predicted value was considered , it was observed that individuals from both 
 the aceig and the arbg had better performance than individuals from the cg ( table 4 ) .
cg : control group , aceig : angiotensin converting enzyme inhibitor group , arbg : 
 angiotensin - ii receptor blockers group .
* statistically different from control group , one - way anova followed by bonferroni 
 test cg : control group , aceig : angiotensin converting enzyme inhibitor group , arbg : 
 angiotensin - ii receptor blockers group .
* statistically different from control group , one - way anova followed by bonferroni 
 test
in this study , we found that elder individuals who use aceis or arbs have better exercise 
 capacity compared to those elderly who do not use this medication .
this result is in 
 agreement with the results of the study by onder et al.26 who also observed a better physical performance in individuals 
 using aceis .
additionally , we also observed an increase in the muscle strength in older 
 adults treated with both aceis and arbs , showing concordance with the results of the study 
 by di bari , et al.15 , that describes a 
 rise in muscle mass in elder patients treated with aceis .
moreover , sumukadas et al.16 reported that treatment with perindopril 
 may increase exercise capacity similar to that by a six - month physical training program . 

vescovo et al.27 reported significant 
 increases in maximum oxygen uptake ( vo2max ) and ventilatory threshold after six 
 months of treatment with losartan .
additionally , corder et al.28 observed an increase in vo2max and exercise 
 duration after twelve weeks of treatment with cilazapril in individuals with chf . on the 
 other hand ,
treatment with enalapril in patients with chf evoked no changes in exercise 
 capacity and vo2max , although a significant increase in the density of skeletal 
 muscle fibers was observed29 .
the exact mechanism by which pharmacological blockade of angiotensin - ii influences the 
 physical performance is still unclear .
initially , 
 it can be assumed that the blockade of angiotensin - ii could trigger metabolic and mechanical 
 changes in the skeletal muscle . in this
context , aceis increase insulin sensitivity , 
 glycogen stockage , and glucose uptake by skeletal muscles , improving muscle metabolic 
 efficiency30 .
in addition , decreased 
 degradation of bradykinin by blocking the ace could improve the blood flow to the skeletal 
 muscles through vasodilatation and an increase in capillary permeability , thus increasing 
 the uptake of glucose and amino acids also , contributing to a higher metabolic 
 efficiency31 .
besides , aceis can reduce 
 the inflammatory response produced by angiotensin - ii32 , which increases the production of interleukin 6 ( il-6 ) and alpha 
 tumor necrosis factor ( tnf ) in vascular smooth muscle cells33 . this reduction in inflammatory status
the aceis may exhibit this effect since they indirectly 
 potentiate the action of bradykinin , which , in turn , releases nitric oxide , a potent 
 suppressant agent of the inflammatory response34 . from these results
, it can be suggested that the beneficial effect observed by treatment 
 with aceis may be at least partially mediated by bradykinin , since the aceis limit the 
 degradation of bradykinin , which plays an important role in modulating endothelium relaxing 
 factors31 .
the reduction of bradykinin 
 as a result of ace inhibition may increase the blood supply to the skeletal muscles by 
 causing vasodilation and increased capillary density , favoring the uptake of glucose and 
 amino acids , leading to a higher metabolic efficiency35 .
these data may suggest that this beneficial effect on the physical 
 performance is due to ace inhibition and not only due to the pharmacological effects of 
 angiotensin ii .
as limitations of this study , it is important to analyze whether this effect 
 was dose or time dependent . inflammatory biomarker levels ( such as il-6 and tnf ) were not 
 assessed in this study .
furthermore , it should be highlighted that cohort as well as 
 clinical randomized trials should be conducted to confirm this hypothesis . considering the beneficial effect of these drug types on physical performance , it can be 
 suggested that such drugs may contribute to a smaller decline in physical capacity related 
 to the ageing process .
it can be concluded that older adults who use aceis or arbs may have 
 a better functional exercise capacity and muscle strength compared to those in controls . 

thus , elderly who use this medication may present a lower decline of functional capacity 
 related to the ageing process .
 [ purpose ] this study aimed to assess the exercise capacity and muscle strength in elderly 
 people using drugs for angiotensin - ii blockage . [ subjects and methods ] four hundred and 
 seven older adults 
 were recruited for this study . 
 data about comorbidities and medication 
 use were recorded and the individuals were divided into three groups : control group- 
 elderly people with normal exercise capacity ( n=235 ) ; angiotensin - converting enzyme 
 inhibitor group  individuals using angiotensin - converting enzyme inhibitors ( n=140 ) ; and 
 angiotensin - ii receptor blocker group- patients using angiotensin - ii receptor blockers ( n= 
 32 ) . 
 exercise capacity was evaluated by a 6-minute walking test and muscle strength was 
 measured using a handgrip dynamometer . 
 [ results ] patients from the angiotensin - converting 
 enzyme inhibitor group ( mean : 99  12% ) and the angiotensin - ii receptor blocker group 
 ( mean : 101  14% ) showed higher predicted values in the 6-minute walking test than the 
 control group patients ( mean : 96  10% ) . patients from the angiotensin - converting enzyme 
 inhibitor group ( mean : 105  19% ) and the angiotensin - ii receptor blocker group ( mean : 
 105.1  18.73% ) showed higher predicted values of muscle strength than control group 
 patients ( mean : 98.15  18.77% ) . 
 [ conclusion ] older adults using angiotensin - converting 
 enzyme inhibitors or angiotensin - ii receptor blockers have better functional exercise 
 capacity and muscle strength . 
INTRODUCTION
SUBJECTS AND METHODS
RESULTS
DISCUSSION