Left ventricular mass index and prevalence of heart disease in the population aged 80 years and over

International Elsevier

CARD10

Journal of Cardiology, 29 (1990) 327-333

327

01163

Left ventricular mass index and prevalence of heart disease in the population aged 80 years and over Baki Komsuoglu,

Ekrem

Duman, Bahtiyar

Department

Sezer

$. Komsuo&t,

$engiin

and Nafrz

of Cardlologv, Karadeniz (Received

Komsuoglu B, Duman E, Komsuoglu mass index and prevalence of heart 1990;29:321-333.

9 March

Sevim

Duman,

Technical University, and Tonya Hospital, 1990; revision

accepted

Bilal G(ir+,

Uluutku Trabzon,

Turkqv

25 June 1990)

SS, Duman S, Gijrcin B, Sengtin B, Uluutku disease in the population aged 80 years and

N. Left ventricular over. Int J Cardiol

Clinical, electrocardiographic and echocardiographic findings of 69 subjects aged 80 years or over were analyzed in order to assess the prevalence of left ventricular mass, hyperlipidemia, hypertension and cigarette smoking. Qf the 69 subjects studied, 41 had no symptoms or sign of cardiovascular disease, 28 had one or more cardiac symptoms (NYHA stage 2-4). 25 had electrocardiographic evidence of left ventricular hypertrophy and there were no differences between the asymptomatic and symptomatic groups. Echocardiographically, the left ventricular mass index ranged between 103 to 247 g/m2 in men and 170 to 251 g/m* in women. In 36 subjects with high left ventricular mass index, the ventricular septal thicknesses ranged from 12 mm to 15 mm in 19 subjects, and posterior wail thicknesses ranged from 12 mm to 16 mm in 17 subjects. Qf the 58 patients with an adequate echocardiogram, 47 had clinically diagnosed hypertension (81%). In our study population, a prevalence of left ventricular hypertrophy (62%), isolated systolic hypertension (26%), definite hypertension (33.3%), high LDLcholesterol (63%), low HDL-cholesterol (26%), abnormal Q wave (16%), cigarette smoking (47.8%) and diabetes mellitus (1.4%) were found. Key words:

Elderly

patients;

Left ventricular

mass index;

Introduction There is now increasing interest in the use of simple multiple noninvasive techniques to evaluate symptomatic and asymptomatic patients with heart disease. Recognition of left ventricular hypertrophy is essential in the assessment of cardiac patients [l-3]. Several investigators have recently reviewed the cardiovascular findings associated

Correspondence to: Prof. Dr. B. Komsuo& Cardiology Dept., KTU Medical School (TIP Fakiiltesi), Trabzon, Turkey.

0167-5273/90/$03.50

0 1990 Elsevier Science Publishers

Hyperlipidemia;

Hypertension

with aging [4,5]. Also in a number of studies, electrocardiographic left ventricular hypertrophy has been found to be associated with an increased risk of coronary artery disease and death [6,7]. Recently, the advent of echocardiography has permitted noninvasive visualization of cardiac structure and allowed in vivo estimation of left ventricular mass. The purpose of this study was to investigate the prevalence of increased left ventricular mass and heart disease in the population aged 80 years and over in the Tonya district of Trabzon Province (Turkey).

B.V. (Biomedical

Division)

328

Materials and Methods

P value of < 0.05 was considered significant. Mitral annular calcium and valvular aortic stenosis were diagnosed by M-mode and two-dimensional echocardiography as previously described [ 181.

Results Of the 69 subjects in the population aged 80 years and over 41 (59.4%) had no symptoms or sign of cardiac disease, 28 (40.6%) had one or more cardiac symptoms (NYHA stage 2-4). Clinical parameters are shown in Table 1. The mean systolic and diastolic blood pressure and time prevalence rates of blood pressure are presented in Tables 1 and 2. The results of the serum lipid concentration are shown in Table 3. The electrocardiographic findings of our subjects are summarized in Table 4.

329 TABLE

1

Clinical

parameters. Asymptomatic

Characteristics

88.6 + 7.5 15 13

Mean age (years) No. of males No. of females No. with stroke No. with diabetes mellitus Systolic blood pressure (mm Hg) Diastolic blood pressure (mm Hg) Heart rate (beats/mm) No. of cigarette smoking subjects (20 or more cigarettes per day)

TABLE

Symptomatic

1 176 86 72

91.4 f 25 16 3 _

k12 + 7 f 5

187 83 67

19

of subjects’

blood pressure

Male

Total Female

(::.5)

(2;.6)

$5,

Borderline (:.5)

(i.9)

(G.3)

$0) 12 (30.0)

$9) 6 (20.7)

c::.s

$0)

(i.9)

(5.8) 69 (100.0)

Definite Isolated

(Z.1) 4

Treated Total (1Z.O) Figures

in parentheses

TABLE

3

(GO)

show percent

89 40 29 3 1 179 84.7 68.4

+lO & 6 + 6

+ 8.7

*11 + 7 +_ 6

33

Of the 69 subjects, 25 had electrocardiographic left ventricular hypertrophy and there were no differences between the asymptomatic and symptomatic groups. The presence of electrocardiographic left ventricular hypertrophy did not correlate with the degree of the echocardiographic left ventricular hypertrophy. Ten subjects had a low voltage on their electrocardiograms (QRS depletions in all extremity leads were < 5 mm). The left ventricular mass index of these 10 subjects ranged between 121 and 231 g/m2, 2 of whom had a high left ventricular mass index. There was no correlation between low voltage and severity of echocardiographic left ventricular hypertrophy. Chronic atrial fibrillation was associated with stroke in three symptomatic subjects. The echocardiographic findings are listed in Table 5. The left ventricular septum and posterior wall thicknesses ranged from 8 to 18 mm and 7 to

levels.

No. of patients

Blood pressure levels

9.6

14

2

Distribution

Total

distribution.

Profile of serum lipids in 69 subjects. Asymptomatic (mean f SD)

Symptomatic (mean f SD)

P value

Total (mean f SD)

Cholesterol (mg/dl) Triglycerides (mg/dl)

283 134

288 137

NS NS

284 136

HDL-C (mg/dl) LDL-C (mg/dl) HDL-C/LDL-C

54 113 167 *67 0.323 f 0.20

< 0.05 < 0.05 i 0.05

46 * 12 169 +51 0.272 f 0.23

(Ratio)

HDL-C = high density standard deviation.

lipoprotein

f37 +42

cholesterol;

LDL-C

*31 *I8

38 ill 177 *53 0.215 f 0.21 = low-density

lipoprotein

cholesterol;

NS = difference

f36 +_43

not significant;

SD =

330 TABLE

4

Electrocardiographic

data.

Finding

Asymptomatic

Symptomatic

Total

Normal Sinus nodal function normal sinus rhythm sinus bradycardia chronic atriaf fibrillation Premature atria1 beats Premature ventricular beats Left ventricular hypertrophy Abnormal Q wave Inferior Anterior Left hemiblocks Left bundle-branch block Bight bundle-branch block 1 o AV block T wave inversion (without Q wave) Inferior Anterior Left atriai enlargement Low voltage

16

10

26

33 2 _

26 4 4 4 3 13 5 2 3 1 2 2

59 6 4 7 4 25 11 6 5 4 1 3 4

14 6 8 11 4

30 16 14 19 10

3 1 12 6 4 2 3 1 1 2 16 10 6 8 6

Discussion

14 mm, respectively. The ventricular septum-posterior wall ratio was > 3 : 1 in 3 patients. These 3 patients were all men. Two patients had hypertension, one had coronary artery disease. The left ventricular mass index ranged between 103 to 247

TABLE

5

M-mode

echocardiographic

LV end-diastolic dimension LV posterior wall (mm)

findings

(n = 58 subjects

(mm)

Ventricular septum (mm) Left ventricular mass index (g/m2) Left atria1 dimension (cm) Aortic root calcification (n) Aortic dimension (mm) Aortic valve calcification (n) Mitral annulus calcification (n) Asymmetric septal hypertrophy Ejection fraction (W) LV = left ventricle;

(n)

n = no. of subjects.

g/m2 in men and 170 to 251 g/m2 in women. The range of the left ventricular mass index was greater in women than in men. In 36 subjects with high left ventricular mass index, the ventricular septal thicknesses ranged from 12 to 15 mm in 19 subjects, and the posterior wall thicknesses ranged from 12 mm to 16 in 17 subjects. The mean resting left ventricular ejection fraction was 59% (range 52-78s) in asymptomatic, and 56% (range 50-74s) in symptomatic subjects. No significant difference in mean dimensions, septal and posterior wall thicknesses, left ventricular mass index, left atria1 dimensions and ejection fraction was found between the two groups.

with adequate

The population of this study represents an unselected group of subjects aged 80 or over. To the best of our knowledge, this is the first report that analyzes the echocardiographic and electrocardiographic findings of left ventricular hypertrophy in people aged 80 or over as an epidemiologic study in Turkey. Experimental and clinical studies have established echocardiography as an accurate method for detecting left ventricular hypertrophy. Recently, Casale et al. reported the predictive role of echocardiographic assessment of left ventricular mass in determining the risk of cardiovascular

echocardiogram

for measurements).

Asymptomatic (n = 31)

Symptomatic (n=27)

Total (n = 58)

49.3 + 4 12.6 f 3 13.2 + 3 177.5 * 41 3.9 f 0.18 31 41 f 6 20 31

53.6 + 11.2+ 12.6 + 165.7 f 4.5 f 27 49 f 17

51.7 11.8 12.9 171.4 4.3 58 44.7 37 57 3 58.4

3 59

*

7

26 _ 56

5 2 3 44 0.9 7

rt 5

+ + f f +

4.1 3.2 3.3 42.7 0.8

f

6.9

+ 6.4

331

events 1191. Levy et al. [20], showed a dramatic increase in the prevalence of left ventricular hypertrophy with age in the general population. In our study, of the 58 patients, 36 had echocardiographically diagnosed marked left ventricular hypertrophy (62%). In the 36 patients the left ventricular septum and posterior wall thicknesses ranged from 12 to 17 mm. In the 22 subjects without left ventricular hypertrophy the ventricular septum and posterior wall thicknesses ranged from 7 to 12 mm. Eleven of the 36 patients were in the asymptomatic group. In the Framingham studies where a free-living population was examined, the prevalence of echocardiographic left ventricular hypertrophy in patients aged 80 years or over ranged from 33% (men) to 50% (women). In the present study, left ventricular hypertrophy in patients 80 years or older ranged from 26% (men) to 36% (women). Savage et al. reported that in normotensive and hypertensive subjects on average, the electrocardiogram detected about 60% of subjects with the most severely hypertrophied hearts [21]. Devereux et al. reported the correlation of severity of echocardiographic left ventricular hypertrophy with prevalence of electrocardiographic left ventricular hypertrophy [22]. This correlation does not exist in our study population. Twenty-one of the 36 patients in this study with left ventricular hypertrophy showed evidence of coronary artery disease (58%). Coronary heart disease events were assessed by medical history, physical examination and 12-lead electrocardiogram. Seven of the patients had pathologic Q waves on the electrocardiogram. The mechanisms by which left ventricular mass is associated with evidence of coronary artery disease are speculative. Age-associated changes in the size, stiffness and arterial tone, of the peripheral vascular bed may result in increased peripheral vascular resistance and lead to left ventricular hypertrophy [23]. Left ventricular hypertrophy and coronary heart disease appear to share common risk factors. The strong relationship between left ventricular hypertrophy and coronary heart disease may be attributable to increases in left ventricular mass which clearly reflect the long-term influences of hypertension [20]. Recent reports from the Framingham

study indicate that left ventricular hypertrophy is highly correlated with increased systolic blood pressure. Left ventricular hypertrophy results in increased myocardial oxygen demand which may precipitate the development of coronary ischemia or infarction [6,20]. Although amyloidosis at this age could not be ruled out solely by negative clinical findings, there were no clinical or echocardiographic findings suggestive of amyloidosis in any of our patients. Previous echocardiographic studies have shown that left ventricular wall thickness increases with age in normal as well as in hypertensive subjects (241. In our study, of the 58 of the patients with adequate echocardiograms, 47 had clinically diagnosed hypertension (81%). Sixteen of these patients had isolated systolic hypertension (37.5%) and 6 of this group had left ventricular hypertrophy, 21 patients of 47, had definite hypertension (61%) and 15 of this group had left ventricular hypertrophy. The prevalence of both isolated systolic (systolic blood pressure > 160 mm Hg, and diastolic blood pressure, > 90 mm Hg) and diastolic hypertension (diastolic pressure, > 90 to 95 mm Hg) in the elderly has been overestimated in most epidemiologic studies [25]. In our study, mean systolic blood pressure was 169 mm Hg and mean diastolic pressure was 84.7 mm Hg. Isolated systolic hypertension was found only in 18 patients (26%). Recent data on screening blood pressure obtained in the Multiple Risk Factor Intervention trial [26] indicate that the presence of isolated systolic hypertension in middle-aged men carried a higher risk of future coronary heart disease than does the presence of diastolic hypertension. In this study 6 of the 18 patients with isolated systolic hypertension had coronary heart disease. In screening for systolic hypertension in the elderly program the prevalence of isolated systolic hypertension was about 10% in persons more than 70 years of age and 20% in persons more than 80 years of age [27]. Atria1 fibrillation, not associated with valvular disease, is the most common cardiac condition associated with an embolic stroke [28]. Chronic atria1 fibrillation was associated with stroke in the present study. Three of the 4 symptomatic pa-

332

tients with chronic atrial fibrillation had had a stroke. Echocardiographically, the mean left ventricular ejection fraction was 59% in the asymptomatic group and a mean of 56% in the symptomatic groups. There was no significant difference between the groups. Other investigators found no age-related reduction of resting left ventricle ejection fraction [29]. However, an age-related diminution in left ventricle ejection fraction has been shown during exercise. The harmful effects of cigarette smoking on health are firmly estabished. In many reports, however, epidemiologic data suggest that coronary disease risk associated with cigarette smoking tends to decrease in older patients [30-331. A recent study by Jajich et al. [34] on the 65- to 74-year-old group showed the coronary artery disease rate to be 52% higher in smokers than in nonsmokers, with the excess risk declining l-5 years after stopping. In our study 33 of 69 patients (all men) still are cigarette smokers (20 cigarettes or more per day). Heart attack was described in 5 of the 19 patients in the symptomatic group and 4 of the 14 of the asymptomatic group. There was no statistically significant difference between the groups. Acknowledgements We are grateful to Prof. M. Rahmi Dirican for his encouragement and advice for this project and thank Orhan Top&al for secretarial assistance. References 1 Kannel WB, Gordon T, Castelli WP, Morgolis JR. EKG-left ventricular hypertrophy and risk of CAD. The Framingham Study. Ann Intern Med 1970;72:813-817. 2 Kannel WB, Sorlie P. Left ventricular hypertrophy in hypertension: prognostic and pathogenetic implication. The Framingham Study. In: Strauer BE, ed. The heart in hypertension. Berlin: Springer-Verlag, 1981;223-242. 3 Komsuoglu B, Gammage DM, Littler WA. Correlation of echocardiographic left ventricular mass index with electrocardiographic left ventricular hypertrophy by voltage criteria. J Cardiovasc Utrason 1987;6:137-140. 4 Wei JY, Gersh BJ. Heart disease in the elderly. Curr Probl Cardiol 1987;12:7-65.

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