- Email: [email protected]
Study of cardiac structure and function assessed by echocardiography in patients older than 100 years
European Geriatric Medicine 7 (2016) 86–89
Available online at
ScienceDirect www.sciencedirect.com
Organ specialists coping with geriatric patients
Study of cardiac structure and function assessed by echocardiography in patients older than 100 years ˜ al-Rey a, J.C. Pin ˜ eiro-Ferna´ndez a,*, R. Monte-Secades a, A. Testa-Ferna´ndez b, R. Rabun a P. Ventura-Valca´rcel a b
Department of internal medicine, Lucus Augusti university hospital, SERGAS, Dr. Ulises Romero, 1, 27003 Lugo, Spain Department of cardiology, Lucus Augusti university hospital, SERGAS, Dr. Ulises Romero, 1, 27003 Lugo, Spain
A R T I C L E I N F O
A B S T R A C T
Article history: Received 2 September 2015 Accepted 30 October 2015 Available online 18 November 2015
Objective: To describe the echocardiographic characteristics of nonhospitalized centenarians in the area of Lugo (Spain). Method: Within a prospective follow-up observational study of 99-year-old and older patients in the area of Lugo (Spain), an echocardiogram was offered to all patients able to move to the clinic. Complete bidimensional and Doppler transthoracic echocardiography were recorded with standard views and procedures. Results: Sixteen patients aged 101 1.3 agreed to perform an echocardiogram. Hypertension was registered in 50% of those subjects and 93% had at least one cardiovascular risk factor, without differences by gender except for smoking (71, 4% male vs. 0% female, P = 0.005). Polypharmacy was common (3.5 1.7 drugs). Charlson index was above 2 points in 37, 5% and mean Barthel index was 59.4 36.1. At the time of the home visit 3 patients had atrial fibrillation. None of the patients included in the study had a normal echocardiogram. Left ventricular hypertrophy was recorded in 43%, systolic dysfunction (left ventricular ejection fraction < 55%) in 31% (no case of severe degree) and left ventricular diastolic dysfunction in 56, 3%. The left atrium diameter was > 40 mm in 8 patients (50%). Mild or moderate valvular lesions were common (93%), mainly mitral or aortic regurgitation. There were no differences by gender. Conclusion: Our centenarians had an abnormal echocardiogram, possibly in relation to physiological changes associated with age and the presence of chronic cardiovascular disease. However, they showed no major structural alterations. ß 2015 Elsevier Masson SAS and European Union Geriatric Medicine Society. All rights reserved.
Keywords: Echocardiography Aged 80 and over Geriatric assessment Cardiovascular disease
Advances in living standards and public health systems have achieved greatly extended life expectancy in recent decades; thus, older population has increased exponentially, leading to a progressive increase in the number of centenarians [1]. In spite of the fact that data on this population are still limited, most of studies are focused on the assessment of their functional and cognitive status. A number of changes have been described in the heart of the elderly, such as the loss of myocytes with subsequent hypertrophy of the remaining cells, calcification involving the conduction and valvular apparatus, and the loss of the arterial compliance. This contributes to systolic hypertension and left ventricular hypertrophy, although it has been recognized that a sedentary lifestyle can be responsible for a large fraction of this so-called ‘age-related’ changes [2].
Clinical studies on centenarians are scarce and usually evaluate basic aspects of health [3,4]. Regarding cardiovascular system there are some data on their cardiovascular risk profile [5] and on the electrocardiographic abnormalities [6]. The presence of structural heart disease in centenarians has been seldom studied. Cardiac anatomy of centenarians has been described in short necropsy series [7–9] and echocardiogram findings have been reported in retrospective inpatient case series [10], nursing home residents [11] and patients limited to ventricular function in the ambulatory setting [12]. The aim of this study is to describe the structural and functional echocardiographic features of a cohort of centenarians in our health setting [13]. 1. Method
* Corresponding author. ˜ al-Rey), E-mail addresses: [email protected] (R. Rabun ˜ eiro-Ferna´ndez), [email protected] (J.C. Pin [email protected] (R. Monte-Secades), [email protected] (A. Testa-Ferna´ndez), [email protected] (P. Ventura-Valca´rcel).
Within a prospective follow-up observational study in the area of Lugo (Galicia, northwest of Spain), the information of all 99year-old and older patients of this area was obtained from the
http://dx.doi.org/10.1016/j.eurger.2015.10.012 1878-7649/ß 2015 Elsevier Masson SAS and European Union Geriatric Medicine Society. All rights reserved.
R. Rabun˜al-Rey et al. / European Geriatric Medicine 7 (2016) 86–89
87
Table 1 Clinical characteristics of the 16 centenarians studied. Male n = 7 (43.8%)
Female n = 9 (56.3%)
Total n = 16
P
Age (years)a Past medical history Smoking Hypertension Diabetes Dyslipidemia Heart disease Stroke At least one of the above
101 1.3
101 1.4
101 1.3
ns
5 2 1 1 2 1 7
0 6 3 1 3 0 8
(88.9%)
5 (31.3%) 8 (50%) 4 (25%) 2 (12.5%) 5 (31.3%) 1 (6.3%) 15 (93.8%)
0.005 ns ns ns ns ns ns
Body mass index (kg/m2) Systolic blood pressure (mmHg) Diastolic blood pressure (mmHg) Heart rate
25.2 3.1 158.2 33 83.5 8.3 81 13
24.3 3.5 128.9 20.3 63.9 14.5 76 12.1
24.6 3.1 140 29 71 15 78 12
ns ns 0.006 ns
Glomerular filtration rate < 60 (mL/min/1.73 m2) Charlson index > 2 Barthel indexa
3 (42.9%) 2 (28.6%) 66.4 27
8 (88.9%) 4 (44.4%) 53.9 42.6
11 (68%) 6 (37.5%) 59.4 36.1
0.04 ns ns
a
(71.4%) (28.6%) (14.3%) (14.3%) (28.6%) (14.3%) (100%)
(66.7%) (33.3%) (11.1%) (33.3%)
Mean (DS).
National Health System register. After contacting the patients and/ or their main caregiver, they were informed about the aims of the study and their consent to participate was requested. We conducted a domiciliary visit by a doctor and a nurse, who completed the study protocol, which included a sampling blood, demographic data, medical history and physical examination [13]. Age, gender, smoking record, drug use, Barthel and Charlson comorbidity index were all registered. The following definitions were established: hypertension (systolic blood pressure > 140 mmHg or diastolic > 90 mmHg), hyperglycemia (fasting glucose > 126 mg/dL), dyslipidemia (total cholesterol > 220 mg/d), renal failure (estimated glomerular filtration rate (MDDR-4) < 60 mL/min/1.73 m2), heart disease (clearly documented history of ischemic heart disease, valvular disease or heart failure), cardiovascular disease (high blood pressure, heart disease, stroke or peripheral arterial disease), comorbidity (Charlson index > 2) and polypharmacy (chronic use of 4 or more drugs). Subsequently, the possibility of performing an echocardiogram was offered to all the patients able to move to the hospital. Complete bidimensional and Doppler transthoracic echocardiography were recorded with standard views and procedures, using various models of Philips echocardiographic equipment. Left ventricular systolic function was assessed by Teichholz method and Simpsons’ biplane method of discs with manual planimetry of the endocardial border in end-diastolic and end-systolic frames. Diastolic function was estimated by combining mitral valve blood flow Doppler with lateral mitral annulus tissue Doppler. Doppler derived right ventricular systolic pressure was calculated from the peak tricuspid regurgitant jet velocity using the modified Bernoulli equation and an estimation of the right atrial pressure depending on the degree of vascular filling and respiratory motion of the inferior vena cava. Considering that no patients had right ventricular outflow tract obstruction, pulmonary artery systolic pressure was considered equivalent to right ventricular systolic pressure [14]. Statistical analysis: a descriptive study of the variables included in the study was performed. Quantitative variables were expressed as mean and standard deviation (SD). Qualitative variables were expressed as absolute value and percentage. In the univariate analysis, we performed the comparison of numerical parameters between test groups using the Student-t test or Mann-Whitney test, as appropriate, after verification of normality using the Kolmogorov-Smirnov test. For the comparison of qualitative
variables, the Chi2 test was performed, Fisher’s exact test was used when the cells contained expected values less than five. Statistical significance was set at P < .05. Statistical analysis was performed using SPSS 17.0 for Windows. The study was approved by the Galician clinical research Ethics Committee. 2. Results Of the 80 interviewed 16 (66, 2% female) were functionally independent, which allowed the transfer to the hospital, and they agreed to perform an echocardiogram. Table 1 shows their main clinical features. Only one patient did not have a prior diagnosis of cardiovascular disease. Polypharmacy was common (3.5 1.7 drugs per patient). Most of the drugs recorded were usually used in the treatment and prevention of cardiovascular diseases. At the time of registration, 50% of patients had hypertension and 3 (18.8%) atrial fibrillation, only one of them with tachycardia (heart rate 104). Left ventricular echocardiographic characteristics are shown in Table 2. None of the patients included in the study had a normal echocardiogram. Forty-three percent (3 males and 4 females) presented left ventricular hypertrophy. Systolic dysfunction (ejection fraction < 55%) was present in 31.3% of subjects (3 mild, 2 moderate, none severe), and diastolic dysfunction in 56.3% (5 men and 3 women). The left atrium was dilated (diameter > 40 mm) in 8 patients (50%). Dilatation of the right atrium and right ventricle was registered in 25% and 18.8%, respectively. The prevalence of valvular heart disease was 93%. The most common lesions were mild or moderate mitral or aortic regurgitation, related to degenerative changes. 3. Discussion This study is one of the largest reports assessing the cardiac structural and functional features of centenarians. Within a prospective study in outpatient centenarians, the echocardiogram showed mild or moderate structural changes of clinical interest, despite a high prevalence of vascular risk factors. Age linearity increases left ventricular mass and wall thickness, leading to a decline of end-systolic stress and a decrease of ventricular afterload (Laplace law) [15]. This could account for the values of ejection fraction above the normality range (ejection
88
R. Rabun˜al-Rey et al. / European Geriatric Medicine 7 (2016) 86–89
Table 2 Left ventricular, valvular and pulmonary artery echocardiographic characteristics of the 16 centenarians.
Left ventricular ejection fraction (Teichholz method) Left ventricular mass index (g/m2) Left ventricular septal wall thickness (mm) Left ventricular posterior wall thickness (mm) Left ventricular fractional shortening (%) Left ventricular telesystolic diameter (mm) Left ventricular telediastolic diameter (mm) Left atrial diameter Valvular lesions Aortic Aortic regurgitation, mild Aortic regurgitation, moderate Mitral Mitral regurgitation, mild Mitral regurgitation, moderate Tricuspid Tricuspid regurgitation, mild Tricuspid regurgitation, moderate Pulmonary hypertension Pulmonary hypertension, mild Pulmonary hypertension, moderate
Male
Female
Total
P
54.7 10.3 190.7 27.4 17.2 11.9 10.7 0.9 32.8 2.9 31.5 2.7 46.8 2.5 38.7 8.6
57.2 10.3 200.2 78.9 11.4 1.8 10.6 1.3 34.8 10 31.4 10.1 47.2 7.8 43.4 4.4
56 10 196 58.5 14 8 10.7 1.1 33.7 6.7 31.5 6.7 47 5.3 41.5 6.6
ns ns ns ns ns ns ns ns
6 5 1 4 4 0 4 3 1 2 1 1
4 4 0 7 4 3 5 4 1 2 0 2
10 (62.6%) 9 (56.3%) 1 (6.3%) 11 (68.8%) 8 (50%) 3 (18.8%) 9 (56.3%) 7 (43.8%) 2 (12.5%) 4 (25%) 1 (6.3%) 3 (18.8%)
ns
(37.6%) (31.3%) (6.3%) (25%) (25%) (25%) (18.8%) (6.3%) (12.5%) (6.3%) (6.3%)
fraction > 75%) reported in up to 86% of centenarians without disorders of contractility, though this condition decreased to 20% in other study [12]. We did not find values above normal in the series and the ventricular ejection fraction was close to lower normality range values in 68,8% of centenarians. All patients showed normal left ventricular diameters, there were a mild increase of ventricular wall thickness in women and interventricular septal thickness in men. Left ventricular hypertrophy was present in 43% overall. Diastolic dysfunction is frequent in hypertensive women who have other cardiovascular risk factors, and may lead to heart failure with preserved ejection fraction [16]. This fact has been reported in 42% of old-aged women [17] and in 80% of centenarians [12]. In our series, left ventricular diastolic dysfunction was present in 56% of individuals, of whom 94% had at least one cardiovascular factor and one third had hypertension. The prevalence of valvular heart disease increases with age. Framingham study showed a higher incidence of valvular disease in the elderly (aged 70–83), with a predominance of mild valvular insufficiency [18]. Nevertheless, in Sadiq study on centenarians, moderate or severe valvular lesions were more frequent [10]. Our data revealed showed a high prevalence of valvular disease (93%), ranging from mild to moderate, with no cases of severe dysfunction. Since Framingham study and ours have been performed in an outpatient setting, the reason for these differences probably lies in the different backgrounds of the studies. The frequency of pulmonary hypertension in our study (25%) was lower than the previously reported (50%) [10]. The values of the pulmonary artery systolic pressure assessed by echocardiography may be overestimated because of advanced age, the degree of tricuspid regurgitation or diastolic dysfunction, and the difficulty in obtaining an accurate reading by the Doppler method [19]. These circumstances, along with the distinctive environments of the reports already commented, could account for the differences observed. Our study has several limitations. Its small sample size restricts the interpretation of results and prevents comparisons by clinically significant factors. On the other hand, most of the patients had previous diagnosis of vascular disease and were receiving drugs that could have affected some of the data. In addition, it should be noted that the present study was carried out in an outpatient setting. Patients who agreed to perform an echocardiogram were centenarians whose clinical condition was good enough to allow them to move to a clinic. So
(25%) (25%) (43.8%) (25%) (18.8%) (31.3%) (25%) (6.3%) (12.5%) (12.5%)
ns
ns
ns
our results are representative of a population of functionally independent centenarians. This might have introduced a sample selection bias in the study, taking into account that echocardiographic abnormalities were of little clinical entity (no severe LV dysfunction or severe valvular lesions), although being prevalent. Therefore, it seems that echocardiography should be supported by other tests to assess the cardiovascular status of this population. In conclusion, our centenarians, while they have an increased cardiovascular risk, show preserved systolic function, left ventricular diastolic dysfunction and mild-moderate valvular lesions. All patients had an abnormal echocardiogram, possibly in relation to physiological changes associated with age and the presence of chronic cardiovascular disease.
Disclosure of interest The authors declare that they have no competing interest.
References [1] Kinsella KG. Future longevity-demographic concerns and consequences. J Am Geriatr Soc 2005;53(Suppl 9):S299–303. [2] Pugh KG, Wei JY. Clinical implications of physiological changes in the aging heart. Drugs Aging 2001;18:263–76. [3] Andersen-Ranberg K, Schroll M, Jeune B. Healthy centenarians do not exist, but autonomous centenarians do: a population-based study of morbidity among Danish centenarians. J Am Geriatr Soc 2001;49(7):900–8. [4] Richmond RL, Law J, KayLambkin F. Morbidity profiles and lifetime health of Australian centenarians. Australas J Ageing 2012;31(4):227–32. [5] Bennati E, Murphy A, Cambien F, et al. BELFAST centenarians: a case of optimised cardiovascular risk? Curr Pharm Des 2010;16(7):789–95. ˜ al-Rey R, Monte-Secades R, Gomez-Gigirey A, et al. Electrocardiographic [6] Rabun abnormalities in centenarians: impact on survival. BMC Geriatr 2012;12:15. [7] Berzlanovich AM, Keil W, Waldhoer T, Sim E, Fasching P, Fazeny-Do¨rner B. Do centenarians die healthy? An autopsy study. J Gerontol A Biol Sci Med Sci 2005;60(7):862–5. [8] Roberts WC. The heart at necropsy in centenarians. Am J Cardiol 1998;81(10):1224–5. [9] Franke H. [Cardiovascular findings in patients over 100]. Z Kardiol 1985;74(Suppl 7):55–63. [10] Sadiq A, Choudhury M, Ali K, et al. Echocardiographic characteristics in patients 100 years of age. Am J Cardiol 2007;100(12):1792–4. [11] Carugo S, Solari D, Esposito A, et al. Clinic blood pressure, ambulatory blood pressure and cardiac structural alterations in nonagenarians and in centenarians. Blood Press 2012;21(2):97–103. ˜ a-Bofill V, Arjona Rodrı´guez IA, Espronceda Sa´nchez K, Cabrera Rojo I, [12] Pen Massip Nicot J. Evaluacio´n ecocardiogra´fica de la funcio´n ventricular izquierda en centenarios. CorSalud 2013;5(4):325–33.
R. Rabun˜al-Rey et al. / European Geriatric Medicine 7 (2016) 86–89 [13] Rabunal Rey R, Monte-Secades R, Veiga Cando MD, et al. [Health status of the oldest old: functional and medical situation in centenarians]. An Med Interna 2004;21(11):543–7. [14] Lang RM, Bierig M, Devereux RB, et al. Recommendations for chamber quantification: a report from the American Society of Echocardiography’s Guidelines and Standards Committee and the Chamber Quantification Writing Group, developed in conjunction with the European Association of Echocardiography, a branch of the European Society of Cardiology. J Am Soc Echocardiogr 2005;18(12):1440–63. [15] Kitzman DW, Scholz DG, Hagen PT, Ilstrup DM, Edwards WD. Age-related changes in normal human hearts during the first 10 decades of life. Part II (Maturity): a quantitative anatomic study of 765 specimens from subjects 20 to 99 years old. Mayo Clin Proc 1988;63(2):137–46.
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[16] McMurray JJ, Carson PE, Komajda M, et al. Heart failure with preserved ejection fraction: clinical characteristics of 4133 patients enrolled in the IPRESERVE trial. Eur J Heart Fail 2008;10(2):149–56. [17] Germing A, Gotzmann M, Schikowski T, et al. High frequency of diastolic dysfunction in a population-based cohort of elderly women – but poor association with the symptom dyspnea. BMC Geriatr 2011;11:71. [18] Singh JP, Evans JC, Levy D, et al. Prevalence and clinical determinants of mitral, tricuspid, and aortic regurgitation (the Framingham Heart Study). Am J Cardiol 1999;83(6):897–902. [19] Escribano Subias P, Barbera Mir JA, Suberviola V. Current diagnostic and prognostic assessment of pulmonary hypertension. Rev Esp Cardiol 2010;63(5):583–96.
Available online at
ScienceDirect www.sciencedirect.com
Organ specialists coping with geriatric patients
Study of cardiac structure and function assessed by echocardiography in patients older than 100 years ˜ al-Rey a, J.C. Pin ˜ eiro-Ferna´ndez a,*, R. Monte-Secades a, A. Testa-Ferna´ndez b, R. Rabun a P. Ventura-Valca´rcel a b
Department of internal medicine, Lucus Augusti university hospital, SERGAS, Dr. Ulises Romero, 1, 27003 Lugo, Spain Department of cardiology, Lucus Augusti university hospital, SERGAS, Dr. Ulises Romero, 1, 27003 Lugo, Spain
A R T I C L E I N F O
A B S T R A C T
Article history: Received 2 September 2015 Accepted 30 October 2015 Available online 18 November 2015
Objective: To describe the echocardiographic characteristics of nonhospitalized centenarians in the area of Lugo (Spain). Method: Within a prospective follow-up observational study of 99-year-old and older patients in the area of Lugo (Spain), an echocardiogram was offered to all patients able to move to the clinic. Complete bidimensional and Doppler transthoracic echocardiography were recorded with standard views and procedures. Results: Sixteen patients aged 101 1.3 agreed to perform an echocardiogram. Hypertension was registered in 50% of those subjects and 93% had at least one cardiovascular risk factor, without differences by gender except for smoking (71, 4% male vs. 0% female, P = 0.005). Polypharmacy was common (3.5 1.7 drugs). Charlson index was above 2 points in 37, 5% and mean Barthel index was 59.4 36.1. At the time of the home visit 3 patients had atrial fibrillation. None of the patients included in the study had a normal echocardiogram. Left ventricular hypertrophy was recorded in 43%, systolic dysfunction (left ventricular ejection fraction < 55%) in 31% (no case of severe degree) and left ventricular diastolic dysfunction in 56, 3%. The left atrium diameter was > 40 mm in 8 patients (50%). Mild or moderate valvular lesions were common (93%), mainly mitral or aortic regurgitation. There were no differences by gender. Conclusion: Our centenarians had an abnormal echocardiogram, possibly in relation to physiological changes associated with age and the presence of chronic cardiovascular disease. However, they showed no major structural alterations. ß 2015 Elsevier Masson SAS and European Union Geriatric Medicine Society. All rights reserved.
Keywords: Echocardiography Aged 80 and over Geriatric assessment Cardiovascular disease
Advances in living standards and public health systems have achieved greatly extended life expectancy in recent decades; thus, older population has increased exponentially, leading to a progressive increase in the number of centenarians [1]. In spite of the fact that data on this population are still limited, most of studies are focused on the assessment of their functional and cognitive status. A number of changes have been described in the heart of the elderly, such as the loss of myocytes with subsequent hypertrophy of the remaining cells, calcification involving the conduction and valvular apparatus, and the loss of the arterial compliance. This contributes to systolic hypertension and left ventricular hypertrophy, although it has been recognized that a sedentary lifestyle can be responsible for a large fraction of this so-called ‘age-related’ changes [2].
Clinical studies on centenarians are scarce and usually evaluate basic aspects of health [3,4]. Regarding cardiovascular system there are some data on their cardiovascular risk profile [5] and on the electrocardiographic abnormalities [6]. The presence of structural heart disease in centenarians has been seldom studied. Cardiac anatomy of centenarians has been described in short necropsy series [7–9] and echocardiogram findings have been reported in retrospective inpatient case series [10], nursing home residents [11] and patients limited to ventricular function in the ambulatory setting [12]. The aim of this study is to describe the structural and functional echocardiographic features of a cohort of centenarians in our health setting [13]. 1. Method
* Corresponding author. ˜ al-Rey), E-mail addresses: [email protected] (R. Rabun ˜ eiro-Ferna´ndez), [email protected] (J.C. Pin [email protected] (R. Monte-Secades), [email protected] (A. Testa-Ferna´ndez), [email protected] (P. Ventura-Valca´rcel).
Within a prospective follow-up observational study in the area of Lugo (Galicia, northwest of Spain), the information of all 99year-old and older patients of this area was obtained from the
http://dx.doi.org/10.1016/j.eurger.2015.10.012 1878-7649/ß 2015 Elsevier Masson SAS and European Union Geriatric Medicine Society. All rights reserved.
R. Rabun˜al-Rey et al. / European Geriatric Medicine 7 (2016) 86–89
87
Table 1 Clinical characteristics of the 16 centenarians studied. Male n = 7 (43.8%)
Female n = 9 (56.3%)
Total n = 16
P
Age (years)a Past medical history Smoking Hypertension Diabetes Dyslipidemia Heart disease Stroke At least one of the above
101 1.3
101 1.4
101 1.3
ns
5 2 1 1 2 1 7
0 6 3 1 3 0 8
(88.9%)
5 (31.3%) 8 (50%) 4 (25%) 2 (12.5%) 5 (31.3%) 1 (6.3%) 15 (93.8%)
0.005 ns ns ns ns ns ns
Body mass index (kg/m2) Systolic blood pressure (mmHg) Diastolic blood pressure (mmHg) Heart rate
25.2 3.1 158.2 33 83.5 8.3 81 13
24.3 3.5 128.9 20.3 63.9 14.5 76 12.1
24.6 3.1 140 29 71 15 78 12
ns ns 0.006 ns
Glomerular filtration rate < 60 (mL/min/1.73 m2) Charlson index > 2 Barthel indexa
3 (42.9%) 2 (28.6%) 66.4 27
8 (88.9%) 4 (44.4%) 53.9 42.6
11 (68%) 6 (37.5%) 59.4 36.1
0.04 ns ns
a
(71.4%) (28.6%) (14.3%) (14.3%) (28.6%) (14.3%) (100%)
(66.7%) (33.3%) (11.1%) (33.3%)
Mean (DS).
National Health System register. After contacting the patients and/ or their main caregiver, they were informed about the aims of the study and their consent to participate was requested. We conducted a domiciliary visit by a doctor and a nurse, who completed the study protocol, which included a sampling blood, demographic data, medical history and physical examination [13]. Age, gender, smoking record, drug use, Barthel and Charlson comorbidity index were all registered. The following definitions were established: hypertension (systolic blood pressure > 140 mmHg or diastolic > 90 mmHg), hyperglycemia (fasting glucose > 126 mg/dL), dyslipidemia (total cholesterol > 220 mg/d), renal failure (estimated glomerular filtration rate (MDDR-4) < 60 mL/min/1.73 m2), heart disease (clearly documented history of ischemic heart disease, valvular disease or heart failure), cardiovascular disease (high blood pressure, heart disease, stroke or peripheral arterial disease), comorbidity (Charlson index > 2) and polypharmacy (chronic use of 4 or more drugs). Subsequently, the possibility of performing an echocardiogram was offered to all the patients able to move to the hospital. Complete bidimensional and Doppler transthoracic echocardiography were recorded with standard views and procedures, using various models of Philips echocardiographic equipment. Left ventricular systolic function was assessed by Teichholz method and Simpsons’ biplane method of discs with manual planimetry of the endocardial border in end-diastolic and end-systolic frames. Diastolic function was estimated by combining mitral valve blood flow Doppler with lateral mitral annulus tissue Doppler. Doppler derived right ventricular systolic pressure was calculated from the peak tricuspid regurgitant jet velocity using the modified Bernoulli equation and an estimation of the right atrial pressure depending on the degree of vascular filling and respiratory motion of the inferior vena cava. Considering that no patients had right ventricular outflow tract obstruction, pulmonary artery systolic pressure was considered equivalent to right ventricular systolic pressure [14]. Statistical analysis: a descriptive study of the variables included in the study was performed. Quantitative variables were expressed as mean and standard deviation (SD). Qualitative variables were expressed as absolute value and percentage. In the univariate analysis, we performed the comparison of numerical parameters between test groups using the Student-t test or Mann-Whitney test, as appropriate, after verification of normality using the Kolmogorov-Smirnov test. For the comparison of qualitative
variables, the Chi2 test was performed, Fisher’s exact test was used when the cells contained expected values less than five. Statistical significance was set at P < .05. Statistical analysis was performed using SPSS 17.0 for Windows. The study was approved by the Galician clinical research Ethics Committee. 2. Results Of the 80 interviewed 16 (66, 2% female) were functionally independent, which allowed the transfer to the hospital, and they agreed to perform an echocardiogram. Table 1 shows their main clinical features. Only one patient did not have a prior diagnosis of cardiovascular disease. Polypharmacy was common (3.5 1.7 drugs per patient). Most of the drugs recorded were usually used in the treatment and prevention of cardiovascular diseases. At the time of registration, 50% of patients had hypertension and 3 (18.8%) atrial fibrillation, only one of them with tachycardia (heart rate 104). Left ventricular echocardiographic characteristics are shown in Table 2. None of the patients included in the study had a normal echocardiogram. Forty-three percent (3 males and 4 females) presented left ventricular hypertrophy. Systolic dysfunction (ejection fraction < 55%) was present in 31.3% of subjects (3 mild, 2 moderate, none severe), and diastolic dysfunction in 56.3% (5 men and 3 women). The left atrium was dilated (diameter > 40 mm) in 8 patients (50%). Dilatation of the right atrium and right ventricle was registered in 25% and 18.8%, respectively. The prevalence of valvular heart disease was 93%. The most common lesions were mild or moderate mitral or aortic regurgitation, related to degenerative changes. 3. Discussion This study is one of the largest reports assessing the cardiac structural and functional features of centenarians. Within a prospective study in outpatient centenarians, the echocardiogram showed mild or moderate structural changes of clinical interest, despite a high prevalence of vascular risk factors. Age linearity increases left ventricular mass and wall thickness, leading to a decline of end-systolic stress and a decrease of ventricular afterload (Laplace law) [15]. This could account for the values of ejection fraction above the normality range (ejection
88
R. Rabun˜al-Rey et al. / European Geriatric Medicine 7 (2016) 86–89
Table 2 Left ventricular, valvular and pulmonary artery echocardiographic characteristics of the 16 centenarians.
Left ventricular ejection fraction (Teichholz method) Left ventricular mass index (g/m2) Left ventricular septal wall thickness (mm) Left ventricular posterior wall thickness (mm) Left ventricular fractional shortening (%) Left ventricular telesystolic diameter (mm) Left ventricular telediastolic diameter (mm) Left atrial diameter Valvular lesions Aortic Aortic regurgitation, mild Aortic regurgitation, moderate Mitral Mitral regurgitation, mild Mitral regurgitation, moderate Tricuspid Tricuspid regurgitation, mild Tricuspid regurgitation, moderate Pulmonary hypertension Pulmonary hypertension, mild Pulmonary hypertension, moderate
Male
Female
Total
P
54.7 10.3 190.7 27.4 17.2 11.9 10.7 0.9 32.8 2.9 31.5 2.7 46.8 2.5 38.7 8.6
57.2 10.3 200.2 78.9 11.4 1.8 10.6 1.3 34.8 10 31.4 10.1 47.2 7.8 43.4 4.4
56 10 196 58.5 14 8 10.7 1.1 33.7 6.7 31.5 6.7 47 5.3 41.5 6.6
ns ns ns ns ns ns ns ns
6 5 1 4 4 0 4 3 1 2 1 1
4 4 0 7 4 3 5 4 1 2 0 2
10 (62.6%) 9 (56.3%) 1 (6.3%) 11 (68.8%) 8 (50%) 3 (18.8%) 9 (56.3%) 7 (43.8%) 2 (12.5%) 4 (25%) 1 (6.3%) 3 (18.8%)
ns
(37.6%) (31.3%) (6.3%) (25%) (25%) (25%) (18.8%) (6.3%) (12.5%) (6.3%) (6.3%)
fraction > 75%) reported in up to 86% of centenarians without disorders of contractility, though this condition decreased to 20% in other study [12]. We did not find values above normal in the series and the ventricular ejection fraction was close to lower normality range values in 68,8% of centenarians. All patients showed normal left ventricular diameters, there were a mild increase of ventricular wall thickness in women and interventricular septal thickness in men. Left ventricular hypertrophy was present in 43% overall. Diastolic dysfunction is frequent in hypertensive women who have other cardiovascular risk factors, and may lead to heart failure with preserved ejection fraction [16]. This fact has been reported in 42% of old-aged women [17] and in 80% of centenarians [12]. In our series, left ventricular diastolic dysfunction was present in 56% of individuals, of whom 94% had at least one cardiovascular factor and one third had hypertension. The prevalence of valvular heart disease increases with age. Framingham study showed a higher incidence of valvular disease in the elderly (aged 70–83), with a predominance of mild valvular insufficiency [18]. Nevertheless, in Sadiq study on centenarians, moderate or severe valvular lesions were more frequent [10]. Our data revealed showed a high prevalence of valvular disease (93%), ranging from mild to moderate, with no cases of severe dysfunction. Since Framingham study and ours have been performed in an outpatient setting, the reason for these differences probably lies in the different backgrounds of the studies. The frequency of pulmonary hypertension in our study (25%) was lower than the previously reported (50%) [10]. The values of the pulmonary artery systolic pressure assessed by echocardiography may be overestimated because of advanced age, the degree of tricuspid regurgitation or diastolic dysfunction, and the difficulty in obtaining an accurate reading by the Doppler method [19]. These circumstances, along with the distinctive environments of the reports already commented, could account for the differences observed. Our study has several limitations. Its small sample size restricts the interpretation of results and prevents comparisons by clinically significant factors. On the other hand, most of the patients had previous diagnosis of vascular disease and were receiving drugs that could have affected some of the data. In addition, it should be noted that the present study was carried out in an outpatient setting. Patients who agreed to perform an echocardiogram were centenarians whose clinical condition was good enough to allow them to move to a clinic. So
(25%) (25%) (43.8%) (25%) (18.8%) (31.3%) (25%) (6.3%) (12.5%) (12.5%)
ns
ns
ns
our results are representative of a population of functionally independent centenarians. This might have introduced a sample selection bias in the study, taking into account that echocardiographic abnormalities were of little clinical entity (no severe LV dysfunction or severe valvular lesions), although being prevalent. Therefore, it seems that echocardiography should be supported by other tests to assess the cardiovascular status of this population. In conclusion, our centenarians, while they have an increased cardiovascular risk, show preserved systolic function, left ventricular diastolic dysfunction and mild-moderate valvular lesions. All patients had an abnormal echocardiogram, possibly in relation to physiological changes associated with age and the presence of chronic cardiovascular disease.
Disclosure of interest The authors declare that they have no competing interest.
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