Echocardiographic findings in the fastest growing segment of our population, the very elderly, are limited in the literature. We performed a retrospective analysis of 431 consecutive nonagenarians who underwent transthoracic echocardiography (2-dimensional, M-mode, pulse and continuous wave Doppler with color flow mapping) at our center. Mean age was 92.4 years, with women being the majority (73% vs 27%). Men were more likely than women to have coronary artery disease (45% vs 36%, p = 0.03), impaired left ventricular (LV) ejection fraction (51% vs 40%, p <0.04), lower mean LV ejection fraction (50% vs 54%, p = 0.01), and regional wall motion abnormalities (31% vs 19%, p = 0.009). Women were much more likely than men to have hypertension (76% vs 52%, p = <0.0001), LV hypertrophy (82% vs 72%, p <0.001), severe left atrial enlargement (31% vs 16%, p = 0.004), moderate to severe mitral annular calcification (22% vs 10, p = 0.006), and tricuspid regurgitation (70% vs 51, p = 0.002). In this, largest to date, study of echocardiographic findings in nonagenarians, abnormal findings were much more common than previously reported. Men were more likely to have coronary artery disease and related findings, whereas women were more likely to have hypertension and related findings.
The very elderly (>85 years of age) constitute a distinct population with a high prevalence of cardiovascular disease. Census statistics demonstrate that the very elderly are the fastest growing segment of the population. The number of very elderly is projected to reach 19 million by 2030, at which time they will constitute 24% of the elderly population and 5% of the entire population. However, our knowledge of the structural and functional cardiac changes in this expanding population remains incomplete. The effects of aging and cardiovascular disease on the heart have been largely examined in autopsy series. A limited number of studies have looked at the effects of cardiovascular disease using standard 2-dimensional echocardiography in the very elderly. Most of these studies have included only a small number of patients >90 years of age. The largest of these studies, the Cardiovascular Health Study, included 838 subjects who were ≥75 years of age. They demonstrated that with increasing age, male gender, presence of coronary artery disease (CAD), and hypertension (HTN), there is an increase in left ventricular (LV) mass, regional wall motion abnormalities, and worsening of LV systolic function. Tunick et al reported echocardiographic findings in 58 nonagenarians and found that 1/2 of them had LV hypertrophy and enlarged left atria. We intend to analyze the gender-specific echocardiographic findings in nonagenarians with known cardiovascular disease.
Methods
We conducted a retrospective review of all consecutive nonagenarians who underwent transthoracic echocardiography from October 2003 to November 2006 at Creighton University (Omaha, Nebraska). All echocardiograms were interpreted by board-certified cardiologists at our institution. Five hundred eighty-eight nonagenarians underwent echocardiography including 2-dimensional, M-mode, pulse and continuous wave Doppler with color flow mapping. In addition, in 400 patients, diastolic function was assessed using Doppler interrogation of mitral inflow and mitral annulus tissue Doppler imaging. Of the 588 nonagenarians, 157 were excluded from the analysis, leaving 431 patients for the final analysis. Of the 157 patients who were excluded, 74 patients had no medical history available, 60 patients underwent an open-heart surgery, and 23 patients had no history of cardiovascular disease. Measurements were made based on the most recent American Society of Echocardiography recommendations. Statistical analyses were performed using chi-square or Fischer’s exact tests (when appropriate) to compare frequencies between men and women and analysis of variance to compare means between the 2 groups using SPSS 17.0 (SPSS, Inc., Chicago, Illinois).
Results
In concordance with previous studies evaluating the very elderly population, women outnumbered men (72% vs 27%). Mean age of the cohort was 92.4 years which was the same for both men and women. HTN was the most common cardiovascular disease, occurring in 70% of nonagenarians. CAD was present in 37%, atrial fibrillation in 36%, pacemaker/implantable cardioverter-defibrillator implantation in 17%, hyperlipidemia in 16%, and diabetes in 13% of nonagenarians ( Table 1 ). Women were much more likely than men to be hypertensive (76% vs 52%, p <0.0001). Men were more likely to have CAD compared to women (45% vs 34%, p = 0.03). There was no difference in the prevalence of other co-morbidities, including heart failure, atrial fibrillation, diabetes mellitus, hyperlipidemia, peripheral vascular disease, stroke, and chronic kidney disease between men and women. Heart failure was present in 59% of nonagenarians, among whom 45% had normal LV systolic function and the remaining 55% had systolic impairment.
| Men | Women | Total | p Value | |
|---|---|---|---|---|
| (n = 118) | (n = 313) | (n = 431) | ||
| Age (years) | 92.3 | 92.4 | 92.4 | 0.70 |
| Hypertension | 61 (52%) | 239 (76%) | 300 (70%) | <0.0001 |
| Congestive heart failure | 74 (63%) | 180 (58%) | 254 (59%) | 0.38 |
| Coronary artery disease | 53 (45%) | 105 (36%) | 158 (37%) | 0.03 |
| Atrial fibrillation | 41 (35%) | 114 (37%) | 155 (36%) | 0.82 |
| Hyperlipidemia | 15 (13%) | 54 (17%) | 69 (16%) | 0.30 |
| Diabetes mellitus | 17 (14%) | 39 (13%) | 56 (13%) | 0.63 |
| Stroke | 16 (14%) | 41 (13%) | 57 (13%) | 0.88 |
| Peripheral vascular disease | 13 (11%) | 22 (7%) | 35 (8%) | 0.23 |
| Medications | ||||
| β blockers | 55 (47%) | 171 (55%) | 226 (53%) | 0.16 |
| Furosemide | 50 (43%) | 173 (55%) | 223 (52%) | 0.02 |
| Angiotensin converting enzyme inhibitors/angiotensin receptor blockers | 45 (39%) | 161 (52%) | 206 (48%) | 0.02 |
| Aspirin | 61 (52%) | 132 (43%) | 193 (45%) | 0.08 |
| Digoxin | 25 (21) | 80 (26%) | 105 (25%) | 0.38 |
| Calcium channel blockers | 19 (16%) | 80 (26%) | 99 (23%) | 0.04 |
| Nitrates | 28 (24%) | 65 (21%) | 93 (22%) | 0.51 |
| Hydrochlorothiazide | 15 (13%) | 69 (22%) | 84 (20%) | 0.04 |
| Warfarin | 17 (15%) | 53 (17%) | 70 (16%) | 0.66 |
| Statins | 15 (13%) | 44 (14%) | 59 (14%) | 0.88 |
| Clopidogrel | 12 (10%) | 29 (9%) | 41 (9%) | 0.85 |
Medication use at the time of echocardiogram was also available and is presented in Table 1 . Beta blockers and furosemide were the most prescribed cardiovascular medications, used by more than 50% of nonagenarians.
Echocardiographic findings in our population are listed in Table 2 . Most nonagenarians (57%) were found to have normal LV systolic function, defined as an LV ejection fraction ≥55%. Mean LV ejection fraction in women was significantly higher than that in men (54% vs 50%, p = 0.01). Mild, moderate, and severe systolic dysfunctions were present in 17%, 15%, and 10% of nonagenarians, respectively. In addition, 86% of them had a normal LV size as measured by LV end-diastolic diameter. LV hypertrophy was determined by measuring the thickness of the LV septum and posterior wall at end-diastole. Significantly more women had LV hypertrophy compared to men (82% vs 72%, p <0.001). Mean LV septal and posterior wall thicknesses in men were 11.7 and 11.7 mm and those in women were 11.8 and 11.5 mm. Moreover, moderate to severe LV hypertrophy was seen more frequently in women compared to men.
| Men | Women | Total | p Value | |
|---|---|---|---|---|
| (n = 118) | (n = 313) | (n = 431) | ||
| Left ventricular ejection fraction >55% | 58 (49%) | 189 (60%) | 247 (57%) | 0.04 |
| Mild impairment (45–54%) | 22 (19%) | 52 (17%) | 74 (17%) | |
| Moderate impairment (30–44%) | 21 (18%) | 46 (15%) | 67 (16%) | |
| Severe impairment (<30%) | 17 (14%) | 26 (8%) | 43 (10%) | |
| Mean left ventricular ejection fraction (%) | 50 | 54 | 53 | 0.01 |
| Mean left ventricular septal thickness (mm) | 11.7 | 11.8 | 11.8 | 0.83 |
| Mean left ventricular posterior wall thickness (mm) | 11.7 | 11.5 | 11.6 | 0.71 |
| Left ventricular hypertrophy | 85 (72%) | 256 (82%) | 341 (79%) | <0.001 |
| Mild | 59 (50%) | 156 (50%) | 215 (50%) | |
| Moderate | 24 (20%) | 73 (23%) | 97 (23%) | |
| Severe | 2 (2%) | 27 (9%) | 29 (7%) | |
| Left ventricular dilatation | 15 (13%) | 46 (15%) | 61 (14%) | 0.59 |
| Regional wall motion abnormalities | 36 (31%) | 59 (19%) | 95 (22%) | 0.009 |
| Mean left atrial size (mm) | 46.7 | 44.4 | 45.1 | 0.02 |
| Left atrial enlargement | 92 (78%) | 239 (76%) | 331 (77%) | 0.72 |
| Mild | 38 (32%) | 70 (22%) | 108 (25%) | |
| Moderate | 35 (30%) | 71 (23%) | 106 (25%) | |
| Severe | 19 (16%) | 98 (31%) | 117 (27%) | 0.001 |
| Right atrial enlargement | 70 (59%) | 213 (68%) | 283 (66%) | 0.08 |
| Diastolic dysfunction | 70/100 (70%) | 209/269 (78%) | 279/369 (76%) | 0.86 |
| Right ventricular systolic pressure (mm Hg) | 43.9 | 46.2 | 45.7 | 0.26 |
The greater part (78%) of our nonagenarian population had normal segmental wall motion. However, men were significantly more likely to have regional wall motion abnormalities compared to women (31% vs 19%, p = 0.009). Left atrial enlargement was seen in 77% of nonagenarians, almost equally in men and women. Mean left atrial sizes were 47 mm in men and 44 mm in women. However, women were significantly more likely to have severe left atrial enlargement compared to men (31% vs 16%, p = 0.001). Right atrial enlargement was also seen equally in men and women (66%). Diastolic function was assessed and reported in 369 nonagenarians. It could not be accurately determined in patients with atrial fibrillation, paced rhythms, and technically difficult and limited studies. Some degree of diastolic dysfunction was found in 76% of nonagenarians with 3/4 of these being mild (grade I diastolic dysfunction).
Structural valvular abnormalities, including sclerotic, stenotic, and regurgitant lesions, were tabulated and analyzed ( Table 3 ). Degenerative changes of aortic and mitral valves were very common in our patient population. Aortic stenosis was identified in 76% of them, almost equally in men and women (75% vs 77%). Mild, moderate, and severe aortic stenoses were found in 53%, 11%, and 12% of nonagenarians, respectively. Mean aortic valve areas in men and women were 1.93 and 1.80 cm 2 , respectively. Mean and peak aortic valve gradients were 10.8 and 18.9 mm Hg in men and those in women were 9.1 and 15.8 mm Hg. Mitral annular calcification was present in 63% of nonagenarians, with women having a slightly higher prevalence than men (57% vs 65%, p = 0.10). Women were significantly more likely than men to have moderate to severe mitral annular calcification (22% vs 10%, p = 0.006). Mitral stenosis was rare, occurring in <1% of patients.
