Original Research Received: March 17, 2014 Accepted after revision: June 10, 2014 Published online: September 10, 2014

Cardiology 2014;129:111–116 DOI: 10.1159/000365137

Pulmonary Artery Systolic Pressure and Mortality in the Oldest Old David Leibowitz a, c Dan Gilon c Jeremy M. Jacobs a, b Irit Stessman-Lande c Jochanan Stessman a, b   

 

 

 

 

Jerusalem Institute of Aging Research, b Department of Geriatrics and Rehabilitation, and c Heart Institute, Hadassah-Hebrew University Medical Center and Hebrew University Hadassah Medical School, Jerusalem, Israel  

 

Key Words Echocardiography · Aging · Pulmonary artery pressure

Abstract Objectives: The objectives of the study were to assess pulmonary artery systolic pressure, its association with clinical and echocardiographic variables and its impact on 5-year mortality in a community-dwelling population of the oldest old. Methods: Subjects were recruited from the Jerusalem Longitudinal Cohort Study. Echocardiography was performed at home, with standard measurements being taken including tricuspid regurgitation (TR) velocity (n = 300). Survival status at 5-year follow-up was assessed via the centralized population registry. Results: The mean TR gradient in the study population as a whole was 30.5 ± 9.4 mm Hg. A significant relationship was noted between right-ventricular systolic pressure (RVSP) and left-atrial (LA) volume (r = 0.27, p < 0.0001), left-ventricular (LV) mass index (r = 0.26, p < 0.0001) and the ratio E/e (r = 0.19, p < 0.03). At the 5-year follow-up, 71 of the 300 subjects (23.7%) had died. TR gradient was significantly associated with mortality in both the unadjusted (HR 1.036, 95% CI 1.015–1.058; p < 0.007) and adjusted (HR 1.036, 95% CI 1.012–1.061; p < 0.0029) models. Conclusions: We demonstrate that RVSP is elevated and re-

© 2014 S. Karger AG, Basel 0008–6312/14/1292–0111$39.50/0 E-Mail [email protected] www.karger.com/crd

 

lated to LV mass, LA volume and reduced diastolic function in the oldest old. An elevated RVSP is significantly associated with mortality in this population. © 2014 S. Karger AG, Basel

Background

People over the age of 85 years (the ‘oldest old’) are the world’s most rapidly growing age group [1]. Aging appears to be associated with increasing pulmonary artery pressure, although the mechanisms for this remain unclear [2–6]. Previous studies that have examined the changes in pulmonary artery pressure that occur with aging included a broad range of ages with limited data on subjects over the age of 85. In addition, existing studies on the elderly have all been performed in the hospital or clinic setting, possibly contributing to a biased study population as subjects in this age group find it harder to leave their homes [7]. Elevated pulmonary pressure has been associated with increased mortality in younger subjects,

D.L. and D.G. contributed equally to this paper.

David Leibowitz, MD Coronary Care Unit Hadassah-Hebrew University Medical Center, Mount-Scopus Jerusalem 91240 (Israel) E-Mail oleibo @ hadassah.org.il

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a

Table 1. Mean ± SD of echocardiographic measurements

but its impact on mortality in this very elderly population remains unclear [4]. Echocardiography is a validated noninvasive method of assessing right ventricular systolic pressure (RVSP), which, in the absence of pulmonic stenosis or RV outflow tract obstruction, correlates with pulmonary artery systolic pressure [8–10]. The introduction of portable echocardiography machines has made it possible to study patients at home, thereby offering a more representative population of the oldest old. Our study was designed to investigate an age-homogenous, community-dwelling sample of the oldest old. Our subjects, aged 85–86 years, underwent home echocardiography in addition to a comprehensive assessment of their social, functional and medical domains. Our objectives were: (1) to describe the range of RVSP, (2) to assess the association between clinical and echocardiographic variables and RVSP and (3) to examine the impact of RVSP on 5-year mortality in this very elderly population. Methods Participants Subjects were recruited from the Jerusalem Longitudinal Cohort Study, which was initiated in 1990 and has followed an agehomogenous cohort of West Jerusalem residents born between June 1920 and May 1921. The methodology has been described elsewhere in detail [11, 12]. Our study examined data from the third-most recent phase of data collection, which took place in 2005–2006. Subjects were interviewed and examined in their homes on two separate occasions, each session requiring the com-

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Cardiology 2014;129:111–116 DOI: 10.1159/000365137

Survivors (n = 229)

Deceased (n = 71)

p value (survived vs. deceased)

37.8 ± 13.7 68.6 ± 19.2 31.1 ± 14.4 123.4 ± 35.8 55.8 ± 9.9 80 ± 22.4 87.6 ± 26.3 1.11 ± 1.3 7.2 ± 2.1 9.5 ± 3.4 6.1 ± 2 8 ± 2.7 12.9 ± 5.4 30.5 ± 9.4

37.7 ± 13.6 67.4 ± 17.6 29.7 ± 12.6 120.0 ± 31.3 56.8 ± 9.0 78.8 ± 21.7 89.1 ± 25.8 1.07 ± 1.4 7.1 ± 2.1 9.8 ± 3.2 6.1 ± 2.0 8.1 ± 2.5 12.8 ± 5.3 29.5 ± 8.4

45.1 ± 17.4 72.1 ± 23.2 35.2 ± 18.2 134.3 ± 46.1 53.1 ± 10.9 84.3 ± 24.2 81.9 ± 27.5 1.3 ± 0.7 7.2 ± 2.4 8.1 ± 3.8 6.1 ± 2.0 7.7 ± 3.3 13.4 ± 11.9 33.7 ± 11.6

0.004 0.14 0.04 0.025 0.009 0.09 0.07 0.12 0.75 0.004 0.99 0.41 0.45 0.006

pletion of a structured interview that lasted about an hour and a half. Information about the sociodemographic, medical, functional and cultural domains was recorded. The institutional ethics committee of the Hadassah Hebrew University Medical Center approved the study design and written informed consent was obtained from all participants. Study Group Echocardiography was performed in 498 randomly selected subjects of 85 years of age, evenly distributed between new recruits and participants from previous phases. Survival status at 5-year follow-up was assessed via the centralized population registry. Follow-up was available for all study subjects. Cardiovascular Measures Diagnosis of ischemic heart disease (IHD) was based on a history of hospitalization for myocardial infarction or acute coronary syndrome, coronary catheterization with evidence of significant coronary artery disease, myocardial infarction on electrocardiogram, a history typical for angina pectoris on exertion or previous coronary artery bypass grafting surgery. Hypertension was defined as requiring treatment with antihypertensive medications or >140 mm Hg systolic or 90 mm Hg diastolic blood pressure on exam. Hyperlipidemia was defined as being on cholesterol-lowering medications. A diagnosis of diabetes mellitus was based on a composite of hypoglycemic medications, a personal history or a medical-record diagnosis. The presence of congestive heart failure (CHF) and chronic lung disease were based on diagnosis at hospital discharge and according to the examination by a research physician at home. Geriatric Measures Self-rated health was assessed according to the response ‘good’ or ‘poor’ to the question ‘How do you rate your general health?’. A cognitive assessment was performed according to a standardized Mini Mental State Examination, with cognitive impairment being

Leibowitz /Gilon /Jacobs /Stessman-Lande / Stessman  

 

 

 

 

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LA volume index, ml/m2 LV end-diastolic volume index, ml/m2 LV end-systolic volume index, ml/m2 LV mass index, g/m2 LVEF, % Mitral valve E-wave, cm/s Mitral valve A-wave, cm/s E/A ratio Tissue Doppler lateral E-wave, cm/s Tissue Doppler lateral A-wave, cm/s Tissue Doppler septal E-wave, cm/s Tissue Doppler septal A-wave, cm/s E:e’ TR gradient, mm Hg

Total (n = 300)

Table 2. Mean peak RV gradient (mm Hg) by baseline character-

istics Mean ± SD (n)

p value

29.5 ± 8.7 (175) 31.2 ± 9.9 (125) 30.0 ± 10.0 (147) 30.9 ± 8.8 (153) 29.6 ± 8.3 (159) 31.3 ± 10.4 (137) 30.0 ± 9.4 (210) 31.8 ± 9.5 (87) 31.1 ± 9.5 (92) 30.2 ± 9.4 (199) 32.2 ± 9.8 (81) 29.9 ± 9.3 (212) 30.2 ± 9.2 (55) 31.8 ± 10.4 (243) 31.3 ± 10.2 (110) 30.0 ± 9.0 (188) 34.9 ± 10.3 (33) 30.0 ± 9.2 (265) 31.7 ± 10 (214) 27.5 ± 7.2 (84) 30.4 ± 9.7 (90) 30.7 ± 9.3 (198) 30.6 ± 9.1 (53) 30.4 ± 9.5 (238) 31.5 ± 10.5 (51) 30.3 ± 9.2 (247)

0.11

Echocardiography A portable echocardiograph (Vivid I; GE Healthcare, Haifa, Israel) was used to perform standard 2-dimensional and Doppler echocardiography on 498 subjects at home. M-mode measurements were taken of the interventricular septum, posterior wall and left-ventricular (LV) end-systolic and end-diastolic diameters according to the recommendations of the European Association of Echocardiography/the American Society of Echocardiography [15]. Measurements were performed for three consecutive cardiac cycles and then averaged. Their height and weight were recorded and body surface area calculated. LV mass was calculated according to a necropsy-validated formula of LV mass (in grams): 0.8 × [1.04 × ((septal thickness + LV internal diameter + posterior wall thickness)3 – (LV internal diameter)3)] + 0.6 and indexed to body surface area [16]. Given the high prevalence of basal septal hypertrophy in this population, septal thickness measurements were taken below the level of the basal septum. Left atrial (LA) volumes were calculated at the end-systole from the apical 4-chamber view and using the area-length method [17]. Ejection fraction (EF) was calculated by averaging measurements of end-diastolic and end-systolic volumes from the apical 4-chamber view using the area-length method for 3 consecutive beats. In patients with atrial fibrillation, measurements were averaged for 5 consecutive beats. Peak systolic mitral annular function (S-wave) was measured as an additional index of systolic function. Diastolic parameters were measured from the apical 4-chamber view using pulsed-wave Doppler at the level of the mitral annulus and tissue Doppler imaging of the septal and lateral myocardial walls. These included early (E) and late (A) transmitral flow velocities, the ratio of early-to-late velocities (E/A), the deceleration time of E velocity and the isovolumic relaxation time. Early (e’) and late (a’) diastolic mitral annular tissue velocities at both the septum and lateral walls were obtained, and the E/e ratio (E:e’) was calculated as an index of diastolic function using the average of the septal and lateral tissue velocities [18]. Patients with atrial fibrillation were excluded from analyses of A-wave velocities. Measurement of tricuspid regurgitation (TR) velocity was performed in a standard way and converted to RV-to-RA pressure gradient using the modified Bernoulli equation for an estimate of RVSP [7–9].

Male Female Education ≤12 years Education >12 years Married Not married Physical activity Not physically active Poor self-rated health Good self-rated health ADL dependence ADL independence Diabetes No diabetes IHD No IHD CHF No CHF Hypertension No hypertension Depression No depression Dementia No dementia Respiratory disease No respiratory disease

Data Analysis Descriptive statistics were performed. The data were normally distributed, so our results are described as means and standard deviations (SDs). Percentages were calculated as appropriate. Continuous variable differences between means were calculated using the Student t test and Pearson correlation coefficients were performed as appropriate. We established both unadjusted and adjusted linear models. Adjusted linear models were performed with TR gradients as dependent variables and gender, ADL, CHF, IHD, hypertension, respiratory disease and the following cardiac measurements: LA volume, LV mass index, E:e’ and LVEF. A 5-yearsurvival analysis was done using the Cox proportional hazards model adjusted for sex, education, physical activity, BMI, diabetes, IHD, CHF, hypertension and pulmonary disease. In addition, cu-

A total of 300 subjects (175 males and 125 females) had measurable TR gradients and they formed the study population. At the 5-year follow-up, 71 of the 300 subjects (23.7%) had died. The mean echocardiographic measurements of the whole study group and divided by survival status are depicted in table 1. LV mass and LA volumes were significantly elevated. EF was within normal limits while tissue Doppler S-wave velocities were reduced, suggesting a component of systolic dysfunction in the cohort. Indices of diastolic function suggested impairment, as expected for such an elderly cohort. Mean TR gradients in the study population as a whole were 30.5 ± 9.4 mm Hg

Pulmonary Pressure in the Elderly

Cardiology 2014;129:111–116 DOI: 10.1159/000365137

0.42 0.12 0.14 0.46 0.055 0.20 0.24 0.0043

Pulmonary artery systolic pressure and mortality in the oldest old.

The objectives of the study were to assess pulmonary artery systolic pressure, its association with clinical and echocardiographic variables and its i...
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