Myocardial contraction fraction predicts mortality in the oldest old.

Background: People over the age of 85 are the world's most rapidly growing age group. Ejection fraction (EF) may be limited prognostically in this population and myocardial contraction fraction (MCF) may be more accurate. The objective of this longitudinal study was to assess the prognosis of MCF in an age-homogenous, community-dwelling population of subjects. Methods: Subjects were recruited from the Jerusalem Longitudinal Cohort Study. Echocardiography was performed with a portable echocardiograph at the subjects place of residence. Standard echocardiographic assessment of cardiac structure and function including MCF was performed. Values of EF and MCF above and below the median for males and females were defined as normal and abnormal in categorical analysis. 5-year mortality was assessed via a centralized government database. Results: 418 subjects (199 males, 219 females) were enrolled in the study of whom 113 (27 %) died at the time of 5-year follow-up. Subjects who died had significantly lower MCF (32 ± 14 % vs 36 ± 12 %; p < 0.004) and EF (51.6 ± 11.6 % vs 56.3 ± 9.4 %; p < 0.0001) than survivors. The association between MCF and mortality remained significant on clinical multivariate analysis as both a categorical and continuous variable while EF was only significant as a continous variable. When both EF and MCF were added to the model only MCF as a categorical variable remained significant. Conclusions: MCF assessed by home echocardiography provides additional prognostic information to EF and may be a superior predictor of 5-year mortality in a community-dwelling population of the oldest old.

Longitudinal changes in cardiac function in the very elderly: the Jerusalem longitudinal cohort study.

BACKGROUND: People over the age of 85 are a rapidly growing age group with a high incidence of congestive heart failure (CHF), in particular heart failure with preserved ejection fraction (HFpEF). The diagnosis of CHF is challenging and longitudinal data assessing cardiac structure and function are necessary to distinguish physiologic from pathologic cardiac aging. The objective of the study was to determine longitudinal changes in cardiac struture and function from ages 85 to 94 years using home echocardiography. METHODS: Subjects were recruited from the Jerusalem Longitudinal Cohort Study. Sixty three members of the initial cohort (32F, 31M) who underwent home echocardiography at age 85 were the subjects of the current study and underwent repeat home 2-D and Doppler echocardiographic assessment at age 94. RESULTS: There were no significant longitudinal changes in left ventricular mass index (LVMI), however LV end-diastolic volume significantly decreased from 113.4 ± 30 to 103.6 ± 35.5 mL (P < 0.02). Ejection fraction (EF) remained stable, however longitudinal systolic function significantly decreased with age from 7.9 ± 1.8 to 6.6 ± 1.4 cm/s2 (P < 0.0001). Diastolic function as assessed by increased E: e' (11.2 ± 3.4 to 16 ± 7.5, P < 0.0001) and increased left atrial volume index (34.1 ± 11.3 to 42.4 ± 13.7 mL/m2, P < 0.0001) was reduced with aging. CONCLUSIONS: This study demonstrated preserved EF with decreased longitudinal systolic function and diastolic function without significant change in LV mass. Changes in LV function in the very elderly may be independent of changes in LV geometry.

Cardiac tamponade and coronary artery pseudoaneurysm after brachial arterial embolectomy, possible role for an aberrant origin of the right coronary artery.

A patient developed hemopericardium shortly after left brachial arterial embolectomy using an embolectomy catheter. Evaluation disclosed evolving pseudoaneurysm of the right coronary artery that was successfully managed by stenting. Misplacement of the embolectomy catheter within the coronary vessel was facilitated by an anomalous origin of the right coronary artery. This complication highlights the importance of correct insertion of the embolectomy catheter using the markers to avoid maladvancement and damage to central vessels.

Left atrial function and mortality in the oldest old.

BACKGROUND: Previous studies demonstrated that left atrium (LA) size is associated with mortality in an elderly population. It remains unclear whether indices of LA function including reservoir, conduit, or booster elements of LA function provide incremental prognostic information. HYPOTHESIS: Echocardiographic measures of the various parameters of LA function would predict 5-year mortality in a community-dwelling population of 85 to 86 year olds independently of LA volume. METHODS: Subjects ages 85 to 86 years old underwent home echocardiography. LA volumes were assessed by the biplane Simpson's method from apical views using measurements of phasic volumes and functions of the LA, including LA expansion index. LA passive and active emptying fractions were assessed. Survival status at 5-year follow-up was assessed. RESULTS: Two hundred eighty-two subjects were included, of whom 87 (31%) had died at follow-up. Survival of the subjects in the lowest quartile of the LA expansion index as well as LA active filling index was significantly lower. When measurements of LA volume index were added to the model, the relationship between survival and indices of LA function remained significant. CONCLUSIONS: This study demonstrated that elderly subjects aged 85 to 86 years with significantly impaired LA function had increased 5-year mortality independently of indices of LA volume.

Left Ventricular Mass as a Risk Factor in the Oldest Old.

In middle-aged and "young elderly" cohorts, higher left ventricular mass (LVM) is associated with worse outcomes. The authors examined LVM and 5-year mortality among community-dwelling 85-year-old patients. A representative sample (n=526, born 1920-1921) from the Jerusalem Longitudinal Cohort Study underwent echocardiography at age 85. LVM was indexed by body surface area (LVM-BSA) or height (LVM-Ht). Patients with higher LVM were less educated and sedentary and had poorer self-rated health, functional limitations, and increased comorbidity. Five-year mortality was 21.7% (n=114). Adjusted 5-year mortality rates were increased for the two upper quintiles of LVM-BSA (hazard ratio [HR], 1.8; 95% confidence interval [CI], 1.05-3.06) and LVM-Ht (HR, 2.2; 95% CI, 1.2-3.5). A step up in mortality occurred around the third quintile corresponding with LVM-BSA 110 g/m(2) or LVM-Ht 51 g/m(2.7). Among the oldest old, elevated LVM is significantly associated with mortality.

Pulmonary artery systolic pressure and mortality in the oldest old.

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 related to LV mass, LA volume and reduced diastolic function in the oldest old. An elevated RVSP is significantly associated with mortality in this population.

Prevalence and prognosis of aortic valve disease in subjects older than 85 years of age.

Although degenerative aortic valve disease is common with increasing age, limited data exist regarding prevalence and prognosis of aortic valve disease among the oldest old. Subjects were recruited from the Jerusalem Longitudinal Cohort Study. Echocardiography was performed at home in 498 randomly selected subjects. Subjects were divided into 3 groups; normal subjects, subjects with valve calcium but without stenosis (AVC), and subjects with aortic stenosis (AS). Survival status at 5-year follow-up was assessed via the centralized population registry. AVC was noted in 55% of the study subjects and AS was seen in 8.2%. There were no significant differences between the 3 groups in any of the clinical parameters examined including risk factors for atherosclerotic heart disease. Of the 498 subjects, 107 (21%) had died at the time of 5-year follow-up. Five-year mortality was similar among the normal (17%) and AVC (20%) subjects but was significantly higher among the subjects with AS (46%; p <0.0001). AS was associated with a nearly fourfold increased likelihood of mortality (hazard ratio 3.7, 95% confidence interval 1.4 to 9.3). In conclusion, among subjects ≥85 years of age, the prevalence of AS is higher than previously reported and not associated with traditional vascular risk factors. AS but not AVC alone was independently predictive of 5-year mortality.

Aging, resting pulse rate, and longevity.

OBJECTIVES: To examine the relationship between resting pulse rate (RPR) and longevity in individuals aged 70 to 90. DESIGN: The Jerusalem Longitudinal Cohort Study (1990-2010) is a prospective longitudinal study of a representative cohort born in 1920-21. SETTING: Home-based comprehensive assessment in 1990, 1998, and 2005. PARTICIPANTS: Individuals aged 70 (n = 453), 78 (n = 856), and 85 (n = 1,044), with follow-up to age 90. MEASUREMENTS: Comprehensive assessment included average RPR, beta-blocker usage, and physical activity level. Mortality data were collected from the Ministry of Interior from 1990 to 2010. METHODS: Cox proportional hazards ratios (HRs) were determined for RPR (continuous variable), adjusting for sex, education, diabetes mellitus, ischemic heart disease, congestive heart failure, hypertension, kidney disease, anemia, physical activity, body mass index, self-rated health, dementia, beta-blocker use, and an interaction term for RPR by beta-blocker use. RESULTS: Mean RPR was 75.1 ± 9.9 at 70, 74.5 ± 10.9 at 78, and 68.5 ± 10.5 at 85 in women and 74.3 ± 10.7 at 70, 73.1 ± 11.2 at 78, and 65.2 ± 10.5 at 85 in men, with a significant decline from 78 to 85 for both sexes. In participants not taking beta-blockers followed up from 70 to 77, 78 to 84, and 85 to 90, mean RPR was lower in survivors than nonsurvivors for women (75.8 ± 9.2 vs 83.5 ± 10.9, P < .001; 75.2 ± 9.8 vs 79.9 ± 12.6, P = .004; 71.5 ± 9.9 vs 74.6 ± 10.7, P = .02, respectively) and men (75.2 ± 10.3 vs 75.2 ± 10.9, P = .98; 73.5 ± 10.1 vs 77.2 ± 12.1, P = .005; 67.1 ± 9.5 vs 70.4 ± 11.7, P = .01, respectively). Adjusted HRs for mortality per 10-beat increase in RPR during follow-up were 1.13 (95% confidence interval (CI) = 0.87-1.47) for 70 to 77, 1.35 (95% CI = 1.11-1.65) for 78 to 84, and 1.17 (95% CI = 1.01-1.37) for 85 to 90. CONCLUSION: RPR declines in the oldest old, and this decline is associated with greater longevity. It may serve as a simple prognostic marker in the oldest old.

Cardiac structure and function and renal insufficiency in the oldest old.

BACKGROUND: People over the age of 85 years have a high incidence of cardiovascular disease and chronic kidney disease. HYPOTHESIS: There is an association between renal function and cardiac structure and function in subjects 85 years of age. METHODS: Subjects born in the years 1920 and 1921 were recruited from the Jerusalem Longitudinal Cohort Study. Echocardiography was performed at the subject's home with assessment of cardiac structure and function. Glomerular filtration rate (GFR) was assessed by the Cockroft-Gault formula, with abnormal GFR defined as ≤60 mL/min/1.73 m(2). RESULTS: There were 310 subjects who were enrolled. When GFR was examined as a continuous variable, linear regression showed a small although statistically significant relationship between GFR and left atrial volume (r = 0.15, P < 0.014), left ventricular mass index (r = 0.12, P < 0.04), and ejection fraction (r = 0.19, P < 0.03) but not with indices of diastolic function (r = 0.02, P < 0.72). However, using the accepted clinical cutoff of 60 mL/min/1.73 m(2), there were no significant differences between subjects with normal and abnormal GFR in indices of cardiac structure. Ejection fraction (57.0 ± 10.4% vs 54.4 ± 10.3%; P = 0.08) and indices of diastolic function (E/e' 12.4 ± 5.0 vs 12.3 ± 4.6; P = 0.89) were not significantly different between the 2 groups. CONCLUSIONS: A weak and clinically insignificant association was found between GFR as a continuous variable and indices of cardiac function. However, using the clinically accepted cutoff, no association between abnormal GFR and cardiac structure or function was observed.

Cardiac structure and function as predictors of mortality in persons 85 years of age.

Individuals aged > 85 years are the world's most rapidly growing age group and have a high incidence of cardiovascular mortality. The objective of this study was to prospectively determine the prognosis of abnormal cardiac structure and function in an age-homogenous, community-dwelling population of subjects born in 1920 and 1921. Subjects were recruited from the Jerusalem Longitudinal Cohort Study. Echocardiography was performed with a portable echocardiograph at the subjects' places of residence. Standard echocardiographic assessment of cardiac structure and function was performed. Five-year mortality was assessed through a centralized government database. Five hundred two subjects (235 men, 267 women) were enrolled in the study, of whom 107 (21%) had died at the time of 5-year follow-up. Subjects who died had significantly higher left atrial volume indexes (42.3 ± 16.5 vs 36.6 ± 12.5 ml/m2, p < 0.01) and left ventricular mass indexes (133.1 ± 47.6 vs 119.8 ± 30.6 g/m2, p < 0.05). Ejection fractions were significantly lower in subjects who died (52.5 ± 11.5% vs 56.4 ± 9.4%, p < 0.003), but indexes of left ventricular diastolic function were not significantly different between the 2 groups (E/e' ratio 13.0 ± 5.3 vs 12.2 ± 4.9, p = 0.18). In conclusion, elevated left atrial volume index and left ventricular mass index and decreased LV systolic function predicted 5-year mortality in a community-dwelling population of subjects aged 85 years, even after correction for possible confounders. Left ventricular diastolic dysfunction did not predict 5-year mortality in this cohort.

Physical activity and cardiac function in the oldest old.

The relationship of physical activity (PA) and cardiac function in the oldest old remains unclear. The objective of this study was to evaluate the relationship between PA and cardiac structure and function, in the oldest old. Subjects were recruited from the Jerusalem Longitudinal Cohort Study that was initiated in 1990 and has followed an age homogeneous cohort of Jerusalem residents born in 1920-1921. A total of 496 of the subjects from the most recent set of data collection in 2005-2006 underwent echocardiography at their place of residence in addition to structured interviews and physical examination. Standard echocardiographic assessment of cardiac structure and function including ejection fraction (EF) and diastolic function as assessed by E:E' measurements was performed. PA was defined as a dichotomous (≥4 hr of light exercise weekly) and as a categorical variable (<4 hr weekly/4 hours weekly/at least 1 hr daily/sport at least twice weekly). On bivariate analysis, mean EF was lower among sedentary versus active women (55.5%±8.5% vs. 58.4%±8.3, p=0.021). No other significant differences were observed between sedentary and active subjects, for either systolic or diastolic function. After adjusting for sex, education, diabetes, ischemic heart disease, hypertension, dependence in activities of daily living, and body mass index (BMI), no significant associations were found between systolic or diastolic function, or left ventricular structure and PA. Gender-specific analyses yielded similar findings. Our study of the oldest old did not demonstrate an association between PA and cardiac structure or function.

Cardiac structure and function and dependency in the oldest old.

OBJECTIVES: To examine the association between cardiac function and activities of daily living (ADLs) in an age-homogenous, community-dwelling population born in 1920 and 1921. DESIGN: Cross-sectional analysis of a prospective cohort study. SETTING: Community-dwelling elderly population. PARTICIPANTS: Participants were recruited from the Jerusalem Longitudinal Cohort Study, which has followed an age-homogenous cohort of Jerusalem residents born in 1920 and 1921. Four hundred eighty-nine of the participants (228 male, 261 female) from the most recent set of data collection in 2005 and 2006 underwent echocardiography at their place of residence in addition to structured interviews and physical examination. MEASUREMENTS: A home-based comprehensive assessment was performed to assess health and functional status, including performance of ADLs. Dependence was defined as needing assistance with one or more basic ADLs. Standard echocardiographic assessment of cardiac structure and function, including ejection fraction (EF) and diastolic function as assessed using early diastolic mitral annular tissue velocity measurements obtained using tissue Doppler, was performed. RESULTS: Of the participants with limitation in at least one ADL, significantly more had low EF (< 55%) than the group that was independent (52.6 % vs 39.1%; P=.01). In addition, participants with dependence in ADL had higher left ventricular mass index (LVMI) (129.3 vs 119.7 g/m²) and left atrial volume index (LAVI) (41.3 vs 36.7 mL/m²). There were no differences between the groups in percentage of participants with impaired diastolic function or average ratio of early diastolic transmitral flow velocity to early diastolic mitral annular tissue velocity (11.5 vs 11.8; P=.64). CONCLUSION: In this age-homogenous cohort of the oldest old, high LVMI and LAVI and indices of systolic but not diastolic function as assessed according to Doppler were associated with limitations in ADLs.

Cardiac structure and function in persons 85 years of age.

Individuals aged >85 years constitute the world's most rapidly growing age group. Despite the rapid growth of this population and its high incidence of cardiovascular morbidity, normative data concerning cardiac structure and function are limited. The objective of this study was to define cardiac structure and function in an age-homogenous, community-dwelling population of subjects born in 1920 and 1921. Subjects were recruited from the Jerusalem Longitudinal Cohort Study. Echocardiography was performed using a portable echocardiograph at the subject's place of residence. Standard echocardiographic assessment of cardiac structure and function was performed. Four hundred fifty subjects (219 men, 231 women) were enrolled in the study. The cohort exhibited large left atrial volumes (64.6 ± 26 ml) and high left ventricular (LV) mass indexes (122 ± 36 g/m(2)) with normal LV volumes. Ejection fractions were preserved (55.3 ± 10.2%), but tissue Doppler s-wave velocities (lateral 7.8 ± 2.1 cm/s, septal 6.7 ± 1.9 cm/s) were reduced. Reduced tissue Doppler e waves (lateral 7.3 ± 2.2 cm/s, septal 6.2 ± 2 cm/s) and elevated E/e' ratios (12.2 ± 4.9) indicated significantly impaired diastolic function. In conclusion, the findings of this study demonstrate a high prevalence of left atrial enlargement, elevated LV mass, evidence of LV systolic dysfunction with preserved ejection fractions, and significant LV diastolic dysfunction in a community-dwelling cohort of 85-year-olds. The finding of elevated E/e' ratios in a subset free of known cardiovascular disease should be considered when clinical assessment of LV diastolic dysfunction in this age group is performed.