The second heart sound in old age.

The second heart sound was studied by phonocardiography and carotid tracings in 103 elderly subjects without overt evidence of heart disease. Their ages ranged from 60 to 99 years. A normal type of splitting was found in 55.3%, and a single sound in 41.7%. The difference between these percentages and those found in 60 normal younger persons was not significant. Thus, a single second sound should not be considered a typical finding in old age. However, a reverse type of splitting, noted in only 3 patients, should be regarded as evidence of severe latent heart disease.

Importance of aortic dilatation in the genesis of the innocent systolic ejection murmur of the aged.

Aortic systolic murmurs and aortic dilatation were studied in a randomized sample of 100 hospital patients over the age of 60. Clinical, phonocardiographic, radiologic and carotid-pulse data provided the basis for graphic characterization of the murmurs. Senile aortic dilatation was common (66 patients). In a high percentage (39 patients), dilatation of the ascending aorta (and sometimes of the arch) was associated with an aortic systolic murmur. The "innocent" type was always associated with aortic dilatation. This "innocent murmur of the aged", even though caused by structural alterations, should be considered in the same light as the "innocent murmur of children", as it is not associated with dynamic embarrassment of the circulation.

Tachyarrhythmias in old age.

The electrocardiograms of 1,171 patients above the age of 65 in a predominantly geriatric institution were reviewed to determine the incidence of tachyarrhythmias. Data on the overall incidence and the individual types of arrhythmias are presented. Atrial fibrillation was the most common arrhythmia observed, followed by atrial flutter and supraventricular tachycardia. Atrial fibrillation often was associated with other evidence of myocardial damage. The significance of sinus bradycardia and grade I A-V block in the pathogenesis of atrial fibrillation and the significance of the tachyarrhythmias are discussed.

Correlates of the echocardiographic waves of the mitral valve in normal subjects of various ages.

A cardiographic study was performed on 71 subjects including 14 children, 42 young and middle-aged adults, and 15 old persons without evidence of heart disease. The echocardiogram of the mitral valve was recorded in the A mode by an analog method and was compared with the electrocardiogram, phonocardiogram, apex cardiogram, and carotid and jugular tracings, simultaneously obtained. The intervals between the various waves recorded by these methods were measured and the results were compared with those reported in the literature. A comparison of the duration of the intervals in the various age groups showed statistically significant differences. In particular, the intervals between the second heart sound and the peak of the E-wave and the E-F intervals in the echogram were longer in adults than in children and also longer in old persons than in younger adults. This important age difference should always be taken into account before attributing any echocardiographic deviations to disease.

Incidence of murmurs in the aging heart.

One hundred patients aged 60 or older were studied clinically after excluding those with cardiac enlargement, definite valvular lesions or electrocardiographic (ECG) evidence of left ventricular hypertrophy. In 30 of the the 100 patients a significant systolic murmur was heard on auscultation. Phonocardiograms (PCGs), mitral echograms and pulse tracings were obtained in 28 of these 30 patients (2 had died meanwhile), and the ECGs and chest roentgenograms were reviewed. In 23 PCG patients there was an early or midsystolic murmur, best recorded at the base of the heart and often transmiteed to the apex. Mitral valve echograms and carotid and jugular pulse tracings were normal in all cases. Chest roentgenograms revealed aortic enlargement in 83 percent of the 23 patients. In the elderly with no evidence of organic heart disease, a basal systolic murmur is probably an aortic flow phenomenon caused by either moderate aortic dilatation or minimal fibrotic fusion of one or more commissures of the aortic valve.

Sounds and pulses as aids to cardiac diagnosis.

Areas of auscultation are reviewed. Heart sounds, clicks, snaps, and murmurs are discussed as they appear in various cardiac problems, particularly with respect to their usefulness in differential diagnosis.

Noninvasive index of cardiac contractility during stress testing: a collaborative study.

The present study was conducted in parallel in three different institutions with a similar purpose but using different technical setups. Based on the experimental demonstration that the external phonocardiogram is similar to the rate of acceleration (d3P/d3t) of the left ventricular pressure, and that catecholamines in a similar way increase the early positive wave of the left ventricular pressure and the first heart sound (S1) of the external phonocardiogram; knowing that exercise causes secretion of catecholamines and sympathetic reflexes, we have studied the S1 changes as a result of exertion in 34 normal young subjects. Blood pressure, heart rate, electrocardiograph, and phonocardiograph recordings of each subject were taken. In 10 subjects, cardiac output was also recorded by impedance cardiography. The result of the study was that the first heart sound increased routinely 4-5 times the normal amplitude; in a few subjects the increase was up to 15 times greater. While the extent of increase of S1 was proportional to the severity and duration of the effort and was usually proportional to the increase of other parameters, exceptions were noted as having marked increase of S1 with moderate increase of either blood pressure or heart rate. This was explained by the different receptors activated by the catecholamines and by the complexity of hormonal and neural influences acting on various organs in a stress test. The amplitude of S1 was found to be a reasonably reliable index for following changes of cardiac contractility during exercise, and the suggestion was made that this parameter should be studied in parallel with the others in routine stress tests.

When does a fourth sound become an atrial gallop?

A study of the fourth sound was conducted on 100 normal subjects (ages 1-88 years) and 42 clinical cases with either aortic stenosis, systemic hypertension or coronary heart disease. This study was based on the graphic recognition of a presystolic sound when the tracing was taken with the use of one or more of 5 different high pass filters. Attention was paid to the existence of the fourth sound, its magnitude, and its vibrational frequency. In general it was accepted that a magnitude of 1/2 of the first heart sound or a frequency of 30 Hz denoted a pathologic fourth sound. However, exceptions were found among normal subjects, so that only the combination of the two criteria could be considered highly significant for a pathologic phenomenon (gallop). Patients with aortic stenosis presented an increase in magnitude of the fourth sound but incidence and vibrational frequency were similar to those of controls. Patients with hypertension had a greater incidence of fourth sounds, especially in middle age (100%); middle age patients usually had a greater magnitude while older patients had more often an increase in vibrational frequency. Patients with coronary heart disease (evidence of old infarcts) had an increase in the incidence, magnitude, and vibrational frequency in comparison with controls. These data and the cause of the fourth sound are discussed. The fourth sound has been repeatedly studied in the past, both as an auscultatory finding and a graphic phenomenon. Attempts were made for separating the normal fourth sound from that denoting a pathological phenomenon but, so far, no clear cut criteria for the differentiation have been obtained. We thought, therefore, that a new study was indicated.

Diagnosis of tricuspid insufficiency by non invasive methods.

The diagnosis of tricuspid insufficiency was first made at the end of last century, based on clinical signs. Graphic tracings of the venous system were soon recorded and were demonstrated useful in the forties and fifties. New methods involving invasive procedure or expensive instrumentation have been described in the last twenty years. The present study was made in order to re-examine the value of the non-invasive, graphic methods, which would assure a simple and inexpensive study for these patients.

Changes of cardiac output caused by aging: an impedance cardiographic study.

The various parameters of cardiac output were studied in 132 healthy subjects from 20 to 89 years of age by impedance cardiography. This noninvasive method supplied data that were similar to those found by others by dye dilution methods. All parameters of cardiac output decrease with age. However, we found a difference between the two sexes in the rate of decrease of the cardiac index: women had a more marked drop at an earlier age and then a steady course, while men had a progressive decrease from the youngest to the oldest group.

First heart sound in atrial septal defect.

This is a retrospective study of 25 patients with secundum-type of ASD, confirmed by catheterization and angiocardiography. As controls, 25 normal subjects of matching age were studied. The phonocardiograms and carotid pulses of the 2 groups were recorded and compared. Special attention was paid to the interval between the 2 main components (Ia and Ib) of the first heart sound, to the amplitude of both Ia and Ib, and to the relationship between carotid upstroke and first heart sound. All intervals between sound components of the patients with ASD were found similar to those of the controls. No increase in amplitude of Ib could be documented. The amplitude of the first heart sound relative to that of the second sound (measured from the ratio I/IIA) was similar to that of the controls, Finally, a slight precedence of aortic valve opening (obtained from the carotid upstroke time minus transmission time) over the second component of the first sound (Ib) was found both in ASD and in controls. In view of these facts, a tricuspid contribution to the mechanism of the b component of the first heart sound appears highly unlikely. On the other hand, this component seems closely related to the dynamic events (blood acceleration and walls deceleration in the aortic root) that follow the aortic valve opening.

Abnormal left ventricular contraction revealed by impedance cardiograms and arterial tracings in bundle branch blocks and old myocardial infarcts.

Following the observation of an unusual pattern of the first derivative of the impedance cardiogram in cases of bundle branch block, a systematic study was performed both in normal controls and clinical cases. This graphic study was supplemented by the simultaneous recording of the first derivative of an arterial tracing, preferably the indirect aortic pulse at the suprasternal notch. These studies were performed in 70 subjects: 30 normal subjects, 14 cases of right bundle branch block, 14 cases of left bundle branch block, and 12 cases of old infarcts. Out of 30 normal subjects, only 2 old persons showed splintering of the main systolic wave. Both right and left bundle branch blocks had in common either a splitting of this wave in 2 peaks or multiple splintering; however, 4 cases in each type of bundle branch block had a normal pattern. Among old infarcts, 7 had a splitting, 3 had multiple splitting, and 2 had a normal pattern. The derivative of the arterial tracings showed a remarkable similarity with that of the impedance cardiogram, revealing that abnormal left ventricular ejection (dyssynergy) was present in all 3 types of lesion. The first derivative of the impedance cardiogram was often more typical than that of the arterial tracings, because it had fewer secondary vibrations or artifacts. Thus, the former seems more sensitive to diagnosing left ventricular abnormalities of contraction, even when the electrocardiogram is normal.

Using noninvasive methods to study the aging heart.

Except in unusual cases, complex or invasive techniques aren't necessary to examine the heart of an elderly patient. Noninvasive methods currently being used are electrocardiography, arterial and venous pulse tracings, echocardiography, and roentgenology. Interesting data have been collected by correlating phonocardiographic with echocardiographic tracings of the mitral valve, as well as with arterial pulse tracings. Two findings that should prevent a hasty diagnosis of heart disease are that the senile heart often has an abnormal fouth sound and that a systolic murmur can be heard in one of five persons. Other studies have shown that about one-third of patients have some type of heart block and that the interval between the aortic component of the second heart sound and the peak of the early diastolic wave of the mitral echogram is longer in old persons.

What is "normal" blood pressure in the aged?

Blood pressure was studied in two groups of institutionalized subjects ranging in age from 50 to over 100 years. The first group comprised 199 selected normal subjects; subjects with any disease, including systemic hypertension, were excluded. The second group consisted of 947 unselected subjects; those with acute illness were excluded. In the first group, systolic pressure increased slightly, but diastolic pressure did not change with increasing age. The blood pressures were still within the limits that were considered normal for younger persons. In the second group, both the systolic and the diastolic pressures progressively decreased with age, so that the former fell below normal limits.

Considerations on the mechanism of the systolic click of mitral valve prolapse.

The Authors briefly discuss the mechanism of production of the systolic click of mitral valve prolapse. A "valvular" mechanism seems inadequate to explain the genesis of vibrations that can be recorded, not only in the external phonocardiogram, but also in the intraventricular pressure tracing, in the apex cardiogram, and even in the left atrial pulse (esophagus). It seems more logical to postulate that the force of deceleration created by the sudden eversion of a mitral leaflet set the whole cardiohemic system (blood, myocardial walls, and the mitral apparatus) into vibration, thus producing the click. In mitral valve prolapse, the contribution to sound production of mitral leaflets and chordae is likely to be minor, as it had been demonstrated for the first heart sound.

Transmission delays of different portions of the arterial pulse. A comparison between the indirect aortic and carotid pulse tracings.

The transmission delays of the upstroke and incisura of the arterial pulse were measured in 128 normal subjects, divided in three groups of increasing age, by comparing the timing of the indirect aortic arch pulse (recorded at the suprasternal notch) (SSN) and the indirect, right carotid tracing (CAR). In the total group, the mean delay of the upstroke was 24.4 msec while the mean delay of the incisura was 19 msec (P less than 0.005). This difference was maximal in the oldest age group and became non significant in the group of children under 12. At slow heart rate, this difference was greater than at a more rapid heart rate. The left ventricular ejection times (LVET), measured on the two pulses, showed a very close correlation (r = 0.96) but the LVET was significantly longer in the SSN tracing, especially in the older subjects. These data reveal that the incisura of the arterial pulse travels more rapidly than the upstroke, especially in older patients and at lower heart rates. The most likely explanation of this fact resides in the frequency-dependent influence of vascular reflections, which is more important with increasing age and slower heart rate. Thus, the transmission velocity along the arterial wall is higher for the higher harmonics of the pulse wave (incisura) than for the lower harmonics (upstroke).

The jugular and hepatic tracings in normal subjects and in conduction defects.

The present study is a revision of the patterns of the jugular and hepatic tracings, two non-invasive tracings of the venous system. The study was performed in 40 subjects; 30 of them were normal while 10 had minor conditions affecting the left heart. The time of onset and peak of the various waves was statistically evaluated in this series. In addition, 14 cases of bundle branch block and 10 cases of grade 2 or 3 atrioventricular block were studied in order to better determine the cause of certain waves. Among the findings are: 1) the presence of a double A wave in 5 normals and in over one-half of the patients with AV block; 2) the frequent occurrence of a double C wave (an occurrence that required the labeling of the two peaks as t and C both in normal subjects and in clinical cases); 3) the possibility of either a double V wave or a small V wave, followed by a large H wave, especially in hepatic tracings. The mechanism of the various waves is discussed and the possible transmission of left-sided mechanical events to the right atrium and the venous system is postulated.

Assessment of left ventricular function by noninvasive methods.

The possibility of evaluating left ventricular function by noninvasive methods is discussed in detail. The methods that are considered are electrocardiograph, phonocardiography, apex cardiography, sphygmography, impedance cardiography, electrokymography, and echocardiography. Following a brief section of 'definitions', each method is described in detail including technical problems, difficulties, and results. The systolic time intervals and the stress tests are briefly discussed. Based on modern experimental studies, the stress test should include both an electro- and a phonocardiogram. In the latter, one would measure the amplitude of the first heart sound as an index of contractility. The conclusion is that combined methods give the best results. They are electrocardiography, phonocardiography, impedance cardiography, and echocardiography. An alternative, dictated by technical problems, is to use at first phonocardiography and impedance plus electrocardiography; then echocardiography plus electrocardiography; and then, if indicated, a stress test might complete the study; the latter should include both an electrocardiogram and a phonocardiogram.