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Cardiovascular Risk Factors and Left Ventricular Geometry in Advanced Age Ruth Teh, Ngaire Kerse, Robert Doughty, Gillian Whalley, Elizabeth Robinson
The 2011 Conference for General Practice 1 Sept 2011, The Langham Hotel, Auckland
Background
In healthy adults, ageing is associated with left ventricular (LV) concentric remodelling (CR)1 In adults >70 years, CR is a more common LV geometric pattern than concentric or eccentric left ventricular hypertrophy (LVH)2
0.42 >0.42 Relative wall thickness
The heart remodels with natural ageing or pathological process. Concentric remodelling (CR)
Concentric hypertrophy (CH)
Normal geometry (NG)
Eccentric hypertrophy (EH)
Normal LVM
LVH
1. Ganau & Realdi. J Hypertens. 1995: 13(12): 1818-22 2. Lavie et al. Am J Cardiol. 2006: 98(10): 1396-9
In elderly men, compare to NG, CR is associated with higher 24-hour heart rate, waist-hip ratio, 2-hour glucose level and lower insulin sensitivity index3 In older adults (mean age 62 yrs) without clinical CVD, CR was predictive of stroke and coronary heart disease4 LVH confers a substantially increase risk for heart failure4 3. Sundström, Lind, Nyström, et al. Circulation. 2000;101(22):2595-600. 4. Bluemke et al. J Am Coll Cardiol. 2008;52(25):2148-55
Milani et al (2006) demonstrates that those with CR who convert to NG have a better prognosis than those who convert to LVH
Milani RV, Lavie CJ, Mehra MR, et al. Am J Cardiol. 2006;97(7):959-63.
What we know:
A whelm of literature has established a list risk factors associated with CVD
What we don’t know:
What is the relationship between CV risk factors and LV geometry in people of advanced age?
Objective
To explore the relationship between left ventricular (LV) geometry and cardiovascular risk factors in those living to advanced age
Method
Cross-sectional study Study sample: 33 Māori aged 75-79; 75 nonMāori aged 85 yrs Recruitment: Rotorua, Whakatane & Opotiki 100 had an echocardiogram
30 Māori; 70 non-Māori
Physical assessments: Ht, Wt, waist and hip circumference, blood pressure Fasting serum: glucose, lipids and 25(OH)D
LV geometry was categorised into four groups based on LVH (LV mass ≥44g/m2.7 for women or ≥48g/m2.7 for men) and relative wall thickness (RWT): >0.42
Concentric hypertrophy (CH)
0.42
Relative wall thickness
Concentric remodelling (CR)
Normal geometry (NG)
Eccentric hypertrophy (EH)
Normal LVM
LVH
Statistical analysis
Descriptive statistics: Socio-demographic data, medical history and clinical characteristics ANOVA/Kruskal-Wallis: comparisons among multiple groups p0.42
Concentric remodelling (CR)
Concentric hypertrophy (CH)
0.42
CH, 10, 12% CR, 12, 14%
NG, 40, 48%
Relative wall thickness
EH, 22, 26%
Normal geometry (NG)
Eccentric hypertrophy (EH)
Normal LVM
LVH
Results:
LV geometry & Anthropometry BMI p=0.002
Those with a normal LV geometry had a lower BMI (23.8kg/m2) than those with abnormal LV geometry
WC p=0.040
Those with a normal LV geometry had a lower WC(89.1cm) than those with abnormal LV geometry
Results:
LV geometry & Body fat
Those with a normal LV geometry had a lower BF% than those with LVH
p=0.018
Results:
LV geometry & other CVD risk factors
Not
different between the four LV geometry groups Systolic and diastolic BP Fasting glucose Lipid profiles
Discussion:
LV geometry and anthropometric measures
Our study: those with abnormal LV geometry had higher BMI and WC 5 6 The MESA and Fels Longitudinal Study found LVM is positively associated BMI and WC 7 In younger adults, increase LVM is a response to metabolic demand . In older adults, increased LVM may be related to morbid morphology of the left ventricle (consequence of CVD risk factors) but there is also the effect of habitual physical activity on LVM and perhaps increasing LVM 8 with ageing is part of the compensatory mechanism.
5. Turkbey, McClelland , Kronmal , et al. JACC: Cardiovascular Imaging. 2010;3(3):266-74. 6. Chumlea, Schubert, Towne, et al. Journal of Nutrition, Health and Aging. 2009;13(9):821-5 7. Payne, Eleftheriou, James, et al. Heart. 2006;92(12):1784-8. 8. Lieb, Xanthakis, Sullivan, et al. Circulation. 2009;119(24):3085-92.
Discussion:
LV geometry and Body Fat
Our study: those LVH had a higher BF% 9 Adipocytes produce significant amount of TNF- and IL-6 ; both 10 cytokines have been implicated for CHF However, we cannot conclude increased BF% adversely affect LV geometry; BF% does not distinguish between visceral and peripheral fat We speculate that cytokines produced by adipocytes mediate the 5,6 relationship between BMI, WC and LV geometry observed in previous and current study.
9. Fantuzzi G. J Allergy Clin Immunol. 2005;115:911-9. 10. Kalogeropoulos, Georgiopoulou, Psaty, et al. J Am Coll Cardiol. 2010;55(19):2129-37.
Discussion:
LV geometry and 25(OH)D
Our study: 25(OH)D levels lowest in those with CR 11 The Hoorn Study found LV geometry was not associated with 25(OH)D but found prevalence of diastolic dysfunction was significantly higher in the first 25(OH)D quartile than the fourth quartile but this association was attenuated after adjustments for age, sex and other CVD risk factors We do not know why those with CR had a lower 25(OH)D than those with NG. We speculate that this relationship is confounded by the association between health status and physical activity; sun exposure is the major source of vitamin D in older adults in New Zealand.
11. Pilz, Henry, Snijder, et al. J Endocrinol Invest. 2010;33(9):612-7.
Study Limitations
Cross-sectional analysis Small sample size Healthy survivor cohort effect
Study Strength
Comprehensive physical assessment inclusive of an echocardiogram on 100 people living to advanced age
Conclusions (1)
CVD is prevalent in advanced age Half of the sample have a normal LV geometry Body composition is related to LV geometry Serum vitamin D differs between LV geometry groups and may be implicated in cardiac remodelling Blood pressure was not associated with LV geometry
Conclusion (2)
Findings from this study extend the limited evidence on the relationship between LV geometry and CVD risk factors Owing to the small sample size, findings from this study need to be interpreted cautiously The Life and Living to Advanced Age, a Cohort Study in New Zealand (LILACS NZ) is currently underway to confirm findings from this study
Acknowledgements
Study participants Community organisations: He Korowai Oranga Rotorua; Māori Health Services, Whakatāne Hospital; Whakatohea Iwi Social and Health Services; Rotorua General Practice Group; The Kaitiaki Advisory Group, Ngā Pae O Te Māramatanga Sonographer: Helen Walsh Funders: HRC, National Heart Foundation
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