Pierre Iaria

Diastolic Blood Pressure and Mortality in the Elderly With Cardiovascular Disease

Isolated systolic hypertension is predominantly observed in the elderly because of increased arterial stiffness. Aggressive treatment leads to excessive lowering of diastolic blood pressure and favors the presence of a J-shaped curve association with mortality. We investigated whether, in the elderly, this pattern of association is a simple epiphenomenon of increased arterial stiffness and impaired cardiac function. In a cohort of 331 hospitalized subjects >70 years old (mean age±SD: 85±7 years), aortic pulse wave velocity and pressure wave reflections, by pulse wave analysis, and cardiac function, by ultrasound, were assessed. During a 2-year follow-up period, 110 subjects died. No association of prognosis with systolic pressure, pulse pressure, or pulse wave velocity was observed. A J-shaped association between diastolic pressure and overall and cardiovascular mortality was observed. Unadjusted Cox regression analysis showed that patients in the first tertile of diastolic pressure (≤60 mm Hg) had higher mortality. In Cox regression analysis, diastolic pressure ≤60 mm Hg was a predictor of mortality independently from cardiac–vascular properties, cardiovascular risk factors, and drug treatment. Multivariate regression analysis showed that increased age and low total peripheral resistance, but not left ventricular function, were the cardinal determinants of low diastolic pressure. An “optimal” diastolic pressure of 70 mm Hg in subjects with isolated systolic hypertension was found. We showed that, in the frail elderly, a value of diastolic blood pressure ≤60 mm Hg is associated with reduced survival, independent from large artery stiffness and left ventricular function, suggesting that more rational antihypertensive therapy, not only based on systolic pressure level, is needed.

Cardiac and arterial calcifications and all-cause mortality in the elderly: The PROTEGER Study

OBJECTIVE To investigate the association of overall mortality with the presence and extent of cardiovascular calcifications. METHODS We investigated the association of cardiac (mitral annulus, aortic valve) and arterial calcifications (abdominal aorta, carotid and femoral arteries) by ultrasonography, with all-cause mortality in a population of 331 high-risk elderly subjects (86.8 ± 6.9 years). After a mean follow-up of 378 days, 110 deaths occurred. RESULTS A simple calcification score, defined by the presence of cardiac and arterial calcifications, was significantly associated with all-cause mortality (HR=1.47, 95% CI: 1.08-1.99), independent of low plasma albumin, increased plasma glucose and creatinine, as well as low diastolic blood pressure. Moreover, arterial calcifications showed negligible prognostic value with a high prevalence >89%, while cardiac calcifications significantly predicted overall mortality (HR=1.92, 95% CI: 1.28-2.87) at a prevalence of 36%. In another Cox regression, mitral annular calcification was proved to be a significant predictor of total mortality (HR=1.61, 95% CI: 1.02-2.54). CONCLUSION The independent association between the extent of calcification and all-cause mortality is consistently significant in this frail elderly population. Arterial calcification presents a very high prevalence but a low predictive value, whereas in cardiac calcification, prevalence is lower but predictive value is much higher.

Prognosis in the hospitalized very elderly: The PROTEGER study

BACKGROUND It was reported that many recognized cardiovascular risk factors were no longer valid in the very elderly and, sometimes, even act in the opposite direction. It remains unclear which cardiovascular risk factors are still vital for death prediction in the oldest-old population. METHODS We assessed cardiac abnormalities and dysfunction by ultrasonography and electrocardiography, blood pressure and arterial stiffness by BP monitor and tonometry, and biochemical parameters by routine laboratory assay, and investigated their associations with all-cause mortality in 331 hospitalized elderly patients (mean age ± standard deviation: 87 ± 7 years). After a mean follow-up of 378 days, 110 deaths occurred. RESULTS As compared with survivals, patients with all-cause mortality had significantly lower left ventricular ejection fraction (LVEF) (57.5 ± 13.8% vs 62.4 ± 11.2%, P = 0.002), low-density lipoprotein (LDL) (3.13 ± 0.98 vs 3.56 ± 0.98 mmol/L, P<0.001) and high-density lipoprotein (HDL) cholesterol (1.06 ± 0.30 vs 1.14 ± 0.32 mmol/L, P = 0.04), albumin (33.1 ± 5.4 vs 35.1 ± 4.5 g, P = 0.002), and creatinine clearance rate (Ccr) (42.4 ± 19.4 vs 55.8 ± 28.2 mL/min, P<0.001), and higher incidence of atrial fibrillation (26.4% vs 12.7%, P = 0.002). In multivariate Cox regression model, LVEF, atrial fibrillation, LDL cholesterol, albumin and Ccr were significant and independent death predictors with hazard ratios of 0.82 (0.70, 0.97), 1.74 (1.11, 2.74), 0.70 (0.57, 0.87), 0.66 (0.54, 0.82) and 0.57 (0.44, 0.75), respectively. CONCLUSIONS In the last stage of lifespan, cardiac systolic dysfunction and atrial fibrillation, as well as malnutrition and renal insufficiency, are crucial risk factors, which should be fully considered in the risk assessment strategy of the hospitalized elderly with cardiovascular diseases.

Gender difference in cardiovascular risk factors in the elderly with cardiovascular disease in the last stage of lifespan: The PROTEGER study

BACKGROUND It is known that the prognostic value of cardiovascular risk factors differed between men and women, but data in the elderly are very limited. METHODS We assessed cardiovascular structural and functional measurements (intima-media thickness, pulse pressure, pulse wave velocity, left atrial dimension (LAD), arrhythmia, deceleration time of transmitral early diastolic flow and left ventricular ejection fraction (LVEF)), by ultrasonography, blood pressure monitor, electrocardiography and applanation tonometry, as well as conventional cardiovascular risk factors (age, body mass index, smoke, total to high density lipoprotein (HDL) cholesterol ratio, and plasma glucose), and investigated their associations with all-cause mortality in men and women, separately, in 331 consecutive patients (87±7years, 74.0% female) with a history of cardiovascular disease from the geriatric departments. After a mean follow-up of 378days, 110 deaths were recorded. RESULTS In the full adjusted models, we found that increased LAD (hazard ratio [HR]=2.24 per 1-standard deviation [SD]; 95% confidential interval [CI]: 1.23-4.09), reduced LVEF (HR=0.60 per 1-SD; 95% CI: 0.38-0.96), and increased total-to-HDL cholesterol ratio (HR=1.99 per 1-SD; 95% CI: 1.05-3.78) were significant predictors of all-cause mortality in men, whereas the presence of arrhythmia (HR=2.47; 95% CI: 1.28-4.78), increased plasma glucose (HR=1.32 per 1-SD; 95% CI: 1.06-1.64) and decreased body mass index (HR=0.60 per 1-SD; 95% CI: 0.44-0.83) could significantly predict all-cause mortality in women. CONCLUSIONS Even in the last stage of lifespan, risk factors for all-cause death still differ significantly in men and women with cardiovascular disease.

Aortic stiffness, inflammation, denutrition and type 2 diabetes in the elderly.

AIM Observational studies in the elderly have shown that some of the classical cardiovascular (CV) risk factors are difficult to interpret. Thus, our study investigated whether increased aortic stiffness is associated with higher mortality risk in both the diabetic and non-diabetic elderly before and after adjusting for geriatric confounders such as inflammation (sedimentation rate, C-reactive protein, orosomucoid levels, leukocyte count) and denutrition parameters (body weight, body mass index [BMI], plasma albumin and prealbumin). METHODS In a cohort of 324 (84 men) hospitalized elderly subjects, including 255 non-diabetic and 69 diabetic subjects, aortic stiffness was assessed by carotid-femoral pulse wave velocity (PWV) together with CV risk factors. Subjects were studied over a 2-year mean follow-up period, thus enabling evaluation of long-term all-cause mortality. RESULTS A total of 105 subjects died during the follow-up. Kaplan-Meier curves showed a significantly higher mortality in the diabetics (P=0.024). Multivariate Cox analyses differed for non-diabetic subjects and diabetics. In the former, the hazard ratio (HR) for an increase of 1 SD (with confidence intervals) was 1.36 (1.07-1.72) for PWV, 0.73 (0.52-1.01) for plasma albumin and 0.63 (0.45-0.89) for BMI. In diabetic patients, the HR was 1.60 (1.02-2.50) for leukocyte count, 1.75 (1.03-2.96) for orosomucoid levels and 0.32 (0.15-0.68) for BMI. CONCLUSION In this very elderly population, although marginally significant on crude analysis, PWV, but not systolic or pulse pressure, was a powerful determinant of total mortality after taking into account the important role of type 2 diabetes. In diabetics, inflammation and denutrition predominated over mechanical factors.

Predictive factors for all-cause mortality in the hospitalized elderly subject: The importance of arrhythmia

BACKGROUND In elderly patients traditional cardiovascular (CV) risk factors are poorly correlated with mortality and few data are available on determinants and consequences of supra-ventricular arrhythmia. In a cohort of 331 hospitalized elderly patients (mean age+/-SD=85+/-7 years), we assessed which CV characteristics were associated with all-cause mortality. AIM OF THE STUDY We wished to determine whether the presence of arrhythmia was associated with an increase of overall mortality in the hospitalized elderly population, and to ascertain which factors were associated with arrhythmia, in order to better understand the underlying mechanisms of both arrhythmia and arrhythmia-related mortality in these patients. RESULTS The relative hazard for overall mortality in the presence of arrhythmia was 2.40 (95% CI: 1.41-4.07; p<0.001), independent of major confounding factors, compared to sinus rhythm. Both arrhythmia and low DBP were independent predictors of mortality but no association or interaction between arrhythmia and DBP was observed. The left atrium diameter was found to be a predictor of arrhythmia, and when entered in the Cox regression analysis, it suppressed arrhythmia from the model predicting all-cause mortality. CONCLUSION In the hospitalized elderly, arrhythmia is an independent predictor of all-cause mortality, and left atrium size is an independent predictor of both arrhythmia and mortality, suggesting that links exist. Therapeutic management could therefore focus more on prevention of heart structure remodelling than on traditional risk factors.

CARDIAC AND ARTERIAL CALCIFICATIONS AND ALL-CAUSE MORTALITY IN THE ELDERLY: THE PROTEGER STUDY: PP.7.290

Objective: To investigate the association of overall mortality with the presence and extent of calcification in the very elderly. Design: Prospective study. Method: We investigated the association of CC (mitral annulus, aortic valve) and AC (abdominal aorta, carotid and femoral arteries) by ultrasonography, with all-cause mortality in a population of 331 elderly high-risk subjects (mean age ± standard deviation (SD): 86.8±6.9 years). After a mean follow-up of 378 days, 110 deaths occurred. Results: A simple calcification score, defined by the presence of CC and AC, was significantly associated with all-cause mortality (hazard ratio (HR) =1.47 per 1-unit, 95% confidential interval (CI): 1.08–1.99), independent of low plasma albumin, increased plasma glucose and creatinine, as well as low diastolic blood pressure. Moreover, AC showed negligible prognostic value with a high prevalence >89%, while CC significantly predicted overall mortality (HR=1.92, 95% CI: 1.28–2.87) at a prevalence of 36% [figure 1]. In another Cox regression, mitral annular calcification was proved to be a significant predictor of total mortality (HR=1.61, 95% CI: 1.02–2.54), independent of plasma albumin, glucose and creatinine, as well as low body mass index and previous CV events. Conclusions: The independent association between the extent of calcification and all-cause mortality is consistently significant in this frail oldest old population. AC presents a very high prevalence but a low predictive value, whereas in CC, prevalence is lower but predictive value is higher. Figure 1. No caption available.

PREVALENCE AND PROGNOSIS OF LEFT VENTRICULAR DIASTOLIC DYSFUNCTION IN THE ELDERLY: THE PROTEGER STUDY: PP.22.354

Background: Although left ventricular diastolic dysfunction (LVDD) was reported to be a significant predictor of mortality, mainly in patients with heart failure, prospective data are limited in the very elderly with high cardiovascular risk. Methods: We investigated the association of severe LVDD, defined by conventional echocardiographic parameters with cardiovascular and all-cause mortality, after a mean follow-up of 378 days, in a population of 331 elderly high-risk subjects (mean age ± standard deviation [SD]: 87±7 years). Results: Compared to left ventricular systolic dysfunction (LVSD), subjects with severe LVDD had a similar prevalence (12% versus 10%) and similar cardiovascular and all-cause mortality (18% versus 19%, 49% versus 50%). Both cardiovascular and all-cause mortality increased progressively and significantly with increasing numbers of LVDD criteria, respectively (P = 0.035, P = 0.013), and reached about 50% for all-cause mortality when at least 2 criteria were met. Additional to classical cardiovascular risk factors and LVSD, severe LVDD provided incremental and independent prognostic value of all-cause mortality with increased chi-squared value (49.4 versus 45.3, P = 0.032). Conclusions: Severe LVDD, diagnosed by conventional echocardiography, has similar prevalence and prognosis as LVSD, and provides incremental prognostic value, highlighting the clinical significance of routine LVDD detection in risk assessment strategies of the very elderly. Figure 1. No caption available.