Cardiovascular Risk Factors and Cardiovascular Risk Factors and Left Ventricular Geometry Left Ventricular Geometry

in Advanced Agein Advanced Age

Ruth TehRuth Teh, Ngaire Kerse, Robert , Ngaire Kerse, Robert Doughty, Gillian Whalley, Elizabeth Doughty, Gillian Whalley, Elizabeth

RobinsonRobinson

The 2011 Conference for General Practice1 Sept 2011, The Langham Hotel, Auckland

BackgroundBackground The heart remodels with natural ageing or The heart remodels with natural ageing or

pathological process.pathological process.

Rela

tive w

all th

ickness

Rela

tive w

all th

ickness

>0

.42

>0

.42

Concentric Concentric remodellinremodellin

g (CR)g (CR)

Concentric Concentric hypertrophhypertroph

y (CH)y (CH)

0.4

20

.42

Normal Normal geometry geometry

(NG)(NG)

Eccentric Eccentric hypertrophhypertroph

y (EH)y (EH)

Normal Normal LVMLVM

LVHLVH

In healthy adults, ageing In healthy adults, ageing is associated with left is associated with left ventricular (LV) ventricular (LV) concentric remodelling concentric remodelling (CR)(CR)11

In adults In adults >70 years>70 years, CR , CR is ais a more common more common LV LV geometric pattern than geometric pattern than concentric or eccentric concentric or eccentric left ventricular left ventricular hypertrophy (LVH)hypertrophy (LVH)22

1. Ganau & Realdi. J Hypertens. 1995: 13(12): 1818-222. Lavie et al. Am J Cardiol. 2006: 98(10): 1396-9

In elderly men, compare to NG, In elderly men, compare to NG, CRCR is is associated with associated with higher 24-hour heart higher 24-hour heart raterate, , waist-hip ratiowaist-hip ratio, , 2-hour glucose 2-hour glucose levellevel and and lower insulin sensitivity indexlower insulin sensitivity index33

In older adults (mean age 62 yrs) In older adults (mean age 62 yrs) without clinical CVD, without clinical CVD, CRCR was predictive was predictive of of stroke stroke andand coronary heart disease coronary heart disease4 4

LVHLVH confers a substantially increase risk confers a substantially increase risk for for heart failureheart failure4 4

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 Milani et al (2006) demonstrates that those with CR who convert to NG have a those with CR who convert to NG have a better prognosis than those who convert better prognosis than those who convert to LVHto LVH

Milani RV, Lavie CJ, Mehra MR, et al. Am J Cardiol. 2006;97(7):959-63.

What we know: What we know: A whelm of literature has established a A whelm of literature has established a

list risk factors associated with CVDlist risk factors associated with CVD

What we don’t know:What we don’t know: What is the relationship between CV risk What is the relationship between CV risk

factors and LV geometry in people of factors and LV geometry in people of advanced age?advanced age?

ObjectiveObjective

To explore the relationship between To explore the relationship between left ventricular (LV) geometry and left ventricular (LV) geometry and cardiovascular risk factors in those cardiovascular risk factors in those living to advanced ageliving to advanced age

MethodMethod

Cross-sectional studyCross-sectional study Study sample: 33 MStudy sample: 33 Māāori aged 75-79; 75 ori aged 75-79; 75

non-Mnon-Māāori aged 85 yrsori aged 85 yrs Recruitment: Rotorua, Whakatane & Recruitment: Rotorua, Whakatane &

OpotikiOpotiki 100 had an echocardiogram100 had an echocardiogram

30 M30 Māāori; 70 non-Mori; 70 non-Māāoriori Physical assessments: Ht, Wt, Physical assessments: Ht, Wt, waist and hip waist and hip

circumference, blood pressurecircumference, blood pressure Fasting serum: Fasting serum: glucose, lipids and 25(OH)Dglucose, lipids and 25(OH)D

LV geometry was categorised into four groups LV geometry was categorised into four groups based on LVH (LV mass ≥44g/mbased on LVH (LV mass ≥44g/m2.72.7 for women or for women or ≥48g/m≥48g/m2.7 2.7 for men) and relative wall thickness for men) and relative wall thickness (RWT):(RWT):

Rela

tive w

all th

ickness

Rela

tive w

all th

ickness

>0

.42

>0

.42

Concentric Concentric remodellinremodellin

g (CR)g (CR)

Concentric Concentric hypertrophypertrophy (CH)hy (CH)

0.4

20

.42

Normal Normal geometry geometry

(NG)(NG)

Eccentric Eccentric hypertrophypertrophy (EH)hy (EH)

Normal Normal LVMLVM

LVHLVH

Statistical analysisStatistical analysis

Descriptive statistics: Socio-Descriptive statistics: Socio-demographic data, medical history demographic data, medical history and clinical characteristicsand clinical characteristics

ANOVA/Kruskal-Wallis: ANOVA/Kruskal-Wallis: comparisons comparisons among multiple groupsamong multiple groups

p<0.05 was considered statistically p<0.05 was considered statistically significantsignificant

Results: Results: DemographicDemographic

Gender: Men 48 (44%);Gender: Men 48 (44%); Women 60 (54%) Women 60 (54%) Marital Status: Marital Status: Widowed 53%; Widowed 53%; married or partnered married or partnered

38%; divorced or separated 6%; never married 3%38%; divorced or separated 6%; never married 3%

Living arrangement: Living arrangement: Private residence 86%; Private residence 86%; retirement village 6%, low level dependency long term retirement village 6%, low level dependency long term

residential care 4% and on the maraeresidential care 4% and on the marae 4%4% Education:Education: Secondary 38%; Secondary 38%; tertiary 36%; primary tertiary 36%; primary

26%26% Financial:Financial: ‘comfortable’ 86%, ‘comfortable’ 86%, ‘just have enough to ‘just have enough to

get along’ 11%, and ‘could not make ends meet’ 3%. get along’ 11%, and ‘could not make ends meet’ 3%.

Results: Results: Medical historyMedical history

Never smoked cigarettes, n=55 Never smoked cigarettes, n=55 (51%)(51%)

Dyslipidemia, n=92 (85%) Dyslipidemia, n=92 (85%) Hypertension, n=91 (84%)Hypertension, n=91 (84%) Type 2 diabetes, n=22 (20%)Type 2 diabetes, n=22 (20%) Clinically manifest CVD, n=72 (67%)Clinically manifest CVD, n=72 (67%)

Results: Results: LV geometryLV geometry

84 of 100 84 of 100 who had an echocardiogram who had an echocardiogram were grouped into four LV geometry groupwere grouped into four LV geometry group

NG, 40, 48%

EH, 22, 26%

CR, 12, 14%

CH, 10, 12%

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tive w

all th

ickness

Rela

tive w

all th

ickness

>0.4

2>

0.4

2

Concentric Concentric remodelling remodelling

(CR)(CR)

Concentric Concentric hypertrophy hypertrophy

(CH)(CH)

0.4

20.4

2

Normal Normal geometry geometry

(NG)(NG)

Eccentric Eccentric hypertrophy hypertrophy

(EH)(EH)

Normal LVMNormal LVM LVHLVH

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tive w

all th

ickness

Rela

tive w

all th

ickness

>0.4

2>

0.4

2

Concentric Concentric remodelling remodelling

(CR)(CR)

Concentric Concentric hypertrophy hypertrophy

(CH)(CH)

0.4

20.4

2

Normal Normal geometry geometry

(NG)(NG)

Eccentric Eccentric hypertrophy hypertrophy

(EH)(EH)

Normal LVMNormal LVM LVHLVH

Results: Results: LV geometry & LV geometry & AnthropometryAnthropometry

p=0.002 p=0.040

Those with a normal LV geometry Those with a normal LV geometry had a lower BMI (23.8kg/mhad a lower BMI (23.8kg/m22) than ) than those with abnormal LV geometrythose with abnormal LV geometry

Those with a normal LV geometry Those with a normal LV geometry had a lower WC(89.1cm) than those had a lower WC(89.1cm) than those with abnormal LV geometrywith abnormal LV geometry

BMIBMI WCWC

Results: Results: LV geometry & Body LV geometry & Body fatfat

Those with a normal Those with a normal LV geometry had a LV geometry had a lower BF% than lower BF% than those with LVHthose with LVH

p=0.018

Results: Results: LV geometry & other LV geometry & other CVD risk factorsCVD risk factors

Not different between the four LV Not different between the four LV geometry groupsgeometry groups Systolic and diastolic BPSystolic and diastolic BP Fasting glucoseFasting glucose Lipid profilesLipid profiles

Discussion: Discussion: LV geometry and LV geometry and anthropometric measuresanthropometric measures

Our study: those with abnormal LV geometry had higher BMI Our study: those with abnormal LV geometry had higher BMI and WCand WC

The MESAThe MESA55 and Fels Longitudinal Study and Fels Longitudinal Study66

found LVM is positively found LVM is positively associated BMI and WCassociated BMI and WC

In younger adults, increase LVM is a response to In younger adults, increase LVM is a response to metabolic metabolic demanddemand77

. . In older adults, increased LVM may be related to In older adults, increased LVM may be related to morbid morbid

morphologymorphology of the left ventricle (consequence of CVD risk of the left ventricle (consequence of CVD risk factors) factors) butbut there is also the effect of there is also the effect of habitual physical activity habitual physical activity on LVM and on LVM and perhaps increasing LVM with ageingperhaps increasing LVM with ageing88

is part of the is part of the compensatory mechanismcompensatory 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: Discussion: LV geometry and Body LV geometry and Body FatFat

Our study: those LVH had a higher BF%Our study: those LVH had a higher BF% AdipocytesAdipocytes produce significant amount of produce significant amount of TNF-TNF- and IL-6 and IL-699

; both ; both cytokines have been implicated for cytokines have been implicated for CHFCHF1010

However, we cannot conclude increased BF% adversely affect However, we cannot conclude increased BF% adversely affect LV geometry; BF% does not distinguish between visceral and LV geometry; BF% does not distinguish between visceral and peripheral fatperipheral fat

We speculate that cytokines produced by adipocytes mediate We speculate that cytokines produced by adipocytes mediate the relationship between BMI, WC and LV geometry observed in the relationship between BMI, WC and LV geometry observed in previousprevious5,65,6

and current study. 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: Discussion: LV geometry and LV geometry and 25(OH)D25(OH)D

Our study: 25(OH)D levels lowest in those with CROur study: 25(OH)D levels lowest in those with CR The Hoorn Study found LV geometry was not associated with The Hoorn Study found LV geometry was not associated with

25(OH)D25(OH)D1111 but found prevalence of but found prevalence of diastolic dysfunction diastolic dysfunction was was

significantly significantly higherhigher in the in the first 25(OH)D quartile than the fourth first 25(OH)D quartile than the fourth quartile quartile but this association was attenuated after adjustments but this association was attenuated after adjustments for age, sex and other CVD risk factorsfor age, sex and other CVD risk factors

We do not know why those with CR had a lower 25(OH)D than We do not know why those with CR had a lower 25(OH)D than those with NG. We speculate that this relationship is those with NG. We speculate that this relationship is confounded by the association between confounded by the association between health status health status and and physical activityphysical activity; ; sun exposure sun exposure is the major source of vitamin D is the major source of vitamin D in older adults in New Zealand.in older adults in New Zealand.

11. Pilz, Henry, Snijder, et al. J Endocrinol Invest. 2010;33(9):612-7.

Study LimitationsStudy Limitations Cross-sectional analysisCross-sectional analysis Small sample sizeSmall sample size Healthy survivor cohort effectHealthy survivor cohort effect

Study StrengthStudy Strength Comprehensive physical assessment Comprehensive physical assessment

inclusive of an echocardiogram on inclusive of an echocardiogram on 100 people living to advanced age100 people living to advanced age

Conclusions (1)Conclusions (1)

CVD is prevalent in advanced ageCVD is prevalent in advanced age Half of the sample have a normal LV Half of the sample have a normal LV

geometrygeometry Body composition is related to LV Body composition is related to LV

geometrygeometry Serum vitamin D differs between LV Serum vitamin D differs between LV

geometry groups and may be implicated in geometry groups and may be implicated in cardiac remodellingcardiac remodelling

Blood pressure was not associated with LV Blood pressure was not associated with LV geometrygeometry

Conclusion (2)Conclusion (2)

Findings from this study Findings from this study extend the limited extend the limited evidenceevidence on the relationship between LV on the relationship between LV geometry and CVD risk factorsgeometry and CVD risk factors

Owing to the small sample size, findings from Owing to the small sample size, findings from this study need to be this study need to be interpreted cautiouslyinterpreted cautiously

The Life and Living to Advanced Age, a Cohort The Life and Living to Advanced Age, a Cohort Study in New Zealand (LILACS NZ) is currently Study in New Zealand (LILACS NZ) is currently underway to confirm findings from this studyunderway to confirm findings from this study

AcknowledgementsAcknowledgements Study participantsStudy participants Community organisations: He Korowai Oranga Community organisations: He Korowai Oranga

Rotorua; Māori Health Services, Whakatāne Rotorua; Māori Health Services, Whakatāne Hospital; Whakatohea Iwi Social and Health Hospital; Whakatohea Iwi Social and Health Services; Rotorua General Practice Group; Services; Rotorua General Practice Group;

The Kaitiaki Advisory Group, Ngā Pae O Te The Kaitiaki Advisory Group, Ngā Pae O Te MāramatangaMāramatanga

Sonographer: Helen WalshSonographer: Helen Walsh Funders: HRC, National Heart FoundationFunders: HRC, National Heart Foundation