Medical Journal of Dr. D.Y. Patil Vidyapeeth

ORIGINAL ARTICLE
Year
: 2013  |  Volume : 6  |  Issue : 1  |  Page : 75--78

Echocardiographic assessment of hypertensive changes in elderly patients with isolated systolic hypertension and its correlation with pulse pressure


Shubhangi A Kanitkar, Meenakshi Kalyan, Anu N Gaikwad, Neeti Singh, Amit S Bhate, M Midhun 
 Department of Medicine, Padmashree Dr. D. Y. Patil Medical College, Hospital & Research Centre, Dr. D. Y. Patil Vidyapeeth, Pimpri, Pune, India

Correspondence Address:
Shubhangi A Kanitkar
Department of Medicine, Padmashree Dr. D. Y. Patil Medical College, Hospital & Research Centre, Dr. D. Y. Patil Vidyapeeth, Pimpri, Pune
India

Abstract

Context: Isolated systolic hypertension (ISH) is increasingly recognized as a cardiovascular risk factor. Increase in pulse pressure is a powerful independent predictor of cardiovascular events. Aims: To study the hypertensive changes by 2D echocardiography in elderly patients with ISH and to compare the hypertensive effects in patients with pulse pressure between 50-70 mmHg and >70 mmHg. Settings and Design: This observational case series study was conducted over a period of 2 years (2009-2011) at a tertiary care hospital in Pune. Materials and Methods: Seventy-six newly diagnosed cases of ISH among the geriatric population over 60 years of age who attended the medicine and geriatric outpatient departments (OPDs) were studied for the hypertensive changes on 2D echocardiography and Doppler. Inclusion criteria were patients ≥ 60 years of age having systolic blood pressure (SBP) >140 mmHg and diastolic blood pressure (DBP) ͳ90 mmHg. The patients were divided into two groups according to pulse pressure (50-70 mmHg and >70 mmHg). Left ventricular hypertrophy (LVH), diastolic dysfunction, and systolic dysfunction were evaluated on 2D echocardiography and correlated with the pulse pressure. Statistical Analysis Used: Chi-square, Odds Ratio (OR) with 95% Confidence Intervals (CI) were done using SPSS. Results: Out of 76 patients, 48 patients (63.1%) had diastolic dysfunction, 46 patients (60.5%) had LVH, and 36 patients (47.4%) had systolic dysfunction on 2D echo. Patients with pulse pressure >70 mmHg showed increased incidence of LVH (75.6%) than those with pulse pressure 50-70 mmHg and (46.2%) respectively. There was no significant change in incidence of systolic dysfunction in the two groups. Conclusions: Incidence of LVH and diastolic dysfunction was more in ISH. Incidence of LVH and diastolic dysfunction was found to be more in patients with wide pulse pressure.



How to cite this article:
Kanitkar SA, Kalyan M, Gaikwad AN, Singh N, Bhate AS, Midhun M. Echocardiographic assessment of hypertensive changes in elderly patients with isolated systolic hypertension and its correlation with pulse pressure.Med J DY Patil Univ 2013;6:75-78


How to cite this URL:
Kanitkar SA, Kalyan M, Gaikwad AN, Singh N, Bhate AS, Midhun M. Echocardiographic assessment of hypertensive changes in elderly patients with isolated systolic hypertension and its correlation with pulse pressure. Med J DY Patil Univ [serial online] 2013 [cited 2019 May 24 ];6:75-78
Available from: http://www.mjdrdypu.org/text.asp?2013/6/1/75/108651


Full Text

 Introduction



Isolated systolic hypertension (ISH) is increasingly recognized as a cardiovascular risk. [1],[2] Raised systolic blood pressure is associated strongly with aging. [3] Increased stiffness of large arteries, increased systolic blood pressure, and increased pulse pressure lead to increased incidence of cardiac and vascular disease. [4] Epidemiological studies have shown that ISH is the most common form of hypertension present in approximately 2/3 of the hypertensive individuals more than 60 years of age. [5] ISH is defined as systolic blood pressure higher than 140 mmHg and diastolic blood pressure less than or equal to 90 mmHg. [6] The main feature of ISH is a decreased distensibility of the aorta and large arteries with subsequent cardiovascular events. [7],[8] The heart adapts to the ensuing increase in wall tension by hypertrophy and increased myocardial contraction time. Although these adaptations seem to preserve systolic function, diastolic impairment becomes apparent as left ventricular (LV) compliance and early diastolic filling decline. [9] As a result, ISH patients demonstrate an increase in LV mass and a high prevalence of left ventricular hypertrophy (LVH), compared with age-matched normotensive individuals. [10] The presence of LVH in ISH patients frequently leads to diastolic dysfunction (DD). [11] Increase in pulse pressure is a powerful independent predictor of cardiovascular events. [12]

We studied the hypertensive changes by 2D echocardiography in elderly patients with ISH and compared them in patients with pulse pressure between two groups identified on the basis of pulse pressure (50-70 mmHg and >70 mmHg).

 Materials and Methods



This study was conducted over a period of 2 years (2009- 2011) at a tertiary care hospital of a medical college in Pune, India. Seventy-six newly diagnosed cases of ISH among the geriatric population over 60 years of age who attended the medicine and geriatric outpatient departments (OPDs) were studied for hypertensive changes on 2D echocardiography and Doppler (GE Pro series LOG1Q 400). LVH, DD, and systolic dysfunction were evaluated. Inclusion criteria were patients ≤ 60 years of age having SBP >140 mmHg and DBP ≥90 mmHg. Patients <60 years of age with known history of combined hypertension and heart diseases (e.g. valvular heart diseases, cardiomyopathy), along with patients having wide pulse pressure due to anemia or thyrotoxicosis were excluded. The patients were divided into two groups according to pulse pressure (50-70 mmHg and >70 mmHg). The findings were then compared and statistical analysis [P value, Chi-square, Odds Ratio (OR) with 95% Confidence Interval (CI)], was done using SPSS.

Estimation of LV mass

Using M-mode techniques, LVH is usually present when myocardial mass estimates exceed 150 g/m 2 in males and 120 g/m 2 in females. LV mass was estimated as:

LV mass = 1.05 [(LVIDD + PWTD + IVSTD) 3 − (LVIDD) 3 ] g,

where

LVIDD = left ventricular internal diameter in diastole,

PWTD = posterior wall thickness in diastole, and

IVSTD = interventricular septum thickness in diastole.

Criteria for DD

Clinically useful mitral inflow parameters include: early filling peak velocity (E), atrial peak velocity (A), E/A ratio, and Deceleration Time (DT) or interval between the peak of the E wave to the zero baseline (reflects mean left atrial pressure and LV compliance). These basic transmitral inflow patterns present a parabolic distribution with respect to the E/A ratio. That is, as the disease progresses from normal to severe DD, the E to A relationship changes as follows:



Normal (E > A)Abnormal relaxation (E < A)

A mitral inflow pattern of abnormal relaxation [E < A; prolonged interventricular relaxation time (IVRT); prolonged DT] commonly is associated with hypertension.

Criteria for systolic dysfunction

Parameters used are Ejection Fraction (EF) and Fractional Shortening (FS).

EF is the percentage change of the LV volumes between systole and diastole, normal value being 58-75% which is calculated as:

(LVEDd) 3 − (LVESd) 3 × 100/(LVEDd) 3 .

FS is the percentage change of LV dimensions between systole and diastole, normal value being 30-45% which is calculated as:

LVEDd − LVESd × 100/LVEDd

where

LVEDd = left ventricular end-diastolic volume and

LVESd = left ventricular end systolic volume.

Systolic dysfunction is EF <50% and FS <30%.

 Results



Out of 76 patients, 45 were males and 31 were females. On 2D echocardiography, 46 out of 76 patients (60.5%) had LVH, 48 patients (63.1%) had DD, and 36 patients (47.4%) had systolic dysfunction.

65 % patients > 70 yrs old had pulse pressure > 70 mmHg [Table 1] 55.5 % males and 38.7% females had pulse pressure > 70mmHg [Table 2] Patients with pulse pressure >70 mmHg showed increased incidence of LVH (75.6%) on 2D echo [Figure 1] than those with pulse pressure of 50-70 mmHg (46%) [Chi-square = 6.93, P < 0.01, OR = 3.63 (95% CI: 1.36-9.67)].{Figure 1}{Table 1}{Table 2}

Thirty-seven patients (81.08%) with pulse pressure >70 mmHg had DD [Figure 1] than those with pulse pressure of 50-70 mmHg (46.2%) [Chi square = 9.95, P < 0.01, OR = 6 (95% CI: 1.77-14.09)].

Incidence of systolic dysfunction was more with pulse pressure of 50-70 mmHg [Chi-square = 0.49, P > 0.05, OR = 0.72 (95% CI: 0.29-1.79)]. [Figure 1]

 Discussion



The present study showed 60.5% of patients had LVH on 2D echo with increased incidence of LVH. Harlen et al. [13] showed the incidence of LVH in ISH. The Systolic Hypertension in Elderly Program (SHEP) trial also showed increased LVH in ISH and also as the predictor of fatal outcome. [14] 48.7% of patients had a pulse pressure of >70 mmHg. When analyzed on the basis of age, 65% of patients >70 years showed a pulse pressure of >70 mmHg. In the age group of 60-70 years, 42.9% of patients had a pulse pressure >70 mmHg. This shows increasing pulse pressure with increasing age. [15] Out of 45 male patients, 55.5% had pulse pressure >70 mmHg, and out of 31 females, 38.7% had pulse pressure >70 mmHg. Joan et al. reported characterizes sex difference in aging trends of pulse pressure within unindustrialized populations. Women had a deeper steady increase in pulse pressure with age than men, whereas men had a stronger curvilinear upswing in pulse pressure with age. [15] Out of 37 patients who had pulse pressure >70 mmHg, 75.6% had LVH. The Framingham heart study has also reported similar observation. 63.1% had DD. Studies performed by Cheng et al. [16] have shown DD to be present in patients of ISH. 81.08% with pulse pressure >70 mmHg had DD. A recent study in Canberra showed the prevalence of DD was 34.7% in 1275 randomly selected residents of Canberra, aged 60-86 years, which revealed that DD is common in elderly. [17]

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