Clinical and morphologic expression of hypertrophic cardiomyopathy in patients > or = 65 years of age

Mitral annular calcification in hypertrophic cardiomyopathy

BACKGROUND

Changes in mitral valve anatomy contribute to left ventricular outflow tract obstruction (LVOTO) in hypertrophic cardiomyopathy (HCM). Mitral annular calcification (MAC) is common among patients with HCM but its implications are currently unknown.

METHODS

We tested the hypothesis that echocardiographic MAC would be associated with anterior displacement of the mitral valve and LVOTO in a cohort of 304 patients with HCM aged ≥ 60 years (mean [SD] age 71.6 [7.7] years, 52% women).

RESULTS

MAC was present in 141 (46%) patients. The mean (SD) MAC offset distance was 9.8 (4.8) mm. A higher proportion of those with MAC compared to those without MAC had SAM (84.2 vs. 63.8%, p < 0.001) and LVOTO (80.9 vs. 57.9%, p < 0.001). In patients with MAC, the septal-mitral valve distance was shorter compared to those without (19.4 [4.0] vs 21.5 [4.9] mm, p < 0.001). The mitral valve position ratio was greater in those with MAC compared to those without (1.00 [0.79, 1.22] vs. 0.86 [0.67, 1.05], p < 0.001) denoting greater anterior displacement, especially in those with MAC and LVOTO. After multivariable adjustment, MAC offset distance was associated with LVOTO (OR 1.16 [95% CI 1.07, 1.28] per mm, p = 0.001). Over a median follow-up of 2.7 years, 42 (29.8%) patients with MAC underwent surgery to relieve LVOTO, with no deaths.

CONCLUSION

This study adds MAC to the known geometrical alterations of the mitral valve that predispose to LVOTO and suggests that surgical relief of LVOTO in the presence of MAC is safe when performed by an experienced surgeon.

Outcomes of Septal Myectomy beyond 65 Years, with and without Concomitant Procedures

Introduction and objectives: Septal myectomy remains the first septal reduction therapy for hypertrophic obstructive cardiomyopathy in young patients and those requiring concomitant procedures. Its role in advanced ages is questioned due to perceived increased risk. We assess the outcomes of surgical relief of obstruction in patients beyond 65 years old. Methods: A single-center retrospective review of patients ≥ 65 years old undergoing septal myectomy through median sternotomy between April 2015 and February 2020. Results: We identified 52 patients. Mean age was 71.8 ± 4.9 years; 36 (69.2%) were females. All were symptomatic. Mean highest LVOT gradient was 90 ± 39 mmHg. All patients had systolic anterior motion (SAM) of the mitral valve and 36 (69.2%) ≥ moderate mitral regurgitation. Additional LVOT interventions beyond myectomy were performed in 34 (65.4%). At least one other cardiac concomitant procedure was performed 44 (84.6%). No perioperative mortality in elective surgery occurred. One patient (1.9%) developed atrio-ventricular block. Postoperative mean gradient was 4.3 ± 1.9 mmHg, with 46 (88.4%) achieving complete resolution of obstruction. Mitral regurgitation was reduced to grade ≤ I in 46 (88.5%). Mean follow-up time was 2.3 ± 1.2 years and 82% of patients were in NYHA I. Survival at 2 years was 98%. Conclusion: Septal myectomy in the elderly is a safe and effective operation despite the need for concomitant procedures. LVOT interventions beyond septal myectomy to relieve obstruction are common in this advanced cohort of hypertrophic cardiomyopathy patients. This operation carried at experienced centers seems an unmatched therapeutic option.

Should there be sex-specific criteria for the diagnosis and treatment of heart failure?

All-cause mortality from cardiovascular disease is declining in the USA. However, there remains a significant difference in risk factors for disease and in mortality between men and women. For example, prevalence and outcomes for heart failure with preserved ejection fraction differ between men and women. The reasons for these differences are multifactorial, but reflect, in part, an incomplete understanding of sex differences in the etiology of cardiovascular diseases and a failure to account for sex differences in pre-clinical studies including those designed to develop new diagnostic and treatment modalities. This review focuses on the underlying physiology of these sex differences and provides evidence that inclusion of female animals in pre-clinical studies of heart failure and in development of imaging modalities to assess cardiac function might provide new information from which one could develop sex-specific diagnostic criteria and approaches to treatment.

Long-term follow-up impact of dual-chamber pacing on patients with hypertrophic obstructive cardiomyopathy

BACKGROUND

Pacing has been proposed as a treatment for patients with hypertrophic obstructive cardiomyopathy (HOCM), but there are few studies with long-term follow-up. We evaluated the long-term effects of dual-chamber pacing therapy for patients with HOCM, and to identify the most prognosis-specific factors for predicting outcome in such treating methods.

METHODS

A total of 37 HOCM patients implanted with dual-chamber pacemakers were enrolled consecutively and followed-up. Thirty-seven cases were followed for 1 year, 26 cases for 2 years, 10 cases for 3 years, and eight cases for 4 years. At each annual point of follow-up after pacemaker implantation, the pacing frequency, pacing threshold, impedance, atrioventricular delay, and cumulative percentage of atrial and ventricular pacing were tested, respectively. In addition, left atrial dimension (LAD), left ventricular end diastolic dimension (LVEDd), left ventricular posterior wall thickness (LVPW), interventricular septum thickness (IVS), left ventricular outflow tract dimension (LVOTd), peak velocity of left ventricular outflow tract (VLVOT), left ventricular outflow tract pressure gradient (LVOTPG), left ventricular ejection fraction (LVEF), and pulmonary artery systolic pressure (PASP) were measured. Mitral valve systolic anterior motion (SAM) was also observed. Pacing parameters and echocardiography indexes before and after pacemaker implantation were dynamically compared.

RESULTS

Pacing frequency and atrioventricular delay were adjusted to 60-70 beats per minute and 90-180 ms, respectively, in order to ensure the ratio of ventricular pacing was more than 98%. Pacing threshold and pacing impedance were kept in normal ranges. The differences of various pacing parameters were of no statistical significance within the 4 years of follow-up (P > 0.05). Compared with prior to pacing, it was observed that the IVS, VLVOT, and LVOTPG declined significantly (P < 0.01), the LVOTd widened significantly (P < 0.01), and the SAM phenomenon improved obviously (P < 0.01) at 1, 2, 3, and 4 years after pacemaker implantation. Additionally, the changes in LAD, LVEDd, LVPW, LVEF, and PASP were statistically insignificant (P > 0.05).

CONCLUSIONS

The cardiac structural reconstruction in patients with HOCM can be chronically improved by dual-chamber pacing therapy. The IVS, LVOTd, VLVOT, and LVOTPG can be used as sensitive and specific factors in evaluating the long-term effects of dual-chamber pacing therapy for HOCM.

Hypertrophic Cardiomyopathy in a Young Adult with RV Aneurysm: Report of a Rare Finding and Review of the Literature

We report a case of a 22-year-old patient with a severe form of hypertrophic cardiomyopathy involving both ventricles, for which he underwent surgical treatment. Echocardiogram and magnetic resonance imaging confirmed the presence of an aneurysm in the inferior-anterior portion of the right ventricle.

Hypertrophic cardiomyopathy with longevity to 90 years or older

Hypertrophic cardiomyopathy (HC) is the most common cause of sudden death in the young, but survival to particularly advanced age is less well appreciated. The investigators report the prevalence, clinical features, and demographics of patients with HC surviving to ≥90 years of age. Of 1,297 patients with HC in the Hypertrophic Cardiomyopathy Center database (Minneapolis Heart Institute Foundation), 26 (2.0%) were identified who had achieved the age of ≥90 years; 18 (69%) were women. HC diagnosis came late in life, at 61 to 92 years (mean 80 ± 8; ≥75 years in 21 patients), recognized fortuitously by the detection of a heart murmur or during family screening (n = 6) or after onset of new symptoms (n = 20). At most recent evaluation (or death) patients were aged 90 to 96.7 years (mean 92.2 ± 2), with 6 presently alive at 91 to 96 years of age; HC did not appear to be the primary cause of death in any patient. Left ventricular wall thicknesses were 15 to 31 mm (mean 20 ± 3); 8 patients (31%) had obstruction to left ventricular outflow at rest (peak instantaneous gradients, 38 to 135 mm Hg). Significant HC-related complications occurred in 13 patients (50%), including progressive heart failure symptoms, atrial fibrillation, and nonfatal embolic stroke. Although no patient died suddenly, 13 (50%) nevertheless carried conventional HC risk markers. A greater proportion of cohort patients reached ≥90 years of age (2.0%) than expected in the general population (0.8%) (p <0.001). In conclusion, HC may be unrecognized until late in life and is consistent with survival to particularly advanced age into the 10th decade of life without the need for major HC-related treatment interventions, and with demise ultimately largely unrelated to this disease. This principle regarding the natural history of HC can afford a measure of reassurance to many patients.

Cardiac magnetic resonance imaging findings are useful for differentiating between hypertrophic obstructive cardiomyopathy and aortic valve stenosis in elderly patients

OBJECTIVE

The objective of this study was to assess whether cardiac magnetic resonance (MR) imaging is useful for differentiating between hypertrophic obstructive cardiomyopathy (HOCM) and aortic valve stenosis (AS) in 21 elderly patients (>75 years old).

METHODS

Cine and delayed contrast-enhanced cardiac MR imaging was performed and used to assess the regional wall thickness, myocardial mass, mitral valve motion, and myocardial hyperenhancement in elderly patients with HOCM and AS.

RESULTS

The basal anterior septal and midventricular inferior septal walls were significantly thicker, the ejection fraction was higher, and the ratio between the basal and midventricular inferior wall thicknesses was lower in patients with HOCM than those in patients with AS. Apical wall thinning and abnormal mitral valve motion were detected in patients with HOCM.

CONCLUSIONS

Structural and functional parameters that are characteristic of HOCM can be assessed in cardiac MR imaging, and these parameters may be useful for differentiating between HOCM and AS in elderly patients.

Diastolic Heart Failure in the Elderly

Most elderly patients, particularly women, who have heart failure have a normal ejection fraction. Patients who have this syndrome have severe symptoms of exercise intolerance, frequent hospitalizations, and increased mortality. The pathophysiology and treatment are not well defined. Control of systemic hypertension may be a key to prevention and treatment. Several large trials of specific agents are currently underway.

Diastolic heart failure in the elderly

Most elderly patients, particularly women, who have heart failure have a normal ejection fraction. Patients who have this syndrome have severe symptoms of exercise intolerance, frequent hospitalizations, and increased mortality. The pathophysiology and treatment are not well defined. Control of systemic hypertension may be a key to prevention and treatment. Several large trials of specific agents are currently underway.

Use of Echocardiography in Patients with Hypertrophic Cardiomyopathy: Clinical Implications of Massive Hypertrophy

We examined the 10-year outcome of 107 patients with hypertrophic cardiomyopathy and massive myocardial hypertrophy as assessed by echocardiography. These patients demonstrated excess mortality in comparison with their expected survival with respect to a general population of individuals (10-year survival 77% vs 95%, P < .001). Adverse events occurred primarily in the youngest and oldest patients. Sudden cardiac death was the most frequent cause of death among the young (overall survival 80%), whereas other causes predominated in older patients (overall survival 31%). For patients aged 30 to 59 years, survival was 97%, no different from their expected survival. Patients with hypertrophic cardiomyopathy and massive hypertrophy identified by echocardiography are at increased risk of death, but this risk is related to age at presentation. Sudden cardiac death is the primary cause in those who are young, whereas other causes predominate in older patients. Middle-aged patients with massive hypertrophy do not experience an excess mortality.

Morphologic Characteristics of Hypertrophic Cardiomyopathy of the Elderly With Cardiac Myosin-Binding Protein C Gene Mutations

BACKGROUND

Several morphologic distinctions between elderly and young patients with hypertrophic cardiomyopathy (HCM) have been reported. In particular, a crescent-shaped left ventricular (LV) cavity with reversed septal curvature, which is often seen in young patients, is rare in elderly patients. However, those studies were carried out before gene testing became available and heterogeneous causes or age-related changes may have been included. The purpose of this study was to determine the morphologic characteristics of elderly patients with HCM definitely caused by a mutation in the cardiac myosin-binding protein C (MyBPC).

METHODS AND RESULTS

Twenty-seven patients with HCM caused by MyBPC gene abnormality were evaluated. Patients were divided into an elderly group (> or = 65 years of age, n = 8) and a young group (< 65 years of age, n = 19). LV hypertrophy was milder in the elderly than in the young for maximum LV wall thickness (18 +/- 5 mm vs 24 +/- 6 mm, p = 0.008) and Wigle score (5.7 +/- 1.5 vs 7.6 +/- 1.6, p < 0.005). However, an abnormal crescent-shaped LV was similarly prominent in both groups (75% in the elderly vs 95% in the young, p = NS). None of the elderly patients showed a proximal septal bulge.

CONCLUSIONS

An abnormal crescent-shaped LV cavity was frequently present in the elderly as in the young when there are MyBPC mutations. It is possible that this morphologic feature could become useful for determining the etiology of HCM in elderly patients.

Proposal for contemporary screening strategies in families with hypertrophic cardiomyopathy

Screening families with hypertrophic cardiomyopathy (HCM) presents a common clinical problem to practicing cardiologists, internists, and pediatricians. The traditional recommended strategy for screening relatives in most HCM families calls for such evaluations with echocardiography (and electrocardiogram [ECG]) on a 12- to 18-month basis, usually beginning at about age 12 years. If such tests show no evidence of left ventricular hypertrophy, i.e., without one or more segments of abnormally increased wall thickness by the time full growth and maturation is achieved (at the age of about 18 to 21 years), it has been customary practice to conclude that HCM is probably absent and reassure family members accordingly that further echocardiographic testing is unnecessary. However, novel developments in the definition of the genetic causes of HCM have defined both substantial molecular diversity and heterogeneity of the disease expression including (in some relatives) incomplete phenotypic penetrance and delayed, late-onset left ventricular hypertrophy well into adulthood. These observations have unavoidably reshaped the customary practice of genetic counseling and established a new proposed paradigm for clinical family screening of HCM families. Therefore, in the absence of genetic testing, strong consideration should be given to extending diagnostic serial echocardiography past adolescence and into mid-life for those family members with a normal echocardiogram and ECG. Of note, recent developments in laboratory DNA-based diagnosis for HCM could potentially avoid the necessity for serial echocardiography in many such relatives.

[Echocardiography in elderly patients]

IN THE CONTEXT OF AGEING: The Doppler echocardiography is a non-invasive technique that permits assessment of the "physiological" ageing of the cardiac and vascular structures, notably including a concentric remodelling of the left ventricle associated with relaxation abnormalities, dilatation of the left atrium, valvular reorganisation and a modification in the large vessels. IN A PATHOLOGICAL CONTEXT: The Doppler echocardiography also detects the various cardiovascular affections related to ageing: valvulopathies, notably calcified aortic stenosis and mitral failure due to mitral anulus calcification or prolapsus of the valve; primary hypertrophic cardiomyopathy or secondary to arterial hypertension or an amyloidosis, and possibly leading to heart failure with spared systolic function, frequent in elderly patients; ischemic cardiopathies that have benefited, as in younger patient, from new echographical stress testing techniques, which safely study the variability in myocardial ischemia. Transoesophageal echography can also be performed in elderly patients, but the indications of this more invasive and less well-tolerated examination must be assessed case by case. It is very useful when an intra-parietal aortic hematoma is suspected or during aortic dissection or infectious endocarditis.

Clinical and echocardiographic features of hypertrophic cardiomyopathy in the elderly

Hypertrophic cardiomyopathy is a familial cardiac disease with exceptionally diverse clinical and morphologic presentations. The influence of age on the disease manifestation has become increasingly clear over the last decade. Most initial reports concentrated on characterization and treatment of the disease in younger individuals, but a better appreciation of hypertrophic cardiomyopathy in elderly patients has yielded important information regarding clinical presentation, morphologic appearance on echocardiography, prognosis, and management. This paper reviews the literature focusing on the age-related differences in hypertrophic cardiomyopathy.

The importance of ventricular septal morphology in the effectiveness of dual chamber pacing in hypertrophic obstructive cardiomyopathy

It has been reported that older patients with hypertrophic obstructive cardiomyopathy (HOCM) benefited the most from dual chamber (DDD) pacing. Since in older patients the distribution of septal hypertrophy and left ventricular (LV) cavity shape differs from that in younger patients, we decided to study the efficacy of DDD pacing on the reduction of LV outflow tract (LVOT) gradient in different patterns of septal hypertrophy. We compared HOCM patients with nonreversed septal curvature, thus preserving the elliptical LV cavity contour (common in the elderly), (group I) versus patients with reversed septal curvature, deforming the LV cavity to a crescent shape (common in the young), (group II). Eighteen HOCM patients were studied (11 patients in group I and 7 patients in group II). After implantation of a DDD pacemaker, the LVOT gradient was measured using Doppler echocardiography at various programmed AV delay intervals to determine the maximal percentage decrease of LVOT gradient from baseline. The measurement was repeated after at least a 6-month follow-up (chronic DDD pacing). The baseline LVOT gradient was comparable between groups (79 +/- 28 vs 81 +/- 25 mmHg, P = 0.92). The LVOT gradient reduction at acute DDD pacing was significantly greater in group I than group II (61 +/- 18% vs 23 +/- 10%, P = 0.0001). This difference in favor of the patients from group I was maintained at midterm follow-up (69 +/- 17% vs 40 +/- 17% P = 0.0076). In conclusion, patients with normal septal curvature and preserved elliptical LV cavity shape had a greater reduction of LVOT gradient after DDD pacing than patients with reversed septal curvature deforming LV cavity. The proposed criterion assessing the septal curvature may be useful to predict the efficacy of DDD pacing in the reduction of LVOT gradient.

Natural history of hypertrophic cardiomyopathy

Hypertrophic cardiomyopathy is a disease of the cardiac sarcomere and is the most common inherited cardiovascular disorder affecting up to 1 in 500 people in the general population. The disease is typified by variable clinical penetrance and heterogeneous clinical expression, resulting in a wide range of clinical manifestations. Most patients have few if any symptoms and a relatively benign clinical course. A minority are at risk of serious complications including ventricular arrhythmia, sudden death, thromboembolism, congestive cardiac failure, heart block, and infective endocarditis. This article reviews the natural history of the disease, with particular emphasis on lessons learned from recent genetic studies.

Gender differences in the presentation of adult obstructive hypertrophic cardiomyopathy with resting gradient: a study of 122 patients

The present study investigated gender differences among adult patients with obstructive hypertrophic cardiomyopathy (OHCM) and resting gradient. Using outflow gradients >10 mmHg and the presence of asymmetrical septal hypertrophy of the left ventricle as inclusion criteria, 122 patients were identified among patients referred for echocardiographic examinations between May 1990 and October 1996. Clinical, echocardiographical and follow-up data were compared between male and female patients. The female patients were significantly older than male patients (mean age +/-SD 66.7+/-10.5 vs 54.8+/-12.5 years). The female patients had a smaller interventricular septal wall thickness, less frequent systolic anterior movement of the mitral valve, more frequent association with hypertension, and less frequent association with ischemic heart disease (IHD) and giant T wave inversion. In this study population, adult female patients presented with OHCM 12 years later than males. Whether this represents female patients' reluctance to seek medical attention early, a different disease process that affects predominantly elderly females, or a gender-specific end organ response to aging, hypertension, IHD and other processes, or the protective effects of estrogen remains to be determined.

Assessment of permanent dual-chamber pacing as a treatment for drug-refractory symptomatic patients with obstructive hypertrophic cardiomyopathy. A randomized, double-blind, crossover study (M-PATHY)

BACKGROUND

Dual-chamber pacing (DDD) has been proposed as a treatment alternative to surgery for severely symptomatic patients with obstructive hypertrophic cardiomyopathy (HCM), based largely on uncontrolled studies.

METHODS AND RESULTS

This prospective, multicenter trial assessed pacing in 48 symptomatic HCM patients with >/=50 mm Hg basal gradient, refractory to drug therapy. Patients were randomized to 3 months each of DDD pacing and pacing backup (AAI-30) in a double-blind, crossover study design, followed by an uncontrolled and unblinded 6-month pacing trial. With randomization, no significant differences were evident between pacing and no pacing for subjective or objective measures of symptoms or exercise capacity, including NYHA functional class, quality of life score, treadmill exercise time or peak oxygen consumption. After 6 additional months of unblinded pacing, functional class and quality of life score were improved compared with baseline (P<0.01), but peak oxygen consumption was unchanged. Outflow gradient decreased 40%, 82+/-32 mm Hg to 48+/-32 mm Hg (P<0. 001), and was reduced in 57% of patients but showed no change or an increase in 43%. At 12 months, 6 individual patients (12%) showed improved functional capacity; each was 65 to 75 years of age. Left ventricular wall thicknesses in the overall study group showed no remodeling between baseline (22+/-5 mm) and 12 months (21+/-5 mm; P=NS).

CONCLUSIONS

(1) Pacing cannot be regarded as a primary treatment for obstructive HCM; (2) with randomization, perceived symptomatic improvement was most consistent with a substantial placebo effect; (3) longer, uncontrolled pacing periods were associated with some subjective benefit but unaccompanied by objective improvement in cardiovascular performance and should be interpreted cautiously; (4) modest reduction in outflow gradient was achieved in most patients; and (5) a small subset (12%) >/= 65 years of age showed a clinical response, suggesting that DDD pacing could be a therapeutic option for some elderly patients.

Clinical profile of hypertrophic cardiomyopathy identified de novo in rural communities

OBJECTIVES

The purpose of this study was to assess the extent to which hypertrophic cardiomyopathy (HCM) exists unsuspected and undetected in the general population.

BACKGROUND

Hypertrophic cardiomyopathy is a disease with diverse natural history for which the potential to produce adverse consequences has been emphasized. However, the possibility of this disease remaining clinically dormant for many years has not been as widely appreciated. Certainly, the clinical recognition of previously undiagnosed patients with HCM may be advantageous by permitting risk stratification for sudden cardiac death or for timely pharmacologic therapy when symptoms intervene.

METHODS

We prospectively conducted an echocardiographic survey in 64 primarily rural communities within Minnesota (populations < 10,000) over a 33-month period.

RESULTS

A total of 15,137 echocardiograms were performed at the request of primary care physicians for the purpose of excluding cardiovascular abnormalities. Hypertrophic cardiomyopathy was identified in 44 patients during the survey (0.29%), and 29 of these patients (0.19% of the 15,137 echocardiograms) had not been previously identified as having cardiac disease or HCM. At diagnosis, ages were 16 to 87 years (mean 57); 14 patients were > or = 60 years of age, and only two were < 30 years. Twenty-four patients (83%) had either no or only mild or transient symptoms; 5 (17%) evidenced severe functional limitation; in eight patients the onset of symptoms had been deferred until > or = 70 years of age. Basal left ventricular outflow obstruction (gradients 20 to 82 mm Hg) was evident in 11 patients (38%). Relatively mild phenotypic expression of the disease was substantiated by localized patterns of left ventricular wall thickening occurring more commonly than diffusely distributed hypertrophy (48% vs. 7%, respectively), and electrocardiograms that were frequently normal (about 25%) and rarely showed evidence of left ventricular hypertrophy (10%).

CONCLUSIONS

These prospectively assembled data show that HCM may remain clinically dormant and undetected within community-based rural populations for many years (often to advanced ages) with a not inconsequential prevalence similar to that of HCM in the general population.

Hypertrophic and restrictive cardiomyopathies in the elderly

Congestive heart failure (CHF) increases with age, but most CHF in the elderly is due to diastolic dysfunction with preserved systolic function. The etiology, pathophysiology, diagnosis, natural history, and treatment of hypertrophic and restrictive cardiomyopathies in the elderly are discussed as a paradigm for CHF with normal systolic function. Hypertrophic obstructive and hypertensive hypertrophic cardiomyopathies are compared and contrasted. As an example of a restrictive cardiomyopathy, the various types of amyloidosis and their clinical import in older patients are covered.

Resting echocardiographic features of latent left ventricular outflow obstruction in hypertrophic cardiomyopathy

We determined resting echocardiographic features predictive of latent left ventricular (LV) outflow obstruction in 50 consecutive patients with nonobstructive hypertrophic cardiomyopathy (26 provocable, 24 nonprovocable with amyl nitrite inhalation) to have a better understanding of the pathophysiology of this condition and to identify such patients without pharmacologic provocation. Measurements included wall thickness, type of hypertrophy, LV outflow tract diameter, degree of mitral systolic anterior motion, outflow pressure gradient, and ventricular volume. The direction of the ejection streamline was measured to assess the magnitude of the drag force acting on the mitral valve. Thirteen of 16 patients (81%) with proximal septal bulge were provocable, whereas only 3 of 8 patients (38%) with asymmetric septal hypertrophy and 10 of 26 (38%) with concentric hypertrophy were provocable (p < 0.05). LV outflow tract was significantly narrower and the angle between the ejection flow and the mitral valve was larger in provocable patients. The sensitivity for predicting provocable patients by a combination of a narrow outflow tract (< or = 2 cm) and a large angle (> or = 35 degrees) was 65%, with a specificity of 80% and a positive predictive value of 79%. When these criteria were combined with the presence of septal bulge, the sensitivity was 35%, but the specificity and the positive predictive value were both 100%. Patients with nonobstructive hypertrophic cardiomyopathy with proximal septal bulge, a narrow LV outflow tract, and an oblique angle between the ejection flow and the mitral valve appeared to be predisposed for latent outflow obstruction. These features are consistent with the presence of the large Venturi and drag forces. Thus, the left ventricle, which is capable of increasing both the Venturi and the drog forces on the basis of the morphologic change, contributes to the development of outflow obstruction with amyl nitrite inhalation.

Cardiovascular disease in elderly patients

OBJECTIVE

To provide an overview of the cardiovascular consequences of the normal aging process in humans and to review unique aspects of the diagnosis and management of heart disease in the elderly population.

DESIGN

We reviewed relevant published articles and summarized the diagnostic approaches and treatment recommendations for congestive heart failure, coronary artery disease, cardiac valvular disease, and arrhythmias in elderly patients.

RESULTS

The aging process is associated with predictable anatomic and physiologic alterations in the cardiovascular system. consequently, the manifestations of heart disease in the geriatric population differ from those found in younger patients. Additionally, outcomes of cardiac diseases and therapeutic options change with advancing age because of such factors as alterations in drug metabolism.

CONCLUSION

Age-related changes in the cardiovascular system result from intrinsic cardiac aspects of human senescence, primary cardiac disease, and influence of comorbid conditions on the heart. The natural history of heart disease is generally adversely affected by age. Although many treatment strategies with demonstrated efficacy in younger patients are relevant in the elderly age-group, careful attention to the influence of concomitant illness, the unique physiologic and pharmacologic changes, and the assessment of the potential effect of therapy on survival and quality of life is essential in treating elderly patients.