Evaluation of the systolic murmur in the elderly

Do systolic murmurs predict mortality in the elderly? A 15-year longitudinal population study of 70-year-olds

Systolic murmurs are common in the elderly but there is a striking paucity regarding published reports on their clinical significance and relation with mortality. This study describes prevalence of systolic murmurs in the elderly and cardiovascular diseases in 70-year-olds with or without systolic murmurs, and investigates the relation between systolic murmurs at age 70 and 15-year mortality. This cohort study is based on 973 (449 males and 524 females) 70-year-olds from Göteborg, Sweden who were examined in 1971/1972 at the Department of Geriatric Medicine, Göteborg University, and was followed-up to the year 2001. The prevalence of systolic murmur was 31% (females 36.4%, males 23.9%). Among subjects with systolic murmurs the prevalence of coronary heart disease (CHD) and hypertension was significantly higher in both sexes and congestive heart failure (CHF) in females only. Systolic murmur was a predictor for mortality in females (RR 1.49, 95% CI 1.17-1.91) but not in males (RR 1.14, 95% CI 0.89-1.49). Diagnosis of a cardiovascular disease was a significant predictor in both sexes for mortality irrespective of having systolic murmurs. In conclusion, there is a significant positive association of cardiovascular diseases with systolic murmurs in the elderly. The increased risk for mortality due to the presence of systolic murmur at age 70 is mediated through cardiovascular diseases.

Syncope. Cost-effective patient workup

Syncope is a common problem in primary care practice that presents a diagnostic challenge. Fortunately, the initial evaluation not only identifies the cause in most patients with an identifiable cause, it also defines the prognosis for these patients. A systematic history, physical examination, and 12-lead ECG are the foundation of this evaluation and provide the most cost-effective diagnostic strategy. When signs and symptoms indicate a neurologic, cardiac, or carotid sinus problem, diagnostic procedures such as angiography, electroencephalography, cardiac catheterization, echocardiography, or carotid sinus massage should be added, but only as necessary to confirm the diagnosis. At the University of Cincinnati, we monitor patients with syncope of unknown origin with 24-hour ambulatory ECG recording and interpret the results as outlined in table 2. If not referred for cardiac or neurologic consultation, these patients are evaluated every three months for a year. This approach can minimize unnecessary testing and improve patient care.