Comparative study of four physical performance measures as predictors of death, incident disability, and falls in unselected older persons: the insufficienza Cardiaca negli Anziani Residenti a Dicomano Study

OBJECTIVES

To compare the ability of the Short Physical Performance Battery (SPPB), 4-m walk test (4mWT), 6-minute walk test (6MWT), and handgrip strength to predict mortality, incident disability, worsening mobility, and falls in older community dwellers.

DESIGN

Cohort study.

SETTING

Population-based.

PARTICIPANTS

Individuals aged 65 and older n = 561) without prevalent basic activity of daily living (ADL) disability participating.

MEASUREMENTS

Separate logistic regression models were developed to predict incident ADL disability, worsening mobility, and falls in 3 years, and Cox regression models were used to assess 7-year risk of death as a function of the four tests, adjusting for covariates.

RESULTS

Performance tests were reciprocally correlated at baseline. After 3 years, 33 (7.3%) of 453 participants reexamined were disabled in ADLs, 87 (20%) had worsening mobility, and 99 (22%) reported falls. Of the 561 baseline participants, 141 (25%) died over the 7 years. All measures predicted incident ADL disability, with adjusted odds ratios (ORs) per unit increase of 0.85 (95% confidence interval (CI) = 0.77-0.93) for handgrip strength, 0.08 (95% CI = 0.02-0.36) for 4mWT, 0.74 (95% CI = 0.61-0.89) for SPPB, and 0.993 (95% CI = 0.988-0.997) for 6MWT. Handgrip strength (OR = 0.88, 95% CI = 0.83-0.93), 4mWT (OR = 0.33, 95% CI = 0.11-0.94), and SPPB (OR = 0.81, 95%CI = 0.71-0.93) predicted worsening mobility. No measure predicted falls; only SPPB (hazard ratio (HR) = 0.92, 95% CI = 0.85-0.997) and 6MWT (HR = 0.997, 95% CI = 0.995-0.999) predicted death.

CONCLUSION

Performance measures are independent predictors of relevant health outcomes, with the exception of falls. Because SPPB is easily applied and is the only measure predicting incident ADL disability, worsening mobility, and death, it is preferable to the other tests.

A rare case of left ventricular outflow obstruction

We report a patient with a mass originating from the anterior mitral valve leaflet causing severe left ventricular outflow tract obstruction. Noninvasive imaging provided the best diagnostic tools for diagnosis. Histological findings showed a very rare giant blood cyst of the mitral valve.

[Long-term follow-up on ventricular pre-excitation in pediatric age]

AIM

Little is known yet about the clinical aspects of ventricular pre-excitation in pediatric age. In order to define clinical course, assess the risk of malignant arrhythmia and evaluate indications for ablative therapy, we studied 82 consecutive pediatric patients (pts) with this affection (61 males-21 females; mean age at diagnosis 5.1 years, range 1 day-15 years).

RESULTS

Mean follow-up time was 66 months (range 3-252). Fifty-six pts (68.3%) were asymptomatic. One patient, who was affected with hypertrophic cardiomyopathy and died suddenly when she was 2 while her cardiac rhythm was being monitored, had an EKG pattern of asystolia. In 28 pts (19 m - 9 f, 34.1%), episodes of reentrant atrio-ventricular tachycardia, ranging from 160 to 320 beats/minute, were documented. Five pts, four of whom were less than 1 year old, had syncope or cardiac failure due to tachyarrhythmia. As far as maximum incidence of symptoms is concerned, two peaks were observed: within the first year and between 14 and 16 years of age. A transesophageal electrophysiologic study was performed in 22 pts, tachyarrhythmias were induced in 15, and risk criteria were satisfied in 3/22 (13.6%). Five pts underwent catheter ablation of an accessory pathway and this was successful in three of them.

CONCLUSIONS

The clinical course in this series of patients has been benign. Nevertheless, during the first year of life cardiac failure or syncope may occur because of high heart rates. The transesophageal electrophysiologic study, which is also easy to perform in pediatric patients, has been sensitive in assessing the risk of malignant arrhythmia, but it shows low predictive accuracy. Lastly, ablative therapy has shown lower efficacy in children than in adult patients.

[Thiamine-deficiency cardiopathy: a rare cause of cardiac failure in childhood]

Cardiac beriberi is a rare cause of heart failure in infancy and the diagnosis is often very difficult. We describe the case of a 4-year-old girl admitted to our Hospital with symptoms of heart failure and diagnosis of myocarditis. In children with acute cardiac failure and suggestive history and signs of peripheral neuropathy, thiamine deficiency should be suspected.

[The sports fitness of patients operated on for aortic coarctation: assessment by exercise Doppler echocardiography]

BACKGROUND

The aim of this study was to assess the utility of Doppler echocardiography both at rest and during isotonic exercise in evaluating competition eligibility of patients with repaired coarctation of the aorta (CoAo).

METHODS

Seventeen young patients (11 male, 6 female; mean age 17.1 +/- 7.9 years) with previous surgical repair of CoAo were examined. Mean follow-up after repair was 10.3 +/- 3.5 years. All patients underwent complete Echocardiographic examination (M-mode, 2D and Doppler) and an exercise test on an ergometric bicycle, with continuous wave Doppler monitoring of flow velocity in descending aorta, with a transducer positioned in the suprasternal notch. Peak and mean Doppler gradients in descending aorta were measured both at rest and during exercise, using the simplified Bernoulli equation. According to peak Doppler gradient at rest, patients were divided into two subgroups: Group IA = patients with peak gradient lower than 25 mmHg; Group IB = patients with peak gradient greater than 25 mmHg. Finally, 17 healthy subjects (Control Group), matched for age and body surface area, were examined.

RESULTS

Systolic and diastolic blood pressure both at rest and during exercise were not significantly different in the 3 groups. Patients of Group IB showed a significant increase of left ventricular mass (124.0 +/- 24.4 vs 85.8 +/- 24.1 g/m2, p < 0.01), and during exercise, a significant increase of peak gradient (68.3 +/- 27.2 vs 23.5 +/- 9.0 mmHg, p < 0.0001) and mean gradient (34.8 +/- 11.5 vs 11.9 +/- 5.0 mmHg, p < 0.0001) at the level of the descending aorta. In patients of Group IA, echocardiographic parameters were not different in comparison with the Control Group, whereas Doppler gradients during exercise were only slightly greater than those observed in the Control Group (peak gradient 36.9 +/- 13.0 vs 23.5 +/- 9.0 mmHg, p < 0.05; mean gradient 19.6 +/- 6.0 vs 11.9 +/- 5.0 mmHg, p < 0.05). However, 4 patients of Group IA showed a peak gradient during exercise greater than 40 mmHg (this value was equivalent to the mean value plus 2 Standard Deviations, observed in the Control Group) with the presence of diastolic flow, whereas exercise systolic blood pressure was lower than 200 mmHg.

CONCLUSIONS

Thus, as a result of this study aimed at evaluating competition eligibility in patients with repaired CoAo, two subgroups of patients have to be distinguished according to Doppler echocardiography results: a) patients with peak Doppler gradient at rest greater than 25 mmHg, for whom competition is forbidden; b) Patients with peak gradient lower than 25 mmHg who must be investigated with exercise Doppler echocardiography to exclude an abnormal increase of Doppler gradients, even if exercise blood pressure is within normal limits.

[Evaluation with Doppler echocardiography of the Bjork-Shiley Monostrut prosthesis in the mitral position]

The Doppler characteristics of Björk-Shiley Monostrut prostheses in mitral position were studied in 53 patients (35 women; 18 men; mean age 53.8 yrs). Valvular function was considered normal on the basis of clinical and echocardiographic evaluation. Mean follow-up after surgery was 23.9 +/- 12.0 months (range 9-53). M-mode, two-dimensional and colour flow mapping echo were performed in each patient. Transvalvular blood flow characteristics were examined by colour flow imaging whereas peak and mean gradient through the valve, pressure half-time and prosthetic area were calculated using continuous wave Doppler. In 84% of patients, colour flow mapping showed a transprosthetic flow with 2 jets; in 78% the jets were different: the main one was directed towards the free wall of left ventricle in 52% and towards the interventricular septum in 48%. Thus, the main jet direction was dependent on the spatial position of the prostheses and the orientation of the disc. In 16% a single jet flow was present during the whole diastole. CW Doppler showed the following parameters: peak velocity 1.6 +/- 0.3 m/s; peak gradient 10.7 +/- 3.9 mmHg; mean gradient 3.8 +/- 2.3 mmHg; pressure half-time 83.3 +/- 16.6 msec; prosthetic area 2.7 +/- 0.51 cm2. No statistically significant difference was found between different size prostheses. Our data show the excellent long term hemodynamic parameters of Björk-Shiley Monostrut mitral prosthesis and confirm the value of colour flow mapping in identifying normal transprosthetic flow profile.