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A&A supplement AM2001-v2.qxd
10.12.2001
11:37
Page 6
CARDIOLOGY
AGEING IS NOT ASSOCIATED WITH QTc
INTERVAL PROLONGATION
AND INCREASED QTc DISPERSION
IN HEALTHY SUBJECTS
DO FAST AMBULANCE RESPONSE AND
AGE HAVE AN IMPACT ON SURVIVAL TO
HOSPITAL DISHARGE OF OUT OF
HOSPITAL CARDIAC ARREST?
A.A. MANGONI, M.T. KINIRONS, C.G. SWIFT AND
S.H.D. JACKSON
E. ABDELAAL, A. AJAJ, S. MOHAMED AND
J. CREAMER
Dept of Health Care of the Elderly, Guy’s, King’s and
St Thomas’ School of Medicine, King’s College
London
Department of Elderly Medicine and Cardiology, City
General Hospital, Stoke-on-Trent
Introduction
QT interval prolongation and increased QT dispersion
are associated with an increased risk of sudden death.
Although previous studies showed an association
between age and QT interval/dispersion, high-risk
patients with other confounding factors were often
considered. We studied the relationship between age
and QT interval/dispersion in a population of healthy
subjects.
Methods
Heart-rate corrected QT interval (QTc, Bazett formula)
and QT dispersion (QTdisp, absolute difference
between the longest and shortest QTc) were calculated from the surface ECG obtained from 175 healthy
subjects undergoing a screening visit between 1990
and 2001. Blood pressure (BP) and heart rate (HR)
were also measured. Subjects were clustered in 3
groups: young (Y, <30 years), middle-aged (M, 30-65
years) and elderly (E, >65 years) subjects.
Results
Table 1 - Baseline characteristics and QT intervals
Age (years)
Systolic BP (mmHg)
Diastolic BP (mmHg)
Mean BP (mmHg)
HR (b/min)
QTc (msec)
Y (n=52)
23.3±0.3
120±2**†
70±1**†
86±1**†
63±1*#
373±3**†
M (n=37)
51.4±2.4
134±2
78±1
97±1
68±1
390±3
E (n=86)
73.8±0.6
144±2
81±1
102±1
66±1
393±3
QTdisp (msec)
37±2
34±3
42±2
Mean±SEM, * p<0.05, ** p<0.01, † vs M and E, # vs M.
Multiple regression analysis showed that gender
(p=0.001) and mean BP (p=0.021) were independent
predictors of QTc, while gender (p=0.019) was the only
predictor of QTdisp.
Conclusions
Ageing is not associated with prolonged QTc and
increased QTdisp in healthy subjects after correcting
for other confounding factors. The relationship between
mean BP and QTdisp might reflect a chronic increase
in cardiac afterload resulting in sub-clinical hypertrophy and inhomogeneous repolarisation.
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Introduction
Survival rates of out of hospital cardiac arrest remain
low despite improvements in providing advanced
cardiac life support. Previous studies suggested that
younger age is one of the predictive factors of survival
following out of hospital cardiac arrest.
Methods
Population based, retrospective study for which data
was collected by reviewing the ambulance and hospital
records of patients who sustained out of hospital cardiac arrest and were admitted to North Staffordshire
Hospital over a 12 months period. A convenience
sample of 158 cases was selected.
Results
We studied 158 cases (56%) the mean age was 67
years with a SD ± 15, 100 (63%) of them were males.
12 patients (7.7%) survived to hospital discharge.
Majority of patients, 142 (90%) had witnessed arrest.
VF was by far the commonest presenting rhythm,
being recorded in 80 cases (51%), followed by EMD in
39 (25%), asystole in 38 patients (24%) and VT in 1
patient. The mean response time for survivors was
05.44 minutes (SD ± 03.2) compared to 6.43 minutes
for non-survivors (SD ± 3.5). The patients who survived had a slightly higher mean age of 70.8 years
versus 66 years for non-survivors.
Conclusion.
Improved survival is associated with fast response
time by ambulance crew, bystander witness and VF
arrest. Although our result was consistent with previous studies we did not find younger age as an important predictive factor for survival.
A&A supplement AM2001-v2.qxd
10.12.2001
11:37
Page 7
CARDIOLOGY
FAMILY HISTORY IN OLDER PEOPLE WITH
VASOVAGAL SYNCOPE
HEAD-UP TILT TABLE TESTING IS SAFE
IN OLDER ADULTS
R. FREARSON, R.A. KENNY, P. DONALDSON AND
J.L. NEWTON
J. LAWSON, L. ARMSTRONG, S. PARRY,
J. NEWTON AND R.A. KENNY
Cardiovascular Investigation Unit (CVIU), Royal
Victoria Infirmary, Newcastle
Cardiovascular Investigation Unit, Royal Victoria
Infirmary, Newcastle upon Tyne
Introduction
Vasovagal syncope (VVS) is a tendency to the common faint. It is a cause of blackouts and falls in older
people. Diagnosis is made by head up tilt (HUT) with
symptom reproduction, however it is often made from
clinical features alone. In one series positive family
history aided diagnosis in subjects presenting ≤age 20
(Mathias et al., Lancet 2001). The aim of this study
was to determine whether positive family history for
blackouts predicts diagnosis of VVS in older compared
to younger patients.
Introduction
The prevalence of syncope in older adults is 10%;
30% 2 yr recurrence. 15% is due to vasovagal
syncope (VVS). The preferred investigation for VVS is
head-up tilt (HUT). Its safety in older adults has not
been reported. The study objective was to review
consecutive adults over 60 yrs attending a syncope
and falls facility who had HUT in order to determine
the incidence of serious adverse events during HUT.
Methodology
1993-99, 543 individuals were diagnosed with VVS by
positive HUT with symptom reproduction and were
identified from the CVIU database. Questionnaires
were sent to all subjects requesting first degree
relative history of blackouts.
Results
Information was received from 392/543 subjects
(72%), 58/392(15%) had died, therefore family history
was available from 334/392 (85%). 207/334 (62%)
were ≥age 65. Overall 66/334 (20%) had positive
family history. 30/66 (45%) with positive family history
were aged ≥65 (30/207(15%)). Mean (95% CI) age of
those with family history of blackouts was 61.4 (57-66)
vs 68.5(67-70) in those without positive family history
(p<0.001). Those ≤age 50 were significantly more
likely to have positive first degree relative history of
blackouts than ≥65 (OR 0.38 (95%CI 0.19-0.76,
p=0.009).
Conclusions
VVS is equally common in older adults. Family history
of blackouts is significantly more likely in younger
adults. Nonetheless, 15% of those with VVS ≥age 65
did have a family history. VVS is more likely to be
secondary to culprit medications or cardiovascular comorbidity in older adults, this may explain the age
related differences in family history.
Method
HUT procedures:
1 HUT to 70º for 40 minutes with no drug provocation; and
2 HUT to 70º for 20 minutes with 800 mcg sublingual
GTN if the initial test is not diagnostic.
Consecutive cardiovascular records were analysed.
Positive test: fall in the systolic blood pressure >50%
of baseline or to less than 90mmHg with or without
significant heart rate slowing. Diagnostic test: when
blood pressure fall associated with symptom-reproduction. Significant complications: cardiac (myocardial
infarction, serious arrhythmia or neurological (cerebrovascular event)).
Results
3189 patients attended; 1704 had HUT; 456 also had
GTN HUT; mean age 75 (60-90); 69% Female.
Hypertension
Ischaemic heart disease
Cerebrovascular disease
Atrial fibrillation
Heart failure
Diabetes
Positive HUT
Positive GTN HUT
Diagnostic HUT
Adverse events
Number
266
253
123
76
27
71
328
208
327
None
(%)
(16)
(15)
(7)
(5)
(2)
(4)
(20)
(48)
(19)
Conclusions
Head-up tilt is a safe procedure in older patients using
this protocol.
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A&A supplement AM2001-v2.qxd
10.12.2001
11:37
Page 8
CARDIOLOGY
ORTHOSTATIC HYPOTENSION:
A COMPARISON OF DIGITAL ARTERY
PHOTOPLETHYSMOGRAPHY WITH
A STANDARD BLOOD PRESSURE
MEASUREMENT TECHNIQUE
TOLERABILITY OF BISOPROLOL
IN OLDER PERSONS WITH CONGESTIVE
HEART FAILURE
A. MOORE, M. WATTS, S.H.D. JACKSON,
C.G. SWIFT AND D. LYONS1
A.J. BAXTER, A. SPENSLEY, J.E. O’CONNELL AND
C.S. GRAY
Clinical Age Research Unit, Kings College Hospital,
London, 1Clinical Age Assessment Unit, Mid-Western
Regional Hospital, Limerick
Department of Geriatric Medicine, University of
Newcastle, Sunderland Royal Hospital
Introduction
Tilt table testing with continuous beat to beat (phasic)
assessment of blood pressure (BP) changes is being
increasingly used to diagnose orthostatic hypotension
(OH). We undertook this study to compare the differences in BP results obtained with simultaneous semiautomatic sphygmomanometry (SAS) and digital
artery photoplethysmography (DAP) upon head up tilt
in older patients with symptomatic OH.
Methods
All patients referred for tilt table testing who described
posturally related symptoms of cerebral hypoperfusion
completed a symptom questionnaire prior to testing.
BP monitoring was carried out with simultaneous SAS
and DAP. Patients were included in the study only if
head up tilt reproduced symptoms and produced a
drop in systolic BP (SBP) >20mmHg or diastolic BP
(DBP)>10mmHg. Mean figures were calculated for
both measurement techniques for systolic, diastolic
before and after tilt. The mean results for each technique were compared with unpaired t tests.
Results
Results were collected on 31 patients. The mean
change in SBP as recorded by DAP and SAS respectively were 41mmHg (95% CI 27,55) and 27mmHg
(95% CI 18,36 ). The mean change in DBP as recorded by DAP and SAS respectively were 13mmHg (95%
CI 9,17) and 11mmHg(95% CI 7,15). The difference
between the recorded BP reductions for each of the
measurement techniques was significant for SBP
(p=0.008) but not for DBP (p=0.59).
Conclusion
DAP detected significantly larger SBP reductions than
SAS in older patients with symptomatic OH. No
significant difference in detecting DBP changes was
found between the two techniques.
8
Introduction
CIBIS II showed the addition of bisoprolol to ACE
inhibitors and diuretics improves mortality and
morbidity in patients with congestive heart failure
(CHF). 85% of participants tolerated bisoprolol and
50% achieved target dose of 10 mg. Mean age of
participants was <65 years, and patients >80 years of
age were excluded [CIBIS-II Investigators. The Cardiac
Insufficiency Bisoprolol Study II (CIBIS-II): a randomised trial. The Lancet. 1999; 353: 9146]. Hence the
tolerability of bisoprolol in older persons remains
unclear. The aim of this study was to determine the
tolerability of bisoprolol in clinically stable older CHF
patients.
Method
This was a prospective observational study. 51 subjects with a mean age of 79 (range 70-89) participated. All had left ventricular systolic dysfunction proven
by transthoracic echocardiography, were clinically
stable, and established on maintenance doses of a
diuretic and an ACE inhibitor. Subjects were given
bisoprolol 1.25 mg and the dose was increased at
weekly intervals to 2.5, 3.75 and 5mg, then at monthly
intervals to 7.5 and 10mg. Target dose was 10 mg.
Reasons for intolerance at each bisoprolol titration was
recorded.
Results
35 (69%) patients tolerated bisoprolol. Mean tolerated
dose 7.6 mg (range 1.25 to 10mg). 21 patients
tolerated 10 mg, 4 patients tolerated 7.5mg and 1
patient 5mg. Reasons for intolerance were either
worsening cardiac failure or side effects of bisoprolol.
Conclusion
Two thirds of older CHF patients can tolerate bisoprolol in comparable doses to participants in CIBIS II.
Whilst intolerance in older persons was twice as
frequent, the majority should still realise therapeutic
benefits from bisoprolol therapy.