INFORMATION SHEET
MASTER CHART
Young old (60-74) 113 (56.5) 56 (56) 0.982
Old old (75-85) 67 (33.5) 33 (33) 0.983 Very old (>85) 20 (10.0) 11 (11) 0.949 Total 200 (100) 100 (100)
P > 0.05
52
In Table 5, the sex distribution of elderly patients with cardiovascular disease matched with controls showed no statistically significant difference in sex distribution, (P>0.05).
53 Table 5
Sex distribution of elderly patients with cardiovascular disease matched with controls.
Sex Male Female N % N %
P-value
Elder patients Control
121 (60.5) 79 (39.5) 0.061 62 (62.0) 38 (38.0) 0.060 Total 183 117
P >0.05
54
Table 6 shows the frequency of different cardiovascular diseases in the elderly patients(200) involved in this study. A total of seven main groups (with eleven sub-groups) of cardiovascular diseases were diagnosed within the study period. Heart failure top the list 94(47%) of which hypertensive heart failure was the commonest cause 60(63.8%), followed by dilated cardiomyopathy 24(25.5%), and lastly valvular heart diseases 10(10.7%).
Hypertension 77(38.5%) was the second common major cardiovascular disease diagnosed, in which uncomplicated hypertension 57(74%) and diabetic hypertensive 20(26%) form the sub-group diagnosed. Stroke as a major cardiovascular disease was third on the list 16(8%). Other cardiovascular diseases diagnosed are: complete heart block 7(3.5%), sinus node dysfunction 3(1.5%)-comprising sick sinus syndrome 2{66.7%} and bradycardia-tachycardia syndrome 1{33.3%}), pulmonary embolism 2(1.0%) and unstable angina 1(0.5%).
55 Table 6
Frequency of different cardiovascular diseases in the elderly patients presenting at Cardiac Care Unit of OAUTHC
Diagnosis Frequency % Heart failure 94 47.0 Hypertension 60 63.8 Cardiomyopathy 24 25.5 Valvular heart disease 10 10.7 Hypertension 77 38.5 Uncomplicated hypertension 57 74 Diabetic hypertensive 20 26 Stroke 16 8.0 Complete heart block 7 3.5 Sinus node dysfunction 3 1.5 Sick sinus syndrome 2 66.7 Bradycardia –Tachycardia syndrome 1 33.3 Pulmonary embolism 2 1.0 Unstable Angina 1 0.5 Total 200 100.0
56
The different cardiovascular disease patterns among sub-groups of the elderly patients are shown in Table 7. Heart failure and
hypertension rank first and second respectively in all the age groups. No case of cardiomyopathy was found in the very old (>85years) subgroup.
Those that presented with unstable angina and bradycardia–tachycardia syndrome were in the very old (>85years) subgroup. The two cases of pulmonary embolism that were seen are in the young old (60-74years) subgroup. Other cases such as diabetic- hypertensive, stroke, valvular
heart disease, complete heart block, were all distributed in the three age groups. No case of sinus node dysfunction was found in the young
old (60-74%) group.
57 Table 7
Frequency of different cardiovascular diseases among sub- groups of the elderly patients presenting at the Cardiac Care
Unit OAUTHC.
Diagnosis Young old Old old Very old P-value (60-74years) (75-85years) (>85years)
Heart failure 52(55.3%) 31(33.0%) 11(11.7%) 0.019 Hypertension 32(61.5%) 21(67.7%) 7(63.6%) 0.022 Cardiomyopathy 18(34.6%) 6(19.4%) 0(0%) 0.000 Valvular heart disease 2(3.9%) 4(12.9%) 4(36.4%) 0.044 Hypertension 45(58.4%) 26(33.8%) 6(7.8%) 0.005
Uncomplicated hypertension 34(75.6%) 19(73.1%) 4(66.7%) 0.000 Diabetic hypertensive 11(24.4%) 7(26.9%) 2(33.3%) 0.001 Stroke 10(62.5%) 5(31.3%) 1(6.2%) 0.115 Complete heart block 2(28.6%) 4(57.1%) 1(14.3%) 0.023 Sinus node dysfunction 0(0%) 1(33.3%) 2(66.7%) 0.017 Sick sinus syndrome 0(0%) 1(100%) 1(50%) 0.048 Bradycardia –Tachycardia 0(0%) 0(0%) 1(50%) 0.000 syndrome
Pulmonary embolism 2(100%) 0(0%) 0(0%) 0.000 Unstable Angina 0(0%) 0(0%) 1(100%) 0.000
58
The frequency of different cardiovascular findings among subgroup of normal elderly control subjects when compared with the elderly patients with cardiovascular disease are shown in Table 8. All the clinico-radiologic parameters were statistically significant (P<0.05), except thickened arterial wall which show no statistical significant in the very old (>85years) compared with control, P=0.94.
59 Table 8
Frequency of different cardiovascular findings among subgroup of normal elderly control subjects compared with the patients using
clinical and Radiological findings.
CV Findings
Young old (60-74years) Old old (75-85years) Very old (>85years) Patients Control p-value Patients Control p-value Patients Control p-value TAW 103(92%) 38(71%) 0.02 67(100%) 33(100%) 0.94 20(100%) 11(100%) 0.94 Brady 4(3.5%) 0(0%) 0.04 5(7.5%) 0(0%) 0.04 2(10%) 0(0%) 0.04 LMB 58(51%) 8(14%) 0.00 40(60%) 10(30%) 0.01 15(75%) 5(45%) 0.03 WPP 11(10%) 2(4%) 0.00 12(18%) 3(8%) 0.01 6(30%) 2(20%) 0.04 PH 6(5%) 1(2%) 0.00 12(18%) 4(12%) 0.04 7(35%) 2(20%) 0.04 S4 43(38%) 6(10%) 0.00 33(50%) 7(21%) 0.00 12(60%) 4(36%) 0.01 BC 35(31%) 2(4%) 0.00 25(37%) 5(15%) 0.01 12(60%) 4(36%) 0.02 Cal. On 45(40%) 15(26%) 0.01 50(75%) 16(50%) 0.03 17(88%) 8(72%) 0.03 CXR
CV = Cardiovascular Brady = Bradycardia
TAW = Thickened arterial wall LMB = Locomotor brachialis BC = Basal crackles
WPP = Wide Pulse Pressure PH = Postural hypotension
Cal on CXR = Calcification seen on CXR (Aorta, valve annuli and leaflets)
60
Table 9 shows the frequency of different cardiovascular findings among subgroup of normal elderly control subjects when compared with the elderly patients with cardiovascular disease using electrocardiography parameters. All the parameters show statistical significance, P<0.05.
61 Table 9
Frequency of different cardiovascular findings among subgroup of normal elderly control subjects compared with the patients using
ECG findings CV
Findings
Young old (60-74years) Old old (75-85years) Very old (>85years) Patients Control pvalue Patients Control pvalue Patients Control pvalue Brady 4(35%) 0(0%) 0.04 5(7.5%) 0(0%) 0.04 2(10%) 0(0%) 0.04 LAE 66(58%) 3(5%) 0.00 41(61%) 3(9%) 0.00 14(70%) 0(0%) 0.00 APC
PR-Pro
10(9%) 2(3%) 0.00 9(13%) 1(6%) 0.01 3(15%) 1(10%) 0.04 11(10%) 2(3%) 0.02 17(25%) 5(15%) 0.03 8(40%) 3(27%) 0.02 RBBB 10(9%) 3(5%) 0.03 13(20%) 3(10%) 0.02 7(35%) 2(18%) 0.02 LVH 70(61%) 3(6%) 0.00 41(61%) 3(8%) 0.00 14(70%) 1(10%) 0.00 VPC 19(17%) 4(7%) 0.02 20(30%) 5(15%) 0.01 6(32%) 2(20%) 0.03
CV = Cardiovascular Brady = Bradycardia
LAE = left atrial enlargement APC = Atrial premature complex PR-Pro – PR prolongation
RBBB = Right bundle branch block LVH = left ventricular hypertrophy VPC = ventricular premature complex
62
In Table 10, the results of echocardiography parameters were shown which assess the frequency of different cardiovascular findings among subgroup of normal elderly control subjects, when compared with the patients with cardiovascular disease. All the parameters show statistical significance (P<0.05) except sclerosis and calcification in the very old subgroup, (P=0.06).
63 Table 10
Frequency of different cardiovascular findings among subgroup of normal elderly control subjects compared with the patients using
echo findings.
CV Findings
Young old (60-74years) Old old (75-85years) Very old (>85years)
Patients Control p-value Patients Control p-value Patients Control p-value LAE 78(69%) 6(10%) 0.00 47(70%) 4(11%) 0.00 16(80%) 1(10%) 0.06 S and C 80(71%) 19(35%) 0.00 61(91%) 24(72%) 0.02 20(100%) 10(95%) 0.00 LVMI(high) 58(51%) 6(10%) 0.00 40(60% ) 5(15%) 0.01 15(75%) 3(27%) 0.01 SH 58(51%) 6(10%) 0.00 38(57%) 4(12%) 0.00 12(60%) 3(27%) 0.01 SD 66(58%) 8(14%) 0.00 40(60%) 5(15%) 0.00 14(70%) 2(18%) 0.00 DD 91(80%) 6(10%) 0.00 61(91%) 7(21%) 0.00 19(95%) 4(36%) 0.00
CV = Cardiovascular
S and C = Sclerosis and Calcification LVMI = Left ventricular mass index SH = Septal hypertrophy
SD = Systolic dysfunction DD = Diastolic dysfunction
64
Table 11 shows the pattern of cardiovascular diseases in terms of sex distribution in the elderly patients with higher frequency in males in virtually all the diseases conditions such as heart failure(52.1%, P=0.249), hypertension(57.1%, P=0.045), stroke (62.5%, P=0.018), sinus node dysfunction (100%, P=0.000), and pulmonary embolism(100%, P=0.000). Heart failure due to cardiomyopathy was higher in females (31.1%, P=0.043)), while valvular heart disease was equal in both sexes (P=0.983), and unstable angina occurred in female only (100%, P=0.000).
65 Table 11
Sex distribution of cardiovascular disease among elderly patients presenting in the Cardiac Care Unit OAUTHC.
Diagnosis Male Female P-value Heart failure 49(52.1%) 45(47.9%) 0.249 Hypertension 34(69.4%) 26(57.8%) 0.046 Cardiomyopathy 10(20.4%) 14(31.1%) 0.043 Valvular heart disease 5(10.2%) 5(11.1%) 0.983 Hypertension 44(57.1%) 33(42.9%) 0.045
Uncomplicated hypertension 32(72.7%) 25(75.8%) 0.042 Diabetic hypertensive 12(27.3%) 8(24.2%) 0.039 Stroke 10(62.5%) 6(37.5%) 0.018 Complete heart block 5(71.4%) 2(28.6%) 0.128 Sinus node dysfunction 3(100%) 0(0%) 0.000 Sick sinus syndrome 2(66.7%) 0(0%) 0.000 Bradycardia –Tachycardia 1(33.3%) 0(0%) 0.000 Syndrome
Pulmonary embolism 2(100.0%) 0(0%) 0.000 Unstable Angina 0(0%) 1(100%) 0.000
66
In table 12, the dietary pattern between patients with cardiovascular diseases(76% high salt diet, 13% atherogenic diet) and control subjects(74% high salt diet, 10% atherogenic diet) are essentially similar. No statistical significance difference between the two groups(P=0.880). The male (patients was on81% high salt diet, 12% atherogenic diet versus controls on 73% high salt diet, 11%
atherogenic diet,P=0.631) compared with female(patients 74% high salt diet,17% atherogenic versus control 70% high salt diet, 14%
atherogenic diet, P=0.633). No statistical significance difference between male and female P>0.05.
67
Table 12
Dietary pattern among patients with cardiovascular diseases and control subjects.
Patients Control P-value High salt Atherogenic High salt Atherogenic
diet diet diet diet
Dietary pattern 76% 13% 74% 10% 0.880 Male 81% 12% 73% 11% 0.631 Female 74% 17% 70% 14% 0.633
68
Table 13, shows the left ventricular geometric pattern in the elderly patients with cardiovascular diseases and the normal elderly control subjects. In the elderly patients, 29(14.5%) had normal left ventricular geometry, while 171(85.5%) had left ventricular hypertrophy of which 28(16.5%) had concentric remodeling, 48(28.03%) had concentric hypertrophy while 95(55.47%) had eccentric hypertrophy. In the normal control subjects, 80(80%) had normal left ventricular geometry, 20(20%) had left ventricular hypertrophy of which 17(83%) had concentric remodeling, none 0(0%) had concentric hypertrophy and 3(15%) were eccentric hypertrophy. The difference in left ventricular geometric pattern between the two groups was statistically significant (P=0.0001).
69 Table 13
Frequency distribution of left ventricular geometric pattern among elderly patients with cardiovascular diseases and
normal elderly control subjects.
Classification Normal Left ventricular hypertrophy
Conc Rem Conc Hyper Ecc hyper
P-value Patients 29(14.5%) 28(16.5%) 48(28.03%) 95(55.47%)
Control 80(80%) 17(85%) 0(0%) 3(15%)
0.0001
Conc Rem = Concentric Remodeling Conc Hyper = Concentric Hypertrophy Ecc hyper = Eccentric hypertrophy
70
CHAPTER SIX DISCUSSION
Cardiovascular disease is the most frequent diagnosis in elderly people9,10 and is the leading cause of death in both men and women2. Data on cardiovascular disease in elderly patients in our environment are scarce. This study revealed various cardiovascular diseases in elderly patients presenting at the Cardiac Care Unit of the Obafemi Awolowo University Teaching Hospitals Complex (OAUTHC) within the period of study. Over 50% of patients recruited were in the age range 60-74years (young old), while those above 85years (very old) constituted 10% of the patients’
population. This finding is similar to the study done in Kenya by Lodenyo et al80 in Nairobi on cardiovascular disease in elderly in-patients at the Kenyatta hospital. This may not be unexpected for various reasons. Firstly, many of the very old patients are reluctant in going to hospital to receive treatment either as a result of age related dementia or age–related physical incapacitation. Secondly, many are living alone, no income, and neglected thereby having difficulty in getting, utilizing or able to afford health care services.
Thirdly, life expectancy is shorter in this part of the world due to poverty and disease burden81. These may therefore explain the
71
progressive decline in the number of elderly seen in this study as one moves from the young old (60-74years) elderly through the old old (75-85years) to the very old (>85years). Similar observation were found in the control group (normal elderly subjects) though, all the normal age related findings in this group did not have significant influence on the results obtained on the elderly patients with obvious cardiovascular disease since statistical significant difference exist between the two groups except, thickened arterial wall and valve sclerosis/calcification in the very old(>85yearsold) sub-group. These two factors cannot rule out the diagnosis arrived at in the selected elderly patients based on standard criteria used in diagnosis.
The pattern of progressive decline in number of elderly seen in this study was similarly observed in the frequency of different cardiovascular diseases among subgroup of the elderly patients which can also be adduced to the same reasons as above.
However, the trend in valvular heart disease revealed a different pattern with more patients seen in the old old (75-85years) and the very old (>85years), and this is simply because, the types of valvular heart disease commonly seen in elderly patients are those due to age related valvular sclerosis and degenerative calcification,
72
which tend to be commoner at >75years of which the young old (60-74years) does not fall into46,47,48. In this study, nonrheumatic valvular heart disease (degenerative) was the commonest valvular heart disease(90%) and the remaining was rheumatic(10%). In the degenerative cause, pure calcific aortic sclerosis with stenosis was the predominant lesion(60%), followed by mixed aortic and mitral valves involvement(40%). No pure mitral degenerative lesion was found.
Complete heart block, sinus node dysfunction (sick sinus syndrome and bradycardia–tachycardia syndrome) were the three major arrhythmias found responsible for the cardiovascular symptoms that brought the patient to the hospital in this study, of which patients concerned presented with presyncope and syncope and are found in elderly subgroup >75years, which are not unexpected due to the fact that these forms of arrhythmias are due to age related changes (fibrosis) in cardiac conducting tissues82.
A case of ischaemic heart disease was seen with clinical and electrocardiographic diagnosis of unstable angina in a diabetic-hypertensive elderly woman referred from the endocrinology unit.
She fell under the very old (>85years) age group. This is in agreement with Skerett et al83 who reported that diabetes is
73
associated with a greater incremental risk in women for coronary heat disease than men. No case of myocardial infarction in the elderly group was found during this study period.
Two cases of pulmonary embolism seen in this study occurred in the young old (60-75years) elderly group instead of the very old or old old elderly group that are more potentially thrombogenic due to aging and more sedentary life style. However, the cases occurred few days after abdominal and orthopaedic surgery which are commoner risk factors for DVT and hence pulmonary embolism.
More males than females in ratio 1.5:1 were seen in this study. This figure is in accordance with the work of Trigo,84 and this is applicable in all the age groups. Similarly, more males were seen virtually in all the cardiovascular diseases. These findings may not be unconnected to the well established fact that women have fewer cardiovascular events than men85. So also, during the period of study, more men tend to complete their investigations compared to the women in which some of the women were therefore excluded from the study even though similar report by Petrie et al86 documented that following a diagnosis of heart failure, more men frequently undergone echocardiography study, stress testing and
74
catheterization and are more likely to be referred to specialists.
Studies have shown that females have longer life expectancy than males87,88 of which may also explain why more males are seen in this study with cardiovascular diseases which in a way, are factors which contribute to reduce life expectancy. Furthermore, heart disease is far more age dependent in women than in men; women with cardiovascular disease are older and have more comorbidities87,88 and therefore, less women are likely to present at the hospital compared to men.
Heart failure (predominantly chronic heart failure with acute decompensation) was the commonest cardiovascular disease diagnosed during the study period, accounting for 47% of all (of which hypertension, cardiomyopathy, valvular heart diseases were the identified underline causes in decreasing order). This is closely followed by hypertension and third on the list is stroke. This finding corroborated the reports of the American Heart Association88 of which chronic heart failure was first on the list. It stated that the incidence of congestive heart failure and the resulting death rate have risen significantly in recent decades. The reason cited was the aging of the population. In addition to this, the commonest cause of heart failure in our environment is
75
hypertension89, which is generally asymptomatic in which people commonly present when complication such as heart failure has developed. Many hypertensive patients seldom visit hospital for medical check–up because the condition is usually symptomless.
Though, there are scarce data on hospital based elderly study, however, Ogunniyi et al8 in a community based study reported cardiovascular disease as the commonest medical problem though hypertension topped the list as opposed to finding in this study.
One reason for this difference may be the different sample population. The frequency of uncomplicated hypertension in this study (28.5%) is similar to previous report (28.1%)8.
The relatively low frequency of stroke in this study is due to the fact that stroke patients normally present to the neurology unit rather than the Cardiac Care Unit.
Similarly, large majority of diabetic patients present to the endocrinology unit. Valvular heart disease accounted for about 5%
of cases seen; virtually all were due to valvular sclerosis and degenerative calcification. Groups of elderly patient that presented with presyncope and syncopal attack were found to have complete heart block (which topped the list) followed by sinus node dysfunction (sick sinus syndrome and bradycardia-tachycardia syndrome).
76
The sex distribution pattern of cardiovascular diseases obtained in this study showed male preponderance in majority of cases except in cardiomyopathy, and unstable angina where females had higher frequency; though equal frequencies are found in both sexes in valvular heart disease. The sex distribution pattern shows no statistical significance. Many factors may have caused the high incidence of cardiovascular disorder in men, who tend to smoke and drink alcohol more than women. Multiple pregnancy and grandmultiparity are important factors in females when cardiomyopathy is considered. Equal frequency of valvular heart disease found in this study were in contrast to report by Stewart et al90 of which there was two fold higher prevalence of calcific aortic valve disease in elderly men (65years and above) than women, though what accounted for the difference may be as a result of higher number of patients and being a community based study in the latter report.
The frequency of cardiogenic syncope resulting from complete heart block, sinus node dysfunction (sick sinus syndrome and bradycardia-tachycardia syndrome) found to be higher in male are in agreement with previous work done by Freed et al91.
77
In conclusion, heart failure, hypertension and stroke constitute about 93.5% of cardiovascular diseases in elderly patients (60years and above) presenting at the Cardiac Care Unit of OAUTHC, Ile-Ife. Arrhythmias due to conduction abnormalities, sclerosis and degenerative calcific valvular heart disease and ischaemic heart disease predominate in elderly of > 75years of age;
and large majority of the cardiovascular diseases were of higher frequency in male elderly. This study therefore attempted to identify those cardiovascular diseases that require aggressive preventive and curative treatment measures, to reduce morbidity and mortality in the elderly.
78
CHAPTER SEVEN Limitations
1. Loss to follow–up for some patients before complete evaluation may not reflect the true incidence.
2. Patients studied were limited to those presenting at the Cardiac Care Unit. Patients without significant cardiovascular disease clinically are unlikely to be referred for evaluation and therefore some asymptomatic cases might have been missed.
3. Some elderly patients with cardiovascular disease such as cerebrovascular disease may be under the management of Neurologists and therefore were not studied.
4. 24 hour Holter ECG was not carried out and therefore some arrhythmias might have been missed.
79 CHAPTER EIGHT
CONCLUSION AND RECOMMENDATION CONCLUSION:
Heart failure, hypertension and stroke constitute about 93.5% of cardiovascular diseases found in elderly patients presenting at the Cardiac Care Unit of Obafemi Awolowo University Teaching Hospitals Complex, Ile-Ife. Arrhythmias due to conduction abnormalities, sclerosis and degenerative calcific valvular heart diseases, and ischaemic heart disease predominate in the elderly of 75years and above. Large majority of the cardiovascular diseases were of higher frequency in males such as heart failure, hypertension, stroke, sinus node dysfunction, and pulmonary embolism; while heart failure due to cardiomyopathy as well as unstable angina are commoner in females.
RECOMMENDATIONS
There is the need for large multicentre studies on elderly patients with cardiovascular disease to further augment the strength of this finding, bearing in mind the relatively small sample size.
Effort is required by stakeholders which include the physicians, other medical practitioners, patients and government to
80
embark on effective and far reaching preventive cardiovascular medicine particularly directed to risk factors and causes of heart failure, hypertension and stroke, the three of which are responsible for about 93.5% of cardiovascular diseases in the elderly.
81 CHAPTER NINE
LINE OF FUTURE RESEARCH
It will be worthwhile in future to determine the prevalence of cardiovascular diseases in the elderly in a community based study.
82
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