Download 老人心電圖之表現差異 EKG Changes in The Elderly

老人心電圖之表現差異
EKG Changes in The Elderly
(波型、心律、振幅、干擾、節奏…).
馬偕紀念醫院心臟內科主治醫師
祁柏慶
老人心電圖之表現差異
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60-80歲& 80歲以上 & 百歲人瑞的心電圖變化
PR interval à bad outcomes? (The ABC study)
AVN conduction and HTN (and aging)
P wave
QRS duration and heart failure
QT interval
Artefactual spikes
Clinical Use of EKG in the elderly
老人心電圖之表現差異
• 60-80歲& 80歲以上 & 百歲人瑞的心電圖變
化
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PR interval à bad outcomes? (The ABC study)
AVN conduction and HTN (and aging)
P wave
QRS duration and heart failure
QT interval
Artefactual spikes
Clinical Use of EKG in the elderly
60-80歲的心電圖變化
• 族群: 171 位60歲以上的健康老人
• EKG完全正常: 38.6%
• 主要的EKG異常有:
– Sinus bradycardia in 31 (18.1%)
– LVH in 25 (14.6%) subjects,
– Premature supraventricular beats in 16 (9.4%) subjects,
– T wave changes in 11 (6.4%) subjects
– RBBB 16 (9.4%) subjects.
– Poor R wave progression in precordial leads in 9 (5.3%)
– Right atrial overload in 4 (2.4%)
Nepal Med Coll J. 2006 Jun;8(2):128-32.
ECG changes : 80s (octogenarians)
• Normal in 27.27 %
• 主要的異常有:
– RBBB 15.15%,
– LVH in 13.93%,
– Poor R-wave progression in precordial leads: 10.91%,
– Atrial fibrillation in 8.48%,
– ST changes in 8.48%,
– Sinus tachycardia in 6.66% and
– Sinus bradycardia in 4.84%
• The mean QTc was 0.41s.
Nepal Med Coll J. 2011 Sep;13(3):216-9.
60-80y/o
vs
>80y/o
Healthy Subjects
EKG完全正常: 38.6%
Normal in 27.27 %
• Sinus brady:18.1%
• RA overload: 2.4%
• Sinus brady: 4.84%
• Atrial fibrillation:
8.48%,
• Sinus tachy: 6.66%
• LVH: 13.93%,
• ST changes: 8.48%,
• RBBB: 15.15%,
• Poor R-wave
progression : 10.91%,
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PAC: 9.4% subjects,
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LVH: 14.6%,
T wave changes:6.4%
RBBB: 9.4%
Poor R wave
progression in precordial
leads: 5.3%
Centenarians > 100y
Eastern Sicily, Italy
• 典型常見的變化: prolonged PR and QT intervals, QRS leftaxis deviation and microvolt T wave.
• 42健康的百歲人瑞
(12 males, 30 females; average age 101.43 ± 1.80 years)
• PR interval mean duration: 190 ± 3.3 ms, QRS: 90 ± 1.4 ms,
QTc interval : 370 ± 3.5 ms.
• Entirely normal ECG recordings were found in 7 centenarians
(16.6%).
• The most frequently observed abnormalities included LAD
and LAHB in 16 centenarians (38.09%)
• LVH and ST-T wave abnormalities in 13 subjects (30.95%)
Gerontology. 2012;58(3):216-20.
Centenarians vs Octagenarian
• Hospitalized patients: 55 centenarians (vs disease-matched octa)
• Centenarians vs octogenarians
– higher heart rate : (81 ± 15 bpm vs. 72 ± 15 bpm, P <0.001)
Less frequently on beta-blockers (7% vs. 36%, P < 0.001).
More frequently APC than octogenarians (18% vs. 3%, P < 0.001)
Tended to have “less” atrial fibrillation (15% vs. 22% respectively, P = 0.21).
More frequently left axis deviation (48% vs. 28%, P = 0.009) and Q waves
(14% vs. 1%, P = 0.02).
– QT interval was more prolonged in centenarians (446 ± 42 ms vs. 429 ± 39 ms,
P = 0.008)
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• Two centenarians (4%) and 24 (15%) octogenarians had a
strictly normal ECG (P= 0.02).
Ann Noninvasive Electrocardiol. 2012 Oct;17(4):372-7.
老人心電圖之表現差異
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60-80歲& 80歲以上 & 百歲人瑞的心電圖變化
PR interval à bad outcomes? (The ABC study)
AVN conduction and HTN (and aging)
P wave
QRS complex
QT interval
T wave
Artefactual spikes
Clinical Use of EKG in the elderly
PR intervalà bad outcome?
• PR interval increases with aging, differs by race,
• Associated AFib, pacemaker implantation, and all-cause mortality.
• Health, Aging, and Body Composition (Health ABC) Study
– Prospective, biracial cohort. 2722 Health participants
– (aged 74±3 years, 51.9% women, 41% black).
• Results:
• Every SD increase (29 ms) in PR interval à
– 13% greater 10-year risk of heart failure (95% CI: 1.02-1.25) and
– 13% increased risk of incident AF (95% confidence interval, 1.04-1.23).
• PR interval >200 ms à
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a 46% increased risk of incident heart failure (95% confidence interval, 1.11-1.93).
• PR interval was not associated with increased all-cause mortality.
• àSignificant relationships of PR interval to heart failure and
AF in older adults.
Electrocardiographic PR interval and adverse outcomes in older
adults: the Health, Aging, and Body Composition study.
Circ Arrhythm Electrophysiol. 2013 Feb;6(1):84-90
The Health ABC study
• Survival curves: PR interval and incident
outcomes examined during 10-year follow-up.
Circ Arrhythm Electrophysiol. 2013 Feb;6(1):84-90
AVN conduction in HTN patients
• AV conduction time = PR interval
• Aging à increase in arterial stiffness and pulse
pressure à Hypertension
• Parameters of blood pressure and arterial
stiffness were related to the PR interval and also
influenced its long-term progression
• Link between baseline increased pulse pressure
or arterial stiffness with the prolongation of the
PR interval with aging.
• It is possible that increased arterial stiffness
favors the increase in the PR interval with age.
Atrioventricular conduction in the hypertensive patient:
influence of aging, pulse pressure, and arterial stiffness.
Rejuvenation Res. 2011 Aug;14(4):405-10
老人心電圖之表現差異
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60-80歲& 80歲以上 & 百歲人瑞的心電圖變化
PR interval à bad outcomes? (The ABC study)
AVN conduction and HTN (and aging)
P wave (and Afib)
QRS duration and heart failure
QT interval
Artefactual spikes
Clinical Use of EKG in the elderly
Effect of natural aging on Afib
• Electrocardiographic P-wave analysis
(P wave dispersion: Pmax - Pmin durations)
• Transthoracic echocardiographic
electromechanical coupling interval (EMC), by
TDI.
• Study population:
– 25 healthy individuals aged ≥65 years (group 1)
– 25 control subjects <65 years (group 2)
Aging Clin Exp Res. 2012 Jun;24(3):265-9.
Natural aging on atrial fibrillation
Group 1 (≥65y)
Group 2 (<65y)
P value
Pmax
107.2 ± 3.58 msec
100.0 ± 3.56 msec
<0.001
PD
43.6 ± 4.98 msec
36.5 ± 3.56 msec
<0.001
Left atrial EMC
24.6 (15.20)
13.3 (4.50)
<0.001
inter-atrial EMC
43.2 (16.05)
33.3 (4.75)
<0.01
significantly higher
significantly delayed
• Significant correlation between left atrial diameter, PD,
Pmax, left atrial EMC, and inter-atrial EMC.
• CONCLUSION:
– Aging is correlated with increased LA size and impaired
diastolic relaxation, which may contribute to a greater risk
of AF in terms of prolonged PD and atrial EMC.
Aging Clin Exp Res. 2012 Jun;24(3):265-9.
老人心電圖之表現差異
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60-80歲& 80歲以上 & 百歲人瑞的心電圖變化
PR interval à bad outcomes? (The ABC study)
AVN conduction and HTN (and aging)
P wave
QRS duration and heart failure
QT interval
Artefactual spikes
Clinical Use of EKG in the elderly
Older adults: QRSd> 100ms àà HF
• QRS durationà cardiac structure and function (by MRI) à incident HF ?
• 4591 eligible participants (51% women; 39% white; mean age 61 years),
75 developed incident HF over a mean follow-up of 7.1 years.
• QRSd >100 ms was significantly associated with MRI measures of cardiac
structure and function, as well as incident HF (HR=2.10, 95% CI: 1.29-3.42; P =
0.003)
• Further adjustment for individual LV structural measures, findings were
attenuated to non-significance. Separate adjustment for LV functional
measures yielded only mild attenuation.
• CONCLUSION:
– Prolonged QRSd is potentially a useful marker of LV structure that may predispose to HF
risk.
Mddle-aged and older adults: the Multi-Ethnic Study of
Atherosclerosis (MESA).
Eur J Heart Fail. 2012 Nov;14(11):1285-92
老人心電圖之表現差異
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60-80歲& 80歲以上 & 百歲人瑞的心電圖變化
PR interval à bad outcomes? (The ABC study)
AVN conduction and HTN (and aging)
P wave
QRS duration and heart failure
QTc interval
Artefactual spikes
Clinical Use of EKG in the elderly
QTc and survival rate
• survival rate of 724 men > 60 years
• The survival rate (Kaplan-Meier) analysis was made
among 228 persons.
• Men > 60 years were not observed the prolongation of
QTc with age increase.
• The survival rate of these men depended on QTc
duration:
– if QTc was 380-409 ms the survival rate was better than in
cases QTc > or = 410 ms (p < 0.006).
– The relative risk of a fatal outcome in men with QTc
duration > or = 410 ms was 1.6 times more than in men
with QTc duration 380-409 ms (95 % CI 1.1-2.3).
[Survival rate of older men in dependence of QT corrected
interval duration]
Adv Gerontol. 2012;25(1):162-5.
Repolarization dispersion
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• Increase of QT dispersion is associated with higher
cardiovascular mortality.
• Age ≧85 years (n = 29, 89 ± 4 years)
• Age 75-84 years (n = 33, 79 ± 3 years)
• Age 65-74 years (n = 32, 68 ± 3 years).
• QT dispersion: (46 ± 21, 47 ± 17, 69 ± 31 ms, p < 0.005)
– significantly increased in the age group ≧85 years than in
the age group 75-84 years and the age group 65-74 years.
• Aging modulates dispersion of ventricular
repolarization, which may contribute to the cardiac
mortality in the very old Asian population.
Aging modulates dispersion of ventricular
Heart Vessels. 2010 Nov;25(6):500-8.
repolarization in the very old of the geriatric population.
老人心電圖之表現差異
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60-80歲& 80歲以上 & 百歲人瑞的心電圖變化
PR interval à bad outcomes? (The ABC study)
AVN conduction and HTN (and aging)
P wave
QRS complex
QT interval
T wave
Artefactual spikes
Clinical Use of EKG in the elderly
Artefactual spikes in EKG
• ~ a worthwhile introspection.
• Common sources of electrical interferences
– external devices, such as alternating current and
improper earthing,
– surgical procedures like diathermy.
– inserted bladder stimulator.
• Highlights the importance of precise
identification of artefacts in the interpretation of
ECG, as well as prompt localisation and
elimination of the source of interference.
Singapore Med J. 2013 Feb;54(2):e46-9.
Artefactual spikes in EKG
Artefactual spikes in EKG
Artefactual spikes in EKG
Clinical Use of EKG in the elderly
Association of major and minor ECG
abnormalities with CHD events.
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Health ABC Study Middle-aged adults., aged 70 to 79 years
Population-based study of 2192 white and black older adults
Adjudicated CHD events were collected over 8 years
Baseline and 4-year ECG abnormalities were classified according to the Minnesota
Code as major and minor.
•Major ECG abnormalities : any of the following:
•Q-QS wave abnormalities (MC 1-1 to 1-2-8);
•left ventricular hypertrophy (MC 3-1);
•Wolff-Parkinson-White syndrome (MC 6-4-1 or 6-4-2);
• Complete BBB or IVCD (MC 7-1-1, 7-2-1, 7-4, or 7-8);
•atrial fibrillation or atrial flutter (MC 8-3);
•Major ST-T changes (MC 4-1, 4-2, 5-1, and 5-2).
•Minor ECG abnormalities :
•minor ST-T changes (MC 4-3, 4-4, 5-3, and 5-4).
JAMA. 2012 Apr 11;307(14):1497-505.
Association of major and minor ECG
abnormalities with CHD events.
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RESULTS:
At baseline, 276 participants (13%) had minor and 506 (23%) had major ECG abnormalities.
Both baseline minor and major ECG abnormalities were associated with an increased risk of
CHD after adjustment
When ECG abnormalities were added to a model containing traditional risk factors alone,
13.6% of intermediate-risk participants with both major and minor ECG abnormalities were
correctly reclassified
After 4 years, 208 participants had new and 416 had persistent abnormalities. Both new and
persistent ECG abnormalities were associated with an increased risk of subsequent CHD
events (HR, 2.01; 95% CI, 1.33-3.02; and HR, 1.66; 95% CI, 1.18-2.34; respectively).
When added to the Framingham Risk Score, the NRI was not significant (5.7%; 95% CI, -0.4%
to 11.8%).
CONCLUSIONS:
Major and minor ECG abnormalities among older adults were associated with an increased
risk of CHD events. Depending on the model, adding ECG abnormalities was associated with
improved risk prediction beyond traditional risk factors.
JAMA. 2012 Apr 11;307(14):1497-505.
EKG Abnormalities and CV Mortality in
Elderly Patients with CKD
• 1192 participants had CKD at baseline; mean age :
74.7±6.2 years.
– 452 (38.8%) had major,
– 346 (29.7%) had minor,
– 367 (31.5%) had no ECG abnormalities.
Major abnormalities
Ventricular conduction defect (Minnesota codes 7.l, 7.2, 7.4);
Major Q-wave abnormalities (codes 1.1–1.2 except 1.2.8);
Minor Q, QS waves with ST-T abnormalities (codes 1.3 or 1.2.8 and 4.1–4.3 or
5.15.3);
Isolated major ST-T–wave abnormalities (codes 4.1, 4.2, 5.1,
and 5.2, without 3.1, 3.3, or 1.1–1.3; left ventricular hypertrophy
(high-amplitude R waves with major or minor ST-T
abnormalities) (codes 3.1, 3.3, and 4.1–4.3 or 5.1–5.3);
–Atrial
. fibrillation (code 8.3); and
First-degree atrioventricular block (code 6.3).
Clin Interv Aging. 2013;8:293-300. Epub 2013 Mar 10.
EKG Abnormalities and CV Mortality in
Elderly Patients with CKD
• Rates of adjudicated CV events and mortality were compared among the
groups using proportional hazards regression models.
• Participants with estimated GFR < 60 mL/min per 1.73 m2 were more
likely to have ECG abnormalities at baseline (adjusted prevalence odds
ratio, 1.23 [95% confidence interval (CI), 1.06–1.43]) than those with GFR
≥ 60 mL/min per 1.73 m2.
• During mean follow-up of 10.3±3.8 years, 814 (68.3%) participants died.
• Compared with participants without ECG abnormalities, participants with
major abnormalities had the highest risk for cardiovascular events and
death; adjusted hazard ratios were 2.15 (95% CI, 1.56–2.98) and 2.27 (95%
CI, 1.56–3.30), respectively. For minor ECG abnormalities, hazard ratios
were 1.24 (95% CI, 0.91–1.70) and 1.48 (95% CI, 1.00–2.18), respectively.
• Conclusions In patients with CKD, major ECG abnormalities are frequently
present and predict a significantly higher risk for death and adverse
cardiovascular outcomes.
Clin Interv Aging. 2013;8:293-300. Epub 2013 Mar 10.
Conclusion
• In the healthy elderly, sinus bradycardia , LVH,
PAC, STT change, RBBB and PRWP are common.
Afib is more common in age more than 80 years.
• PR interval is related to bad outcomes, including
Afib and heart faliure.
• PR prolong is especially observed in the
hypertensive patients (aging with arterial
stiffness)
• P wave dispersion and electromechanical
coupling increased with age and related to LA
size and Afib.
Conclusion
• QRS duration more than 100ms in the age >
60y/o was reported to be associated with heart
failure
• QTc interval (>410ms) in the elderly is correlated
with CV mortality. QT dispersion is increased with
age.
• Artefactual spikes are a worthwhile
introspections.
• Clinical Use of EKG in the elderly can be as useful
as predictors of CHD in healthy subjects or
mortality in CKD patients.
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