Longitudinal Changes in LV Diastolic Function in Late Life
- Using data from the ARIC study, measures of LV diastolic function worsened late in life during a follow-up interval of 6.6 years (subject age increasing from 74 ± 4 years to 80 ± 4 years).
- Traditional cardiac risk factors were associated with worsening of measures of LV diastolic function.
- Greater increases in measures of LV filling pressure were associated with concomitant increases in pulmonary artery systolic pressure and self-reported dyspnea.
What longitudinal changes occur in left ventricular (LV) diastolic function late in life?
Data from the prospective community-based ARIC (Atherosclerosis in Communities) study were used to identify 2,524 older adult participants who underwent protocol-based echocardiography at both study visit 5 (2011-2013) and visit 7 (2018-2019). The primary measures of LV diastolic function were tissue Doppler e’, E/e’ ratio, and left atrial volume index (LAVi). The presence of dyspnea was self-reported.
Mean age was 74 ± 4 years at visit 5 and 80 ± 4 years at visit 7; 59% of participants were women, and 24% were black. At visit 5, mean e’septal was 5.8 ± 1.4 cm/s, E/e’septal was 11.7 ± 3.5, and LAVi was 24.3 ± 6.7 mL/m2. Over a mean of 6.6 ± 0.8 years between visits, e’septal decreased by 0.6 ± 1.4 cm/s, E/e’septal increased by 3.1 ± 4.4, and LAVi increased by 2.3 ± 6.4 mL/m2. The proportion of participants with ≥2 abnormal diastolic measures increased from 17% to 42% (p < 0.001). Compared to participants free of cardiovascular (CV) risk factors or diseases at visit 5 (n = 234), those with prevalent CV risk factors or diseases but without prevalent or incident heart failure (HF) (n = 2,150) demonstrated greater increases in E/e’septal and LAVi. Greater increases in E/e’septal and LAVi each were associated with greater increases in pulmonary artery systolic pressure (PASP) and LV mass index. In analyses adjusted for CV risk factors, increases of E/e’septal and LAVi both were associated with the development of dyspnea between visits.
Diastolic function generally deteriorates over 6.6 years in late life, particularly among people with CV risk factors, and is associated with development of dyspnea. The authors conclude that further studies are necessary to determine if risk factor prevention or control will mitigate these changes.
HF with preserved ejection fraction (HFpEF) accounts for at least half of all HF; and although the pathophysiology of HFpEF is heterogeneous, LV diastolic function plays a fundamental role. Previous cross-sectional studies have suggested worsening of LV diastolic function at older ages. The ARIC study is a large, predominantly bi-racial epidemiological cohort study that originally enrolled 15,792 subjects in four US communities between 1987 and 1998, and subsequently included standardized echocardiography at study visits 5 (2011-2013) and 7 (2018-2019).
This study, which examines data from a smaller subset of patients with available echocardiography data at visits 5 and 7 and without exclusion criteria including atrial fibrillation and left-sided valve disease, found that measures of LV diastolic function on average worsened late in life, although deterioration was not present in all subjects; that traditional cardiac risk factors were associated with worsening of measures of LV diastolic function; and that greater increases in measures of LV filling pressure were associated with concomitant increases in PASP and self-reported dyspnea. Because younger subjects and subjects with fewer comorbid conditions were more likely to have attended visit 7, survivor bias and attendance bias likely resulted in underestimation of the magnitude of adverse changes in measures of LV diastolic function. As the authors point out, future studies are needed to address whether risk factor modification even late in life can influence the deterioration of LV diastolic function and development of dyspnea or HF.
Keywords: Dyspnea, Echocardiography, Geriatrics, Heart Failure, Risk Factors
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