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Aims To determine the prevalence of left ventricular systolic dysfunction in 75-year-old men and women.Methods and Results In a population-based random sample of 75-year-old subjects (n=433; response rate 70·1%) the left ventricular systolic function was determined using two echocardiographic methods: (1) wall motion in nine left ventricular segments was visually scored and wall motion index was calculated as the mean value of the nine segments and (2) ejection fraction as measured by the disc summation method. Presence of heart failure was determined by a cardiologist's clinical evaluation. Wall motion index was achievable in 95% of the participants while ejection fraction was measurable in 65%. Normal values were obtained from a healthy subgroup (n=108) and left ventricular systolic dysfunction was defined as the 0·5th percentile of the wall motion index (i.e. <1·7). In participants in whom both ejection fraction and wall motion index were achievable, wall motion index <1·7 predicted ejection fraction <43% with a sensitivity and specificity of 84·0% and 99·6%, respectively. The prevalence of left ventricular systolic dysfunction was 6·8% (95% CI, 5·6–8·0%) and was greater in men than in women (10·2% vs 3·4%,P =0·006). Clinical evidence of heart failure was absent in 46% of the participants with left ventricular systolic dysfunction.Conclusions Left ventricular systolic dysfunction is common among 75-year-olds with a prevalence of 6·8% in our estimate. The condition is more likely to affect men than women. In nearly half of 75-year-olds with left ventricular systolic dysfunction there is no clinical evidence of heart failure. [ABSTRACT FROM PUBLISHER]

The mechanisms behind ventricular premature beats may be divided into two main categories, reentry and modulated parasystole. Although it is relatively easy to distinguish among arrhythmia generating mechanisms on the cellular level, it is far more difficult in the clinic. Modulation of ventricular parasystole by sinus beats has been shown to result in a biphasic phase response curve. Two cases are reported where the deduction of such phase response curves from long-term ECG recordings is discussed and described as a stepwise procedure. [ABSTRACT FROM AUTHOR]

Modulation of ventricular parasystole by sinus beats has been shown to result in a biphasic phase response curve. Some reports also indicate that the modulation effect could be described by a triphasic response with an early phase o/acceleration, which would correspond to the supernormal phase of excitability. Two cases of such triphasic phase response curves are reported. The coexistence of ventricular couplets and parasystole is also discussed. The second beat of the couplet has often been explained by reentry or reflection, but could also be interpreted as due to supernormal modulation, resulting in an accelerated second ectopic response. [ABSTRACT FROM AUTHOR]

Background A considerable body of echocardiographic studies has described how athletic training induces morphological adaptation of the left ventricle in male endurance athletes, but only a few studies have described left ventricular adaptation in female endurance athletes. In contrast to changes in the left ventricle far less attention has been directed towards right ventricular changes due to extensive physical exercise. The purpose of this study was to obtain normal values and to determine if there are any differences in right and left ventricular cavity and wall dimensions between female orienteers and females with a mainly sedentary lifestyle.Methods Echocardiography was performed in 42 highly trained elite female orienteers and 32 healthy female students with a predominantly sedentary lifestyle. The 74 females had no history of cardiac disease, a normal electrocardiogram and showed no echocardiographic abnormalities. M-mode and two-dimensional measurements of the right and left ventricular cavity and wall were obtained in elite orienteers and sedentary females. For the right ventricle and wall, multiple cross-sections were used and measurements were obtained from the right ventricular inflow and outflow tract.Results The left ventricular end-diastolic cavity dimension and the left ventricular wall thickness were significantly greater in the athletes compared with the sedentary controls. The right ventricular inflow tract measurements were all significantly greater in the orienteers compared with the controls but the right ventricular outflow tract measurements were comparable in the study groups. The right ventricular wall thickness, calculated as the mean of three different wall measurements was an average of 13% greater in the athletes compared with the sedentary controls.Conclusion This study suggests symmetrical cardiac enlargement with a concomitant increase in both the right and left ventricular wall, probably reflecting the increased haemodynamic loading in the female athletes. [ABSTRACT FROM PUBLISHER]

Exercise-induced myocardial ischemia has been shown to alter left ventricular (LV) diastolic filling. An abnormal response of Doppler indexes of LV filling during and after exercise testing has been demonstrated to be a sensitive marker of coronary artery disease. A paucity of data is available regarding reference values and the physiological variation in LV filling indexes after exercise in healthy subjects of similar age. We therefore evaluated 77 healthy subjects (33 men and 44 women) aged 50 years by Doppler echocardiography at rest and 15 and 60 minutes after exercise testing. The peak velocity of early diastolic filling (E-wave), the peak velocity of atrial filling (A-wave), the early to atrial peak velocity (E/A) ratio and the deceleration time of early velocity were measured. There was a decrease in the E/A ratio 15 minutes after exercise compared with the E/A ratio at rest in women (1.13 +/- 0.23 vs 1.23 +/- 0.27; p <0.001) and men (1.03 +/- 0.22 vs 1.15 +/- 0.20; p <0.001). The E/A ratio 60 minutes after exercise did not differ significantly from rest in women (1.23 +/- 0.27 vs 1.18 +/- 0.24; p = NS), but men had a lower E/A ratio 60 minutes after than before exercise (1.04 +/- 0.23 vs 1.15 +/- 0.20; p <0.001). There was no difference in deceleration time of the E-wave before and after exercise. Multivariate analysis revealed that the E/A ratio 15 and 60 minutes after exercise was strongly independently associated with the E/A ratio at rest (p <0.001) and heart rate 15 and 60 minutes after exercise (p <0.005) in both women and men. It is concluded that there is a physiological decrease in the E/A ratio 15 minutes after exercise in healthy subjects, and Doppler LV filling indexes after exercise are strongly associated with LV filling indexes at rest and with heart rate. [ABSTRACT FROM AUTHOR]

Identifying cardiac disease in patients with extracardiac artery disease (ECAD) is essential for clinical decision-making. Electrocardiography (ECG) is an easily accessible tool to unmask subclinical cardiac disease and to risk stratify patient with or without manifest cardiovascular disease (CV). We aimed to examine the prevalence and prognostic impact of ECG changes in outpatients with ECAD. Outpatients with carotid or lower extremity artery disease (n = 435) and community-based controls (n = 397) underwent resting ECG. The patients were followed during a median of 4·8 years for CV events (hospitalization or death caused by ischaemic heart disease, cardiac arrest, heart failure, or stroke). ECG abnormalities were classified according to the Minnesota Code. Major (33% versus 15%, P<0·001) but not minor ECG abnormalities (23% versus 26%, P = 0·42) were significantly more common in patients versus controls. During the follow-up, 141 patients experienced CV events. Both major ECG abnormalities [hazard ratio (HR) 1·58, 95% confidence interval (CI) 1·11-2·25, P = 0·012] and any ECG abnormalities (HR 1·57, 95% CI 1·06-2·33, P = 0·024) were significantly associated with CV events after adjustment for potential risk factors. In conclusion, ECG abnormalities were common in these outpatients with ECAD. Major and any ECG abnormalities were independent predictors of CV events. Addition of easily accessible ECG information might be useful in risk stratification for such patients., (© 2017 Scandinavian Society of Clinical Physiology and Nuclear Medicine. Published by John Wiley & Sons Ltd.)

Background: Factor analysis reduces a set of directly measured variables into a smaller set of underlying factors representing unique statistically independent domains termed "factors." In middle-aged people, previous factor analyses of the components of the metabolic syndrome have identified two to four factors. Many of these analyses report blood pressure as one of these factors., Methods: We performed a factor analysis of the individual continuous components of the metabolic syndrome among 198 men and 203 women comprising 65% of all 75 year olds from the city of Västerås in Sweden., Results: The metabolic syndrome comprised two factors. Factor 1, the metabolic factor, consisted of waist circumference, high-density lipoprotein cholesterol, triglycerides, and fasting glucose, whereas factor 2, the blood pressure factor, consisted of systolic and diastolic blood pressure. These two factors explained 58% (factor 1, 31%, and factor 2, 27%) of the total variation in men. The corresponding figures for women were 63% (factor 1, 36%, and factor 2, 27%). Factor 1 was significantly related to a decreased 10 years of survival for men, with a hazard ratio (HR) of 1.30 (95% confidence interval [CI] 1.07-1.58, P = 0.008), and nearly significantly for women, with a HR of 1.27 (95% CI 0.98-1.64, P = 0.071). In a pooled analysis adjusting for sex, known cardiovascular disease, and hypertension, high blood pressure, and current smoking, the HR for factor 1 was 1.20 (95% CI 1.02-1.49, P = 0.026). Factor 2 was not significantly related to survival., Conclusions: Factor analysis of the basic variables of the metabolic syndrome among 75 year olds from a general population identified a metabolic factor and a blood pressure factor. The former factor was significantly related to 10-year survival and the relationship remained after adjusting for known cardiovascular disease and hypertension and current smoking.

Background: Insulin resistance (IR) is a risk factor for diabetes and atherosclerotic diseases. The metabolic syndrome (MetS) reflects IR. Waist circumference (WC) is the most easily registered component of MetS. The objective was to compare WC alone with MetS as defined by the National Cholesterol Education Program (NCEP) and the International Diabetes Federation (IDF) for their abilities to predict IR in elderly without known diabetes., Methods: The study included 223 women and 210 men comprising 70% of a random sample of 75-year-olds from a general population. IR was conventionally defined as the gender-specific upper quartile of the Homeostasis Model Assessment-Insulin Resistance (HOMA-IR) index in individuals without known diabetes., Results: 1) The positive association between WC and IR is stronger in women than in men. 2) WC >88 cm alone is nearly as good as MetS, using NCEP criteria, in predicting IR in women. 3) According to the ROC curve, the optimal cut-off point for WC predicting IR was between 96 and 97 cm (men) and between 88 and 89 cm (women). The relative risk of IR was 5.6 (95% CI: 3.1-11.9) for women with WC >88 cm and 1.9 (1.5-2.8) for men with WC >96 cm. 4) The NCEP criteria predicts IR significantly better than the IDF criteria., Conclusion: WC >88 cm in women indicates a high likelihood of IR and is almost as good as MetS defined using the NCEP criteria in predicting IR. MetS defined using the NCEP criteria predicts IR better than MetS defined using the IDF criteria.

Background: A positive relation between the metabolic syndrome (MetS) and inflammatory activity has been reported. The purpose of this investigation was to study the relationships between 1) white blood cell (WBC) count and MetS, 2) WBC count and the individual components of MetS and 3) WBC count and insulin sensitivity in 75-year-old women and men from the general population., Methods: The study included 200 women and 196 men comprising 64% of the 75-year old people from the city of Västerås in Sweden. MetS was defined according to the National Cholesterol Education Program (NCEP)., Results: WBC count (10(9)/L; median and interquartile range) was 5.7 (4.9-6.8) for women and 6.3 (5.4-7.2) for men, P < .001 for gender difference. For women with and without MetS, WBC count was 6.3 (5.3-7.3) and 5.4(4.7-6.3), respectively. For men the corresponding figures were 6.7 (5.9-7.6) and 6.1 (5.4-7.1).The difference in WBC count between individuals with and without MetS was significant (P < .001 for women; P = .014 for men). All individual components of MetS (with exception of blood pressure) were more strongly associated with WBC count for women than for men. Insulin sensitivity, measured as HOMA-IR (HOmeostasis Model Assessment-Insulin Resistance) index, was significantly associated with WBC count in women but not in men., Conclusions: In this elderly population, individuals with MetS had a higher WBC count than those without. Women had a lower WBC count and stronger relationship between WBC count and insulin sensitivity than did men.

Background: Low heart rate recovery (HRR) at exercise test and the metabolic syndrome (MetS) are both predictors of cardiovascular morbidity and mortality. We studied in 75-year-old women and men, representative of the general population, the relationship between (1) HRR and the MetS, (2) HRR and the individual components of the MetS, and (3) HRR and insulin sensitivity., Methods: A cross-sectional study of randomly selected 75-year-olds from a general population was performed (191 women and 194 men). The MetS was defined according to the National Cholesterol Education Program criteria. Heart rate was measured as beats per minute immediately after exercise and at 4 minutes into recovery., Results: Heart rate recovery (median and interquartile range, beat/min) was 48 (37-58) for women and 49 (38-58) for men. Thirty-seven percent of the women and 25% of the men had the MetS. Heart rate recovery was 52 (42-61) for women with the MetS and 42 (31-49) for those without. The corresponding values for men was 50 (39-61) and 47 (35-54); the difference between individuals with and without the MetS was significant for women (P < .001) but not for men (P = .084). The following significant correlation coefficients between HRR and MetS components were found: for women, waist circumference (-0.43, P < .001), high-density lipoprotein cholesterol (0.37, P < .001), insulin sensitivity (-0.37, P < .001), fasting plasma glucose (-0.30, P < .001), and triglycerides (-0.24, P = .001); for men, triglycerides (-0.20, P = .005). The sex disparity in the strength of correlation reached statistical significance for insulin sensitivity (P < .001) and waist circumference (P = .042)., Conclusion: Among 75-year-olds, the MetS and related components are more strongly correlated to HRR in women than in men.

Doppler echocardiography was used to describe left ventricular filling and ejection during upright bicycle exercise in 24 healthy male endurance athletes. The transmitral pressure gradient was estimated and isovolumetric relaxation, filling and ejection time and transmitral and aortic flow velocities were measured at rest and during exercise. From rest to peak exercise (at a heart rate of 160 bpm), the mean left ventricular filling time was shortened by 73%, the ejection time by 31%, while the isovolumetric relaxation time was shortened by 62%. At peak exercise, the maximum aortic flow velocity almost doubled and the maximum transmitral flow velocity more than doubled, with a tenfold increase in the mean transmitral pressure gradient. The increase was significant (P<0.001) at each level of exercise. The left ventricular filling rate measured as volume per time was 185 +/- 62 ml s(-1) at rest and it increased to 986 +/- 192 ml s(-1) at peak exercise. This study demonstrates large changes in diastolic filling indices during upright exercise and it shows that the heart is able to increase its filling rate five times from rest to peak exercise.

Mitral annulus motion (MAM) is a predictor of mortality in selected patient groups, but its prognostic value in less selected populations is not known. In a community-based random sample of 75-year-old men and women (n = 408), left ventricular function was measured as: (1) maximum amplitude of MAM; and (2) wall-motion index. During a median follow-up of 7.2 years, 83 persons died (26 from cardiac causes). Left ventricular function as measured by MAM predicted the risk of all-cause and cardiac mortality independently of other potential risk factors in this community-based sample. Regarding cardiac mortality, the predictive ability of MAM was also independent of left ventricular systolic function measured as wall-motion index. MAM may prove to be a valuable complement to other echocardiographic methods in the assessment of prognosis in less selected populations.

Background: Plasma concentration of B-type natriuretic peptide (BNP) has been suggested as a powerful screening tool for left ventricular systolic dysfunction. However, there are reports indicating that the 12-lead electrocardiogram (ECG) could be just as powerful. We aimed to evaluate the 12-lead ECG and BNP as screening tools for left ventricular systolic dysfunction in an elderly, unselected population., Methods: In a randomly selected population-based sample of 75-year-old men and women (n = 407), diagnostic characteristics were evaluated for the ECG and plasma concentration of BNP to detect left ventricular systolic dysfunction., Results: Sensitivity, specificity, and negative and positive predictive values for the ECG to detect left ventricular systolic dysfunction were 96%, 79%, 100%, and 26%, respectively. The corresponding values for the BNP (cut-off value 28 pg/mL) were 93%, 55%, 99%, and 13%. In participants without major abnormalities in the ECG, left ventricular systolic dysfunction was found in <1% (1/302), irrespective of BNP concentrations. In participants with abnormal ECGs, systolic dysfunction was more prevalent in persons with abnormal BNP concentrations than in those with normal concentrations (35% vs 3%, difference 32%, 95%CI for the difference 16%-44%), Conclusions: In 75-year-old subjects both the ECG and the plasma concentration of BNP are highly efficient in excluding left ventricular systolic dysfunction. However, compared with the BNP, the ECG yields a lower number of false positive cases. In screening for left ventricular systolic dysfunction, the BNP has a diagnostic value in addition to the ECG, but only in individuals with abnormal ECGs.

The biplane disc summation method is the recommended echocardiographic procedure to determine left ventricular (LV) ejection fraction (EF). Assessment of mitral annulus motion (MAM) or wall motion scoring index (WMI) has been reported to be less dependent on image quality compared with the recommended method, and proposed as a surrogate to the disc summation method in calculation of LVEF. We aimed to compare MAM and WMI in the echocardiographic assessment of LVEF. In a randomly selected population-based sample of 75-year-old men and women in sinus rhythm (n = 409) MAM, as measured by M-mode, was compared with WMI, calculated as the mean value of wall motion scoring in 9 LV segments. LVEF, as measured by the biplane disc summation method was used as reference. The limits of agreement (mean difference +/- 1.96 SD) between LVEF and corresponding MAM values were -18 to +13 LVEF%, and between LVEF and corresponding WMI values were -12 to +13 LVEF%. The areas under the receiver operating characteristic curves for MAM and WMI to predict a LVEF < 50% were 0.892 and 0.998, respectively (95% confidence interval of the difference 0.062-0.149). The corresponding areas for MAM and WMI to predict a LVEF < 40% were 0.955 and 0.998, respectively (95% confidence interval of the difference 0.017-0.069). In conclusion, the ability of WMI to estimate LVEF was more favorable than MAM in this population-based sample of 75-year-old participants. The findings suggest that the WMI is preferable to MAM in estimating LVEF.

We describe our experience using a database (Sicare, Siemens Elema) containing 381,000 ECGs covering 90% of all ECGs during 11 years in the county of Västmanland, Sweden, with 260,000 inhabitants. The database expedites rapid recovery of earlier ECGs. For instance, in patients admitted to coronary care with chest pain and ST-elevation, speedy access to an earlier ECG with identical ST-elevation may be crucial for avoiding unnecessary and potentially harmful thrombolysis. The database also enables us to select ECGs with a specific diagnosis, for instance atrial fibrillation. This facilitates characterization and quality control of treatment of atrial fibrillation in a well-defined population.

Altered left ventricular (LV) diastolic filling has been shown in subjects with hypertension. Age is a major determinant of Doppler indexes of LV diastolic filling; therefore, a group of subjects of uniform age should preferably be chosen, if other determinants of diastolic LV filling are to be studied. A limited body of data is available regarding Doppler indexes of LV filling in hypertensive persons of a similar age. We therefore evaluated 26 hypertensive subjects (13 women and 13 men) 50 years old by Doppler echocardiography. The peak velocity of early diastolic filling (E wave), the peak velocity of atrial filling (A wave), the early-to-atrial peak velocity (E/A) ratio, and the deceleration time of early velocity were measured. The peak E wave velocity was 0.76 +/- 0.11 versus 0.62 +/- 0.13 m/s (P < 0.005), and the E/A ratio was 1.11 +/- 0.24 versus 0.93 +/- 0.23 (P < 0.05) in hypertensive women and men, respectively. The peak A wave velocity was increased and the E/A ratio was decreased in both hypertensive women and men compared with healthy 50-year-old subjects. In multivariate analyses, LV diameter, body mass index, and gender correlated with the E/A ratio in hypertensive persons. It is concluded that there is a significant difference in Doppler LV filling indexes between 50-year-old hypertensive women and men. LV diameter, gender, and body mass index are independent determinants of LV diastolic inflow in similarly aged hypertensive persons.

During the period 1979-92, 16 (15 men and one woman) sudden unexpected cardiac deaths occurred among young Swedish orienteers. This finding indicated a sharp increase in the death rate of orienteers, and necropsy demonstrated that myocarditis was a common histopathological finding. Therefore, an extensive non-invasive cardiac investigation was performed. A total of 59 male élite orienteers (mean age 23 years) and 36 cross-country skiers and middle-distance runners (mean age 22 years), serving as controls, were examined by both echocardiography at rest and radionuclide ventriculography at rest and during exercise. Wall motion abnormalities were found in eight orienteers using echocardiography. The purpose of this study was to examine whether the group of orienteers with wall motion abnormalities found using echocardiography had a smaller increase in ejection fraction from rest to exercise using radionuclide ventriculography than the rest of the orienteers and the controls, indicating an aggravation of the wall motion abnormalities during exercise. There were no significant differences in the ejection fraction at rest between the groups. In the orienteers with wall motion abnormalities (group 1), 62% (five out of eight) had less than a 0.05 unit increase in left ventricular ejection fraction compared with 27% (14 out of 51) of the remaining orienteers (group 2) and 19% (7 out of 36) of the controls (group 3). A comparison of athletes in group 1 with those in groups 2 and 3 combined revealed a statistically significant difference (P < 0.05). The divergent response in left ventricular ejection fraction during exercise suggests an aggravation of the wall motion abnormalities with exercise. Both the echocardiographic and the radionuclide ventriculographic findings indicate that the orienteers in group 1 had concealed left ventricular damage.

Considerably more publications appear on left ventricular morphology than on the right ventricle. The reasons for this imbalance are related to the complex shape of the right ventricular cavity and its position beneath the sternum, making imaging, measurement and functional assessment much more complex than the left ventricular chamber. Little attention has been directed towards right ventricular changes because of training, therefore the present study was designed to assess right ventricular changes due to extensive training by comparing cavity and wall dimensions in 29 sedentary men (mean age 23 years) and 82 elite male orienteers (mean age 22 years). The elite orienteers had on average significantly larger right ventricular outflow (10%) and right ventricular inflow (12%) tract 2 and 3 dimensions. The right ventricular wall measurements were on average 13% larger in the orienteers than the sedentary men. The right ventricular enlargement in endurance athletes probably reflects the increased haemodynamic loading that is caused by prolonged and extensive physical training. The thicker right ventricular wall in endurance athletes increases the contractile reserve and decreases wall stress in the right ventricle.