Symptoms associated with an abnormal echocardiogram in elderly primary care hypertension patients

Prediction of cardiovascular events in the elderly primary care patient with hypertension: the value of additional laboratory testing, ECG and echocardiography

BACKGROUND

A strict risk stratification identifying hypertensive patients at risk for future cardiovascular disease in primary care would be desirable.

AIM

To investigate the association between elevated BNP, LVH on ECG, and LVH on echocardiogram and the development of cardiovascular events (CVE), especially heart failure and all cause-mortality (ACM), in a hypertension primary care population without symptoms of heart failure.

DESIGN AND SETTING

Prospective cohort study in five Dutch general practices between 2010-2012 and 2020.

METHOD

530 patients (60-85 years) underwent laboratory testing, ECGs and echocardiograms at baseline. The incidence of new CVEs and ACM at up to nine years' follow-up was recorded by data extraction from the digital information systems.

RESULTS

Among the 530 participants, 31 (5.8%) developed a coronary event, 44 (8.3%) a cerebrovascular accident, 53 (10.0%) atrial fibrillation, 23 (4.3%) heart failure and 66 (12.5%) died. Cox regression analyses, adjusting for relevant Framingham covariates showed that elevated BNP increased the risk of ACM, CVE and specifically heart failure independently by respectively, 44% (HR 1.44; 95% CI [1.07-1.94], p=-0.017), 45% (HR 1.45; 95% CI [1.15-1.82], p= 0.002) and 288% (HR 3.88, CI 95% 2.13-7.10, p<0.001). LVH on ECG increased the risk of ACM independently by 108% (HR 2.08; 95% CI [1.14-3.81], p=0.017). LVH either on ECG and/or echo increased the risk of heart failure independently by 309% (HR 4.09; 95% CI [1.34-12.49], p=0.014).

CONCLUSION

In primary care hypertensive patients, BNP seems to be an important marker predicting future cardiovascular events, especially heart failure, as well as all-cause death.

Psychological distress is independently related to new coronary events at 8 years' follow-up in elderly primary care patients with hypertension

OBJECTIVE

Occurrence of psychological distress in hypertensive patients could have a negative synergistic effect on future cardiovascular events (CVEs). The aim of this study was to determine the association between anxiety or depressive symptoms in elderly hypertensive primary care patients and the development of new CVEs and all-cause mortality.

METHODS

A prospective cohort study was conducted in five Dutch general practices between June 2010 and January 2012. Patients with primary care managed hypertension, aged 60-85 years, were included and completed the GAD-7 and PHQ-9, measuring anxiety and depressive symptoms respectively. The incidence of new CVEs (coronary event, cerebrovascular disease, atrial fibrillation and heart failure) and all-cause mortality at 8 years' follow-up was recorded by data extraction of the digital information systems.

RESULTS

Among the 555 included participants (mean age 70 ± 6.6 years; 56% female), 29 (5.2%) had a new coronary event, 42 (7.6%) a cerebrovascular disease, 57 (10.3%) atrial fibrillation, 22 (4%) heart failure and 68 (12.3%) died. Elevated anxiety and depression scores increased the risk of a coronary event independently and significantly by 12% (HR 1.12; 95% CI [1.04-1.22], p = 0.005) and 18% (HR 1.18; 95% CI [1.08-1.28], p < 0.0001), respectively, adjusted for relevant (Framingham) baseline covariates. No associations were found with regard to other CVEs and all-cause mortality.

CONCLUSION

In a random sample of elderly primary care hypertension patients there was a significant association between psychological distress and the occurrence of new coronary events after 8 years' follow-up but not with other CVEs and all-cause mortality.

Electrocardiography for the detection of left ventricular hypertrophy in an elderly population with long-standing hypertension in primary care: a secondary analysis of the CHELLO cohort study

OBJECTIVES

To investigate: (1) the prevalence of left ventricular hypertrophy (LVH) in elderly primary care patients with long-standing asymptomatic hypertension, and (2) the diagnostic value of ECG as a screening tool in the detection of LVH compared with echocardiography in this specific patient population.

DESIGN AND SETTINGS

A cross-sectional study in five general practices in the south-east of the Netherlands.

PARTICIPANTS

Patients with primary care-managed hypertension, aged between 60 and 85 years, without known heart failure.

PRIMARY AND SECONDARY OUTCOME MEASURES

Between June 2010 and January 2013, the patients underwent structured interviews, blood pressure assessment, laboratory testing, ECGs and echocardiograms. The primary outcome was to investigate the ability of ECG to detect LVH, compared with echocardiography as a reference test (gold standard).

RESULTS

Four hundred and twenty-two patients (44% male; ages 70±7 years) who underwent ECG and echocardiographic assessment to determine LVH were included. The median duration of hypertension was 10 (4-15) years. The overall prevalence of LVH was 44%, which increased with age (p<0.001); up to 60% of patients were ≥75 years. ECG intimated LVH in 47 patients (11%) but in only 26 of those (55%) was LVH confirmed by echocardiography. The sensitivity of ECG for detecting LVH was poor (14%).

CONCLUSIONS

Asymptomatic primary care patients with long-standing hypertension have a high prevalence of previously undetected LVH, which increases with age. ECG is inadequate for detecting LVH in these patients. Early detection of LVH could potentially create more awareness for the optimal regulation of hypertension and compliance to therapy. Therefore, echocardiography should be considered a screening device for the detection of LVH in this population.

Psychological distress and personality factors in takotsubo cardiomyopathy

Background

Takotsubo cardiomyopathy (TCC) is a transient condition characterised by severe left ventricular dysfunction combined with symptoms and signs mimicking myocardial infarction. Emotional triggers are common, but little is known about the psychological background characteristics of TCC. This study examined whether patients with TTC have higher levels of psychological distress (depressive symptoms, perceived stress, general anxiety), illness-related anxiety and distinct personality factors compared with healthy controls and patients with heart failure.

Methods and Results

Patients with TCC (N = 18; mean age 68.3 ± 11.7 years, 77.8 % women) and two comparison groups (healthy controls: N = 19, age 60.0 ± 7.6, 68.4 % women and patients with chronic heart failure: N = 19, age 68.8 ± 10.1, 68.4 % women) completed standardised questionnaires to measure depression (PHQ‑9), perceived stress (PSS-10), general anxiety (GAD-7), illness-related anxiety (WI-7) and personality factors (NEO-FFI and DS-14). Psychological measures were obtained at 23 ± 18 months following the acute TTC event. Results showed that patients with TCC had higher levels of depressive symptoms (5.2 ± 5.2 vs. 2.5 ± 2.4, p = 0.039) and illness-related anxiety (2.1 ± 1.7 vs. 0.7 ± 1.3, p = 0.005) compared with healthy controls. Patients with TCC did not display significantly elevated perceived stress (p = 0.072) or general anxiety (p = 0.170). Regarding personality factors, levels of openness were lower in TCC compared with healthy controls (34.2 ± 4.3 vs. 38.2 ± 5.6, p = 0.021). No differences between TCC and heart failure patients were found regarding the psychological measures.

Conclusions

TCC is associated with higher levels of depressive symptoms, more illness-related anxiety and less openness compared with healthy controls. These data suggest that TCC is associated with adverse psychological factors that may persist well after the acute episode.