Η επίδραση της ηλικίας στη δομή και λειτουργία του μυοκαρδίου στους ηλικιωμένους

Transcription

1 Η επίδραση της ηλικίας στη δομή και λειτουργία του μυοκαρδίου στους ηλικιωμένους Ελένη Νάκου Καρδιολογική Κλινική, Πανεπιστημιακό Νοσοκομείο Ηρακλείου

2 None Disclosures

3 Time modifies many biologic processes

4 Homeostenosis Aging Disease and disease is not inevitable with aging However, the chance of developing some diseases increases with age This is a function of homeostenosis With homeostenosis, an insult that may be withstood in a younger person pushes the elderly beyond their functional capacity, causing decompensation, disease, or death.

5 Homeostenosis refers to the concept that, from maturity to senescence, diminishing physiologic reserves are available to meet challenges to homeostasis. Homeostenosis leads to the increased vulnerability to disease that occurs with aging. Aging heart = homeostenotic heart

6 The age-associated cardiovascular changes must be construed as specific risk factors for the cardiovascular diseases

7 Why should you care? More of the pie going to elderly Department of Health and Human Services. (2010, June 23). Projected Future Growth of Older Population (data). Retrieved June 2012, from Administration on Aging:

8 Definition of aging Old age stages Young-Old (ages 65-74) Middle-Old (ages 75-84) Old-Old (age 85 and older) WHO

9 Sequence of changes Molecular Aging Gene expression Enviromental exposures Structural Functional Cardiovascular remodelling Functional impairment Cardiovascular disease

10 Structural changes Remodelling of left ventricle cardiomyocytes apoptosis, necrosis myocyte size (hypertrophy) synthesis of fibroblasts and degradation of collagen The left atrium left atrial volume, corrected for body size, increases roughly 50 percent from the third decade to the eighth. Similar anatomical changes are observed in the right side of the heart, although they are not as prominent as in the left side Biernacka A, Aging Dis 2011; 2:158-73

11 Sigmoid Septum

12 Valvular changes Calcific or degenerative aortic valve disease is considered the most common valvular lesion encountered among elderly patients

13 Aortic valve fenestrations Akiyama K, Circ J. 2004;68:439-43

14 Aziz F, Tex Heart Inst J 2007; 34: Aging myocardium Lambl s Excrescences

15 Mitral annulus calcification (MAC)

16 Mitral annulus calcification (MAC)

17 Mitral Valve Leaflet Buckling vs Mitral valve prolapse Waller BF, et al, Clin Cardiol 1988;

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19 Structural changes Conducting system # of pacemaker cells (necrosis, apoptosis) Fibrous tissue infiltration, increased deposition of adipose tissue, amyloid and collagen in sinoatrial node s pacemaker cells. The foregoing structural changes exist to a smaller degree at the level of atrioventricular node and bundle of His and to a greater degree within the bundle branches

20 Sequence of changes Molecular Aging Gene expression Enviromental exposures Structural Functional Cardiovascular remodelling Functional impairment Cardiovascular disease

21 Functional changes Afterload Diastolic dysfunction Contractility Heart rate/conduction system

22 LV functional changes Afterload LV wall thickness LV wall stiffness LV chamber size

23 LV functional changes LV wall stiffness LV Diastolic dysfunction Diastolic dysfunction grade I

24 RV functional changes Chia EM, J Am Soc Echocardiogr 2014;27:

25 LV functional changes Baltimore Longitudinal Study of Aging (BLSA) Contractility decreases with age This is in part due to the molecular changes considered earlier: Decreased β adrenergic responsiveness Impaired Ca2+ handling Zghal F, Echocardiography 2011;28:

26 LV functional changes GLS=-18.3 Xia JZ, et al Echocardiography.2014 Mar;31(3):335-9

27 LV functional changes Rotation and torsion of the left ventricle are more pronounced in the elderly population and it may help explaining recent observations describing that normal EF can be present despite impaired myocardial contractility Mor-Avi, et al. J Am Soc Echocardiogr 2011;24:

28 RV functional changes RVEF remains relatively well preserved with aging, as does LV ejection fraction. However, the global systolic strain is also reduced, with differential reductions in basal and mid segmental strain with age Chia EM, J Am Soc Echocardiogr 2014;27: Maffessanti F, et al Circ Cardiovasc Imaging 2013; 6:

29 All the changes that have been discussed so far relate to a person at rest.

30 What Happens When You Exercise?

31 Changes during exercise

32 Changes during exercise Baltimore Longitudinal Study of Aging Lakkata EG, et al Circulation 2003;107: In the aging human heart the maintaining of cardiac output during exercise is supported more heavily by the Franck-Starling mechanism and less by sympathetic stimulation demonstrating the presence of an age-related change in the adrenergic modulation

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34 Functional changes Heart Rate HR rises above HRint when the SAN is stimulated by the sympathetic nervous system. The aged heart gets a smaller increase in CO by removing vagal tone than the younger heart The decreased HRint and adrenergic responsiveness all contribute to the decreased HRmax of the aged heart. Taffet, G., & Teasdale, T. (2007) Self-Instructional Modules in Geriatric Medicine..

35 Functional changes Heart Rate Heart rate variability, perhaps due to decreased parasympathetic tone and decreased sympathetic responsiveness, also decreases with age Lakatta EG, Circulation ;107:139-46

36 Functional changes Heart Rythm Data available in older subjects supports that the median age of patients with AF is 75 years, with prevalence of 2.3 % and 5.9% in people older than 40 years and 65 years, respectively. Approximately 70% of individuals with AF are between 65 and 85 years of age Christoph Ohlmeier et al. Europace 2013;15: Strait JB et al, Heart Fail Clin 2012 Jan;8(1):143-64

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38 Chronologic age is not an accurate predictor of physical condition or behavior Sue Saxon & Mary Jean Etten, Physical Change & Aging

39 Cardiac aging is not an homogenous process Physical condition seems to be driven by: Lifestyle choices exercise nutrition stress management Genetics Environment Robert Redford at age 64

40 Take home messages

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43 Aging the academy of time