Portal de Periódicos da CAPES

Hearts of the “Oldest Old”

1988; Elsevier BV; Volume: 63; Issue: 6 Linguagem: Inglês

10.1016/s0025-6196(12)64893-9

1942-5546

Bruce F. Waller,

Genetics, Aging, and Longevity in Model Organisms

“Old age” has been the subject of numerous publications in the medical and nonmedical media. Many books and magazines articles have focused on longevity and life extension, and numerous dietary supplements and cosmetic products have been marketed to delay aging. Whereas the average length of life has increased from 47 to 73 years in the United States, the maximal life-span apparently has not increased.1Fries JF Aging, natural death, and the compression of morbidity.N Engl J Med. 1980; 303: 130-135Crossref PubMed Scopus (2086) Google Scholar Data on the number of centenarians in England have been available since the early 1800s, and during this 180-year period, despite a consider-able change in mean life expectancy, no appreciable change has been noted in the number of persons living longer than 100 years.1Fries JF Aging, natural death, and the compression of morbidity.N Engl J Med. 1980; 303: 130-135Crossref PubMed Scopus (2086) Google Scholar, 2McWhirter N Guinness Book of World Records, 1988. Bantam Books, New York1988: 15-18Google Scholar In Sweden, where careful investigations of centenarians are carried out, apparently no one has yet exceeded 110 years of age.1Fries JF Aging, natural death, and the compression of morbidity.N Engl J Med. 1980; 303: 130-135Crossref PubMed Scopus (2086) Google Scholar, 2McWhirter N Guinness Book of World Records, 1988. Bantam Books, New York1988: 15-18Google Scholar An estimated 1 in 10,000 persons (0.01%) in developed countries lives beyond the age of 100 years. In the United States, the mid-1983 figure of centenarians was 0.01%, and in China, their 1982 census revealed 0.04% centenarians.2McWhirter N Guinness Book of World Records, 1988. Bantam Books, New York1988: 15-18Google Scholar The 1988 edition of the Guinness Book of World Records notes that the greatest authenticated human age is 120 years, and the current “oldest old” is a 114-year-old woman who lives in Wales.2McWhirter N Guinness Book of World Records, 1988. Bantam Books, New York1988: 15-18Google Scholar Only eight others (five women) are currently living beyond age 105 years.2McWhirter N Guinness Book of World Records, 1988. Bantam Books, New York1988: 15-18Google Scholar Although the maximal life-span may not be increasing, clearly the number of persons surviving into the 70s, 80s, and 90s is increasing. In the United States, the population segment 85 years of age or older is about 2.6 million (1%). This segment of our population is projected to be the fastest growing in the next 10 years, doubling by the year 2000 and increasing to 5% by the year 2050.3Waller BF Morgan R The very elderly heart.Cardiovasc Clin. 1987; 18: 361-410Google Scholar, 4Coe RM Social epidemiology of diseases of aging.in: Blumenthal HT Handbook of Diseases of Aging. Van Nostrand Reinhold Company, New York1983: 45-70Google Scholar, 5Siegel JS Recent and prospective demographic trends for the elderly population and some implications in health care.in: Haynes SG Feinleib M Second Conference on the Epidemiology of Aging. NIH Publication No. 80-969. US Department of Health and Human Services, Washington, DC1980: 289-314Google Scholar In addition to social, economic, and political implications, this “old-age boom” poses major medical issues. Despite an increasing number of persons surviving 90 years or more, little general medical information and, more specifically, cardiovascular data are available for this age group. Specific data about causes of death are also sparse.3Waller BF Morgan R The very elderly heart.Cardiovasc Clin. 1987; 18: 361-410Google Scholar, 5Siegel JS Recent and prospective demographic trends for the elderly population and some implications in health care.in: Haynes SG Feinleib M Second Conference on the Epidemiology of Aging. NIH Publication No. 80-969. US Department of Health and Human Services, Washington, DC1980: 289-314Google Scholar, 6Pomerance A Cardiac pathology in the elderly.Cardiovasc Clin. 1981; 12: 9-54PubMed Google Scholar, 7Pomerance A The pathology of senile cardiac amyloidosis.J Pathol Bacteriol. 1966; 91: 357-367Crossref PubMed Scopus (33) Google Scholar, 8Pomerance A Cardiac pathology and systolic murmurs in the elderly.Br Heart J. 1968; 30: 687-689Crossref PubMed Scopus (26) Google Scholar, 9Sugiura M Hiraoka K Ohkawa S Shimada H A clinico-pathological study on the heart diseases in the aged: the morphological classification of the 1,000 consecutive autopsy cases.Jpn Heart J. 1975; 16: 526-537Crossref PubMed Scopus (23) Google Scholar, 10Gross JS Neufeld RR Libow LS Gerber I Rodstein M Autopsy study of the elderly institutionalized patient: review of 234 autopsies.Arch Intern Med. 1988; 148: 173-176Crossref PubMed Scopus (177) Google Scholar, 11Waller BF Roberts WC Cardiovascular disease in the very elderly: analysis of 40 necropsy patients aged 90 years or over.Am J Cardiol. 1983; 51: 403-421Abstract Full Text PDF PubMed Scopus (136) Google Scholar, 12McKeown F Heart disease in old age.J Clin Pathol. 1963; 16: 532-537Crossref PubMed Scopus (7) Google Scholar, 13Kohn RR Cause of death in very old people.JAMA. 1982; 247: 2793-2797Crossref PubMed Scopus (169) Google Scholar The paucity of medical information in this very elderly age group is related in part to the limited number of autopsies performed on patients 90 years of age or older.5Siegel JS Recent and prospective demographic trends for the elderly population and some implications in health care.in: Haynes SG Feinleib M Second Conference on the Epidemiology of Aging. NIH Publication No. 80-969. US Department of Health and Human Services, Washington, DC1980: 289-314Google Scholar The percentage of deaths for which autopsies are performed declines substantially with increasing age, such that autopsy examinations are done on only about 5% of those who die at 85 years of age or older and about 4% of those who die at 90 years of age or older.5Siegel JS Recent and prospective demographic trends for the elderly population and some implications in health care.in: Haynes SG Feinleib M Second Conference on the Epidemiology of Aging. NIH Publication No. 80-969. US Department of Health and Human Services, Washington, DC1980: 289-314Google Scholar In this issue of the Proceedings (pages 552 to 564), Lie and Hammond present morphologic data on the “senescent heart” from 237 autopsy studies of patients who were 90 to 105 years old at the time of death. The authors should be congratulated on an excellent study that contributes much to our understanding of the pathologic changes in the old-age heart and the causes of death in this age group. Reports such as this help to provide a sturdy framework for the diagnosis and treatment of cardiovascular disease in the elderly age group. In the study by Lie and Hammond, cardiovascular disease (including stroke) accounted for 48% of the deaths. This finding is similar to our finding in autopsy studies of patients 90 years old or older (52% cardiovascular deaths3Waller BF Morgan R The very elderly heart.Cardiovasc Clin. 1987; 18: 361-410Google Scholar, 11Waller BF Roberts WC Cardiovascular disease in the very elderly: analysis of 40 necropsy patients aged 90 years or over.Am J Cardiol. 1983; 51: 403-421Abstract Full Text PDF PubMed Scopus (136) Google Scholar) but is at variance with three other studies (25%,12McKeown F Heart disease in old age.J Clin Pathol. 1963; 16: 532-537Crossref PubMed Scopus (7) Google Scholar 29%,10Gross JS Neufeld RR Libow LS Gerber I Rodstein M Autopsy study of the elderly institutionalized patient: review of 234 autopsies.Arch Intern Med. 1988; 148: 173-176Crossref PubMed Scopus (177) Google Scholar and 31%13Kohn RR Cause of death in very old people.JAMA. 1982; 247: 2793-2797Crossref PubMed Scopus (169) Google Scholar cardiovascular deaths). Differences between the former and the latter studies include the definition of “elderly” (more than 64 years old,10Gross JS Neufeld RR Libow LS Gerber I Rodstein M Autopsy study of the elderly institutionalized patient: review of 234 autopsies.Arch Intern Med. 1988; 148: 173-176Crossref PubMed Scopus (177) Google Scholar older than 70 years,13Kohn RR Cause of death in very old people.JAMA. 1982; 247: 2793-2797Crossref PubMed Scopus (169) Google Scholar and 90 years old or older3Waller BF Morgan R The very elderly heart.Cardiovasc Clin. 1987; 18: 361-410Google Scholar, 11Waller BF Roberts WC Cardiovascular disease in the very elderly: analysis of 40 necropsy patients aged 90 years or over.Am J Cardiol. 1983; 51: 403-421Abstract Full Text PDF PubMed Scopus (136) Google Scholar) and the method of data acquisition (use of autopsy protocols or death certificate analyses10Gross JS Neufeld RR Libow LS Gerber I Rodstein M Autopsy study of the elderly institutionalized patient: review of 234 autopsies.Arch Intern Med. 1988; 148: 173-176Crossref PubMed Scopus (177) Google Scholar, 12McKeown F Heart disease in old age.J Clin Pathol. 1963; 16: 532-537Crossref PubMed Scopus (7) Google Scholar, 13Kohn RR Cause of death in very old people.JAMA. 1982; 247: 2793-2797Crossref PubMed Scopus (169) Google Scholar versus personally reexamined cases,3Waller BF Morgan R The very elderly heart.Cardiovasc Clin. 1987; 18: 361-410Google Scholar, 11Waller BF Roberts WC Cardiovascular disease in the very elderly: analysis of 40 necropsy patients aged 90 years or over.Am J Cardiol. 1983; 51: 403-421Abstract Full Text PDF PubMed Scopus (136) Google Scholar such as was done by Lie and Hammond). Knowledge of “normal” or “expected” aging-related changes in the old-age heart has practical importance. By definition, aging processes are usually considered “normal” in that they occur in all members of a population.14Kohn RR Heart and cardiovascular system.in: Finch CE Hayflick L Handbook of the Biology of Aging. Van Nostrand Reinhold Company, Cincinnati1977: 281Google Scholar These processes are usually progressive and physiologically irreversible.3Waller BF Morgan R The very elderly heart.Cardiovasc Clin. 1987; 18: 361-410Google Scholar Changes in the cardiovascular system seem to be central to the general concept of aging, in that aging of the cardiovascular system per se may promote the generalized debilitation of other organ systems.15Strehler BL Mildvan AS General theory of mortality and aging.Science. 1960; 132: 14-21Crossref PubMed Scopus (405) Google Scholar Clear identification and separation of changes due to aging alone are difficult if not impossible tasks. As stated by Sobel,16Sobel H Ageing and age-associated disease (letter to the editor).Lancet. 1970; 2: 1191-1192Abstract PubMed Scopus (9) Google Scholar the effects of aging per se (“genetically programmed”) may not always be distinguished from the effects of pathologic processes (“acquired or initiated from external events”). Certain commonly observed cardiac autopsy changes in the very elderly heart may be considered “normal aging changes”—that is, morphologic changes that do not produce clinical signs of cardiac dysfunction during life. These observations can be divided into six areas: (1) myocardium (walls), (2) chambers (cavities), (3) valves, (4) epicardial coronary arteries, (5) conduction system, and (6) aorta.3Waller BF Morgan R The very elderly heart.Cardiovasc Clin. 1987; 18: 361-410Google Scholar, 7Pomerance A The pathology of senile cardiac amyloidosis.J Pathol Bacteriol. 1966; 91: 357-367Crossref PubMed Scopus (33) Google Scholar, 17Edwards JE Pathology of the aging heart.in: Libow LS Cardiovascular Aspects of Geriatric Medicine. Vol 2. Hoffman-LaRoche, Nutley, New Jersey1981: 29Google Scholar Expected or normal aging-associated changes in the myocardium of the very elderly heart include brown atrophy, basophilic degeneration, increased subepicardial fat, and focal amyloid deposits.3Waller BF Morgan R The very elderly heart.Cardiovasc Clin. 1987; 18: 361-410Google Scholar Heart weight in the very elderly patient generally increases with advancing age.3Waller BF Morgan R The very elderly heart.Cardiovasc Clin. 1987; 18: 361-410Google Scholar, 18Kitzman DW Scholz DG Hagen PT Ilstrup DM Edwards WD Age-related changes in normal human hearts during the first 10 decades of life. Part II (Maturity): a quantitative anatomic study of 765 specimens from subjects 20 to 99 years old.Mayo Clin Proc. 1988; 63: 137-146Abstract Full Text Full Text PDF PubMed Scopus (389) Google Scholar Furthermore with advancing age, the size of the left ventricular cavity is reduced (non-dilated), but the size of the left atrial cavity is increased (dilated). Morphologic alterations of the cardiac valves with increasing age include focal fibrous thickening at the margins of closure, calcific deposits in the bases of one or more aortic cusps, and calcium deposits in the mitral valve annulus, which is the hallmark of the very elderly heart.3Waller BF Morgan R The very elderly heart.Cardiovasc Clin. 1987; 18: 361-410Google Scholar Aging-related changes in the epicardial coronary arteries include tortuosity, increased cross-sectional area (dilation),7Pomerance A The pathology of senile cardiac amyloidosis.J Pathol Bacteriol. 1966; 91: 357-367Crossref PubMed Scopus (33) Google Scholar calcific deposits, and, usually, minimal atherosclerotic plaque consisting of dense fibrous tissue and calcific deposits (“hard lesions”). The cardiac conduction system also exhibits aging-associated changes, including a reduction in sinus node cells, increased sinus node fat and collagen, and increased fibrosis of the atrioventricular node, bundle of His, and main bundle branches.3Waller BF Morgan R The very elderly heart.Cardiovasc Clin. 1987; 18: 361-410Google Scholar Normal aging-related changes of the aorta include dilatation of the ascending portion including all three sinuses of Valsalva, calcific deposits at the sino-tubular junction, and dilatation, elongation, and tortuosity of the thoracic and abdominal aorta. Two normal aging-related changes observed in the very elderly heart may mimic cardiac disease and cause confusion when viewed on an echocardiogram. The normal reduction in size of the left ventricular cavity occurs primarily in the base-to-apex, long-axis dimension. Partly as a result of the decrease in long-axis dimension and partly as a result of a rightward shift of the dilated ascending aorta, the basal portion of the ventricular septum bends leftward and bulges into the left ventricular outflow tract. This alteration in shape yields a curved ventricular septum that has been termed the “sigmoid septum” by Goor and colleagues.19Goor D Lillehei CW Edwards JE The “sigmoid septum”: variation in the contour of the left ventricular outlet.Am J Roentgenol. 1969; 107: 366-376Crossref Google Scholar This normal aging-associated change of the ventricular septum is important to recognize anatomically as well as echocardiographically because the basal ventricular septal bulge into the left ventricular outflow tract may mimic asymmetric septal hypertrophy seen in hypertrophic cardiomyopathy. Both the old-age heart and the heart with hypertrophic cardiomyopathy have small left ventricular cavities, thickened chamber walls, thickened mitral valve leaflets, and dilated left atrial cavities. In contrast, the old-age heart has a dilated ascending aorta, thickened and calcified aortic valve cusps, calcium deposits in the mitral annulus, and absence of a left ventricular outflow tract plaque, all of which help distinguish it from the heart with hypertrophic cardiomyopathy. With decreasing left ventricular cavity size with advancing age, the area containing the mitral leaflets and chordae tendineae is reduced. Thus, during ventricular systole, the mitral leaflets “buckle” or protrude into the left atrium, because of “leaflet-cavity disproportion.”3Waller BF Morgan R The very elderly heart.Cardiovasc Clin. 1987; 18: 361-410Google Scholar This leaflet protrusion may mimic the mitral valve prolapse pattern seen with a floppy mitral valve. Although floppy mitral valves are occasionally observed in elderly patients, most valve protrusions in this patient population are not the result of prolapsing floppy valves but rather the consequence of changes in left ventricular cavity size. Anatomically, the “buckling valve” in elderly patients has a normal leaflet area and a normal or reduced annular circumference in contrast to the increased leaflet area and dilated annular circumference of the floppy mitral valve.20Waller BF Morrow AG Maron BJ Del Negro AA Kent KM McGrath FJ Wallace RB McIntosh CL Roberts WC Etiology of clinically isolated, severe, chronic, pure mitral regurgitation: analysis of 97 patients over 30 years of age having mitral valve replacement.Am Heart J. 1982; 104: 276-288Abstract Full Text PDF PubMed Scopus (164) Google Scholar Calcium deposits in the mitral annulus in the elderly heart also may accentuate the leaflet buckling with mounds of calcium beneath the posterior leaflet. Echocardiographically, the normal age-related buckling mitral valve can be distinguished from the abnormal floppy mitral valve by observing thickened and redundant leaflets of the floppy valve in comparison with the thin-appearing leaflets of the normal old-age mitral valve. In addition, the degree of leaflet protrusion is generally greater in the floppy mitral valve than in the “buckling” old-age valve. A dilated left atrium will not help separate the floppy mitral valve from the normal old-age mitral valve because left atrial dilatation is present in both conditions.