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← Section VI · Miscellaneous Topics (Role of Echo)
VI.H

Aging Changes

5 cards

Notes

Normal age-related changes

Structure

  • Sigmoid septum ("septal knuckle") - basal septal bulge into the LVOT; usually asymptomatic but can cause LVOT obstruction with volume depletion.
  • Mitral annular calcification (MAC) - often circumferential, may extend to leaflet bases.
  • Aortic valve sclerosis (calcification without significant obstruction).
  • Aortic root dilation (2–3 mm larger than young adult on average).
  • Modest LA and LV cavity enlargement.
  • BSA-indexed systolic and diastolic volumes DECREASE with age.

Function

  • LV systolic function preserved.
  • Diastolic function: normal age-related pattern of impaired relaxation:
    • E velocity decreases.
    • A velocity increases.
    • E/A crossover ~ age 50–60 (E/A < 1 in older adults is common).
    • DT prolongs.
    • IVRT prolongs.
  • Systolic hypertension → hypertensive LV remodeling.
  • Pulmonary artery pressures rise mildly with age (~1 mmHg/decade).

Common findings mistaken for pathology

  • Sigmoid septum vs. basal HCM (careful - sigmoid septum usually has normal e′ and no fibrosis).
  • Aortic sclerosis (peak velocity < 2.5 m/s) vs. mild aortic stenosis.
  • Lipomatous hypertrophy of atrial septum vs. mass.
  • Increased echogenicity of mitral annulus (MAC).

Pathology more common in elderly

  • Degenerative AS (calcific).
  • Cardiac amyloidosis (ATTR wild-type, esp. in men > 70).
  • HFpEF.
  • Atrial fibrillation.
  • Chronic ischemic heart disease.

Cards

  • basicVI.H-001
    How does the mitral E/A ratio normally change with aging?
    → E velocity decreases and A velocity increases. E/A crossover at age 50–60. In older normal adults E/A is often < 1 — this is 'age-appropriate' impaired relaxation, not pathologic diastolic dysfunction.
  • basicVI.H-002
    What is a sigmoid septum and why does it matter clinically?
    → An age-related basal septal bulge into the LVOT ('septal knuckle'). Usually asymptomatic. In volume-depleted or hyperdynamic states it can cause dynamic LVOT obstruction that mimics HCM.
  • basicVI.H-003
    Aortic sclerosis vs mild aortic stenosis — how are they distinguished on Doppler?
    → Aortic sclerosis: peak aortic velocity < 2.5 m/s (no significant obstruction, thickened cusps only). Mild AS: peak 2.6–2.9 m/s with some restriction of cusp motion.
  • basicVI.H-004
    What patient population is most affected by wild-type ATTR amyloidosis?
    → Elderly men (typically > 70 years). Presents as HFpEF with concentric LVH and apical-sparing GLS pattern. Diagnosed with PYP scan (grade 2–3 uptake); treated with tafamidis.
  • basicVI.H-005
    How do BSA-indexed LV volumes change with age?
    → They DECREASE with aging — a fact often missed. Reference ranges must be age-adjusted or interpretation adjusted accordingly.