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Changes in ECG pattern with advancing age

Article  in  Journal of basic and clinical physiology and pharmacology · December 2011

DOI: 10.1515/JBCPP.2011.017 · Source: PubMed


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J Basic Clin Physiol Pharmacol 2011;22(4):97–101 © 2011 by Walter de Gruyter • Berlin • Boston. DOI 10.1515/JBCPP.2011.017

Changes in ECG pattern with advancing age

Rupali Sachin Khane1,*, Anil D. Surdi2 and Rajamati based test capable of identifying symptomless heart disease
Shakar Bhatkar3 and determining which patient should be referred for further
1 non-invasive testing or cardiac catheterization.
Department of Physiology, D.Y. Patil Medical College,
Kolhapur, Maharashtra, India
Department of Physiology, Dr. V.M. Medical College, Keywords: bundle branch block; cardiovascular disease epi-
Solapur, Maharashtra, India demiology; left axis deviation; sinus bradycardia; ST-T wave
Department of Physiology, D.Y. Patil Medical College, abnormalities; ventricular premature beats.
Kolhapur, Maharashtra, India
Currently, cardiovascular diseases are the leading causes of
Background: The rising prevalence of cardiovascular dis- death among the elderly. The second half of the 20th cen-
ease with advancing age can be attributed to the cumulative tury has witnessed a global spread of a cardiovascular disease
effect of the normal aging process and cardiovascular risk epidemic. A fundamental observation of cardiovascular dis-
factor. Another factor to consider is the changing age struc- ease epidemiology is the distinct age-related increase in the
ture of the population. The normal aging process is associated incidence of nearly all manifestations of heart and circulatory
with extensive changes throughout the cardiovascular system disease across the life span. Several reasons for this change
that influence the epidemiology, clinical features, response have been advanced. Improved public health measures and
to therapy and prognosis of cardiovascular diseases in older the development of antimicrobial agents diminish many pre-
adults. Thus, there is a need for evaluation of cardiac status of viously major causes of mortality. Another factor to consider
the elderly population. is the changing age structure of the population. Thus, as life
Methods: The resting electrocardiogram (ECG) permits us to expectancy is greater, the aging process causes increased car-
suspect or diagnose a large number of cardiac disorders. As a diac problems making the elderly population more disabled
non-invasive, less expensive and simple technique, the ECG with resultant increases in cardiac morbidity and mortality.
can be even more useful in developing countries, such as The health transition in India also reflects the growing bur-
India where resources are limited and cardiovascular diseases den of cardiovascular diseases. It accounts for approximately
are rapidly emerging as a major health problem. The present 12 million deaths annually and is the most common serious,
study was carried out in 400 apparently healthy asymptomatic chronic life-threatening illness (1). By the year 2020, cardio-
subjects (age range: 45–74 years) selected from the general vascular diseases will still be the leading cause of death, and
population of Solapur city. All these subjects were screened furthermore cardiovascular diseases will increase to approxi-
for prevalence of various ECG abnormalities in relation to age mately 140–160 million, with 80% burden on developing
by recording resting 12-lead electrocardiogram. ECGs were countries (2).
coded and classified as abnormal, according to the Minnesota The era has begun where attempts are being made to pre-
code system. vent cardiovascular disease in the elderly or to detect it at
Results: This study has outlined the overall relationship a very early stage. Accurate identification of high-risk indi-
between the electrocardiographic abnormalities and advanc- viduals for cardiovascular disease coupled with a successful
ing age. Indeed, the close parallel relationship between the preventive approach is the preferred strategy, for control of
incidence of abnormal ECG and advancing age found in our the cardiovascular disease epidemic.
study suggests that the ECG can be a highly reliable indica- Thus, keeping all these facts in mind, the present study
tor of heart disease even in sixth or seventh decades when the was undertaken to investigate the electrocardiogram (ECG)
validity of other parameters, such as history or symptoms is in apparently healthy elderly individuals and to study the
often diminished. changes in ECG pattern with advancing age.
Conclusions: In summary, the ECG in apparently healthy
asymptomatic subjects identifies subgroups at high risk of
Materials and methods
cardiovascular diseases. Thus, the resting ECG is an office-
*Corresponding author: Dr. Rupali Sachin Khane, Assistant Study population
Professor in Physiology, D.Y. Patil Medical College, Kolhapur,
Maharashtra, India This study was conducted in Solapur city. Apparently healthy
Phone: +91-9890045256, E-mail: asymptomatic subjects aged 45–74 years were selected for this
Previously published online September 8, 2011 study (Table 1). Selection criteria included apparently healthy

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98 Khane et al.: Changes in ECG pattern with advancing age

Table 1 Distribution of males and females in different age groups. (3) (Table 2). Data were analyzed by applying the χ2-test. The
level of significance for correlation was tested using the χ2-test
Age groups 1 2 3 Total at p<0.001.

Age range, years ≥45 to ≤54 >54 to ≤64 >64 to ≤74

Males 91 85 84 260
Total 138 135 127 400 Results

Out of 400 ECGs, 152 ECG recordings showed various

asymptomatic subjects in the age group of ≥45 to ≤74 years.
abnormalities. It was observed that the distribution of elec-
Exclusion criteria included: 1) subjects with a history of cardio-
trocardiographic abnormalities in descending order of fre-
vascular disease. Criteria for cardiovascular disease included the
following criteria to be fulfilled: (i) positive response to the World
quency were left axis deviation, sinus bradycardia, ST-T
Health Organization Rose angina questionnaire and (ii) documen- wave abnormalities, bundle branch block, left ventricular
tary evidence of previous cardiovascular disease treated at home hypertrophy (LVH), Q-QS pattern, ventricular premature
or hospital. 2) Subjects with a history of hypertension, other car- beats, right ventricular hypertrophy (RVH) and right axis
diovascular diseases, respiratory diseases and diabetes mellitus. 3) deviation (RAD).
Subjects receiving drugs that are known to interfere with cardiac We found higher prevalence of ST-T wave abnormalities,
or respiratory functions, such as β-blockers, sympathomimetic LVH and sinus bradycardia in the second age group, whereas
drugs, antihypertensive drugs and vasodilators. 4) Subjects with the prevalence of bundle branch block and ventricular prema-
a history of chronic alcohol consumption and/or chronic tobacco ture beats (VPBs) was high in the second and third age group
consumption in any form. 5) Evidence of hypertension (systolic
(Table 3). The prevalence of ECG abnormalities showed a
blood pressure >140 mm Hg and or diastolic blood pressure
highly significant association with advancing age (p<0.001)
>90 mm Hg). 6) Subjects with obesity. Body mass index (BMI) of
≥27 in males and BMI of ≥25 in females was considered as criteria
(Figures 1 and 2).
for obesity. The subjects were randomly selected from the general
population of Solapur city. Informed consent was obtained from
each subject. Discussion

The ECG has been widely described in medical reports as

Clinical evaluation
a useful diagnostic tool for assessing ‘silent’ heart disease.
All participants underwent a personal interview assessing demo- Many epidemiological studies have shown an association
graphic information, health history, personal habits including alcohol between ECG findings with advancing age and subsequent
consumption and smoking, physical activity as well as the Rose coronary and cardiovascular disease and mortality (4). The
questionnaire for angina and intermittent claudication. use of ECGs in epidemiological research has been greatly
The presence of angina, possible myocardial infarction or intermit- facilitated by the introduction of the Minnesota code classifi-
tent claudication was assessed by using the defined Rose question- cation system.
naire criteria (3). Direct patient interview for a history of myocardial Among the elderly, the prognostic significance of specific
infarction was also employed.
ECG abnormalities is mostly due to the underlying heart dis-
Subjects were examined for pulse, blood pressure, height, weight,
ease, although also aging alone appears to induce alterations
BMI and systemic examination.
in the cardiac structure and function. However, among the
elderly a reliable history of previous cardiovascular disease
Recording of blood pressure Both systolic and diastolic blood is difficult to obtain than among younger age groups. In addi-
pressures were measured in lying down position after resting for
tion, among the aged, heart disease can be symptomless due
approximately 5 min. A minimum of two readings at 5 min intervals
were recorded. If blood pressure ≥140/90 mm Hg was noted, a third
to decreased physical activity and also in some conditions,
reading was taken after 30 min. The lowest of the three was taken as
blood pressure.
Table 2 Minnesota coding: the various ECG abnormalities were
defined according to the Minnesota code system.
Calculation of BMI BMI was calculated by dividing the weight
(measured in kilograms with the subject wearing routine clothes) by ECG abnormalities Minnesota code
square of the height (measured in meters without any footwear).
Q/QS pattern 1-1, 1-2, 1-3
Left axis deviation (LAD) 2-1
Recording of ECG Before recording of the ECG, the whole Right axis deviation (RAD) 2-3
procedure was explained to the subject. The subject was asked to Left ventricular hypertrophy (LVH) 3-3
relax in supine position. Then, a resting 12-lead ECG was recorded Right ventricular hypertrophy (RVH) 3-2
in supine position, in accordance with classical recommendations ST-T abnormalities 4-1, 4-2, 5-2, 5-3
on a BPL 108 ECG machine. All ECGs were recorded between Complete left bundle branch block (LBBB) 7-1-1
09.00 h and 12.00 h in a cool and calm atmosphere, at room Complete right bundle branch block (RBBB) 7-2-1
temperature varying from 27°C to 30°C. ECGs were coded and Ventricular premature beats (VPBs) 8-1-2
classified as abnormal according to the Minnesota code system Sinus bradycardia 8-8

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Khane et al.: Changes in ECG pattern with advancing age 99

Table 3 Prevalence of ECG abnormalities in different age groups.

Sr. no. Age group no. 1 2 3 Total

1 LAD 5 (3.28%) 14 (9.21%) 14 (9.21%) 33 (21.7%)

2 Sinus bradycardia 8 (5.26%) 12 (7.89%) 10 (6.57%) 30 (19.73%)
3 ST-T abnormalities 8 (5.26%) 13 (8.55%) 6 (3.94%) 27 (17.76%)
(A) LBBB 0 7 (4.6%) 10 (6.57%) 17 (11.18%)
(B) RBBB 0 5 (3.28%) 5 (3.28%) 10 (6.57%)
5 LVH 2 (1.31%) 9 (5.92%) 5 (3.28%) 16 (10.52%)
6 Q/QS pattern 2 (1.31%) 5 (3.28%) 5 (3.28%) 12 (7.88%)
7 VPBs 0 1 (0.65%) 4 (2.63%) 5 (3.28%)
8 RVH 0 0 1 (0.65%) 1 (0.65%)
9 RAD 0 0 1 (0.65%) 1 (0.65%)
10 Total 25 (17.1%) 66 (43.42%) 61 (40.13%) 152
Out of 400 ECGs recorded, 152 showed abnormalities in their ECG pattern. The prevalence of ECG abnormalities showed a highly significant
association with advancing age (p<0.001).

such as diabetes mellitus, endocrinological diseases, syphilis, activity and parasympathetic activity with advancing age.
hyperlipidemia and atherosclerosis. In older age, there is decreased sympathetic activity and
The present study was carried out in 400 apparently healthy increased parasympathetic activity leading to increased vagal
asymptomatic subjects in the age range of 45–74 years to tone, which causes a decrease in heart rate (9). Thus, it can
assess the influence of age on ECG. be an expression of vagotonia, reduced adrenergic sensitivity
of the aging sinus node and degeneration of the sinus node
Left axis deviation itself (10, 11).
Microelectrode recordings of cardiac muscle action
In our study, the incidence of left axis deviation was 21.7%. potential also demonstrate age-related changes in cardiac
It showed an increase in prevalence with increasing age, i.e., membranes. The rat myocardium shows three major elec-
3.28% in the first age group and 9.21% in the second and third trophysiological changes with advancing age as follows (9):
age groups. Campbell et al. (5) found that left axis deviation 1) the maximum rate of increase of phase 0 decreases; 2) the
was the most common ECG abnormality with an incidence plateau phase of depolarization becomes more prominent; and
of 3% in their study. Mihalick and Fisch (6) noted an 11% 3) the time necessary to achieve 95% repolarization increases.
incidence of left axis deviation in their study and also noted Age-related changes in the intracellular Na+ and K+ con-
a significant association with increasing age. Our findings are tents of the aging heart might be major determinants in its
in agreement with the literature. increasing resting action potential and decreasing conduction
Some authors (6, 7) attributed this change to greater free- velocity with age (9).
dom of motion of the heart within the thorax in the elderly
subject due to the anatomical changes in the older popula- ST-T wave abnormalities
tion as follows: 1) progressive development of kyphoscoliosis
with increasing AP diameter; 2) lowering of the diaphragm In our study, the incidence of ST segment and/or T-wave
due to pulmonary emphysema; 3) loss of the elasticity and abnormalities in the absence of bundle branch block, LVH
increased resistivity of the tissues surrounding the heart; and and other conduction defects was 17.6%. The majority of
4) elongation of the aorta. subjects were from the second age group.
Another possibility related to left axis deviation is that dur-
ing the first 6 months of life, the normally vertical axis moves
leftward because the left ventricle grows faster than the right. 1%
By the age of 6 months, adult proportions have been reached 3% 1%
and the axis then remains stable until, with advancing age in Sinus bradycardia
8% 22% ST-T wave abnormalities
later life, a leftward drift sets in again (8). 10%
20% RBBB
Sinus bradycardia
11% LVH
In our study, the incidence of sinus bradycardia was 19.37%. Q/QS pattern
It was observed that the prevalence was higher in the sec- VPBs
ond and third age groups (7.89% and 6.57%, respectively) RVH
compared with the first age group (5.26%). In our study, RAD
we found a decrease in heart rate with advancing age. This
can be attributed to the imbalance between the sympathetic Figure 1 Prevalence of ECG abnormalities.

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100 Khane et al.: Changes in ECG pattern with advancing age

10 age groups (5.92% and 3.28%, respectively). The increasing

9 I Age group
prevalence of LVH with advancing age can be cardiac muscle
II Age group
7 hypertrophy, mainly LVH in elderly subjects (14).
6 III Age group

4 Q/QS pattern
1 The incidence of Q/QS pattern in our study was 7.89%.
0 It was noted that the incidence continues increasing with








increasing age. There are two community-based studies con-







ducted in India for estimating the prevalence of cardiovas-





cular disease, which supports our findings. It was observed


in the studies that, in India, cardiovascular disease occurs a


decade earlier than in developed countries. The peak is at

51–60 years (15).
Figure 2 Prevalence of ECG abnormalities in different age
Ventricular premature beats (VPBs)

In our study, the incidence of VPBs was 3.28%. In relation

Campbell et al. (5) observed 15% prevalence of ST-T wave to age, it was observed that the prevalence of VPBs increases
abnormalities, especially T-wave flattening, and an increase in with increasing age (0.65% in the second age group and
frequency with age. These ST-T wave abnormalities indicate 2.63% in the third age group). It was also observed that there
subclinical myocardial damage from coronary atherosclerosis was no evidence of VPBs in the first age group. The increased
that later can be clinically manifested as sudden death. ST-T incidence of VPBs in the older age group could be due to ana-
wave abnormalities in the ECG can reflect inequalities in ven- tomical, biochemical and electrophysiological changes of the
tricular recovery, and disparity in recovery of excitability in aging process in the old heart that can alter its normal physi-
cardiac muscle is related to increased vulnerability to arrhyth- ological properties and produce greater excitability, irritabil-
mias (12). Thus, the electrocardiographic signal permits detec- ity and slowed conduction (9).
tion of cardiac status at high risk of ventricular arrhythmias. In addition, in the elderly subjects, the anatomical heart
The higher incidence of ST segment and T-wave abnormalities changes attributed to the aging process, such as focal thicken-
in the second age group demonstrated herein could reflect a ing of the elastic and reticular nets and infiltration of fat in
myocardium more vulnerable to fatal ventricular arrhythmias. the cardiac muscle fiber that could act as a focus to gener-
ate premature beats (9). The presence of VPBs identifies a
Bundle branch block group with an electrically unstable myocardium which with
an episode of myocardial ischemia is more likely to develop
In our study, the incidence of bundle branch block was 17.76%, ventricular fibrillation (12).
with the incidence of left bundle branch block being 11.18% Thus, in our study we found an increase in prevalence of
and right bundle branch block 6.57%. In addition, another pos- ECG abnormalities with advancing age.
sible explanation is that this age difference reflects the caus-
ative factor being the aging process which mainly affects the
conduction system of the heart and could be the crucial factor Summary and conclusions
influencing prognosis (13). It was also observed that it was
totally absent in the first age group. The incidence for complete This study has outlined the overall relationship between
right bundle branch block (RBBB) was 3.28% in the second electrocardiographic abnormalities and advancing age. We
and third age groups. The incidence for complete left bundle found the total prevalence of ECG abnormalities was 38%
branch block (LBBB) was 4.6% in the second age group and (152/400). The various ECG abnormalities in decreasing
was increased to 6.57% in the third age group. The association order of frequency were left axis deviation, sinus bradycardia,
of bundle branch block with advancing age indicates abnor- bundle branch block, ST-T wave abnormalities, LVH, Q/QS
malities of the myocardium or the conduction system of the pattern, VPBs, RVH and RAD. It was also noted that there is
heart that predispose to the development of fatal arrhythmias, a highly significant increase in prevalence of ECG abnormali-
and alternatively progressive impairment of the conduction ties with advancing age, suggesting strong age dependency.
system would result in complete heart blockage (13). There are satisfactory biological explanations for each
of the electrocardiographic abnormalities identified in this
Left ventricular hypertrophy study. This strengthens the case that there is a true association
between ECG abnormalities and advancing age. Indeed, the
In our study, the incidence of left ventricular hypertrophy was close parallel relationship between the incidence of abnormal
10.52%. It was observed that the incidence was greatest in the ECG and advancing age found in our study suggests that the
second age group (5.92%). In comparison with the first age ECG could be a highly reliable indicator of heart disease even
group (1.31%) the incidence was higher in the second and third in sixth or seventh decades.

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Khane et al.: Changes in ECG pattern with advancing age 101

Thus, we conclude that: 1) some risk-laden elements of car- comprehensive assessment of mortality and disability from dis-
diovascular disease can be silent in elderly due to diminished eases. Injuries and risk factors in 1990 and projected to 2020.
physical activity, but these can be identified with the ECG; 2) MA, USA: Harvard School of Health, 1996.
our findings also lead us to suggest that high-risk asymptom- 3. Rose GA, Blackburn H, Gillum RF, Prineas RJ. Cardiovascular
survey methods, 2nd ed. WHO monograph series no. 56. Geneva:
atic people in middle age should undergo an ECG screening
World Health Organization, 1982:124, 162.
to prevent the development of cardiovascular disease and its 4. De Bacquer D, De Baker G, Kornitzer M. Prevalence of ECG
complications; 3) persons over 45 years of age should undergo findings in large population based samples of men and women.
follow-up with ECG screening at regular intervals for early Heart 2000;84:625–33.
detection and prevention of cardiovascular disease. 5. Campbell A, Caird FI, Jackson TF. Prevalence of abnormalities of
electrocardiogram in old people. Br Heart J 1974;36:1005–11.
6. Mihalick MJ, Fisch C. Electrocardiographic findings in the aged.
Acknowledgments Am Heart J 1974;87:117–28.
7. Olbrich O, Woodford W. The effect of body position on the pre-
We are very thankful to Dr. Gurunath Parale D.M. (Cardiologist), cordial electrocardiogram in young and aged subject. J Gerontol
Solapur, for his kind help and suggestions at various stages of the 1953;8:56.
study. We would like to extend special thanks to Dr. Mrs. Muley, 8. Marriott, HJL. Practical electrocardiography. 8th ed. Baltimore:
Professor of Anesthesia, for her cooperation. Last but not the least Williams & Wilkins, 1988. pp.39.
we are very thankful to all those subjects who participated in this 9. Platt D. Geriatrics 1: cardiology and vascular system, central
study. nervous system. 1st ed. Berlin, Germany: Springer Verlag, 1982.
pp. 110–23.
10. Jones J, Srodulski ZM, Romisher S. The aging electrocardio-
Conflict of interest statement gram. Am J Emerg Med 1990;80:240–5.
11. Kostis JB, Moreyra AE, Amendo MT. The effect of age on heart
Authors’ conflict of interest disclosure: The authors stated that there rate in subjects free of heart disease. Studies by ambulatory elec-
are no conflicts of interest regarding the publication of this article. trocardiography and maximal exercise stress test. Circulation
Research funding: None declared. 1982;65:141–5.
Employment or leadership: None declared. 12. Rabkin SW. Electrocardiographic abnormalities in apparently
Honorarium: None declared. healthy men and the risk of sudden death. Drugs 1984;28:28–
13. Assantachai P, Panchauinnin P, Pisalarskij D. An electrocardio-
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