|Year : 2021 | Volume
| Issue : 2 | Page : 45-53
Normal values of echocardiographic parameters and incidence of valvular heart findings in 2229 iranian peaple: Results from the “HAMRAH survey”
Azin Alizadehasl1, Hooman Bakhshandeh2, Parham Sadeghipour3, Bahram Mohebbi3, Mohammadreza Baay2, Mohammad Javad Alemzadeh-Ansari3, Zahra Hosseini3, Zeinab Norouzi2, Majid Maleki2, Feridoun Noohi2, Yasaman Khalili2, Nasim Naderi2, Hamidreza Pouraliakbar2, Behshid Ghadrdoost2, Maedeh Arabian2, Shiva Khaleghparast2, Shabnam Boudagh4
1 Department of Cardio-Oncology Research Center, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
2 Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
3 Cardiovascular Intervention Research Center, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
4 Echocardiography Research Center, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
|Date of Submission||25-Mar-2021|
|Date of Decision||03-May-2021|
|Date of Acceptance||12-May-2021|
|Date of Web Publication||29-Jul-2021|
Dr. Shabnam Boudagh
Echocardiography Research Center, Rajaie Cardiovascular Medical and Research Center, Niyayesh Ave, Vali-asr Street, 199691115, Tehran
Source of Support: None, Conflict of Interest: None
Introduction: It is crucial to define the normal ranges of echocardiographic parameters and their relationships with age, sex, race, and geographical differences given the failure of the existing literature to reflect the diversity of the world's populations. This study aimed to determine the normal ranges of echocardiographic systolic and diastolic values and the incidence of valvular heart lesions with or without rheumatic involvement in a sample of Iranian population. Methods: The Echocardiography Heart Assessment and Monitoring in Rajaie Hospital study is a population-based investigation conducted in Rajaie Cardiovascular Medical and Research Center. A total of 2229 Iranian individuals between 30 and 75 years of age without clinical cardiovascular diseases were invited through a multistage random sampling process, and they underwent two-dimensional and Doppler echocardiography. The left ventricular (LV) ejection fraction, the interventricular septal thickness, the ascending aortic size, the LV diastolic function, the valvular heart disease (VHD) severity, and rheumatic valvular involvement were assessed. Results: The study population comprised 2229 patients: 882 men (40%) and 1347 women (60%) at an age range of 39–58 years and a mean age of 48 years. The average body mass index was 28.8 kg/m2 (25.9–32 kg/m2), and the median body surface area was 1.86. Mildsystolic dysfunction was reported in 119 patients (5.7%) and moderate systolic dysfunction in 19 (0.9%). LV systolic dysfunction was significantly correlated with the male sex, age, and hypertension (P < 0.001). The mean interventricular septal thickness was 8 mm. Mild LV hypertrophy (LVH) was detected in 5.5% of all the patients and moderate LVH in 0.4%. The mean interventricular septal thickness significantly increased with age (P < 0.001), and it was higher in the men than in the women (8.2 mm [7.8–9.2] vs. 8 mm [7–8.25]; P < 0.001). Mild LVH and moderate LVH were significantly correlated with hypertension, diabetes mellitus, hyperlipidemia, chronic kidney disease, and diastolic dysfunction (P < 0.001). Diastolic dysfunction was found in 29% of the patients (28.6% mild and 0.2% moderate). Significant correlations were found between LV diastolic dysfunction and age, the female sex, diabetes mellitus, hypertension, hyperlipidemia, and hypercholesterolemia (P < 0.001). The mean ascending aortic size was 31 mm in the men and 29 mm in the women. The ascending aortic size exceeded 37 mm in 5% of the men and 3.5% of the women. The indexed ascending aortic size was 1.54 cm/m2 in the men and 1.66 cm/m2 in the women. Valvular heart lesions were diagnosed in about half of the study population. The most common findings were mild regurgitation in the mitral and tricuspid valves. Multiple valvular disorders were found in 55% of the patients. Among significant (moderate and more-than-moderate) VHDs, tricuspid regurgitation (36%), mitral regurgitation (33%), and aortic regurgitation (19%) were the most frequent VHDs. Rheumatic valvular involvement was diagnosed in 31 (1.4%) patients. Conclusions: Echocardiographic parameters vary with age, sex, and race, and they should be population adjusted. We recommend further research in different areas of Iran to obtain sufficient data for the creation of an applicable guideline regarding echocardiographic parameters.
Keywords: Echocardiography, left ventricular function, left ventricular hypertrophy, reference values, valvular heart disease
|How to cite this article:|
Alizadehasl A, Bakhshandeh H, Sadeghipour P, Mohebbi B, Baay M, Alemzadeh-Ansari MJ, Hosseini Z, Norouzi Z, Maleki M, Noohi F, Khalili Y, Naderi N, Pouraliakbar H, Ghadrdoost B, Arabian M, Khaleghparast S, Boudagh S. Normal values of echocardiographic parameters and incidence of valvular heart findings in 2229 iranian peaple: Results from the “HAMRAH survey”. Res Cardiovasc Med 2021;10:45-53
|How to cite this URL:|
Alizadehasl A, Bakhshandeh H, Sadeghipour P, Mohebbi B, Baay M, Alemzadeh-Ansari MJ, Hosseini Z, Norouzi Z, Maleki M, Noohi F, Khalili Y, Naderi N, Pouraliakbar H, Ghadrdoost B, Arabian M, Khaleghparast S, Boudagh S. Normal values of echocardiographic parameters and incidence of valvular heart findings in 2229 iranian peaple: Results from the “HAMRAH survey”. Res Cardiovasc Med [serial online] 2021 [cited 2021 Dec 4];10:45-53. Available from: https://www.rcvmonline.com/text.asp?2021/10/2/45/322581
| Introduction|| |
Echocardiography is the most widely used modality for the assessment of cardiac size and function. The normal values of two-dimensional (2D) and Doppler-derived velocities may vary with age, sex, race, and geographical areas; accordingly, robust reference values concerning what constitutes normal cardiac structure and function in echocardiography are needed. The current Doppler echocardiographic reference values are derived mainly from studies on American and European populations with wide heterogeneity in their inclusion and exclusion criteria, and there is a dearth of data on the Asian population.,,,,,, The structure and function of cardiac chambers might be different between individuals with European or American Caucasian origins and individuals with other ethnicities, necessitating standardized protocols based on stringent guidelines to obtain high-quality, reproducible echocardiographic measurements.
The current investigation, conducted on a sample of Iranian individuals as a part of the Echocardiography Heart Assessment and Monitoring in Rajaie Hospital (ECHO-HAMRAH) study, aimed to determine the normal ranges of echocardiographic systolic and diastolic parameters and their relationships with age, sex, body surface area, and geographical region-dependent differences. Further, the incidence of valvular heart lesions and rheumatic involvement was investigated.
| Methods|| |
The ECHO-HAMRAH is a sub-study on the HAMRAH cohort study, which is a population-based cohort study for the assessment of 10-year cardiovascular risk profiles in a randomly selected sample of Iranian individuals. This study enrolled 2229 adults aged between 20 and 79 years and without clinical cardiovascular diseases. Informed consent was obtained from all participants. Patients with a history of known cardiovascular diseases including congenital anomalies of the heart and vessels, significant coronary artery disease, myocardial infarction, history of any cardiac surgery, and intervention were excluded from the study. The study patients' demographic characteristics including nationality, age, sex, physical activity, smoking status, and eating habits in conjunction with their clinical data including a family history of cardiovascular diseases, diabetes mellitus, hypertension, hypercholesterolemia, hyperlipidemia, and smoking, noncardiac diseases, and drug history were recorded in a prepared questionnaire. A detailed description of the methodology and aims of the HAMRAH study has been recently published.
Afterward, the study patients underwent 2D echocardiography to determine the left ventricular ejection fraction (LVEF) with visual assessment; the interventricular septal (IVS) thickness; the valvular heart disease (VHD) severity; the ascending aortic size; the grading of diastolic dysfunction based on the mitral inflow pattern (the peak velocities of early [E] and late [A] diastolic flows [the E/A ratio]), the left atrial volume index, the tricuspid regurgitant velocity, and tissue Doppler velocities (E' medial and E' lateral); and the pathology of underlying VHDs including rheumatic involvement and mitral valve prolapse. All the studies were performed with the GE Vivid 7 System (GE Healthcare, Chicago, Illinois, USA), equipped with an M3S multifrequency, phased-array transducer, and tissue Doppler imaging facilities. Data were acquired with the participants at rest, lying in the left lateral decubitus position. Gray scale images were obtained through second harmonic imaging (1.7/3.4 MHz). Gain and depth were adjusted to optimize the images for each participant. All the echocardiographic examinations were performed by expert echocardiographers and supervised by echocardiologists. All the measurements were obtained in keeping with the recommendations of the American Society of Echocardiography/the European Association of Cardiovascular Imaging chamber quantification and diastolic function guidelines.
The data were analyzed by survey analysis and SPSS software, version 16, for Windows (SPSS Inc, Chicago, Illinois). The study protocol was approved by the institutional ethics committee. The study patients' names and information were saved, and the participants were reassured regarding the confidentiality of their identity and personal data.
| Results|| |
The results are classified and discussed in two major categories: general characteristics and echocardiographic results.
The present study evaluated 2229 patients: 882 men (40%) and 1347 women (60%) at an age range of 39–58 years and a mean age of 48 years. The height of the patients ranged between 155 and 169 cm with an average of 161 cm. The patients' weight ranged from 67 to 85 kg with an average of 76 kg. In addition, the average body mass index was 28.8 kg/m2 (25.9–32), and the median body surface area was 1.8 (1.7–2). These data are shown in [Table 1].
Comorbidities and drug history
Comorbidities among the study population were evaluated as several diseases including diabetes mellitus, hypertension, hyperlipidemia, hypercholesterolemia, chronic kidney disease, hypothyroidism, hyperthyroidism, malignancies, and rheumatic disease. Drug history was also recorded for all the patients. The most frequent comorbidity among the patients was hypercholesterolemia (20%), and the most common drug prescribed was the statin group (6.8%). Other results are summarized in [Table 2].
Echocardiographic evaluation was done in terms of list the parameters including the IVS thickness at end-diastole, the LVEF, the ascending aortic size, the indexed ascending aortic size, and the grading of left ventricular (LV) diastolic function [Table 3].
The mean IVS thickness was 8 mm. Mild LV hypertrophy (LVH) was observed in 5.5% of all the cases and moderate LVH in 0.4%. The IVS thickness was significantly increased with age (P < 0.001), and it was higher in the male patients than in their female counterparts (8.2 mm [7.8–9.2] vs. 8 mm [7–8.25]; P < 0.001). Mild LVH and moderate LVH exhibited significant correlations with hypertension, diabetes mellitus, hyperlipidemia, and chronic kidney disease (P < 0.001) [Table 4].
|Table 4: Associations between interventricular septal thickness and background characteristics|
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The LVEF in most of the patients (93.4%) was normal (>52% in men and 54% in female). Mild systolic dysfunction was detected in 5.7% of the patients (n = 117) and moderate systolic dysfunction in 0.9% (n = 19) [Table 3]. LV systolic dysfunction was significantly correlated with the male sex, age (P < 0.001), and hypertension (P < 0.001) [Table 5].
|Table 5: Moderate and severe left ventricular systolic dysfunction and the relevant factors|
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LV diastolic function was normal in the majority of the patients (71. 2%). Diastolic dysfunction was found in 29% of the study population (28.6% mild and 0.2% moderate). Severe diastolic dysfunction (restrictive pattern) was not seen in any of the patients. Correlations were assessed between mild and moderate LV diastolic dysfunction and list the parameters including sex, age, and other comorbidities. Statistically meaningful correlations were observed between mild and moderate LV diastolic dysfunction and age (P < 0.001), the female sex, diabetes mellitus, hypertension, hyperlipidemia, and hypercholesterolemia (P < 0.001) [Table 6].
|Table 6: Mild and moderate diastolic left ventricular dysfunction and the relevant factors|
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The mean ascending aortic size was 31 mm in the men and 29 mm in the women. The ascending aortic size exceeded 37 mm in 5% of the male patients and 3.5% of the female patients [Table 3]. The indexed ascending aortic size was 1.54 cm/m2 in the men and 1.66 cm/m2 in the women [Figure 1].
|Figure 1: The image illustrates the mean (95% CI) of the normal and indexed diameters of the ascending aorta according to sex|
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Valvular heart findings
Valvular heart lesions were found in about half of the patients. The most common findings were mitral valve involvement (42%), followed by the involvement of the tricuspid (37%), pulmonary (30%), and aortic (7%) valves. Multiple valvular disorders were reported in 55% of the patients. Among significant (moderate and more-than-moderate) VHDs, the most frequent were tricuspid regurgitation (TR) (36%), mitral regurgitation (MR) (33%), and aortic regurgitation (19%).
Concerning the mitral valve, the most reported findings were mild MR (39%), with 2.4% (n = 54) of the patients exhibiting moderate and more-than-moderate MR. Mitral valve prolapse was found in 3% of the study population. Nine patients had mitral stenosis; and in those with significant (moderate and severe) mitral stenosis, rheumatic involvement was the most frequent underlying pathology [Table 7].
Regarding the aortic valve, the most frequent disease was mild aortic regurgitation (6%), followed by significant (moderate and more-than-moderate) aortic regurgitation (1.3%). Only 7 cases (0.3%) of aortic stenosis were found.
Apropos of the pulmonary and tricuspid valves, the most frequent diseases were mild pulmonary regurgitation (30%) and mild TR (35%), respectively.
Distribution of valvular problems in major groups of valvular heart diseases
Rheumatic VHDs were diagnosed in 31 patients, with the most frequent diseases being those of the mitral (52%) and tricuspid (52%) valves. Multiple valvular disorders were found in 55% of the patients. Mitral valve prolapse was diagnosed in 64 patients, and the most common involvement was mild MR (36%) [Table 8].
|Table 8: Distribution of valvular problems in major groups of valvular heart diseases|
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| Discussion|| |
The present population-based study with its high statistical power is the first of its type to be conducted in Iran. Heart centers across Iran adhere to the European and American guidelines, and we sought to determine population-based echocardiographic reference values for our country with a view to reflecting the heterogeneity of human populations. These results may be helpful not only in routine echocardiographic examinations but also in the interpretation of the echocardiographic results of clinical trials.
Several studies have underscored a significant correlation between the LV mass and age and concluded that the aging process can increase the LV mass and decrease the LV volume; nonetheless, they have found no significant correlation with sex.,, Gardin et al. showed that the LV mass was different between white and black Americans. A study by Baldo et al. on a sample of the black African population found LVH in 41% of the patients, with a higher frequency in females. Their results are concordant with those reported for African Americans. In our study, the range of the IVS thickness was 7.8–9.2 mm in men and 6–8.25 mm in women. We detected LVH (mild and moderate) in 5.9% of our study population. Further, the mean IVS thickness was significantly higher in our male patients (P < 0.001), and the IVS thickness exhibited a significant correlation with aging, diabetes mellitus, hypertension, and LV diastolic dysfunction (P < 0.001). The recent guidelines stipulate that the normal IVS thickness ranges from 6 to 10 mm in males and from 6 to 9 mm in females, which our measures were in the lower range of spectrum. Asch et al. enrolled patients from 15 countries, with the majority of the participants coming from Asia or the white race. Their study showed that the IVS thickness ranged between 6 and 12 mm in males and between 5 and 11 mm in females in the Asian population. It, therefore, appears that the normal range of the IVS thickness is low in the Iranian population in comparison with other nations.
Systolic function is one of the most valuable echocardiographic parameters in the assessment of many cardiac diseases. The LVEF plays an important role in the prognosis of patients.,,, Consequently, it is crucial that its normal range must be determined in different races. The recent guidelines specify that the normal range of the LVEF is from 52% to 74%. In their investigation, Asch et al. reported that the LVEF was higher in females in that it ranged between 58% and 69% in female participants and between 57% and 68% in male participants. They also showed that the LVEF was approximately similar in different races and that there was no significant difference vis-à-vis the LVEF between the study groups from different countries. Another investigation demonstrated that LVEF values exceeding 53% were normal and that LVEF values below 40% were crucial in the prognosis of patients. We considered LVEF values surpassing 52% in men and 54% in women to represent normal LV systolic function and found that more than 93% of our study population met this criterion. According to our results, systolic dysfunction had a significant correlation with age, the male sex, and hypertension (P < 0.001).
The guidelines of the British Society of Echocardiography state that normal LVEF values are 55% or greater in both males and females, borderline LVEF values range between 50% and 54%, and normal IVS thickness measures range from 6 to 12 mm in males and from 5 to 11 mm in females. Normal values of the LVEF according to Galderisi et al. were 52% or greater in males and 54% or greater in females.
Based on the guidelines of the British Society of Echocardiography, the normal aortic size in the proximal ascending aorta ranges from 1.15 to 1.99 cm/m2 in males and from 1.14 to 1.98 cm/m2 in females. Galderisi et al. concluded that the normal size of the proximal ascending aorta was 1.7 cm/m2 or less in males and 1.9 cm/m2 or less in females. In our study, the indexed ascending aortic size was 1.54 cm/m2 in men and 1.66 cm/m2 in women, which is not significantly different from the recent guidelines regarding chamber quantification [Figure 1].
One of the changes in echocardiographic parameters during the aging process is LV diastolic dysfunction due to increased stiffness in the LV. Furthermore, mild diastolic dysfunction is predicted in healthy elderly people.,,,,,,,,,,,,,,, We detected a significant correlation between age and LV diastolic dysfunction (P < 0.001). LV diastolic dysfunction was also significantly correlated with diabetes mellitus, hypertension, and hyperlipidemia (P < 0.001).
A study by Daimon et al. in Japan showed that changes in LV diastolic parameters wrought by aging were different between the two sexes. In women, menopausal status could be a reason for vascular dysfunction and proliferation of smooth muscles. Decreased estrogen levels are one of the causes of diastolic dysfunction in postmenopausal women. Estrogen regulates calcium influx at L-type calcium channels, calcium uptake by the sarcoplasmic reticulum, and increase myofibrillar calcium sensitivity, suggesting that estrogen deficiency may impair myocardial calcium handling and active LV relaxation L-type calcium channels, calcium uptake by the sarcoplasmic reticulum, and myofibrillar calcium sensitivity, suggesting that estrogen deficiency may impair active LV relaxation. Likewise, in our study, diastolic dysfunction was significantly correlated with the female sex.
We diagnosed VHDs in approximately half of our study population. The most common of such diseases was mild regurgitation in the mitral and tricuspid valves. Our results revealed multiple valvular disorders in 55% of the patients. Among significant (moderate and more-than-moderate) VHDs (n: 161), the most frequent were TR (36%), MR (33%), and aortic regurgitation (19%). In the large population-based study of Nkomo et al. between 11,911 individuals, they found 651 adults with moderate or severe valve disease that frequency increased with age and MR was the most common and mitral stenosis the least common. Likewise to our study, the Framingham Heart Study reported that MR and TR were most common valve lesion, followed by AR in general population. We detected rheumatic valvular involvement in 31 patients (1.4%), of whom 54% had multiple valvular disorders. The most likely reason for the low incidence of rheumatic VHDs is our random patient selection from a sample of individuals among the moderate-to-high socioeconomic residents of the Iranian capital, Tehran. Our results demonstrated mitral valve prolapse in 64 patients (3%), and the most common involvement was mild MR.
The prevalence of rheumatic VHDs has decreased in developed countries, while it is still a concern in developing countries.,, In developed countries, the most common cause of VHDs is degeneration due to the aging process., Asian and Middle Eastern countries are areas with the highest prevalence of rheumatic VHDs in the world.,,,
In the Swedish population, aortic stenosis (47.2%), MR (24.2%), and aortic regurgitation (18.0%) were reported as the most common VHDs, with most of the patients being in the elderly group. Aortic stenosis was mainly in consequence of atherosclerosis, and rheumatic fever was rarely reported. In a study conducted in Buea Regional Hospital in Cameroon, patients with left-sided VHDs were enrolled. Degenerative valve diseases were the most common involvement (47%), followed by rheumatic valvular involvement (44%). According to an investigation in Uganda in East Africa, rheumatic valvular involvement was the most common cause of VHDs (53%), followed by degenerative valve diseases (42%). Mitral valve prolapse was reported in only 1.4% of the patients. Genereux et al. identified aortic stenosis as the most frequent VHD in elderly patients aged above 65 years. A study by Demirbağ et al. showed that the leading cause of VHDs in the Turkish population was rheumatic heart disease, with the most prevalent ones being MR and multiple valvular disorders.
| Conclusions|| |
Echocardiographic parameters vary with age, sex, and race; they should, therefore, be normalized according to the population of each area. We recommend that other studies should be undertaken in various areas of Iran for the formulation of a reliable guideline regarding the normal range of echocardiographic parameters in the Iranian population.
This study was approved by ethical committee of Iran university of medical sciences.
We are thankful to Hamidreza pasha, Maryam Forouzesh, MS, Nurse in critical care, Zohre Gholami, MS, Jamileh Karimnejad, MS, Sedighe Zakeri, MS for their contribution to the Echo-HAMRAH study.
Financial support and sponsorship
This research is financially supported by Rajaei Cardiovascular Medical and Research Center.
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8]