Inverted mitral inflow pattern in echocardiography among the elderly — A marker of non-cardiovascular mortality and cognitive dysfunction Tuomas Kerola a, ⁎, Tuomo Nieminen a,b , Raimo Sulkava c , Olli Vuolteenaho d , Sirpa Hartikainen e , Raimo Kettunen a a Department of Internal Medicine, Päijät-Häme Central Hospital, Lahti, Finland b Department of Pharmacological Sciences, Medical School, University of Tampere, Tampere, Finland c School of Public Health and Clinical Nutrition, Division of Geriatrics, University of Kuopio, Kuopio, Finland d Department of Physiology, Faculty of Medicine, Biocenter Oulu, University of Oulu, Oulu, Finland e Faculty of Pharmacy, University of Kuopio and the Kuopio Research Centre of Geriatric Care, Finland abstract article info Article history: Received 1 December 2010 Accepted 1 January 2011 Available online 9 March 2011 Keywords: Elderly Echocardiography Prognosis Mortality Dementia Background: An echocardiographically measured inverted mitral inflow pattern (E/A ratio), a measure of left ventricular diastolic function, has been repeatedly shown to predict mortality. Despite its known association with several non-cardiovascular disease states, its connection to non-cardiovascular mortality remains unknown. Methods: A total of 323 individuals aged more than 75 years were examined and followed up for a median of 7.6 years in a prospective population-based echocardiographic cohort study carried out in Eastern Finland. Cox proportional hazards regression models were used to determine the prognostic power of echocardio- graphic parameters on total, cardiovascular, and non-cardiovascular mortality, with special interest on inverted E/A ratio. Results: The left ventricular mass index was a significant predictor of total and cardiovascular mortality. It had no connection to non-cardiovascular mortality. Inverted E/A ratio was associated with total mortality in the age- and sex-adjusted (HR = 1.54; 95% CI = 1.14–2.07) as well as in the fully adjusted multivariable model (HR = 1.55; 95% CI = 1.10–2.19). Regarding cardiovascular mortality, the inverted E/A ratio showed no predictive value in the age- and sex-adjusted (HR = 1.24; 95% CI = 0.80–1.91) or the fully adjusted (HR = 1.31; 95% CI = 0.78–2.22) models. Inverted E/A was a strong predictor of non-cardiovascular mortality in both the age- and sex-adjusted model (HR = 1.86; 95% CI = 1.24–2.80) and the multivariable model (HR = 1.81; 95% CI = 1.13–2.89). Dementive illness was the only prior disease more common among individuals with an inverted mitral inflow pattern. Conclusions: An echocardiographically measured inverted mitral inflow pattern is a robust predictor of total and non-cardiovascular mortality among the elderly general population, with no significant connection to cardiovascular mortality. © 2011 Elsevier Ireland Ltd. All rights reserved. 1. Introduction Aging is associated with left ventricular stiffening and the attenu- ation of the peak early diastolic filling velocity (E). Consequently, the atrial systole component of the diastolic filling (A) increases, the net result being a decrease in the echocardiographically measured E/A ratio [1]. Despite the introduction of tissue Doppler measures, the measure- ment of E/A ratio is an integral part of estimating the diastolic function of the heart [2]. Inverted mitral inflow (E/A b 1.0) is used as a marker of the mildest form of left ventricle diastolic dysfunction, impaired relaxation with normal filling pressure [2]. In the elderly, lower E/A limits – 0.6 or, more commonly, 0.75 – have been used for an inverted mitral inflow pattern [3–5]. Several large population-based studies have investigated the prognostic value of echocardiography for mortality. Left ventricular mass [4,6,7] and ejection fraction (EF) [8] have been demonstrated to predict mortality almost uniformly; only one of the larger studies showed no association with EF and mortality [4]. An inverted mitral inflow pattern has also been linked to total mortality and cardiovas- cular mortality [3,4], with one study finding the association only in men [4]. In healthy individuals, decreased left ventricular preload [9] and low central blood volume have been linked to an inverted mitral inflow pattern [10]. In addition to dehydration, an inverted mitral inflow pattern has been reported to be linked to several non-cardiovascular conditions such as liver cirrhosis [11,12] and pulmonary hypertension International Journal of Cardiology 155 (2012) 70–74 ⁎ Corresponding author at: Department of Medicine, Päijät-Häme Central Hospital, Keskussairaalankatu 7, 15850 Lahti, Finland. E-mail address: tuomas.kerola@phsotey.fi (T. Kerola). 0167-5273/$ – see front matter © 2011 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijcard.2011.01.086 Contents lists available at ScienceDirect International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard