EPIDEMIOLOGY
Effect of Aging on the Electrocardiogram
SARA BACHMAN, MS
DAVID SPARROW, MS
L. KENT SMITH, MD
Boston, Massachusetts
From the Normative Aging Study, Veterans Ad-
ministration Outpatient Clinic and Evans hmorial
hpartment of Clinical Research and Department
of h%tdicine,University Hospital, Boston University
Medical Center. Boston, Massachusetts. support
for this research was provided by the Medical
Resew& Service of the Veterw Administration,
Boston, Massachusetts. Manuscript received
September 24,1980; revised manushpt received
April 7, 1981, acceoted Awil9. 1981.
. Adrhss for reprG E&d Sparrow. Normative
Aging Study, Veterans Administration Outpatient
Clink, 17 Court Street, Boston, Massachusetts
02108.
Previous cross-sectional population studies have shown age differences
in electrocardiographic wave patterns, including lower wave amplitudes
and a leflward shift of the frontal plane axis in older people. However,
cross-sectional results may be due to cohort differences and the data
imply only that these changes actually occur in persons as they age. In
order to examine electrocardiographic changes with aging in the same
persons, serial recordings, obtained 10 years apart, were taken in 440
healthy male participants of the Normative Aging Study, who were 23 to
66 years old on their first examlnatlon. At examlnatlon 1, I? and S wave
amplitudes were smaller and frontal plane axis measurements were
shifted to the left in older men. Longitudinal changes In these same vari-
ables were consistent with the cross-sectional resufts. In addltlon, the
P-R and Q-T interval durations were longer, the QRS duration was shorter
and the T wave amplitude was smaller at the second examination. The
longitudinal rate of change of S wave amplitude varied among age groups,
decreasing more in younger men. Thus, some prevlously described
cross-sectional age differences truly represent longitudinal age trends
in electrocardiographic patterns.
There have been several studies, mostly cross-sectional in nature, ex-
amining the relation of age to electrocardiographic patterns. These
studies have analyzed various aspects of the electrocardiogram including
frontal plane axis and wave amplitudes. For instance, several cross-
sectional studies1-5 have shown that frontal plane axis measurements
of older people are shifted leftward in comparison with the axis mea-
surements of younger people. Other such studies have indicated that the
amplitude of the T wave is lower in older age groups4p5as is the amplitude
of the R wave6-8 and the S wave.g
In contrast to the consistent age trends found in frontal plane axis and
wave amplitudes, results of cross-sectional studies on differences in
electrocardiographic interval durations have been equivocal. It has been
reported both that the P-R interval lengthens with advancing age415Jo
and that it diminishes or remains the same in older people.6J1J2 Results
of cross-sectional analyses of the duration of the Q-T interval indicate
that it may increase4 or show no change13 with age. The QRS duration
has not been reported to vary with age.4J3
Cross-sectional differences may not necessarily represent true aging
trends. Rather, such differences may be a result of cohort effects or se-
lective survival. Only a longitudinal study of serial electrocardiograms
in the same persons would be able to determine definitively which
changes actually occur with age. Although there have been a few longi-
tudinal studies of initial electrocardiographic patterns as risk fac-
tors,lJ4-16 only one study17 has examined serial electrocardiograms to
determine changes with age. The subjects were fit men, but of a limited
age group (mean age 24, standard deviation 2 years). The men were
followed up for 24 years, during which time electrocardiograms were
recorded four times. Subjects exhibited leftward axis deviation, a de-
crease in R, S and T wave amplitudes and an increase in the P-R interval
with age. In a significant number of subjects heart disease or abnormal
September 1981 The Amerkan Journal of CARDIOLOGY Volume 48 513
EFFECT OF AGING ON THE ELECTROCARDIOGRAM-BACHMAN ET AL.

electrocardiographic findings developed. These results TABLE I

indicated that in young men longitudinal electrocar- Weight (kg) and Blood Pressure (mm Hg)
diographic changes largely confirmed previous cross-
Examination 1 Examination 2
sectional findings.
An analysis of serial electrocardiograms of a broad age Variables Mean SD Mean SD
range of healthy men has not been performed. The Weight 79.6 10.1 60.6 10.6
purpose of this report is to determine if the previously Systolic blood 121.7 9.9 119.5 11.6
demonstrated cross-sectional electrocardiographic pressure
Diastolic blood 75.9 7.3 74.0 7.1
differences represent longitudinal electrocardiographic pressure
age trends in such a population. The electrocardiograms
SD = standard deviation.
of 440 healthy men (aged 23 to 66 years) of the Nor-
mative Aging Study were examined in this investigation.
Recordings were taken from two time points, about 10 R, S and T wave amplitudes, frontal plane axis and P-R, QRS,
and Q-T duration. Electrocardiograms were recorded after
years apart. Subjects meeting the study criteria of being administration of a 100 g glucose load, and tracings were sent
free of diseases that might affect the electrocardiogram to the Laboratory of Physiological Hygiene, University of
at both examinations were examined for electrocar- Minnesota for coding. R wave amplitudes were measured in
diographic changes that occur with apparent normal leads I, II and III; the largest amplitude in these leads was
aging. utilized. Amplitudes of S waves were measured in leads Vi to
V:j; the largest amplitude in these leads was utilized. Ampli-
Methods
tudes of T waves were measured in lead Vs. P-R, QRS and Q-T
Study subjects: The sample of 440 healthy men was se- interval durations were obtained in lead II. Wave amplitudes
lected from members of the Normative Aging Study. This were measured to the nearest millimeter and wave durations
longitudinal study of aging began in 1963 with 2,280 mostly were measured to the nearest hundredth of a second. Quality
middle income, healthy participants aged 21 to 81 (mean age control methods used included two independent readings of
42 years). Since that time, biomedical and psychosocial data all records with adjudication of disagreements by a third
have been regularly collected on participants, providing a person.*]
comprehensive longitudinal data base. Currently, about 1,900 Analysis of data: After receipt of the coded information,
members of the original sample remain active. A complete the data were examined cross-sectionally and longitudinally
description of the Normative Aging Study population has for variation in electrocardiographic measurements among
been published.lsJs age groups. Cross-sectional differences among four age groups
Members of the Normative Aging Study were selected to in the first examination data were analyzed using a one way
participate in the present study if they satisfied the following analysis of variance design. The amount of longitudinal
criteria. First, subjects were required to have two electro- change of the electrocardiographic variables was tested using
cardiogram recordings, taken approximately 10 years apart, a paired t test to determine if the mean level of the electro-
the first between 1967 and 1969 and the second between 1978 cardiographic waves changed significantly in the years be-
and 1979. This time criterion limited the sample to 593 tween examinations. Variation in rate of electrocardiographic
subjects. Second, in accordance with Framingham Heart change among age groups was analyzed using average mea-
Study criteria,*O 153 subjects were excluded from this group surements of annual change. These variables were computed
because of a history or findings of hypertension, ischemic heart by subtracting examination 1 measurements from examina-
disease, pulmonary infarction or rheumatic fever at either tion 2 measurements and dividing by the number of years
examination. The remaining 440 participants, aged 23 to 66 between examinations. Variation among age groups in rate
years (mean 39) at the time of the first electrocardiogram, were of electrocardiographic wave change was examined using a one
included in the study sample. Because these subjects were way analysis of variance design.
randomly selected, one can assume that the results can be It has been hypothesized that body weight may affect
generalized to the remainder of the healthy Normative Aging electrocardiographic measurementsi Analyses indicated that
Study population. The representativeness of the Normative weight did not materially affect electrocardiographic mea-
Aging Study sample has previously been discussed.ls surementsin the study population. Therefore, this variable
Electrocardiographic measurements: The electrocar- was not controlled in statistical analyses. It should be em-
diographic variables examined in this investigation included phasized that all subjects examined here were considered

TABLE II
Cross-Sectional Electrocardiographic Variatlon Among Age Groups: Examlnatlon 1 Data

Age (yr) on First Examination

<30 30-39 40-49 >49

Variables (n = 26) (n = 212) (n = 168) (n = 12) P

R amplitude (mm) to.43 10.53 9.01 9.25 <O.OOl

S amplitude (mm) 15.21 14.21 12.22 12.42 <O.OOl
Frontal plane axis () 48.93 48.13 36.50 38.83 <O.OOl
P-R duration (ms) 15.89 16.23 16.04 16.25 NS
QRS duration (ms) 7.64 7.51 7.36 8.00 NS
Q-T duration (ms) 37.82 37.50 37.99 39.58 = 0.05
T amplitude (mm) 5.21 4.57 4.31 4.42 NS
NS = not significant; p = probability.

514 September 1961 The American Journal 01 CARDIOLOGY Volume 46

 EFFECT OF AGING DN THE ELECTRDCARDIDGRAM-BACHMAN ET AL.

healthy at both examinations. Measures of weight and blood TABLE III

pressure for the two time points are shown in Table I. Only Mred I Test of Annual Electrocardiographic Change
minimal changes in these variables were observed over the 10
Annual Change
year period.
Results Variables Mean SD P

Cross-sectional results: Examination 1 data were R amplitude (mm) -0.08 0.18 <O.OOl
S amplitude (mm) -0.26 0.36 <O.OOl
examined to determine cross-sectional association of age Frontal plane axis() -0.99 1.93 <O.OOl
with the electrocardiogram (Table II). Subjects were P-R duration (ms) +0.03 0.22 <O.OOl
QFtS duration (ms) -0.04 0.19 <O.OOl
grouped into four age categories for one way analysis of Q-T duration (ms) +0.26 0.37 <O.OOl
variance. Four examination 1 variables differed signif- T amplitude (mm) -0.15 0.26 <O.OOl
icantly among age groups. R and S wave amplitudes
were significantly lower in older people. Frontal plane
axis differed significantly among age groups; values were
lower in older subjects, indicating more left axis devia- certain cross-sectional age differences and longitudinal
tion. The Q-T duration was longer in older age changes in electrocardiographic patterns were observed.
groups. Results indicated that, in older subjects, R and S wave
Longitudinal results: The results of the paired t amplitudes were lower, the frontal plane axis mea-
test, investigating changes in electrocardiographic surement was deviated more to the left and the Q-T
variables between the two examinations, are presented interval duration was longer. All variables changed
in Table III. All variables changed significantly from significantly between the two examinations according
examination 1 to examination 2. Mean R, S and T wave to paired t test results. Results also indicated that the
amplitudes were lower at the second examination than rate of change of S wave amplitude was greater in
at the first. Frontal plane axis moved to the left at the younger than in older subjects, the amplitude decreas-
second examination; P-R and Q-T interval durations ing between examinations in all age groups.
lengthened, and QRS duration was shorter at the second QRS amplitude: In most leads, the R wave is the
examination. largest positive deflection, reflecting the electrical ac-
The null hypothesis that mean annual change rate did tivity of the heart that occurs during ventricular depo-
not differ among age groups was tested using an analysis larization; the S wave signals the end of depolarization.
of variance design (Table IV). The annual rate of change Our longitudinal results of changes in R and S wave
in R and S wave amplitudes varied significantly among amplitudes supported previous findings suggesting that
age groups. Rates of decline in S wave amplitudes were there is less ventricular electrical force in the heart with
greater in younger than in older age groups. No consis- increasing age. 6,g Younger men exhibited greater
tent trend was found for R wave amplitudes. The rate changes than older men in the continual decrease of S
of change of the other variables did not differ signifi- wave amplitude through adulthood.
cantly among age groups. T wave amplitude: Previous cross-sectional stud-
We examined whether the nonsurvivors of the study ies4s5 have indicated lower T wave amplitudes among
population had similar or more electrocardiographic older persons. Similarly, our longitudinal analysis re-
changes initially than the survivors. Our analysis re- vealed a decrease in the T wave amplitude between
vealed that there were only 13 nonsurvivors; approxi- examinations, suggesting a diminution of repolarization
mately half were under age 50 years and half were aged currents with age. These results from serial measure-
50 years or more. No significant differences between ments confirm the inferences made from other cross-
survivors and nonsurvivors were observed for any of the sectional studies that changes in T wave amplitude
electrocardiographic variables. occur with aging.
Electrical axis: Although some leftward shift of the
Discussion frontal plane axis with advancing age is considered
On the basis of data collected from a sample of 440 normal,8 exaggerated shifts may be of clinical impor-
healthy participants of the Normative Aging Study, tance. Leftward shifts of the frontal plane axis to 30 or

TABLE IV
Longitudinal Rate of Electrocardlographlc Change Variation Among Age Groups

Age on First Examination

<30 30-39 40-49 >49

Variables (n = 26) (n = 212) (n = 188) (n = 12) P
R amplitude (mm) -0.14 -0.09 -0.05 -0.16 <O.Ol
S amplitude (mm) -0.37 -0.30 -0.22 -0.11 <0.05
Frontal plane axls () -0.98 -0.96 -1.02 -1.07 NS
P-R duration (ms) -0.00 0.03 0.03 0.01 NS
QRS duration (ms) -0.02 -0.04 -0.05 -0.09 NS
Q-T duration (ms) 0.25 0.31 0.27 0.07
T amplitude (mm) -0.17 -0.13 -0.13 -0.20

September 1961 The American Journal cl CARDIOLOGY Volume 46 515

EFFECT OF AGING ON THE ELECTROCAROIOGRAM-BACHMAN ET AL.
more have been associated with heart disease.22 How-
ever, more recent studies of leftward axis movement3
indicate that such movement is not associated with
heart disease even though it is significantly associated
with age. The present study suggests that frontal plane
axis changes occur with age in an apparently normal
population.
P-R, QRS and Q-T interval durations: Interval
duration measurements are representative of the con-
duction time of electrical currents in the heart. The P-R
and QRS interval durations did not vary among our
cross-sectional age groups, a finding previously reported
by others. 4,6~11~13
However, longitudinally, the P-R du-
ration increased and the QRS duration decreased,
suggesting that there may be true age-related changes
in these measurements. Both cross-sectional and lon-
References
1. Ostrandsr LD. Left axis deviation: prevalence, associated condi-
tions and prognosis. Ann Intern Med 1971;75:23-5.
2. Yano K, Peskoe SM, Rhoads GE, Moore JO, Kagan A. Hemiblock
among 8,000 Japanese-American men. Am J Cardiol 197535:
809-15.
3. Mihalick MJ, Fisch C. Electrocardiographic findings in the aged.
Am Heart J 1974;87: 117-28.
4. Simonson E. The effect of age on the electrocardiogram. Am J
Cardiol 1972;29:64-73.
5. Pipberger HV, Goldman MJ, Llttmann D, Murphy GP, Cosma J,
Snyder JR. Correlations of the orthogonal electrocardiogram and
vectorcardiogram with constitutional variables in 518 normal men.
Circulation 1967;35:536-55.
6. Mihalick MJ, Flsch C. Should ECG criteria be modified for geriatric
patients? Geriatrics 1977;32:65-72.
7. Goldbarg AN, Kurczynski TW, Helterstein HK, Steinberg AG.
Electrocardiographic findings among the total adult population of
a large religious isolate. Circulation 1970;41:255-69.
8. Blackburn H, Vasquez CL, Keys A. The aging electrocardiogram.
A common aging process or latent coronary artery disease? Am
J Cardiol 1967;20:618-27.
9. Raunlo H, Rissanen V, Lampainen E. Significance of a prominent
S wave in leads 1 and Vs in the electrocardiograms of middle-aged
and elderly hospital patients. Ann Clin Res 1976;8:347-58.
10. Cheraakln E, Rlngsdorf WM. Younger at heart: a study of the P-R
interval. J Am Geriatr Sot 1971;19:271-5.
11. Raftery EB, Cashman PMM. Long-term recording of the electro-
cardiogram in a normal population. Postgrad Med 1978;52:Suppl
7~32-7.
12. Del Vecchio PJ. Electrocardiographic findings in hospitalized
non-cardiac geriatric patients. J Am Geriatr Sot 1967;15:340-
5.
516 September 1981 The American Journal of CARDIOLDGY
gitudinal results showed a lengthening of the Q-T in-
terval duration in older subjects, supporting the results
of Simonson.
Implications: No longitudinal studies have previ-
ously examined serial electrocardiographic measure-
ments of a broad age range of healthy subjects. Results
of our analyses suggest that previously reported cross-
sectional electrocardiographic age differences actually
reflect normal longitudinal age trends in some wave
patterns. In addition, we have demonstrated that serial
electrocardiographic measurements show changes that
occur with age, even in wave patterns that do not vary
cross-sectionally. These results identify electrocardio-
graphic changes that can be expected with normal aging
in a group of men regarded over time as apparently free
from heart disease.
13. Simonson E, Keys A. The effect of age and body weight on the
electrocardiogram of healthy men. Circulation 1952;6:749-6 1.
14. Rose G, Baxter PJ, Reid DD, McCartney P. Prevalence and
prognosis of electrocardiogram findings in middle-aged men. Br
Heart J 1978;40:636-43.
15. Blackburn H, Taylor HL, Keys A. The electrocardiogram in pre-
diction of five-year coronary heart disease incidence among men
age forty through fifty-nine. Circulation 1970;41:Suppl 1:154-
61.
16. Calrd FL Campbell A. Jackson TFM. Sianificance of abnormalities
of electrocardiogram in old people. Brieart J 1974;36:1012-8.
17. Harlan WR, Graybiel A, Mftchel RE, Oberman A, Osborne RK.
Serial electrocardiograms: their reliability and prognostic validity
during a 24-year period. J Chronic Dis 1967;20:853-67.
18. Bell B, Rose CL, Damon A. The Normative Aging Study: An in-
terdisciplinary and longitudinal study of health and aging. Aging Hum
Dev 1972;3:5-17.
19. Bosse R, Ekerdt DJ, Sllberl JE. The Veterans Administration
Normative Aging Study. In: Mednick SA, Harway M, eds. Longitu-
dinal Research in The United States. Boston: Martinusnighoff, in
press.
20. Shurtleff D. Some characteristics related to the incidence of car-
diovascular disease and death: Framingham Study, l&year fol-
low-up. Section 30. Department of Health, Education and Welfare
Publication (NIH) 74-599. Bethesda, MD: National Institutes of
Health, 1974: 17-32.
21. Rose GA, Blackburn H. Cardiovascular Survey Methods. Geneva,
Switzerland: World Health Organization, 1968:104-5.
22. Gorman PA, Calatayud JB, Abraham S, Caceres CA. Effects of
age and heart disease on the QRS axis during the seventh through
the tenth decades. Am Heart J 1964:67:39-43.
Volume 48