I. The clinical features of acute myocardial infarction were compared in 72 patients over the age of 70 and 128 younger patients. Complications related to severity and ultimate prognosis such as congestive heart failure, cardiogenic shock, ventricular fibrilation and atrial fibrilation were more common in the elderly. Hospital mortality was 25% for the this ages 70 or over and 13% for the those under 70-a mortality ratio about 2:1. II. The extent and severity of selcetive coronary cineangiographic findings were analyzed in aged patients. The selective coronary cineangiographic findings were compared in 81 patients over the age 65 and 55 patients under the age 40 with more than 75% coronary narrowing of Iumen. Mutiple vessel disease (LMT, two vessel and three vessel disease) for patients over the age 65 was demonstrated 64% (52/81) versus 49% (27/58) for patients under the age 40 (p<0.05). The incidence of significant LAD lesion due to atherosclerosis was 79% in the older patients and 57% in the younger patients (p<0.05). III. A morphological study on the myocardial infarction its aging changes and relation to athersclerosis was performed in human hearts. The coronary sclerosis contains both componets induced by physiological aging phenomenon and by pathological atheromatous change in the arterial wall. A total 556 semicomsecutive autopsied hearts was subjected for macroscopical study for narrowing of the coronary artery, using multiple cross sectioning method. Significant average coronary narrowing more than 5 in coronary narrowing index (CNI), was observed at the 4th decade and later of male and at the 5th decade and later of female, with 10 years delay in female to male. The CNI in cases without any risk factors for atherosclerosis, increased with linear parallelism to growing age in male showing more than 5 of CNI at the 7th decade or latter, and it increased with a dome formation at the 5th to 6th decade in female with not beyond 5 of the CNI at any age group. Coronary arteries of 215 autopsied hearts with myocardial infraction were examined for sclerotic narrowing and thrombotic occlussion. The overall incidence of coronary thrombosis in the infarction was 53% and the incidence was higher in the masive necrosis (M) type infarction, to 70% in male and 63% in female. In the M type infarction, the highest incidence was recorded in the old male (84%) and in the older female (69%). The anteior infarction fairly matched thrombosis in the anterior descending, but the posterior one did not show such and intimate relation to thrombosis in the right coronary artery. The myocardial infarction in the elderly is characterized by association to advanced coronary sclerosis and low incidence of thrombus in the coronary arteries.
It is now well recognized that cardiomyopathy is not a rare condition in the elderly. However clinical characteristics of elderly patients have not been fully understood. Therefore the present study compares a history, clinical findings and long-term prognosis between in elderly patients (50 years or more) and in young or middle-aged patients with cardiomyopathy. In hypertrophic cardiomyopathy (HCM), the young group had a high familial occurrence with a sex ratio of approximately 1:1. This was consistent to the generally accepted concept that HCM is a genetic disorder with autosomal dominant inheritance. In contrast, elderly patients with HCM were observed predominantly in male and frequently associated with a history of hypertension, while familial occurrence was less than 50%. Japanese apical hypertrophy was again predominant in middle-aged and elderly male and frequently showed a history of hypertension, but was rare in familial occurrence. In addition, we revealed in case-control study a statistically significant association of a history of hypertension with HCM (relative risk=2.9) and apical hypertrophy (rr=3.5) aged 35 years or more. Hence elderly patients with HCM seemed to include a subgroup of patients who have a different mode of inheritance from autosomal dominant pattern and an association with hypertension. Clinically, elderly patients with HCM showed less imparied left ventricular performance and exercise tolerance and more favorable prognosis despite of older age, suggesting a late onset of the condition in this group. In dilated cardiomyopathy (DCM), younger patients frequently documented preceding flu-like symptoms, implying a possible relation to myocarditis. As recent studies have suggested that inherited disturbance of the immunological system would be related to this condition, genetic defect may be an underlying abnormality in the younger group of DCM. In contrast, elderly patients with DCM frequently showed a history of hypertension and of habitual alcohol intake. Although impairment of systolic performance of the left ventricle did not differ, elderly patients demonstrated less elevated left ventricular end-diastolic pressure, less advanced fibrosis predominated in the perivascular pattern and less poor prognosis. Hence acquired factors, such as hypertension and alcohol, seemed to be associated in the development of myocardial damage in the elderly patients with DCM. From the above findings, it was concluded that elderly patients with cardiomyopathy have several clinical characteristics different from younger patients who primarily develop the disease based on genetic abnormalities. The elderly patients usually showed a milder from of the disease, probably of late onset, and a more favorable prognosis. The association with acquired factors such as hypertension and alcohol would be important in the development and progression of the disease in the elderly patients.
Among 4, 000 consecutive autopsy cases over 60 years during past 17 years, there were a total of 485 cases (11.5%) with valvular heart diseases showing both clinical and pathologic evidences. The incidence of the valvular diseases in the aged was aortic regurgitation (AR) in 204 cases (45%) and mitral regurgitation (MR) in 171 cases (37%), followed by aortic stenosis (AS) in 45 cases (10%), mitral stenosis (MS) in 27 cases (6%). As an etiology of the valvular disease, degenerative type was found in 195 cases (43%), ischemic origin in 91 (20%), followed by syphilitic in 56 (12%) and rheumatic in 49 (11%). Congenital origin was also found in 18 cases (4%). Among various types of valvular diseases in the aged, degenerative AR was most common in 140 cases, followed by MR due to papillary muscle dysfunction in 91 cases. The clinical characteristics in cases with valvular diseases were as follows: atrial fibrillation was prominent in MS; congestive heart failure was found in 60% of cases except those with degenerative AR; cardiac death was frequent in syphilitic and rheumatic AR; association of hypertension was found in 50% of cases with MR and degenerative AR.
Aging significantly increases the incidence of atrial fibrillation (AF) and premature contractions. Analysis of ECG recorded on approximately 240, 000 subjects who had medical health check for the past 10 years, showed that the incidence of AF was significantly higher in the elderly population of more than 70 years in age (2.5% for men and 0.3% for women) than in younger population. In geriatric clinics AF is much more frequently encounted, and its management constitute a major part of routine work. In a study of a smaller clinical cohort of elderly patients with AF, the three major underlying diseases were valvular, hypertensive, and ischemic heart disease, and 10% of patients showed no clinically recogniable heart disease (lone AF). Since no uniform atrial contraction exists in AF, ventricular filling and hence, stroke volume depend mainly on rapid ventricular filling, which is a function of R-R intervals and inflow resistance. The pulse Doppler technique showed that in individual patients LV inflow volume and the stroke volume of the immediately following beat seemed to solely depend on R-R intervals; they remained approximately constant when the R-R interval was longer than the threshold inherent in individual patients, and linearly decreased with progressive shortening of R-R interval when the R-R interval was shorter than the threshold. The threshold is determined by LV inflow resistance and becomes longer in patients with mitral stenosis or lowered LV compliance. Analysis of pulse Doppler tracings of mitral inflow velocity suggested that LV compliance decreased with aging in healthy men. This finding suggestes that AF imposes s greater hemodynamic burden on the elderly than the younger population, even if no significant heart disease exists. In patients with paroxysmal AF, the response of heart rate (HR) to treadmill exercise was remarkably greater in AF than in sinus rhythm, and this hyperresponsiveness of HR seems to be responsible for shorter exercise time observed in AF. Although digitalis alleviated the excessive response of HR to exercise and significantly improved exercise tolerance, the in-exercise HR seemed to be still inadequately high in many AF patients. A single oral dose of verapamil (80mg) or diltiazem (60-90mg) was shown to further suppress the in-exercise HR and prolong treadmill exercise time in AF patients on maintenance doses of digitalis. However, β-blockers on a similar test schedule showed no significant improvement in exercise tolerance in spite of marked suppression of HR. Additional use of these CA antagonists to digitalis was considered as an effective regimen for control of in-exercise HR in AF. Of 432 patients with acute cerebrovascular accident studied with brain CT, AF was significantly more frequent in 340 patients with cerebral infarction (18.8%) than in 95 with cerebral hemorrhage (2%). In another cohort of 72 concecutive patients with acute cerebrovascular accident studied with cerebral angiography, the incidence of AF was 2.7% in 37 patients with cerebral hemorrhage, 20.7% in 29 with cerebral thrombosis, and 80% in 5 with cerebral embolism, being significantly higher in cerebral embolism than in the former two. In a study population of 102 patients with cerebral embolism confirmed by cerebral angiography, AF was observed in 73 patients (71.6%), of whom 23 had lone AF. These our observations indicate that cerebral embolism is intimately related to AF and suggest that even lone AF can be the cause of systemic embolism. Detection of patients with high risk of cerebral embolism and its prevention are the urgent clinical problem in the management of AF patients.
During a period of 14 years (1970-1983), the reconstructive vascular surgery was applied to 143 cases (202 limbs) with athero-occlusive diseases (A. S. O.) and 18 cases with renal artery atherosclerosis showing renovascular hypertension and/or renal dysfunction. The operation was indicated for intermittent claudication (117 cases) and the severely ischemic legs due to the diffuse atherosclerosis or the acute arterial thrombosis (26 cases). Large number of the patients under 69 years of age came into the group with intermittent claudication (91% of the cases). But for the more aged patients, limb salvage was the chief purpose of the operation (15 among 23 cases). Early and late operative results for intermittent claudication were quite satisfactory. The five-year patency rate of the bypass graft implanted for aortoiliac A. S. O. was 80%. But limb salvage rate for the severely ischemic legs was only 57%. All of the cases who underwent remedial operation to the renal arteries showed severe hypertension (average, 201/114mmHg). Seven cases were impaired their renal function. Cure or improvement of hypertension was obtained in 83% of patients. Although 5 of 7 patients were normalized their renal function, acute renal failure occureed to 3 patients immediately after the reconstruction with one death. Two hundred and fifty cases underwent abdominal aneurysmectomy during the period of 32 years (1952-1983). Recently the operative results have been markedly improved. The operative mortality is 4.5% for the elective cases and is 17% for the ruptured during the recent 10 years. There was a significant difference between the 5-year survival rate of the operated and that of the non-operated (62% for the operated, 16% for the non-operated). The predominant cause of death of the non-operated was a rupture of the aneurysm (38%). On the basis of these results, the conclusion is summarized as following. 1) Reconstructive vascular surgery benefits the aged patient with intermittent claudication to enjoy the rest of his life actively. 2) Acute arterial thrombosis is not only limb theratening but sometimes a fatal condition for the aged patients and difficult to treat even in the recent years. 3) Renal artery reconstruction is the treatment of choice for renovascular hypertension due to atherosclerosis, but one of the problems to be solved is occasional occurence of acute renal failure immediately after the operation in the cases with renal malfunction caused by severe bilateral disease. 4) Life prolongation effect of the abdominal aortic aneurysmectomy is clearly confirmed, therefore an active attitude is advisable to operate for the abdominal aortic aneurysm.
It is well known that abnormality of coagulation-fibrinolytic system and abnormal metabolism of serum lipids play an important role in development of thrombus and atherosclerosis. Blood coagulation-fibrinolytic factors (Fbg, FDP, AT-III, α2-PI, FN, Factor XIII, α1AT, α2-M) and serum lipids (T-C, TRG, β-Lp, HDL-C, Apo AI, AII, Apo AI/AII ratio) were examined in 38 aged patients with old cerebral thrombosis (Ave 72.4 years). i) Serum Apo AI and All levels were significantly lower in patient group than in control group (p<0.01). ii) Fibrinogen levels were significantly higher in patient group (p<0.0005) but α2-PI, FN and Factor XIII levels were significantly lower in patient group (p<0.025). AT-III, FDP, α1-AT and α2-M levels showed no significant change. iii) Correlation with serum lipids and blood coagulation-fibrinolytic factors were as follows, a) Apo AI levels showed positive correlation with α2-PI levels in patient group. b) Apo AI levels showed negative correlation with α2-PI levels in control group. c) β-Lp levels showed positive correlation with FN levels in patient group. iv) FN levels showed positive correlation with α2-PI levels in patient group. These results indicated that the aged patients with old cerebral thrombosis were in the hypercoagulablity state associated with lowering of Apo AI and Apo AII in serum lipids.
Clinical usefulness of tripamide, a diruetic hypotensive agent, was evaluated by a double blind comparative method in 33 elderly essential hypertension of 60 years or more (average age, 65.9) and those of 59 younger patients uder 60 years (average age, 50.0). A hypotensive effect was considered present when a decrease of 20/10mmHg in systolic/diastolic pressure or a decrease of 13mmHg or more in mean pressure was obtained. This fall in blood pressure was demonstrated in 84.8% of elderly patients and 59.3% of younger ones, the rate being higher in the elderly than in the younger patients (p<0.05). However, the average change of blood pressure was 32.0/13.2mmHg for elderly patients and 26.9/11.2mmHg for younger patients. There was no significant difference between the two age groups. Hematological tests showed no significant changes, and hemoconcentration was not noted in either of the two age groups. Biochemical studies revealed that serum Cl- and alkaline posphatase were decreased, and serum urea nitrogen and uric acid were elevated in elderly patients. In younger patients serum Cl- was decreased, and serum total cholesterol, Ca2+, uric acid, and urea nitrogen were elevated. Serum Na+, K+ and fasting blood sugar showed no change in either of the two groups. the cardio-thoracic ratio was decreased in elderly patients. Side effects of tripamide were noted in 5 of 59 younger patients (8%), while elderly patients were free from side effects. When abnormal laboratory data were included in side effects, the incidence of side effects was 15% (9/59) for younger patients and 12% (4/33) for elderly patients. The rate of usefulness for tripamide was 78.8% for elderly patients and 52.5% for younger patients, the difference between the two age groups being statistically significant (p<0.05). The results of this study seem to provide the evidence that tripamide is more beneficial for the elderly than for the younger patients in controlling essential hypertension.
We previously reported a method of two dimentional CT measurment by digitizer connected with personal computer. Brain atrophy index (BAI) and ventricular area index (VAI) are calculated as Fig. 1. Using this method, we studied the brain atrophy in 43 patients with idiopathic Parkinson's disease (mean age: 59.5 years) comparing with age-matched normal subjects (mean age: 58.6 years). There was no statistical significance in BAI nor VAI at the level of lateral ventricle and basal ganglia between two groups. There was significant correlation between age and these indices in both groups at cerebrum. On the other hand, infratentrial brain atrophy was more remarable in Parkinson's disease group than that of controls (p<0.05). Only in Parkinson's disease group, the BAI was significantly correlated with age at infratentrial level. In conculsion Parkinson's disease may accelerate aging of brain, especially in infratentrial brain.
A 64 year old woman was admitted to our hospital for fever diarrhoea and severe left frank pain. She had a long standing diabetes and was in poor control with diet. A plain abdominal x-ray film showed oval gases within both renal shadows. CT scan also showed gases in the both renal prenchma and perinephric. Subsequent blood, urine and stool cultures grew a lot of Klebsiella Pneumoniae respectively. A diagnosis of gas- forming infection of the both kidneys (so-called Emphysematous Pyelonephritis) was made. The patient did not improve despite intensive therapy and died for uremia and septic shock with DIC. Postmortem examination was done. Both kidneys contained subcapsular gases, multiple visible necrotic abscesses and showed destruction of parenchumal architecture. Microscopic examination revealed a massive inflammatory polymorphonuclear infiltrates involved of acute suppurative endoarteritis. Both kidneys had typical appearance of diffuse diabetic nephrosclerosis. In Japan, a few cases was reported in literatures and the prognosis was poor in a half of the reported cases despite appropriate medical and surgical intervention.