To elucidate the predictors of the mortality rate in the elderly with chronic heart failure (HF), 120 consecutive patients (mean age, 75.2±7.8 years) with heart failure (NYHA I-II) were analyzed prospectively for 5 years. [Methods] Left ventricular ejection fraction (EF), left ventricular diastolic and systolic dimension (LVDD and LVDS) and wall thickness (WT) were measured by echocardiogram. Venipuncture for measurement of ANP and norepinephrine (NE) was done in supine position after 30 minute rest. [Results] 1) HF was associated with hypertension (47.5%), ischemic heart disease (34%), valvuar disease (15%) and atrial fibrillation (AF, 23%). 2) 15 and 11 patients died for cardiac and non-cardiac events, respectively. 3) There was no difference in mean ages, gender, blood pressure, plasma-NE, EF, LVDD, LVDS, WT and AF between cardiac death and control groups. However, plasma ANP was higher in cardiac death group (173pg/ml) than in control group (76pg/ml) (p<0.01). 4) Cox proportional hazard regression model revealed that ANP was an independent predictor for cardiac death (p<0.005). We conclude that only plasma ANP level predicts long-term prognosis of chronic heart failure in the elderly.

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To elucidate the clinical features of acute myocardial infarction (AMI) and post-MI silent myocardial ischemia (SMI) in the elderly, and efficacy of therapy in an era of coronary intervention, a total of 10, 607 patients with AMI who were enrolled in a multicenter survey between 1982 and 1992 were examined. The elderly had a higher ratio of females, noncardiac illness, atypical symptoms at the onset of AMI, severe pump failure at admission, cardiac rupture and multivessel disease. Hospital mortality was markedly higher in patients ≤75 years, and it was 4-fold compared with patients <65 years. In the the last 5 years, the rate of application of coronary angiography and primary PTCA significantly increased even in the very elderly. In contrast, use of thrombolysis highly diminished. Hospital mortality declined (14.6 vs 11.9%, p<0.001) in every age group compared with the first 5 years, although it was higher in the elderly even in the last 5 years. Investigation of 642 survivors after AMI admitted to one hospital showed that the elderly had a higher incidence of SMI and post-MI angina compared with the non-elderly. Clinical features of SMI were similar in both groups. However, medical treatment was more prevalent and recurrence of MI and cardiac death during follow-up (average 27 months) were more frequent in the elderly. In this retrospective study, characteristics of AMI and SMI, and effectiveness and limitation of therapy in the elderly were clearly demonstrated. It was evident that hospital mortality of the elderly had improved, although it was still higher than the nonelderly.

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To compare the efficacy of estriol (E₃) in postmenopausal and senile osteoporosis, we administered orally 1g/day calcium lactate either alone (control groups) or with 2mg/day estriol (estrogen groups) for 10 months to 20 postmenopausal women aged 50-65 years and to 29 elderly women aged 70-84 years, and measured their bone mineral density of the lumbar vertebrae by dualenergy X-ray absorptiometry. Out of 41 subjects who completed 10 months of treatment, 8 postmenopausal women and 12 elderly women in the estrogen groups had significant (p<0.05) increases in bone mineral density (5.59±4.79% of the respective basal values). Ten postmenopasual women and 11 elderly women in the control groups had decreases bone mineral density (-4.02±7.00% and -3.26±4.60% of the respective basal values) at the 10th month. Genital bleeding as a side effect of estriol was seen in 6 out 29 elderly subjects at this dose. Moreover, decreases in the levels of calcium, total cholesterol, and triglycerides in serum, and an increase in the level of high-density lipoprotein-cholesterol were seen only in the elderly women receiving estriol. Although a lower dosage of estriol may be recommended for elderly subjects, these observations suggest that hormone replacement therapy with estriol is effective against degenerative osteoporosis, and that low-turnover bones in elderly women are also responsive to estriol.

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From 1983 to 1986, 100, 352 urban residents were screened for cardiovascular disease. Glucose and protein levels in urine, total cholesterol, triglycerides, high density lipoprotein cholesterol, blood pressure, and aortic pulse wave velocity were measured. Retinal examinations and electrocardiography were also done. A follow-up survey was conducted two years after screening. A total of 34, 895 subjects had no disease and 301 had arteriosclerotic diseases. The occurrence of cardio- and cerebrovascular diseases could not have been predicted from any one abnormal result on a screening test, but might have been predicted from multiple abnormal results, with each factor having its own weight and a unique association with other factors. The risk of disease increased multiplicatively higher rather than additively with the number of abnormal test results. We used Hayashi's quantification method III to determine which combination of abnormal test results was associated with a higher risk of arterio sclerotic diseases, and thus developed a comprehensive indicator of disease risk by grouping several abnormal test results that were affected by different factors. This evaluation system can be used to predict the onset of arteriosclerotic diseases to some degree and can contribute to preventive medicine.

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We previously reported that dyspnea on exertion in patients with congestive heart failure was not associated with pulmonary function ar rest, but was associated with the appearance of the anaerobic threshold and with the respiratory compensation point during exercise. Here we described a study of the influence of aging on the onset of dyspnea on exertion in elderly and in young patients with congestive heart failure. A total of 53 patients were studied: 35 were less than 65-year-old (average age, 47-year-old; 19 men and 16 women) and 18 were more than 65-year-old (average age, 70-year-old; 13 men and 5 women). All patients underwent maximal graded exercise testing on a bicycle ergometer. The workload increased according to a ramp protocol, and perceived exertion was evaluated with the Borg scale. The anaerobic threshold, the respiratory compensation point, and the peak VO₂ were recorded. Values of 13 (somewhat hard) and 17 (very hard) on the Borg scale were considered to mark the start of dyspnea on exertion and an increase in dyspnea on exertion respectively. In the young patients, dyspnea on exertion began at about the time that the anaeerobic threshold was reached, and it increased at about the time that the respiratory compensation point was reached. In contrast, elderly patients dyspnea on exertion began 70 seconds after the anaerobic threshold was reached, and it increased 30 seconds after the respiratory compensation point was reached. The VO₂ at the start of dyspnea on exertion and the VO₂ at the anaerobic threshold correlated more closely in the young patients than in the old patients. The same was true of the VO₂ at the time that dyspnea on exertion increased and the VO₂ at the respiratory compensation point. These findings suggest that elderly patients with congestive heart failure are less sensitive to the stimuli that cause dyspnea than are young patients.

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Because the number of people who reach an advanced age has been increasing at an unprecedented rate in Japan, geriatricians are expected to play a central role in health care for the elderly. However, only 16 out of 80 medical schools (20 percent) now have departments of geriatrics for undergraduate education. To develop undergraduate education in the field of geriatrics, a survey was sponsored by the Research Projects on Aging and Health (Health Science Research Grant the Ministry of Health and Welfare of Japan). A questionnaire regarding the present status and future plans of the university about a program in geriatrics, was sent to deans of medical faculties or vice-presidents of medical schools. The questionnaire included questions about current status and future plans regarding undergraduate geriatric education, the presence of a department or clinic of geriatrics, educational requirements in the field of geriatrics, opportunities for practice, institutions of practice, research on geriatrics, and other suggestions. The response rate was 93.7 percent (74/79). Departments or clinics of geriatrics had been established in 15 institutions (20.3 percent) and were planned in 18 (24.3 percent). Undergraduate education in geritrics was considered necessary in 73 schools (98.7 percent) and indispensable as an obligatory subject in 56 (75.7 percent). Clinical practice was considered more important and effective than lectures in 50 schools (63.3 percent). Corrdinated lectures on basic biomedical gerontology (such as mechanism of aging) and geriatric medicine for chronic degenerative diseases such as senile dementia were considered essential to the curriculum. In practicing geriatrics, experience in providing medical care to aged patients as well as social support and a welfare system for the aged is emphasized. Institutions, nursing homes, and geriatric hospitals outside medical schools be easily accessible. It was generally agreed that geriatrics should be taught in advanced classes. In conclusion, medical shools in Japan regard undergraduate education in geriatrics as necessary and agree on the optimal curriculum, but it is not universally implemented.

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Undergraduate education in gerontology and geriatric medicine has become more important because of a progressive increase in the aged population. To assess curricula in geriatric medicine and to survey the opinions of teaching staffs as to the ideal curriculum, a questionnaire was sent to professors of gerontology and geriatric medicine at 14 medical schools. Responses were obtained from all 14 professors. In all medical schools, students are given lectures in the fifth or sixth year, or both. The total number of hours for the lectures varied from a few hours to 40 hours, and contents of the lectures varied between schools. Medical staffs pointed out that little time is allocated to geriatric medicine. They also emphasized the importance of bedside teaching.

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This study was done to clarify relationships between the degree of periventricular lucency (PVL), and lesions in the carotid arteries and the legs as detected with B-mode ultrasonography and the ankle pressure index, respectively. According to the distribution of PVL on computed tomography, 45 patients were divided into 2 groups: 22 patients with diffuse PVL (from the periventricular white matter to the subcortical area, DPVL group) and 23 patients with PVL localized in the frontal deep white matter (LPVL group). Plaque, defined as a thickened intima-media complex of 2.1mm or more, was divided into two types; mural plaque and nodular plaque. Hypertension was more common in the DPVL group than in control groups, which consisted of 70 age-matched patients with cerebral thrombosis without PVL (CTH group) and 50 controls with neither PVL nor cerebrovascular lesions (NCT group). All patients in the DPVL group met the diagnostic criteria for Binswanger's disease proposed by Bennett DA. The incidence of low API indices (<0.9) in the DPVL group (45%) was significantly higher than that in the NCT group, and it was slightly higher than that in the LPVL group. Carotid lesions, mainly nodular plaques, were seen in 82% of patients in the DPVL group and in 74% of those in the LPVL group; these percentages were significantly higher than those in the CTH (49%) and NCT (40%) groups. In particular, bilateral carotid lesions were more common in the DPVL group than in the other three groups. The degree of PVL correlated with lesions in the carotid arteries and the legs. These correlations suggest that the arterial lesions not only resulted from a risk factor (hypertension) for PVL, but also promoted PVL by causing extra- and intra-cranial arterial lesions. Furthermore, they imply that LPVL is a precusor to DPVL.

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