[Gianturco expandable metallic stents in the treatment of superior vena cava syndrome caused by lung cancer]

Treatment of superior vena cava syndrome (SVCS) caused by advanced lung cancer is still controversial. We inserted Gianturco expandable metallic stents (GEMS) in 5 patients with SVCS due to the extension of lung cancer. GEMSs were introduced intravenously through the catheter after intraluminal balloon dilation of the stenotic sites. SVCS was successfully and easily relieved by this method without any significant complication. GEMS placement seems to be a useful alternative to bypass grafting procedure for the treatment of SVCS.

[Congestive heart failure in elderly readmitted patients]

The clinical features of congestive heart failure in the elderly were investigated in 104 patients (57 males, 47 females, mean age of 79.2). Patients were divided into two subgroups, the readmission group, 33 patients who were readmitted within 6 months after discharge, and the non-readmission group. Chief complaints were dyspnea, edema, chest pain, loss of appetite, chest compression, and palpitation. Heart failure was caused by infection, myocardial ischemia, arrhythmia, inappropriate drug usage including poor drug compliance, the use of beta-blockers, excessive intake of sodium, and anemia. Careful use of drug was essential especially in the readmission group. Major underlying heart disease were ischemic heart disease (39.4%), valvular disease (26.9%), hypertensive heart disease (9.6%), with cardiomyopathy, congenital heart disease seen in the minority. There was no statistically significant difference in underlying heart diseases between the two groups. Supraventricular arrhythmias such as atrial fibrillations, paroxysmal atrial fibrillations, paroxysmal supraventricular tachycardias, and premature atrial contractions were noted in 85.3% of the cases. Drugs for treatment were diuretics, digitalis, isosorbide dinitrate, calcium antagonists. ACE inhibitors and alpha-blockers were also used, showing that vasodilators were more extensively used than before. The major complications were hypertension (39.4%), renal dysfunction (27.9%), cerebrovascular disease (26.9%), diabetes mellitus (16.5%), arteriosclerosis obliterans (7.7%). Renal dysfunction, arteriosclerosis obliterans was seen significantly more frequently in the readmission group. The prognosis at one year after admission was significantly worse in the readmission group. In summary, the major underlying diseases were ischemic heart disease, valvular disease, and hypertensive heart disease. Ischemic heart disease was seen more frequently than in previous investigations at our hospital.(ABSTRACT TRUNCATED AT 250 WORDS)

Diminished nocturnal decline in blood pressure in elderly hypertensive patients with left ventricular hypertrophy

To assess the circadian blood pressure (BP) changes in elderly hypertensive patients with left ventricular hypertrophy (LVH), the ambulatory BP was measured noninvasively every 30 minutes for 24 hours in those patients with LVH (n = 15) and without LVH (n = 23), and in normotensive elderly subjects (n = 11). Although the daytime systolic BP (SBP) was comparable in the two hypertensive groups, the nighttime SBP in patients with LVH tended to be higher than in patients without LVH (149.0 +/- 15.1 versus 138.4 +/- 20.1 mm Hg, p less than 0.10). The LV mass index correlated significantly with the nighttime SBP (r = 0.43, p less than 0.01), but not with the daytime SBP (r = 0.24, ns), with clinic SBP (r = 0.14, p = ns) or the SBP after handgrip exercise (r = 0.31, p = ns). The difference in the systolic BP between daytime and nighttime (D-N SBP) in patients with LVH (2.8 +/- 9.4 mm Hg) was significantly less than that in patients without LVH (12.8 +/- 16.0 mm Hg) (p less than 0.02). In addition, the D-N SBP correlated inversely with the left ventricular mass index (r = -0.33, p less than 0.05). It was concluded that hypertension in the elderly with LVH was associated with a diminished nocturnal decline in blood pressure.

[Acute hemodynamic effects of intravenous bolus injection of isosorbide dinitrate in aged patients with congestive heart failure]

In order to investigate whether intravenous bolus injection of isosorbide dinitrate (ISDN) is a safe and efficient therapy in aged patients with congestive heart failure, we studied acute hemodynamic effects in 11 patients. Peak effects on preload were observed after 5 to 10 minutes of bolus injection and unloading effects continued effectively for 60 minutes. At peak effect, pulmonary systolic pressure decreased from 50.2 +/- 2.6 to 36.2 +/- 2.6 mmHg (-28.5%, p less than 0.01) and pulmonary end diastolic pressure decreased from 25.0 +/- 2.2 to 18.5 +/- 2.1 mmHg (-26.0%, p less than 0.01). Mean pulmonary artery wedge pressure decreased from 23.4 +/- 2.2 to 16.0 +/- 2.1 mmHg (-31.6%, p less than 0.01). Mean right atrial pressure decreased from 10.5 +/- 1.8 to 7.4 +/- 2.0 mmHg (-29.5%, p less than 0.01). Blood pressure, heart rate, cardiac index, systemic and pulmonary vascular resistance showed no significant changes. Thus, intravenous bolus injection of ISDN showed a potent vasodilator effects on preload, and may be a safe and useful treatment for aged patients with acute congestive heart failure.

The cardiac functional reserve in elderly hypertensive patients with abnormal diurnal change in blood pressure

OBJECTIVE

To evaluate the left ventricular function of hypertensive patients with abnormal diurnal change in blood pressure.

DESIGN

We compared left ventricular structural and functional characteristics between hypertensive patients with a normal diurnal change in blood pressure (H2 group) and those with a nocturnal blood pressure increment (H1 group) using echocardiography.

METHODS

The study group consisted of 36 hypertensives and 16 normotensives whose 24-h ambulatory blood pressure monitorings were measured non-invasively. The hypertensive group was subdivided into the H1 group, consisting of 11 patients (76 +/- 7 years), and the H2 group with 25 patients (73 +/- 7 years). The normotensive control group had a mean age of 73 +/- 6 years. Echocardiographic examinations were performed before and at the end of isometric exercise (handgrip for 3 min) and isoproterenol infusion (0.02 micrograms/kg per min for 5 min).

RESULTS

The left ventricular mass index in the H1 group was significantly greater than in the H2 or control group. Left ventricular fractional shortening (LVFS) at rest in the H1 group was also significantly greater than in the other two groups. However, the peak late: early diastolic filling ratio, which indicated diastolic function, significantly deteriorated in the H1 group compared with the H2 and control groups. Furthermore, changes in LVFS after isometric exercise in the H1 group were more suppressed than in the H2 or control group. In addition, a significantly lower increment in LVFS after isoproterenol was observed in the H1 group compared with the H2 or control group.

CONCLUSION

The H1 group had greater left ventricular mass and impaired left ventricular functional reserve than the H2 group.

[Effect of antiplatelet and anticoagulant therapy on secondary prevention and long-term prognosis after acute myocardial infarction in aged patients]

The long-term efficacy and side effects of antiplatelet and anticoagulant therapy for secondary prevention after the first acute myocardial infarction (AMI) were retrospectively assessed in 133 patients over 60 years of age during a mean follow-up period of 36.6 months. Seventy five patients received antiplatelet and anticoagulant therapy (group 1) and 58 patients did not (group 2). In group 1 patients, 54, 12 and 9 patients received ticlopidine, aspirin and warfarin, respectively. Mean age, sex ratio, site of AMI, max CPK value and left ventricular ejection fraction in the convalescent phase did not differ between the two groups. There were no differences between the two groups in terms of the number and kind of combination drugs such as nitrate, beta-blocker and Ca antagonist. During the follow-up period 40 patients died; 18 patients (45%) suffered cardiac death and 22 patients (55%) experienced non-cardiac death. Nineteen patients had recurrent MI and 37 patients had cardiac events which were defined in total as cardiac death, recurrent MI and unstable angina pectoris. The total mortality rate and rate of recurrent MI based on the life time table method were significantly lower in group 1 than in group 2 by the generalized Wilcoxon test. The cumulative total mortality rate in the fifth year was 24.2% in group 1 and 49% in group 2. The cumulative rate for recurrent MI in the fifth year was 7.4% in group 1 and 27.5% in group 2 (p less than 0.05). However, the rate of cardiac events did not differ between the two groups.(ABSTRACT TRUNCATED AT 250 WORDS)

Effect of nifedipine tablets on ambulatory blood pressure in patients aged less than 60 and greater than 65 years with systemic hypertension

To evaluate the effect of age on the pattern of circadian blood pressure after nifedipine tablets, ambulatory blood pressure after administration of low and high doses of nifedipine, taken twice daily, was measured over a 24-hour period in 10 elderly and 8 young hypertensive patients. After a 2-week control period without antihypertensive drug, 10 mg of nifedipine was administered twice daily for 2 weeks (low-dose period), followed by 2 weeks of 20 mg (high-dose period). At the end of each period, ambulatory BP monitoring was conducted every 30 minutes for 24 hours, using an ABPM 630 (Nippon-Colin, Komaki, Japan). In both groups, averages of systolic and diastolic BP for the entire day decreased significantly from the control to the low-dose periods. However, after the high-dose period, only the elderly group had further significant reduction of systolic BP, whereas no further reduction was seen in the young group. Separate analysis of whole-day data into daytime and nighttime values revealed that a further decrease in systolic BP after the high-dose period in the elderly group was a reflection of nighttime decline. It was suggested that circadian BP patterns after administration of nifedipine tablets in the elderly differed from those in young hypertensive patients, especially after administration of the high-dose.

[Systolic anterior motion of the anterior mitral leaflet and/or the chordae tendinae in the elderly]

Systolic anterior motion of the anterior mitral leaflet and asymmetric septal hypertrophy (ASH) are characteristic features of hypertrophic obstructive cardiomyopathy (HOCM) on an echocardiogram. Among 9,670 patients over 60 years old examined by echocardiography from January, 1984 to October, 1990, 55 patients showed systolic anterior motion of the anterior mitral leaflet and/or the chordae tendinae (SAM). We investigated clinical features and morphological features of the left ventricle on an echocardiogram in the 55 patients with SAM. They were classified into three groups according to the degree of SAM. Thirty eight cases (group I) had no mitral and/or chordal-septal contact, 10 (group II) had brief contact (less than 30% on the echocardiographic systole) and 7 (group III) had prolonged contact (greater than or equal to 30%). Ages ranged from 60 to 99 with a mean age of 78.2 years. There were 19 males and 36 females and there was a predominance of females in each group. Thirty five cases had hypertension and 34 left ventricular hypertrophy on electrocardiograms. One case of group I, 3 of group II and 7 of group III had a clinical diagnosis of HOCM. In comparison with each group, the incidence of LVH (SV1 + RV5 greater than or equal to 35 mm) was 52% in group I, 90% in group II and 83% in group III and that of LVH (SV1 + RV5 greater than or equal to 70 mm) was 29%, 20% and 67%, respectively. On echocardiographic examination, the diastolic descent rate of the anterior mitral leaflet in the 3 groups was 36.1 +/- 13.1 mm/sec, 19.4 +/- 13.1 mm/sec and 10.7 +/- 11.8 mm/sec (p less than 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)

Does the variability of casual blood pressure contribute to progressive subcortical vascular encephalopathy of Binswanger's type?

Our hypothesis was that progressive subcortical vascular encephalopathy of Binswanger's type (PSVE) in the elderly can be induced by repeated hypotension or greater variability of blood pressure in hypertensives, regardless of antihypertensive therapy. We retrospectively studied PSVE blood pressure, and compared them with those in atherothrombotic cerebral infarction (ACI) or in hypertensive cerebral hemorrhage (HCH). During the last seven years prior to death, neither the annual variability nor the annual mean value of systolic or mean arterial blood pressures in PSVE was different from that in ACI or in HCH. The present study did not support our hypothesis.

Receptor types mediating the rise in the cytosolic free calcium concentration by L-aspartate and L-glutamate in immature cerebellar neurons with N-methyl-D-aspartate receptors

L-Aspartate (Asp) and L-glutamate (Glu) increased the cytosolic free calcium concentration ([Ca]in) in medium-sized cerebellar neurons having N-methyl-D-aspartate (NMDA) receptors. The sustained rise in [Ca]in induced by Asp, but not by Glu, was reduced by the addition of NMDA antagonists, which consistently suppressed the rise in [Ca]in induced by a low concentration of Asp or Glu in combination with glycine. The results suggest that Asp is a more preferential agonist of NMDA receptors than Glu, although Glu can also be an agonist in the presence of glycine.

Effects of aging on the cardiopulmonary receptor reflex in hypertensive patients

In order to evaluate the effects of aging on cardiopulmonary receptor function in hypertensive patients, hemodynamic responses after unloading were studied in middle aged and older hypertensive patients. Twenty-one hypertensive patients were divided into 2 groups according to age. The younger group consisted of 9 patients less than 65 years old (mean age: 57.2 years) and the older group contained 12 patients more than 65 years old (77.2 years). Following 10 min rest, deactivation of cardiopulmonary receptors was obtained by reducing central venous pressure through the application of graded negative pressures of -10, -20, and -40 mmHg to the lower body. Blood pressure, pulse rate, and forearm blood flow were measured at baseline and at each level of negative pressure. Furthermore, plasma norepinephrine and plasma renin activity levels were measured at baseline and at -40 mmHg. Forearm blood flow was measured by venous occlusive plethysmography using a Silastic strain gauge applied around the forearm. Forearm peripheral vascular resistance was calculated by dividing the mean arterial pressure by the forearm blood flow. Baseline mean blood pressure, pulse rate, and peripheral vascular resistance were similar in both age groups. Following lower body negative pressure (LBNP), mean blood pressure and pulse rate did not change, suggesting the selective deactivation of cardiopulmonary receptors. The increase in peripheral vascular resistance at LBNP of -40 mmHg in the older group (20.0 +/- 6.2) was significantly lower than that in the younger group (15.5 +/- 8.9, p less than 0.05). Furthermore, the increase in peripheral vascular resistance after LBNP was inversely related to age (Y = -0.32X + 38.8, r = -0.43, p less than 0.05). Increases in plasma norepinephrine and plasma renin activity in the older group were not different from those in the younger group. It is concluded that the sensitivity of cardiopulmonary baroreceptor function in hypertensive patients deteriorates with increasing age.

[Cholesterol, atherosclerosis and cerebro-cardiovascular complications in 3,236 elderly autopsy cases]

The effect of serum cholesterol on aortic, cerebral, coronary and femoral atherosclerosis as well as on the incidence of cerebral and myocardial infarctions were analyzed in 3,236 consecutive autopsies in the elderly. Serum cholesterol levels declined over the age of 80 in both genders. The cholesterol levels of females were significantly higher than that of males in each age group from the sixties through the nineties. The increase in serum cholesterol was correlated with the progression of coronary atherosclerosis in both genders, but not with cerebral or femoral atherosclerosis. Slight progression of aortic atherosclerosis was observed when serum cholesterol was over 160 mg/dl. Cholesterol induced progression of coronary atherosclerosis was found in cases with hypertension, but not in the normotensive group. In accordance with the progression of coronary atherosclerosis, the incidence of myocardial infarction increased with an elevation of serum cholesterol levels, and this relationship between myocardial infarction and cholesterol levels was found only in patients with hypertension. No correlation was found between the incidence of cerebral infarction and serum cholesterol levels. It was concluded that hypercholesterolemia in the elderly is a risk factor of myocardial infarction in cases with hypertension, but is not a risk factor of cerebral infarction.

Prevalence of antibody to hepatitis C virus in a blood donor population

Blood samples from 2000 accepted blood donors and 343 deferred donors with antibody to hepatitis B core antigen (anti-HBc) and/or an alanine aminotransferase (ALT) elevation were evaluated for antibody to hepatitis C virus (anti-HCV). Sixteen (0.8%) of the 2000 sera initially reacted on enzyme-linked immunosorbent assay (ELISA); 12 (0.6%) were repeatably reactive. One repeatably reactive sample had an elevated ALT; two reacted on anti-HBc testing and had ALT elevations. When the repeatably reactive ELISA samples were tested by an immunoblot assay, four reacted, three were indeterminate, and five did not react. Among the 343 deferred donors, HCV antibodies were detected in 8 (3.8%) of 210 anti-HBc-reactive samples, 12 (11.8%) of 104 elevated-ALT samples, and 15 (52%) of 29 combined elevated-ALT and anti-HBc-reactive samples; 25 of 28 reacted on immunoblot. The anti-HBc-reactive sera were subdivided into groups according to strength of anti-HBc reactivity (weak or strong) and antibody to hepatitis B surface antigen status and then were compared for anti-HCV reactivity rates. The group of samples showing the greatest frequency of anti-HCV had strong anti-HBc reactivity. For blood donors, the anti-HCV test correlates with the surrogate tests for non-A, non-B hepatitis (anti-HBc and ALT); however, most anti-HCV-reactive units remain undetected by surrogate tests, so that implementation of anti-HCV screening should further reduce the transmission of HCV via transfusion.

GABA inhibits the rise in cytosolic free calcium concentration in depolarized immature cerebellar Purkinje cells

gamma-Aminobutyric acid (GABA) reduced the peak rise or slowed the rate of rise in cytosolic free calcium concentration ([Ca]in) induced by quisqualate, kainate, or high KCl in immature cerebellar Purkinje cell bodies. The sustained rise or repeated transient of [Ca]in induced by tetraethylammonium, veratridine, or Bay-K-8644 was lowered to the basal level by adding GABA, although the inhibition by GABA of Bay-K-8644-induced rise in [Ca]in was only slight and transient in some cells. These findings indicate that GABA inhibits the rise in [Ca]in by hyperpolarizing the membrane potentials at Purkinje cell bodies.

[Myocardial infarction beginning with cerebral symptoms in 30 cases of cardio-cerebral apoplexy]

A clinicopathological analysis of myocardial infarction with an onset of stroke-like symptoms was carried out on 30 autopsy cases at the Tokyo Metropolitan Geriatric Hospital. The cases were classified into four groups according to the types of brain lesions, I: embolism (n = 17), II: thrombosis (n = 9), III: bleeding (n = 2), and IV: no remarkable focal lesion (n = 2). Classification was made based on clinical findings, and pathological features. The characteristic clinical findings were conciousness disturbance, no elevation of blood pressure at the onset of stroke, hemiplegia and shock. However, the typical anginal chest pain was found in only 17% of cases. The underlying diseases and complications were hypertension, atrial fibrillation (Af), disseminated intravascular coagulation (DIC), renal failure, malignant neoplasma, and diabetes mellitus. The incidences of Af, DIC, mural thrombus, non-bacterial thrombotic endocarditis (NBTE) were significantly higher in the group with cerebral embolism than in the group with cerebral thrombosis. The coronary stenotic index was also smaller in the group with cerebral embolism. Therefore, the major etiology of cardio-cerebral apoplexy was a simultaneous embolism to the brain and heart due to Af, NBTE or, DIC.

Analysis of advancing age on the response to nicardipine among 467 adult hypertensive patients

The antihypertensive response to nicardipine was analyzed in 467 hypertensive patients who had participated in four similarly designed double-blind clinical studies in which the effectiveness of nicardipine was evaluated. This population was divided into five age groups. The difference in response rates between the youngest (less than or equal to 39 years) and oldest group (greater than or equal to 70 years) of patients was less than 5%. After 12 weeks of treatment with nicardipine, the rate of response for each decade ranged from 65% to 77%. The per cent decrease in blood pressure was not age dependent, but did correlate with the pretreatment systolic and diastolic blood pressure (P less than 0.001). No age-related trend in side effects was observed. The incidence of side effects ranged between 0% among the oldest patients to 17.3% in patients 50-59 years of age. No adverse metabolic effects were found in any age groups. These results indicate that nicardipine, a calcium entry-blocker, is effective and useful in adult hypertensive patients of all ages.

Cardiac performance in elderly hypertensive patients with left ventricular hypertrophy: responses to isometric exercise and beta-agonists

To assess the cardiac functional reserve of elderly hypertensive patients with left ventricular hypertrophy (LVH) we studied cardiac function after isometric exercise and beta-adrenergic stimulation. Forty-five elderly hypertensive and 16 normotensive patients (NC group) were recruited for the study. The hypertensive patients were divided into two groups: those with LVH (n = 17) mass index (LV mass index greater than 130 g/m2; H1 group) and those without LVH (n = 28) (H2 group). Echocardiographic studies were performed before and after isometric exercise (handgrip) and isoproterenol (ISP) administration. We measured the LV mass index, fractional shortening (FS), isovolumic relaxation time (IRT), and the ratio of late and early diastolic transmitral flow velocity (A/E). The FS at rest in the H1 group was significantly higher than those in the H2 and NC groups. In the H1 group, the IRT was elongated and A/E was greater than in the NC group, which indicated the impaired diastolic function in the H1 group. After the HG stress, the FS in the H1 group significantly decreased whereas it did not change in the H2 or NC groups. The FS increased in all three groups after the infusion of ISP, although the increment of FS was smaller in the H1 group. In conclusion, (a) diastolic function was impaired whereas systolic function was supranormal at rest in the hypertrophied heart of the elderly hypertensive patients and (b) when exercise or pharmacological stress was loaded, the systolic function deteriorated, suggesting the impairment of cardiac reserve in those patients.

Subtypes and proportions of cerebrovascular disease in an autopsy series in a Japanese geriatric hospital

Of 1721 consecutive autopsies performed on patients over 60 years of age in Tokyo Metropolitan Geriatric Hospital, 550 (32% of all autopsied cases) revealed symptomatic cerebrovascular lesions. Among the 550 patients, intracranial hemorrhage was found in 19%, cerebral infarction in 75%, and coexisting cerebral hemorrhage and cerebral infarction in 6%. Twenty-eight percent of the cerebral infarctions were embolic infarctions of cardiac origin, half of which were caused by nonvalvular atrial fibrillation, and 69% were non-embolic infarctions of cardiac origin. Progressive subcortical vascular encephalopathy accounted for 15% of the cerebral infarctions. Two-thirds of all lobar cerebral hemorrhages were amyloid angiopathy-related. Nonvalvular atrial fibrillation is the most important cardiac source of embolic stroke. Progressive subcortical vascular encephalopathy is one of the characteristic features of ischemic lesions, and cerebral amyloid angiopathy is an important cause of lobar cerebral hemorrhage in the aged.

Regulation of the cytosolic free calcium concentration by Na+ spikes in immature cerebellar neurons with N-methyl-D-aspartate receptors

N-Methyl-D-aspartate and glycine increased the cytosolic free calcium concentration ([Ca]in) in medium-sized cerebellar neurons. Spontaneous changes in [Ca]in were occasionally observed in NMDA-responsive cells, but large increases in [Ca]in were triggered only through depolarizations by adding veratridine or K+ channel blockers in every cell examined. The [Ca]in increase was suppressed by voltage-dependent Na+ and Ca2+ channel blockers and by an inhibitory transmitter (GABA), suggesting that the generation of Na+ spikes is involved in the increase in [Ca]in.

[A clinical study of hypertrophic obstructive cardiomyopathy in the elderly]

Seven elderly patients with hypertrophic obstructive cardiomyopathy (HOCM), who had the three following characteristics on echocardiograms 1) extremely thickened septum, 2) systolic anterior motion of the mitral valve, 3) mid systolic semi-closure of the aortic valve, were clinically evaluated. Ages ranged from 73 to 86 years old (average 78.9% yr.) and all were women. None had not a family history of hypertrophic cardiomyopathy but they had mild hypertension. Six patients showed a significant high voltage on the ST-segment and T-wave abnormalities ("strain" pattern). The left ventricular posterior wall as well as the septum was thickened in 5 and the remaining 2 showed asymmetrical septal hypertrophy (ASH) on echocardiograms. The left ventricular cavity was narrowed due to left ventricular hypertrophy and the shape of the left ventricular cavity was ovoid in all patients. The aorto-septal angles in these 7 patients were 80 degrees to 120 degrees. In addition, proximal septal bulge in all and anterior displacement of the mitral posterior leaflet due to the mitral ring calcification (MRC) in some patients contributed to the narrowing of the left ventricular outflow tract, and the mitral valve was pulled up toward the septum because of the good left ventricular systolic function (ejection fraction: 70 to 94% by echocardiography) and blood was ejected at a high velocity through a narrowed outflow tract (Venturi effect). Pressure gradients in the left ventricular outflow tract was 38 to 146 mmHg in 5 examined by cardiac catheterization. Biopsy specimens were obtained from 2 patients, showing hypertrophic myocytes (diameter: 20 to 30 micron) in 2 and mild disarray in 1.(ABSTRACT TRUNCATED AT 250 WORDS)

[Development of coronary atherosclerosis in the elderly]

The role of aging, hypertension and plasma cholesterol in the development of coronary atherosclerosis was examined in 3569 consecutive autopsy cases, aged 60 to 99 years, at the Tokyo Metropolitan Geriatric Hospital. The prevalence of coronary atherosclerosis increased with aging. Both systolic and diastolic hypertension were related to the prevalence of coronary atherosclerosis. High plasma cholesterol (230 mg/dl) was related to increased prevalence of coronary atherosclerosis. This effect was observed in a hypertensive group, but not in a normotensive group. To define the effect of hypertension on vascular diseases, endothelial cells from spontaneously hypertensive rats (SHR) were obtained and characterized in terms of cellular response. Cellular Ca2+ level in response to A23187 was significantly enhanced in SHR compared to normotensive Wistar-Kyoto rats (WKY). Thus, aging, hypertension and high plasma cholesterol are risk factors for coronary artery atherosclerosis in the elderly.

Pseudohypertension in the elderly

Pseudohypertension is a condition in which indirect blood pressure measured by the cuff method overestimates the true intra-arterial blood pressure. Despite the clinical importance of pseudohypertension, reports regarding its prevalence are scarce. We compared direct measurements of brachial arterial blood pressure with those measured indirectly by the cuff method in 59 healthy volunteers aged greater than 65 years, with or without hypertension, in order to investigate the prevalence of pseudohypertension in the elderly. The average systolic blood pressure of 161.5 mmHg obtained by the indirect method was significantly lower than the 169.2 mmHg obtained by the direct method was not significantly different from the 76.9 mmHg obtained by the direct method. Only one volunteer was observed in whom the indirect cuff method overestimated the diastolic blood pressure by greater than 10 mmHg, which was defined as pseudohypertension. Thus, the prevalence of pseudohypertension was only 1.7%. The difference in systolic blood pressure between the two methods was 8.7 mmHg in Osler-positive cases and was not significantly different from the 6.9 mmHg observed in Osler-negative cases. Pulse wave velocity was significantly correlated with the systolic blood pressure (y = 11.4x + 66.1, r = 0.65, P less than 0.05). No correlation was observed between the pulse wave velocity and direct/indirect pressure differences for either systolic or diastolic measurements. These results show that the prevalence of pseudohypertension is very low in a non-selected elderly population and that Osler's maneuver was not related to the pressure difference between the direct and indirect methods.

[Percutaneous gastrostomy]

Enteral feeding is the preferred method of nutritional management in malnourished patients with intact gastrointestinal function. Although the surgical gastrostomy is usually effective, its morbidity and mortality is still not negligible. Recently, alternative percutaneous method for placement of gastrostomy tube have been developed and several large series have been published in the English literatures. Since May 1986 we have performed percutaneous gastrostomy on over 30 patients and there were only one major morbidity but no procedure-related mortalities. The purpose of this paper is to describe our experience and to discuss its potential problems.

[Gastric cancer and obstructive uropathy]

In recent 5 years, we have experienced 24 cases of advanced gastric cancer associated with obstructive uropathy. Included were 19 cases of undifferentiated, 3 cases of differentiated and 2 cases of unknown histological type. Obstructive uropathy is diagnosed based on the typical radiological findings such as dilatation and delayed demonstration of the upper collecting systems. Pathologically, undifferentiated type of gastric cancer had tendency to spread infiltrating along the vessels, nerves and the lymphatics without alteration of the ordinary anatomical structures. In such cases, mucosal surface of the urinary tract tended to be spared in spite of extensive tumor invasion. It was proven that several radiological findings were characteristic of urinary tract involvement secondary to gastric cancer. Either thread-like ureteral stricture by IVU or ring-like appearance of the ureter by CT is one of those typical findings. Renal sinus involvement may occur continuously to diffuse retroperitoneal invasion and it appears as a thickened wall of renal pelvis or soft tissue mass directly extending into the fatty tissue of renal sinus by CT. In such cases IVU has less diagnostic ability because of the lack of mucosal destruction. If the urinary bladder is involved, it typically shows chestnut-bur appearance by IVU and diffuse wall thickening by CT. In cases of advanced gastric cancer, particularly in cases of histologically undifferentiated type, CT and IVU images should be carefully interpreted in consideration of the infiltrative art of tumor extension.

[Radiation tolerance of partially irradiated liver in a multidisciplinary treatment for hepatoma]

Radiation tolerance of the partially irradiated liver was studied in eight patients with primary hepatoma treated by a multimodal approach. Seven patients were treated by transarterial embolization therapy (TAE) with Lipiodol-MMC, and two patients were treated by operation, combined with radiotherapy. Six patients had liver cirrhosis and the other one had renal dysfunction. Respiration-gated irradiation was employed to reduce a treatment volume for seven patients. Radiation portals were carefully tailored using the embolized Lipiodol or a metal clip inserted into the tumor as references. Two or three portals were used for each patient. The treatment volume ranged from 64 to 1400 cm3. The target dose ranged from 50.4 Gy to 81.0 Gy, from 73.5 to 108.6 in TDF. Liver function tests (GOT, GPT, LDH, ALP, ChE and total Bilirubin) were examined for 30 weeks after initiation of irradiation. Three patients showed abnormal value in more than 5 tests. Of these three patients, the hepatic hilum was included in the treatment volume in two, and the tumor progressed during the observation period in two. Leukopenia and thrombopenia were observed, but these values were not below 2000 and 40000/mm3, respectively, although the thrombocyte count before irradiation was below 100000/mm3 in 7 patients. AFP titers decreased after the treatment in six out of seven patients with abnormally elevated pretreatment titer. The survival period after staring irradiation was 6.5 to 25 months. "The volume dose" did not correlate well with the degree of the liver function aggravation.(ABSTRACT TRUNCATED AT 250 WORDS)

Nonvalvular atrial fibrillation as a cause of fatal massive cerebral infarction in the elderly

By studying 3,408 consecutive autopsied elderly patients, we found that two thirds of the 132 massive cerebral infarctions (86) were embolic, of cardiac origin. Embolic infarction associated with nonvalvular atrial fibrillation was seen in 48 cases (36%), half due to the first stroke. Embolic infarction associated with heart disease other than nonvalvular atrial fibrillation was seen in 23 cases (17%), and that from nonbacterial thrombotic endocarditis was seen in 15 cases (11%). Thrombotic infarction or infarction of nonembolic cardiac origin was found in only 39 cases (30%). Of 56 patients with fatal massive cerebral infarction who died less than or equal to 2 weeks after their stroke, 25 (45%) had embolic strokes associated with nonvalvular atrial fibrillation. Our study shows that nonvalvular atrial fibrillation is a very important cause of fatal massive cerebral infarction in the elderly.

[Pulmonary infarction associated with bronchogenic carcinoma]

Pulmonary infarction may be associated with bronchogenic carcinoma. Radiopathological correlation was performed in four patients. There were two cases of squamous cell carcinoma, one case of adenocarcinoma and one case of large cell carcinoma. Infarcts in patients with squamous cell carcinoma were obscured on plain radiographs by a large primary tumor or atelectasis of the affected lobe. Infarcts in adenocarcinoma and large cell carcinoma were clearly demonstrated on plain radiographs; 1 to 2 cm in size, round or polygonal in shape, blurred in margin, and located at the periphery of the same lobe as the primary tumor. Rapid appearance of infarcts was helpful in distinguishing from intrapulmonary metastasis. Invasion of the pulmonary artery, pulmonary vein and bronchial wall in hilar region was thought to be responsible for pulmonary infarction. Pulmonary infarct should be considered in patients with centrally invasive bronchogenic carcinoma, when a small ill-defined opacity appears at the periphery of the involved lobe over a short period.

Calcium-activated neutral protease inhibitor (E-64c) and reperfusion for experimental myocardial infarction

We examined the efficacy of the combination of coronary reperfusion and calcium-activated neutral protease (CANP) inhibitor (E-64c) for the treatment of acute myocardial infarction in dogs. In 34 dogs, the left anterior descending artery (LAD) was occluded and reperfused after 1 hour (Groups A and B). In the remaining 49 dogs, the LAD was ligated (Groups C and D). E-64c (100 mg/kg, Groups A and C) or vehicle (Groups B and D) was injected intravenously before and after the coronary occlusion or ligation. After 24 hours the hearts were removed. The proportion of the infarct size in the LAD perfusing area (risk zone) in Group A was 47.3 +/- 9.7%, significantly lower than in Group C (54.8 +/- 8.2%, p less than 0.05) or Group D (58.7 +/- 10.0%, p less than 0.01). There was a significant difference between Group B (52.9 +/- 8.6%) and Group D as well (p less than 0.05). The effects of reperfusion (p = 0.0016) and E-64c (p = 0.0226) per se on infarct size were significant, but the combination of reperfusion and E-64c was not additive. The decrease in CPK activity in the risk zone was significantly lower in the reperfused group (p = 0.0001). The mCANP activity was higher in the border zone and lower in the infarct zone. The trend in the mu CANP activity was similar to that of mCANP. Thus, treatment with a CANP inhibitor in the early phase of acute myocardial infarction may be marginally beneficial in combination with reperfusion.

[Pharmacokinetics and pharmacodynamics of antihypertensive drugs in the elderly]

In order to study pharmacokinetics and pharmacodynamics of antihypertensive drugs in the elderly, plasma concentration and blood pressure response to 4 antihypertensive drugs with different modes of action (captopril, nifedipine retard tablet, bunazosin, arotinolol) were measured in young and elderly hypertensive patients without liver or renal dysfunction after oral administration of each drug. Systolic and diastolic blood pressure fell after 25 mg of captopril in both groups and the rate of decrease in each group was similar. Plasma concentration of captopril at 1 and 2 hours after administration in the elderly group tended to be higher than in the young group. Suppression of angiotensin-converting enzyme activity persisted longer in the elderly group than in the young group. The area under the curve (AUC) of captopril in the elderly group (335.4 +/- 98.6 hr.2ng/ml) was significantly greater than in the young group (186.7 +/- 79.9) (p less than 0.005), while no significant differences in Cmax, Tmax and T1/2 were observed. The percent decrease in systolic blood pressure in the elderly group (25.2 +/- 10.2%) after 1 hour of nifedipine tablet (20 mg) was significantly higher than in the young group (16.6 +/- 1.5%) (p less than 0.05). Cmax and AUC of nifedipine in the elderly tended to be higher than in the young group (303.5 v.s. 210.0 ng/ml and 1258.9 v.s. 725.1 hr.ng/ml, p less than 0.1, respectively). The percent decrease of diastolic blood pressure after 2 mg of bunazosin was also significantly higher in the elderly group than in the young group (p less than 0.05).2+ antihypertensive response after captopril and arotinolol in two groups.

Highly sensitive enzyme immunoassay of human interferon-beta 1

A highly sensitive sandwich enzyme immunoassay for human interferon-beta 1 (HuIFN-beta 1) was developed. HuIFN-beta 1-containing samples and horseradish peroxidase (HRP)-labeled mouse anti-HuIFN-beta 1 monoclonal antibody (Fab') were incubated overnight at 2-10 degrees C in the wells of a 96-well microtiter plate, onto which affinity-purified rabbit anti-HuIFN-beta 1 polyclonal antibody was coated. The EIA was able to detect 0.5 IU/ml of HuIFN-beta 1, thus showing higher sensitivity than bioassay. The values obtained by the EIA closely paralleled those obtained by bioassay in the concentration which bioassay can detect. In order to detect the concentration below 0.5 IU/ml of HuIFN-beta 1, the avidin/biotin-amplified EIA was also developed. The use of biotinylated mouse anti-HuIFN-beta 1 monoclonal antibody (F(ab')2) and HRP-avidin in the EIA made it possible to detect 0.1 IU/ml of HuIFN-beta 1. These EIAs were applied for the studies such as process control of HuIFN-beta 1 production, pharmacokinetics of HuIFN-beta 1, and determination of serum level of HuIFN-beta 1 in healthy subjects.

Double-blind studies of calcium antagonists in the treatment of hypertension in Japan

Japanese studies of six calcium antagonists are reviewed, and the antihypertensive response to these drugs is analyzed in groups of young, middle-aged, and old subjects. The phase III clinical trials were performed in double-blind group studies that compared the calcium antagonist with a standard drug. In accordance with the guidelines for the clinical evaluation of antihypertensive agents, patients with a blood pressure level greater than or equal to 160/95 mm Hg after receiving a placebo for 4 weeks were enrolled in the study. The test drug was then administered for 12 weeks. A decrease in blood pressure by 20/10 mm Hg from the pretreatment level or a blood pressure level below 149/89 mm Hg was considered to indicate a response. The response rates for nicardipine, diltiazem, nifedipine tablets, long-acting nicardipine, nilvadipine, and nitrendipine were 64.6, 67.4, 68.6, 69.7, 70.7, and 65.9%, respectively. The average pretreatment blood pressure level was 170-175/100 mm Hg, and the average decrease in blood pressure was about 25/14 mm Hg. The reproducibility of the response rate of nicardipine used as a standard drug was shown in four different double-blind studies, where the response rate ranged from 65 to 72%. Side effects were observed in 8-18% of subjects, and the rate of side effects was also found to be reproducible in nicardipine studies. In severe hypertension unresponsive to diuretics and beta-blockers, response rates ranged from 79 to 93%. The antihypertensive response to calcium antagonists was not related to age, but correlated with the pretreatment blood pressure level. Therefore, calcium antagonists are effective and useful in treating mild, moderate, and severe hypertension in patients of all ages.

Isolated right ventricular infarction resulting from thrombotic occlusion of a hypoplastic right coronary artery

Three cases of isolated right ventricular infarction resulting from thrombotic occlusion of a hypoplastic right coronary artery were found in 4,000 consecutive autopsies performed at Tokyo Metropolitan Geriatric Hospital. The incidence of isolated right ventricular infarction was 0.08%. The clinical profile of the first case was characterized by shock, pulmonary congestion, pleural effusion, decreased V1R and V2R on ECG, a small elevation of CPK and transaminase, elevation of fibrin degenerative products and decreased platelet count. The patient responded to volume expansion, heparin and catecholamines. One year later she died from cerebral bleeding. In the second case, mild aortic regurgitation and atrial fibrillation were present. He died suddenly during an episode of pneumonia. In the third case, there was chronic obstructive lung disease, atrial fibrillation and lung cancer. He died of respiratory failure. On autopsy, the coronary arteries revealed a marked left dominant and right hypoplastic pattern in all cases. The right coronary artery perfused only the free wall of the right ventricle. Complete occlusion of the hypoplastic right coronary artery resulted in isolated right ventricular infarction. In addition, chronic pulmonary disease and arrhythmia may be contributory.

Antihypertensive efficacy and safety of urapidil, alone or in combination with beta-blockers, in patients with phaeochromocytoma

The clinical efficacy and safety of urapidil, used alone or in conjunction with beta-blockers, were evaluated in 14 patients with phaeochromocytoma. Following a 1-week placebo run-in period, the patients were treated with sustained-release capsules of urapidil, initially 30 mg twice a day, followed by dose adjustment within 30-270 mg (mean +/- s.d. 144 +/- 73) per day for 7-29 days (21 +/- 8 days). In six patients, beta-blockers were added to control associated tachycardia. Blood pressure and pulse rate were successfully controlled in 11/14 patients (78.6%) during the therapy. Both the frequency and the severity of hypertensive paroxysms were clearly reduced in 7/8 patients, who showed frequent paroxysms of hypertension during placebo treatment. A variety of subjective symptoms observed in 13 patients during placebo treatment improved during drug therapy in nine patients (69.2%). Side effects occurred in five patients but were minor and well tolerated except in one patient, who was withdrawn from urapidil monotherapy due to facial oedema and finger stiffness which persisted even after reducing the daily dose from 306 to 270 mg. Overall, in terms of antihypertensive effectiveness, improvement in subjective symptoms and the safety profile, urapidil was considered very useful in four patients (28.6%), useful in six (42.9%), slightly useful in three and useless in one. Urapidil therefore appears to be a worthwhile agent in the treatment of patients with phaeochromocytoma.

Anticoagulant therapy in recurrent cerebral embolism: a retrospective study in non-valvular atrial fibrillation

For the prevention of recurrent embolic stroke, 23 elderly patients with non-valvular atrial fibrillation (NVAF) were treated with oral anticoagulants (warfarin) during a mean period of 3.8 years. Only one patient suffered recurrent embolism, and another had acute myocardial infarction. There was no cerebral haemorrhage during the treatment. In an untreated control group (from an autopsy series), recurrent embolic strokes occurred in 18 of 70 NVAF patients (26%) during a mean period of 1.3 years. Long-term anticoagulant therapy appears to be effective in the prevention of recurrent embolic stroke in elderly patients with NVAF.

Clinical evaluation of the plasma levels of immunoreactive atrial natriuretic peptide in elderly patients with heart diseases

Plasma levels of immunoreactive atrial natriuretic peptide (ANP) were estimated in 69 elderly patients over 60 years of age (mean 76.4 years) with or without heart diseases and in ten young, healthy volunteers (mean 33.0 years) to evaluate the clinical significance of ANP in the elderly. Plasma ANP levels in nine patients without heart diseases were significantly (P less than .01) higher than in the ten young, healthy subjects (mean +/- SD, 46.0 +/- 22.0 vs 22.1 +/- 6.3 pg/mL) and a significant positive correlation was observed between ANP level and age in these subjects (r = 0.60, P less than 0.01). Plasma ANP levels in 60 patients with heart diseases (158.4 +/- 158.5 pg/mL) were significantly (P less than 0.05) greater than in nine patients without heart diseases. Plasma ANP levels in patients with congestive heart failure or atrial fibrillation were 285.8 +/- 185.2 or 223.0 +/- 185.9 pg/mL, respectively; each of these values was significantly (P less than 0.01) higher than in patients without heart diseases. In three patients with paroxysmal atrial fibrillation, plasma ANP levels during atrial fibrillation were three times greater than when atrial fibrillation returned to normal sinus rhythm (377.3 +/- 78.5 vs 101.1 +/- 68.5 pg/mL). These results indicate that plasma ANP levels increase with advancing age, and that increased ANP levels are associated with various heart diseases in elderly subjects, possibly through stretch of the atrial wall.

Cardiovascular disease in the aged: overview of an autopsy series

As an overview of cardiovascular disease in the aged, 3657 autopsy cases were analyzed for the frequency and age-wise incidence of cardiovascular disease. The three major categories, ischemic heart disease, valvular heart disease, and aortic aneurysm and dissection were described. 1. The incidence of overall cardiovascular disease increases sharply between the ages of 60 and 75. Prevention and treatment could be effectively directed at this age group. 2. The incidence of organic cardiovascular disease was: myocardial infarction 19.8 percent; valvular disease 10.0 percent; arteriosclerosis obliterans 3.5 percent; aortic aneurysm and dissection 3.3 percent; pericarditis 2.1 percent; cardiomyopathy 1.6 percent; cor pulmonale 1.4 percent; congenital heart disease 0.7 percent; and others 0.8 percent. 3. As coronary sclerosis progresses, death from ischemic heart disease increases; however, 7 out of 10 patients with 3 vessel disease still die of causes other than ischemic heart disease (pneumonia, malignancy etc.). The general management of infection and malignant neoplasms is important in addition to treatment of cardiovascular disease. 4. Except for mitral stenosis, valvular heart disease, the etiology of which is mostly non-rheumatic, increases with advancing age. 5. In aortic aneurysm, the rupture rate is relatively high in the thoracic aorta; however, this may be caused by the successful surgical repair of abdominal aneurysms. An aneurysm below 6 cm in diameter is not absolutely safe from rupture. 6. In aortic dissection, the interval from onset to the death of the patient is often too short to consider surgery.

[A staged surgical treatment of an abdominal and iliac aneurysm associated with hydronephrosis and urinoma: report of a case]

Hydronephrosis and urinoma are extremely rare complication of the abdominal aneurysm. A case of the aorto-iliac aneurysm associated with right hydronephrosis and urinoma is reported. The patient is 71 year-old female. She was admitted because of right lower abdominal pain. A diagnosis of the infrarenal abdominal aneurysm with involvement of the common iliac artery and right hydronephrosis due to ureter obstruction was made. A leakage of urine from right renal pelvis (urinoma) was also confirmed. A staged treatment for hydronephrosis was selected. At first, percutaneous nephrostomy was made under ultrasonographic guidance. Urinoma was completely disappeared thereafter. Two weeks later, the aneurysm was replaced with a Y-shaped Dacron graft and the right ureter was mobilized from the perianeurysmal fibrous tissue. On the 35th postoperative day, balloon ureteroplasty was performed through the nephrostomy catheter. Three months after operation, nephrostomy catheter was successfully withdrawn because of improved urinary passage through the right ureter. We emphasize the efficacy of staged surgical treatment combined with percutaneous nephrostomy for the abdominal aneurysm associated with hydronephrosis.

Effects of hypertension and antihypertensive drugs on cardiovascular complications in the elderly

The role of hypertension and antihypertensive drugs in cardiovascular complications was evaluated in 380 elderly people living in the Tokyo Metropolitan Gerontology Center. The subjects were classified into four groups according to the presence or absence of hypertension and their antihypertensive treatment, and followed up prospectively for 5 years from 1979 to 1984. The average age of each group was 74 to 76 years. Cerebrovascular disease was observed in 19.3% of male hypertensives and 10.1% of male normotensives (p = 0.078). The drug treated group revealed no cerebral hemorrhage and less cerebral infarction. This tendency was not observed in females. Ischemic heart disease was prevalent in the drug treated group (10.9% vs 4.5%, p = 0.023) irrespective of blood pressure level. Risk factors such as body mass index, skinfold thickness, serum cholesterol, albumin, creatinine, blood urea nitrogen and uric acid at entry were elevated in the drug treated group. Diuretics were used in 92% of the drug treated group; in 53% as monotherapy and in 39% as combination therapy with other antihypertensive agents. The metabolic effect of diuretics may increase the incidence of ischemic heart disease in the elderly. We might conclude that hypertension in the aged accelerates cerebrovascular complications, and that antihypertensive treatment is effective even in this group. However, the wide use of diuretics could increase the incidence of ischemic heart disease. Careful selection of antihypertensive drugs as well as dose adjustment are needed in the treatment of elderly hypertensives.

Evaluation of electrocardiographic criteria for left ventricular hypertrophy based on anatomical comparison

The reliability of precordial electrocardiographic criteria for left ventricular hypertrophy (LVH) was evaluated by comparing it with the anatomical findings of 421 postmortem hearts examined by the chamber dissection technique. Of these 421 postmortem hearts, 136 without cardiovascular disease served as normal controls. The weights of the left ventricular free wall with interventricular septum (LV + S) and of the whole heart in normal controls were 153 +/- 36 grams (mean +/- SD) and 289 +/- 67 grams, respectively. Correlation coefficients between LV + S and whole heart were 0.89 for men and 0.90 for women. Anatomical LVH was defined as the weight of LV + S exceeding the average plus one standard deviation of that of a normal control heart. Anatomically established LVH was found in 99 (28%) of 353 cases having precordial electrocardiograms available for evaluation. The sensitivity, specificity, and predictive accuracy of electrocardiographic criteria for LVH were as follows: SV1 + RV5 greater than 3.5 mV, 56.6%, 76.0% and 47.9%; SV1 + RV5 greater than 4.0 mV, 45.5%, 87.4% and 58.4%; SV1 + RV5 greater than 5.0 mV, 21.2%, 94.5% and 60.0%; SV1 + RV5 greater than 3.5 mV with strain type ST-T, 35.4%, 93.3% and 67.3%; SV1 + RV5 greater than 4.0 mV with strain type ST-T, 29.3%, 94.9% and 69.0%; SV1 + RV5 greater than 5.0 mV with strain type ST-T, 14.1%, 98.0% and 73.7%; strain type ST-T, 36.4%, 92.5% and 65.5%; nonspecific ST-T, 26.3%, 76.4% and 30.2%; SV1 + RV5 greater than 3.5 mV with nonspecific ST-T, 12.1%, 93.3% and 41.4%; and right anteriorly directed T vector, 39.4%, 89.4% and 59.1%.(ABSTRACT TRUNCATED AT 250 WORDS)

[Mitral regurgitation due to ruptured chordae tendineae in the aged: a clinicopathologic study]

We observed 13 cases of mitral regurgitation (MR) due to ruptured chordae tendineae (RCT) among 4,000 consecutive autopsies of patients over 60 years of age (0.33%). There were four men and nine women whose average age was 79.8 yrs. Five cases had a single RCT (Group I) and eight had multiple RCT (from two to eight chordae) (Group II). The sites of RCT were in the posterior mitral leaflet (PML) in nine, the anterior leaflet in one, and both in three. All in Group I showed RCT in the PML; the posterior scallop in two and the middle scallop in three. The average heart weight was 340 g in Group I and 431 g in Group II. Sclerosis of the coronary arteries, the circumference of the mitral valve ring, and thickness of the leaflets did not differ significantly. Estimated volume of the left atrium was significantly greater in Group II than in Group I (185 ml vs 57 ml, p less than 0.05). Jet lesions were observed in 10 of the 13 cases. The etiologies of RCT were previous endocarditis in two, mitral valve prolapse in three, and spontaneous rupture in eight. Congestive heart failure was observed in three (60%) in Group I and eight (100%) in Group II (p less than 0.01). Cardiothoracic ratio more than 60% was observed in three (60%) of Group I and six (75%) of Group II. Atrial fibrillation was demonstrated in one in Group I (20%) and six (75%) in Group II (p less than 0.05), and cardiac death in one (20%) in Group I and six (75%) in Group II (p less than 0.05). Phonocardiograms showed pansystolic murmur in all cases, third heart sound in nine (69%), and fourth heart sound in four (57%). Echocardiographically, RCT was diagnosed in six of nine cases (67%). In conclusion, patients with RCT involving more than two chordae tendineae can show more severe clinical course than cases with a single RCT.