Atrial fibrillation (AF) represents a high risk of systemic embolism, particularly of stroke (S). This is true not only when AF is associated with an organic cardiopathy, but also in the so-called nonvalvular AF (NVAF). Not all cases of AF are of the same S-risk; such risk is higher for rheumatic AF and lower for NVAF. Therefore, a risk stratification is important in order to decide long-term antithrombotic prophylaxis. Five major trials have recently examined the thromboembolic prophylaxis in this group of patients. These randomised prospective open studies showed a significant reduction of S and systematic embolism in patients receiving low dose of warfarin (W), even in the elderly, as compared to placebo, and the incidence of hemorrhagic complications was also very low. Significant benefits of aspirin (ASA) were observed only in one trial in patients, except those older than 75 years. In a double blind, randomised trial indobufene was found effective resulting in 67% reduction of S and systematic embolism in patients with various cardiac diseases in AF or sinus rhythm. Consequently, a reasonable policy would be to treat patients with NVAF (also old ones) with anticoagulants unless contraindications or lone atrial fibrillations are present; in the latter cases ASA and indobufene should be considered. In the secondary prevention of ischemic S, W has given good results, whereas ASA and indobufene seem to be promising.

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Permanent cardiac pacing and thromboembolic risk in elderly patients.

In patients undergoing permanent cardiac pacing, the maintenance of atrial contractility is important to ensure adequate ventricular filling and to guarantee an optimal ventricular ejection capacity. The appropriate pacing mode, assuring a suitable mechanical atrioventricular coupling, prevents the onset of atrial fibrillation and contributes to reduction of the risk of subsequent systemic and pulmonary thromboembolic episodes. We examined 461 patients (266 males and 195 females, aged between 52 and 97 years, average age 76.5 +/- 18) paced for conduction disturbances of various degrees and etiology. Of them, 323 patients received ventricular demand pacemaker (VVI group, average age 77.9 years); 138 underwent dual chamber pacing (DCP group, average age 75.2 years), 117 of the latter received universal demand pacing (DDD) and 21 atrial synchronous ventricular demand pacing (VDD). The patients were subsequently divided into two age-groups: Group A (</= 75 years, 174 patients), and Group B (>/= 75 years, 287 patients). According to pacing mode and successive development of stable atrial fibrillation (AF), we analysed the occurrence of systemic and/or pulmonary thromboembolic episodes and the incidence of fatal events. During our study, performed from January 1986 to August 1993, 70 embolic episodes were observed in the VVI group and six in the DCP group. Eighty-four patients with VVI units developed AF during follow-up, compared with only five patients in the DCP group. Our data indicate that VVI patients have a higher incidence of AF, embolic complications and cerebrovascular mortality, in comparison with the DCP group. VVI pacing should be avoided, especially in older patients, when atrial rhythmical activity is present.

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The role of transesophageal echocardiography in the diagnosis of ischemic stroke in the elderly.

Cardioembolic stroke is quite common (15% of all ischemic strokes) not only in younger patients but also in the elderly. Clinical diagnosis is often difficult. Transthoracic echocardiography (TTE) seems to be the most reliable non-invasive method of examination. Because of the close topographical relationship between heart and esophagus, transesophageal echocardiography (TEE) is particularly suitable to evaluate those cardiac structures (left atrium and appendage) where the embolus can most likely be found. Using TTE and TEE, we studied 62 patients older than 65 years of age (mean age 76 +/- 6), having been affected by ischemic stroke. TEE proved to be clearly superior to TTE in the diagnosis of cardioembolic stroke, without any major complication during the execution of this diagnostic method.

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Long-term therapy of patients with heart failure. Drug therapy: from trial results to clinical practice.

Heart failure (HF) represents a major problem in Western countries due to its high prevalence, frequent need for hospitalization and extremely severe prognosis. There have been remarkable advances in long-term drug therapy. During the last decade, the use of vasodilatators, in particular of angiotensin-converting enzyme (ACE)-inhibitors, has been added to the traditional therapy based on diuretics and digitalis. There have been several controlled clinical trials demonstrating the long-term benefits of these drugs for survival. ACE-inhibitors have reduced the risk of mortality in HF, not only by their systemic vasodilatator action but also by their positive effects on ventricular remodelling. In fact, their use has led to a reduction in the incidence of sudden death, and progression of pump dysfunction. A reduction in the incidence of coronary events was also observed. ACE-inhibitors, in combination with diuretics and digitalis, have been rightfully introduced into long-term therapy of HF. At present, other pharmacological options, like flosequinan, some beta-blockers, and some calcium antagonists such as felodipine and amlodipine, hold promise, but further controlled trials are required before they can be introduced into the therapeutic repertoire of HF management.

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Epidemiological aspects of isolated systolic hypertension in the elderly population as cerebrovascular risk factor.

A large number of studies indicate that isolated systolic hypertension (ISH) is an important cerebrovascular risk factor. This clinical state is very common in elderly people who are the most exposed to stroke risk. Therefore, it is important to know the real prevalence of ISH, in order to predict the possible incidence of cerebrovascular disease in the elderly population. In the Camerano study on hypertension, we have verified the prevalence of ISH in the elderly. ISH has been considered clinically when the systolic arterial pressure (SAP) was higher than 160 mmHg, and the diastolic arterial pressure (DAP) was lower than 90 mmHg. In our study population, an ISH prevalence of 11.9% was found in the elderly (above 60 years of age); whereas in the adult population (between 30 and 60 years), it amounted only to 4.5%.

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Congestive heart failure in the elderly requiring hospital admission.

Fifty consecutive elderly (> 60 years) patients admitted to our department with congestive heart failure (CHF) entered a prospective database, to define their main clinical, instrumental and cognitive characteristics. In addition we evaluated the patterns of drug therapy in this aged population. Eighty percent of this sample had been previously hospitalized for CHF. Two or more associated diseases were present in 92%. Heart disease was ischemic or hypertensive in etiology in 80% of patients. Acute dyspnea was the most common presenting symptom. Atrial fibrillation or flutter were found in 38% of patients. Ultrasound evaluation evidenced left ventricular dysfunction of a systolic type in 49% and of a diastolic type in 28.6% of subjects. Diuretics and cardiac glycosides were the most widely administered drugs, followed by ACE-inhibitors, nitrates and dobutamine. Older ( >or= 75 years) patients were treated with more agents, with a trend to a lesser use of dobutamine. Moderate to severe mental deficit was present in 20.8% of our sample, while significant depression was more common (54.2%). The main implications of the clinical profile of the elderly patient hospitalized for CHF are discussed.

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Arterial hypertension in the elderly: a review.

Arterial hypertension in the elderly is an argument of growing interest and relevance in our society for many reasons, the main ones being: (i) Progressive aging of the population with a particularly high number of very old subjects. (ii) The high prevalence of arterial hypertension found mainly as an isolated systolic form or a prevalently systolic one in the elderly population. (iii) Acknowledgement of the significant impact of hypertensive disease on elderly people, e.g., on the cardiovascular risk factor and on the quality of life. (iv) Results of important clinical trials have demonstrated that, using an adequate therapy, it is possible to reduce both cardiovascular morbidity and mortality even in elderly persons.

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Intermittent dobutamine therapy in patients with advanced congestive heart failure.

Congestive heart failure is an increasingly common condition carrying a poor prognosis and a decay in the quality of life. Usually frequent and lengthy hospitalizations are required with heart failure, with obvious discomfort for the patient and increase in health costs. Heart transplantation is rarely possible due to shortage of donors. Thus, improvement of pharmacological strategies for the management of these patients is desirable. The present study evaluated the effects of intermittent dobutamine infusion in elderly patients (mean age 75.9 years), hospitalized for advanced (NYHA, 1973, class IV) congestive heart failure of ischemic etiology. Dobutamine infusions of 2, 4 and 6 microg/kg/min for 36 h every 2-4 weeks were randomly prescribed to 24 subjects, who were then followed up every three months for an average of ten months. Data on mortality, cardiovascular events and NYHA (1973) functional classifications were systematically collected. Our study shows that while in this series of patients mortality remained high (50% at 12 months), there was an improvement in the NYHA-classification during the follow-up, and a decrease in the need for hospitalization. In addition, side effects were relatively rare, with only two patients interrupting dobutamine treatment. We conclude that intermittent dobutamine infusion is a reasonable treatment option in elderly patients with congestive heart failure unresponsive to conventional treatments.

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Dual chamber pacing in the treatment of congestive heart failure.

The present work reviews current literature and the authors' experience of dual chamber pacing in the treatment of patients with congestive heart failure (CHF). In these patients, the atrial contribution to ventricular filling may be less than optimal, especially in the presence of first degree atrioventricular block or mitral insufficiency, both of which are common in the elderly subject with CHF. Dual chamber pacing with short atrioventricular delays has proved effective in enhancing ventricular filling and, in selected cases, cardiac output, with improvement in clinical and instrumental parameters of heart failure. However, for an appropriate atrioventricular synchronization of the left chambers during pacing, the interatrial conduction time must be considered, to avoid atrial contraction against a closed mitral valve. Thus, dual chamber pacing may be a treatment option for CHF that fails to respond to medical therapy.

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Hospital payment system based on diagnosis related groups in Italy: early effects on elderly patients with heart failure.

Prospective payment systems (PPS) based on diagnosis related groups (DRG) has recently been introduced in Italy and has already changed certain practice patterns of medical staff. Treatment of chronic diseases and those which specifically address the elderly population, such as chronic heart failure (CHF), can be strongly conditioned by this kind of system. This paper concerns an overview of CHF patients within the DRG system, supported by age-related variables, re-admission rates and cost analysis. We analyzed a sample of four hospitals in Central Italy and 1987 patients were admitted for CHF. The results show that after DRG introduction, length of stay was shorter, but re-admission rate increased, especially where the elderly were concerned. Average costs of service provision decreased, mainly due to the reduction in length of stay. However, no reduction was reported in the quality of care in terms of available diagnostic and the rapeutic resources. These early data indicate a change in the practice patterns of medical staff, including the risk of untimely discharge of elderly patients suffering from chronic diseases, for whom a long term monitoring system of service quality would be necessary.

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Archives of gerontology and geriatrics. Preface.

Explore the source record for details and available documents.

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Permanent ventricular and dual chamber cardiac stimulation: role of pacing mode in relation to chronic atrial fibrillation risk and stroke development.

Ventricular single chamber permanent cardiac pacing undoubtedly eliminates symptoms related to extremely low cardiac rate, but also contributes to increased morbidity due to onset of permanent atrial fibrillation (PAF). Many studies have shown the superiority of atrial and dual chamber cardiac pacing in reducing atrial fibrillation risk and in preventing correlated embolic complications. It is not known, however, if this advantage is maintained in the elderly and in particular in the oldest old people. From 1986 onwards, we analyzed 690 chronically paced patients, 472 received a single chamber ventricular pacemaker (VP), while 218 received a dual chamber pacemaker (DP). All patients underwent regular controls every 6 months. End points of the study were the onset of atrial fibrillation, embolic events and death. Life table analysis of the incidence of all the events during a follow-up of 120 months was carried out, distinguishing two groups (VP and DP) homogeneous in mean age and type of cardiopathy. The total incidence of PAF was 51.4% in the VP and 11.4% in the DP group (P<0.05). After 7 years from implant, PAF was present in 90% of VP and 20% of DP patients (P<0.001). We found a significantly higher occurrence of cerebral ischemic events (stroke or transient ischemic attacks) in the VP group (P<0.05). Even if no great difference in mortality was found between the two groups, a significant reduction of cardiovascular mortality associated with DP has been observed in the subgroup of patients with sick sinus syndrome.

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Sexual dimorphism in arterial hypertension: an age-related phenomenon.

Epidemiological, clinical and experimental evidence is available indicating that male subjects develop hypertension with a higher probability than age-matched females. The sexual dimorphism of blood pressure (BP) has been observed both in normotensive and hypertensive subjects. In order to analyze the presence of sexual dimorphism of arterial hypertension (AH) and its relationship to the aging process - particularly to the menopause - the population screened in the Camerano Study has been examined. In addition, to evaluate sex-related differences in the AH, another sample of 3765 patients from our Hypertension Centre has also been considered. Our samples displayed a real cross-over in the prevalence of arterial hypertension, hypercolesterolemia, hyperglycemia and obesity in women versus men, after the menopausal period. In fact, in the adult group (20-54 years) the prevalence of arterial hypertension was significantly higher (P<0.005) in males (9.2%) than females (6.4%), whereas in the older group (>54 years), we observed a significantly higher prevalence (P<0.001) in females (46.6%) than in males (34.7%). These results suggest that the menopause and age can play a separate role in the sexual dimorphism of arterial hypertension. A significant gender-related difference in hypertensive patients was found only in hypercholesterolemia above the age of 50 years, namely, females have this disorder more frequently.

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Simvastatin in the treatment of hypercholesterolemia in elderly patients.

Twenty elderly (mean age, 69 years), hypercholesterolemic patients (low-density lipoprotein [LDL] levels greater than or equal to 160 mg/dl) were supplied a lipid-lowering diet for one month and then received 10 mg of simvastatin daily for 12 months. Total cholesterol levels fell significantly, from 304.6 mg/dl at baseline to 277.4 mg/dl after one month on the diet, to 245.9 mg/dl after one month of simvastatin, and to 216.1 mg/dl after two months of simvastatin; total cholesterol levels remained significantly lower (221.6 mg/dl at month 12). LDL levels decreased significantly, from 217.6 mg/dl at baseline to 130.4 mg/dl at month 12. High-density lipoprotein levels increased significantly only at months 2 and 3. Apolipoprotein (apo) A levels increased significantly, from 147.2 mg/dl at baseline to 217.9 mg/dl at month 12. There were no significant changes in triglyceride or apo B levels. No changes in blood pressure, heart rate, or body weight or in results of laboratory tests were noted. Few side effects were reported. It is concluded that simvastatin is safe and effective in the treatment of hypercholesterolemia in elderly patients.

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