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The evolution of reperfusion therapy in the treatment of acute myocardial infarction (AMI) has highlighted the extraordinary importance of rapid and accurate diagnosis of infarcts due to thrombosis of a major epicardial vessel, the so-called Q-Wave Myocardial Infarction or Transmural Myocardial

We investigated the accuracy of self-report of hospitalization for acute myocardial infarction (MI) by elderly persons in a community-based prospective study. Among 3809 persons aged 65 years or older followed up for 6 years, self-reported hospitalization for MI was validated by review of primary records and Medicare diagnoses. Among 147 who self-reported MI and for whom hospital records were available, the diagnosis was confirmed in 79 (54%). Myocardial infarction was not a reason for hospitalization among the remaining 68 participants; misclassification with other cardiovascular diagnoses was common. Medicare diagnosis correlated well with primary hospital records. Using Medicare diagnoses as the standard, the diagnosis of MI was confirmed in 53% of self-reports; the sensitivity and specificity of self-report were 51% and 98%, respectively. False-negative reporting was common because only half of hospitalizations for MI were reported. Self-report of hospitalization for MI by elderly persons in the community may be unreliable for ascertaining trends in cardiovascular diseases.

Old age as our society is experiencing it is a new phenomenon. Never before in history have societies of developed countries enjoyed such longevity of life. In the next several decades the United States will face an unparalleled increase in the absolute number of elderly persons in our population. How will health care professionals, policy-makers, and society in general face the mammoth task of providing quality cardiovascular care for the elderly in an environment of limited financial resources? This article discusses the demographic, fiscal, and health policy implications of our aging society with particular emphasis on existing and anticipated impediments to the delivery of cardiovascular care to this rapidly expanding segment of our population.

CHD in the elderly population will continue to be a source of major concern because of the increasing costs entailed and uncertainties about how the widespread array of diagnostic and therapeutic interventions, often expensive and sometimes hazardous, should be applied. Financial, political, and health policy decisions will continue to occupy much attention, but it is likely that philosophic considerations about aging and death, both from the individual and the societal perspective, will be of paramount importance of deciding how the substantial resources available to the elderly will be used. Randomized, controlled trials are unlikely to play a major role in resolution of management dilemmas in the elderly because of the extraordinary heterogeneity in this population. Registries (databases) involving carefully prospectively collected key variables are likely to be a more effective approach. Critical characterization of complications of procedures, adverse drug reactions, and collection of follow-up data on functional status are among the critical questions, and these can be answered by registry studies. Algorithms and clinical rules developed in younger cohorts are not directly transferable to the elderly cardiovascular patients, further emphasizing the need for prospectively collected, syndrome-specific data. Treatments convincingly demonstrated to reduce mortality in absolute terms more in the elderly than in the young are underused. The heterogeneity of aging emphasizes the wide variability in patients' ability to withstand the stress of procedures and complications of disease and makes clear the need to consider physiologic reserve and biologic age rather than chronology. With better characterization of biologic age and physiologic reserve, more precise estimates of outcomes of therapies and interventions can be made, and patients can be given better information and with their families have more realistic expectations. Better-informed decisions will result. Biologic age will be multifactorial, involving cognitive, emotional, physical, and nutritional attributes as well as specific organ function (lung, kidney, liver) because no single feature can characterize the total elderly patient. The concept of competing risks among the cardiovascular disease being treated, comorbidity, risks of study, and life expectancy will evolve because even the most successful therapy will have limited effect on longevity in the very old. Although important research at the cellular and molecular level will characterize and provide better understanding of the aging process, it is not likely that this basic information will be immediately useful in the management of the large number of elderly patients with major cardiovascular disease. Preventive measures, including physical exercise, mental stimulation, avoidance of depression, good nutrition, and abstinence from tobacco use, are useful approaches to postpone or ameliorate the consequences of aging and allow patients to tolerate cardiovascular diseases better when they become manifest.

Managed care in the United States is evolving rapidly and currently presents a complex mosaic of administrative and clinical practices that show considerable regional variation. The concept of managed care has existed for many years, but until recently older patients with chronic conditions, such as cardiovascular disease, have not been sought after by managed care organizations. This situation is hardly surprising because such patients account for a disproportionate share of health care costs and could endanger the profitability of any enterprise that assumes their care for a preset fee. The success of managed care in moderating health care spending among the employed and societal and political pressures to control the growth of Medicare costs, however, have led to the expansion of managed care options for older populations. This article represents only a snapshot of a huge moving picture and is, of necessity, incomplete because experience in this population is limited. For purposes of this article, managed care is defined as a system to structure critical aspects of the delivery of care in a way that controls cost, while maintaining or improving the quality of care. Even within such a simple definition, a wide variety of models may exist, with varying degrees of control over provider behaviors that influence costs and outcomes of care. The promise of managed care lies in the use of strategies that provide maximal health care value, which can be defined as the optimal tradeoff of technical quality, functional outcomes, costs, access to care, and patient and provider satisfaction. The perils, however, are the facts that health care value is not easily assessed and that short-term marketplace success may depend on selection of healthier patients and denial of complex but necessary care. For older patients with cardiac disease, these promises and perils are critically important because these patients have more to gain from improved systems of care, yet are more likely to suffer if their needs are not met.

The Studies of Left Ventricular Dysfunction (SOLVD) comprises 2 double-blind, randomized clinical trials to test improved survival by angiotensin-converting enzyme inhibitor in patients with left ventricular dysfunction, with or without congestive heart failure. Patients entering the trials may be a highly selected subset of the population of such patients; those with the worst and best prognosis are likely to be excluded. To obtain the clinical history of a broader group, a registry of 6,273 patients included a relatively unselected cohort of patients with heart failure or left ventricular dysfunction, or both, from SOLVD hospitals. Registry data were obtained from hospital records. Because data collection from medical records may lead to incomplete data and more investigations in "sicker" patients, 898 randomly chosen subjects from different disease strata were seen in clinic where neurohumoral measures, echocardiograms, x-rays and electrocardiograms were obtained, and a 6-minute walking test was performed. The design and methodologic features, and the baseline characteristics of the participants in this 2-tiered registry are described, and its use in complementing the results and interpretation of the SOLVD trials is discussed.

Reperfusion may limit the amount of potentially salvageable myocardium through the introduction of cellular elements into previously ischemic but viable myocardium (reperfusion injury). It has been demonstrated that intracoronary infusion of a 20% intravascular perfluorochemical emulsion (Fluosol) significantly reduces infarct size and results in improved left ventricular function in the canine model. This pilot study was performed to explore the existence of myocardial reperfusion injury in humans.Utilizing Fluosol as a probe in conjunction with emergency coronary angioplasty, 26 patients presenting within 4 h with a first anterior myocardial infarction were randomized to emergency angioplasty or angioplasty followed by a 30-min intracoronary infusion of Fluosol at 40 ml/min. Global and regional ventricular function were assessed immediately and a mean of 12 days after successful angioplasty with contrast ventriculography. Infarct size was semiquantitated with thallium-201 single-photon emission computed tomography (SPECT) images before discharge. Twelve patients (six undergoing angioplasty alone, six treated with angioplasty and Fluosol) had an occluded infarct-related vessel (Thrombolysis in Myocardial Infarction [TIMI] grade 0 to 1) at the time of emergency catheterization and were included in the final analysis.At 12 days after successful angioplasty, the improvement in regional ventricular function was greater in patients receiving adjunctive therapy with intracoronary Fluosol versus those undergoing angioplasty alone utilizing both the radial shortening and centerline method, respectively (23 ± 3.1% vs. 8 ± 2.3%, p < 0.02; and −1.6 ± 0.4 vs. −2.9 ± 0.2 SD/chord, p < 0.05). Tomographic infarct size expressed as a percent of the left ventricle was also reduced in Fluosol-treated patients (3.5 ± 2.2% vs. 18.3 ± 4.7%, p < 0.05). No significant differences in collateral blood flow, extent of coronary artery disease or residual stenosis after angioplasty were observed.This preliminary study suggests that myocardial reperfusion injury may be an important factor in limiting myocardial salvage in patients undergoing reperfusion. These findings have important clinical implications because adjunctive therapy may further amplify the beneficial effects of mechanical or pharmacologic reperfusion. Additional prospective randomized trials must be done to confirm and extend these preliminary results.

Sir William Osler’s contributions to clinical medicine in general are considered by many as unique. His skills as an expert pathologist, master clinician, astute diagnostician, and above all a gifted teacher and author are extolled in numerous contemporary as well as posthumous publications. His observations and writings on cardiovascular diseases are among his most important and influential.’ The congenitally bicuspid aortic valve was one of Osler’s favorite subjects. It was also the topic of his first presentation to the Association of American Physicians published in the premier issue of the association’s transactions.2 In that article, Osler presented his findings in >800 consecutive autopsies which contained 18 cases of bicuspid, aortic valve. His background and expertise in pathology provided a unique opportunity to highlight the relation between observed pathology and the corresponding physiologic derangements. It is, therefore, at first glance, surprising that although infective endocarditis, heart failure, and cardiac hypertrophy were identified as important findings in patients with bicuspid aortic valve, there is no mention of aortic valvular stenosis. Could Osler have missed the now well-established association between this anatomic defect and the propensity for aortic stenosis? We review Osler’s manuscript and propose a simple hypothesis that explains the discrepancy in the prevalence of aortic vaIve stenosis between Osler’s initial report and the current knowledge that a congenitally bicuspid aortic valve with calcific deposits and acquired stenosis is the most common cause of aortic stenosis in middle-aged patients. Table I lists the clinical characteristics of the 18 cases of congenitally bicuspid aortic valve reported in Osler’s autopsy series. When the cause of death was known, infective endocarditis and congestive heart failure were the etiologies in 14 of 16 patients. Varying degrees of left ventricular hypertrophy were present in all but 2 patients. Incompetence of the bicuspid valve was noted in 3 patients and cusp perforation in the setting of infective endocarditis in another 2. Aortic cusp thickening and sclerosis were noted in 13 patients, but frank valvular aortic stenosis was not seen in any patient. He correctly pointed out that the bicuspd aortic valve was “invariably thickened and the seat of sclerotic changes.”