D'Arcy Little, MD, CCFP, Academic Fellow, Department of Family and Community Medicine, University of Toronto, and Director of Medical Education, York Community Services, Toronto, ON.

Introduction
Congestive heart failure (CHF) is a serious common, condition. It qualifies as one of the most important contributors to cardiovascular morbidity and mortality in the developed world. Due to the burgeoning elderly population, as well as to new treatments for acute myocardial infarction which are allowing more patients to survive with impaired ventricular function, the incidence of CHF will continue to increase dramatically.¹ While significant improvements in CHF therapy have been made in the last few decades with the development of angiotensin-converting enzyme inhibitors (ACE inhibitors), as well as a clarification of the role of beta-blockers in therapy, additional strategies are still needed to further reduce progression of disease and consequent morbidity and mortality.^1,2 Angiotensin receptor blockers (ARB) may represent an additional approach to the treatment of CHF with the possibility for improved outcomes. Despite physiological explanations that would make such an assertion sound, significant supporting clinical data are currently lacking.

Ernane D. Reis, MD, Assistant Professor, Department of Surgery, Mount Sinai School of Medicine, New York, NY.
Osvaldo J. Yano, MD, Attending Vascular & Endovascular Surgeon, Saint Francis Hospital, Roslyn, NY.

Introduction
Peripheral vascular [arterial] disease (PVD) of the lower extremities is a result of generalized atherosclerosis, and has the same risk factors as do stroke and myocardial infarction.¹ PVD is associated with increased mortality even in asymptomatic patients,² and is an important cause of complications and death after successful coronary revascularization.^3,4 Twenty-five percent of patients with limb-threatening ischemia die within one year of diagnosis.² In patients older than 60 years, the prevalence of clinically detectable PVD is approximately 15%, and claudication occurs in up to 5%.² PVD also reduces ambulatory capacity and quality of life and, therefore, represents an enormous human and financial burden to individual patients and society.⁵

During the last decade, management of arterial disease of the lower extremities has undergone remarkable changes. A true medical revolution is ongoing, as a consequence of the successful introduction of new technologies that can be used alone or in conjunction with established surgical and radiological methods.

Results from the Multicentre Randomized Arterial Revascularization Therapy Study

V. Legrand¹ MD, PhD, FESC,
P. Serruys² MD, PhD, FACC, FESC,
WK Lindeboom³ PhD,
M. Vrolix⁴ MD,
G. Fransen⁴ MD,
P. Materne⁵ MD,
G. Dekoster⁵ MD,
R. Seabra-Gomes⁶ MD,FESC,
J. Queiroz E Melo⁶ MD

¹CHU Liege Belgium.
²Thoraxcenter, Rotterdam, The Netherlands.
³Cardialysis, Rotterdam, The Netherlands.
⁴St Jansziekenhuis, Genk, Belgium.
⁵CHR Citadelle, Liege, Belgium.
⁶Hosp Santa Cruz, Carnaxide, Portugal.

Key words : coronary angioplasty, stent, coronary bypass surgery, elderly.

Introduction
As the population ages, an increasing number of elderly patients are presenting with symptomatic multivessel coronary artery disease requiring revascularization. However, the most appropriate myocardial revascularization procedure for older patients with multivessel disease is still controversial. Indeed, it is well recognized that the procedure-related morbidity associated with either percutaneous coronary intervention (PCI) or coronary artery bypass graft (CABG) increases dramatically with age.

Levent Ozdal, MD, Research Fellow, Department of Urology, McGill University, Montreal, QC.
Simon Tanguay, MD, FRCS(C), Associate Professor, Department of Urology, McGill University, Montreal, QC.

Benign prostate hyperplasia (BPH) is the most common benign neoplasm in aging men. Although microscopic evidence of BPH occurs in 80% of men who are at least 80 years old, clinical enlargement of the gland only occurs in half of all men in this age group. Furthermore, symptomatic disease only develops in about half of men with clinically enlarged prostate glands.¹

Lower urinary tract symptoms (LUTS) of BPH can be obstructive or irritative in nature. Most symptoms occur and progress slowly in aging men. The treatment of BPH is usually indicated once patients develop either moderate or severe symptoms, or in the presence of complications due to bladder obstruction. Complications of BPH due to chronic obstruction include recurrent urinary tract infection, bladder stones, incontinence, gross hematuria, urinary retention or renal failure.

The aim of BPH treatment should include improving or eradicating symptoms, reversing the complications of the disease and preventing additional sequelae. Treatment is typically based on the severity of symptoms and patient preference.

Anne-Sophie Rigaud, Hôpital Broca, CHU Cochin-Port-Royal, Paris, France.
Bernard Forette, Centre Claude Bernard de Gérontologie, Hôpital Sainte Périne, Paris, France.

Abstract
Diastolic blood pressure is considered an important risk factor for the development of cerebrovascular disease, congestive heart failure and coronary heart disease. However, it is now clear that isolated systolic hypertension and elevated pulse pressure play an important role in the development of these diseases, which are the major causes of cardiovascular morbidity and mortality among subjects aged 65 years and older. The benefit of antihypertensive therapy in reducing the incidence of cardiovascular and cerebrovascular complications has been shown for systolic and systolo-diastolic hypertension in all age groups. Because of the higher risk of cardiovascular disease in the elderly, the effect of antihypertensive treatment appears greater in patients over 60 or 65 years when expressed as an absolute risk reduction.

Definition
Essential (i.e. primary) hypertension is the main cause of hypertension in the elderly population. However, secondary, especially renovascular hypertension is more common in older than in younger adults. The incidence of hypertension in the elderly is high. In an ambulatory population aged 65-74, the overall prevalence is 49.6 % for stage 1 hypertension (140-159/90-99 mmHg), 18.2% for stage 2 (160-179/100-109 mmHg), and 6.

G. Tong, MD, PhD
Jody Corey-Bloom, MD, PhD
Department of Neurosciences,
University of California San Diego, CA, USA.

Introduction
Alzheimer disease (AD), the most common form of dementia in the elderly, is characterized clinically by multiple cognitive deficits, including memory loss, visuospatial impairment, disorientation and language dysfunction. These features are often accompanied by behavioural and mood changes. A definitive diagnosis of AD can only be made by biopsy or autopsy. The major neuropathological features of AD are neuritic plaques and neurofibrillary tangles.

Cholinergic neurotransmission in the central nervous system (CNS) plays a key role in memory, attention, learning and other cognitive processes. Although other neurotransmitter deficiencies (e.g., noradrenaline, dopamine, serotonin and glutamate) have been noted, the cognitive impairments seen in AD patients have been largely attributed to decreased cholinergic neurotransmission. AD, in part, is characterized by the loss of neurons in basal forebrain cholinergic cells, especially in the nucleus basalis of Meynert, which projects to the cerebral cortex and hippocampus.

Jocalyn P Clark, MSc, PhD candidate
Department of Health Sciences,
University of Toronto and
The Centre for Research in Women's Health,
Toronto, ON.

Stroke is the third leading cause of death for North American women and the leading cause of long-term disability in Canada. According to the Ontario Ministry of Health and Long-Term Care, in 1994/95 stroke-related costs in the province totaled $857 million. The Canadian Stroke Network estimates annual costs for stroke in Canada to be 2.7 billion dollars. Over the next five years the incidence of stroke is expected to increase by over 30%, and those figures could jump to 68% within two decades. Every year among women, stroke claims more than twice as many lives as does breast cancer. Indeed, according to Dr. Beth Abramson, a cardiologist at St. Michael's Hospital in Toronto and an expert in women and stroke, "The issue of stroke in women is a significant one. This is due to potential bias in treatment of female stroke patients, but also to the greater co-morbidity and health care costs associated with treating women when they suffer from stroke."

Like other cardiovascular conditions, stroke in women is highly age-dependent: women are, on average, several years older than men when they suffer their first stroke and tend to be sicker. Owing to this age dependence, the health burden of stroke will only magnify as the proportion of elderly women in the population increases over time.

Wilbert S. Aronow, MD, CMD
Department of Medicine,
New York, Medical College
Department of Geriatrics and Adult Development,
Mount Sinai School of Medicine,
New York, NY, USA.

There are conflicting data regarding the association of abnormal serum lipids with stroke in older men and women.^1-4 Despite these conflicting data, simvastatin and pravastatin have been demonstrated to cause a significant reduction in the incidence of stroke in older men and women with coronary artery disease (CAD) in the Scandinavian Simvastatin Survival Study,⁵ in the Cholesterol and Recurrent Events Trial,^6-10 and in the Long-Term Intervention With Pravastatin in Ischaemic Disease Study (Table 1).^11,12

Scandinavian Simvastatin Survival Study
The Scandinavian Simvastatin Survival Study was a prospective double-blind, placebo-controlled trial which randomized 4,444 men and women (2,282 of whom were 60 to 70 years of age) with CAD and hypercholesterolemia to treatment with either 20 mg to 40 mg of simvastatin daily or placebo.⁵ Simvastatin significantly reduced serum total cholesterol by 25% from 261 mg/dL to 196 mg/dL, serum low-density lipoprotein (LDL) cholesterol by 35% from 188 mg/dL to 122 mg/dL, and serum triglycerides by 10% from 133 mg/dL to 120 mg/dL. It significantly increased serum high-density lipoprotein (HDL) cholesterol by 8% from 48 mg/dL to 52 mg/dL.⁵ At 5.

Findings of a Provocative New Meta-Analysis

Jason M. Burstein, MD
Internal Medicine Resident,
University of Toronto,
Toronto, ON.

Shabbir M.H. Alibhai, MD, MSc, FRCP(C)
Clinical Assistant, Internal
Medicine & Geriatrics,
University Health Network, Toronto, ON.

Introduction
Atrial fibrillation is a common cardiac condition that challenges many physicians, including primary care and emergency doctors, general internists, geriatricians and cardiologists. One of the best-understood and most studied complications is cardio-embolic stroke. While management of atrial fibrillation may seem straightforward, it is interesting to note that there are still large variations in practice patterns, and a recent meta-analysis was contradictory to many previous studies and guidelines. This paper will focus on the epidemiology and treatment of atrial fibrillation in the older population and will examine both the reasons for variations in practice pattern and the conflicting evidence in major medical journals.

Epidemiology and Causes of Atrial Fibrillation
Age is perhaps the most important influence on the incidence and prevalence of disease. The prevalence rate of atrial fibrillation is 2-3% at age 60 to 65 and 8-10% at age 80. Up to 70% of all affected patients are at least 65 years old. The incidence of atrial fibrillation before age 50 is 0.

Dr. Angela G. Juby, MBChB, Cert Geriatrics
Associate Clinical Professor, Division of Geriatrics,
Department of Medicine, University of Alberta, Edmonton, AB.

Dr. Paul Davis, MBChB, FRCP, FRCPC
Associate Dean, Faculty of Medicine, University of Alberta,
Professor, Division of Rheumatology,
Department of Medicine, University of Alberta, Edmonton, AB

Introduction
Rheumatoid arthritis most commonly presents in the 3rd and 4th decades of life; elderly patients with initial presentation and patients whose disease persists into the later decades of life can present interesting challenges. In particular, the differences in clinical presentations of rheumatoid disease in the elderly when compared to younger patients may lead to difficulty in making a definitive diagnosis. There may be diagnostic challenges related to the interpretation of laboratory findings, particularly serological tests. Elderly patients often have comorbidities; therefore, pharmacologic management of rheumatoid disease must be undertaken with caution to reduce interference with the stability of other organ system therapies, and the potential for drug-disease and drug-drug interaction and polypharmacy must be addressed. Finally, it is important to dispel the attitude that "arthritis" is a process associated with "normal aging.