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An analysis of cardiac fatal cases from elementary, junior and senior high school students of Osaka revealed the following features: 1) The mortality rate of the cardiacs under the heart disease program is two times as high in senior high school students as in elementary school and junior high school students. The same rate for males is significantly higher than the rate for females. 2) The mortality rate according to types of heart disease is the highest among cardiomyopathy. This rate is followed by the rates for acquired valvular heart disease, for unoperated congenital heart disease and for operated congenital heart disease in that order. However, the actual number of fatal case is largest among those with congenital heart disease exceeding more than half of the total number of deaths. 3) Recently the mortality rate showes a decreasing tendency. The number of deaths due to chronic congestive heart failure has decreased, but sudden deaths have increased. 4) Sudden deaths are mostly encountered in moderate or severe cardiac cases. Therefore, it is mandatory to accurately locate the cases with high potentiality for sudden death and to place them under proper supervision. 5) In one third of the cases of sudden death, no significant physical or behavioral causes were found to trigger the death. It seems to be difficult to prevent all the sudden deaths, therefore, it is important to establish successful emergency programs.

The rate for sudden unexpected death among the male school children and high school student was 3.4 per 100,000, and among the female was 2.0 per 100,000. The rate showed the tendency to increase with age among the male, but not in the female. Most of the sudden deaths occurred during day time while they were awake and the death during sleep occurred in 9.2%. The sudden death in the school occurred in 26.5%. Concerning the causes of the death, in 20.5% of the cases it was unknown (even though acute heart failure was the terminal symptoms). In 18.1% basal heart disease was responsible, in 15.7% asthmatic spell and in 10.8% cerebral hemorrhage. It was found that 38.6% of the sudden death cases were as usual in the condition preceding to the onset of the symptom, 18.1% of cases had been complaining of tiredness or overwork and 9.6% had been with symptoms of respiratory infection. The sudden death of handicapped children was occupying 25.3% of the deaths encountered in the present study.

Under the Heart Disease Program for elementary school children and junior high school students in Osaka City, the cardiac patients found through mass examination are supposed to be checked annually by the program's staff. After their graduation from junior high school, however, the cardiac patients leave our medical jurisdiction. In order to gather information from those graduates, we have mailed and continue to mail questionnaires to them once every 5 years. By analyzing that information, we sought to describe the natural history of congenital heart disease in young adults. The study revealed that among graduates older than 20 years of age as of March 31, 1978, 17.5% underwent initial cardiac surgery; 1.8% were found to have no more cardiac lesions due to spontaneous healing; 12.3% answered that they had no significant changes; 2.0% were found to have deteriorated cardiac lesions and 2.1% of the graduates had died. Eight point one per cent of the graduate did not answer, although minimum data as to whether they were alive or not was gathered. The mortality rates were calculated by using all follow-up data. It was revealed that the mortality rate for cardiac patients under 14 years of age, for those between 15 and 20 years of age and for those older than 21 years of age are 14 times, 6 times and 3 times as high as the general population in each age group, respectively. The mortality rate for those with mild cases of cardiac lesions is 3 times higher than the general population. It is 13 times higher among moderate cases and 77 times higher among severe cases when compared to the general population.

The follow up study on rheumatic heart disease was carried out over a 20 year period by the questionaire method. Two hundreds and seventy-nine patients were analyzed and the following results were obtained. 1) Sixteen cases (5.5%) died, 20 cases (6.8%) showed deterioration, 155 cases (53.1%) were unchanged, 35 cases (12.0%) were improved, 12 cases (4.1%) were announced that their valvular lesions disappeared and 22 cases (7.2%) underwent cardiac surgery. The more severe the findings at the final examination under our program, the poorer the courses. 2) The cases having a severe status index showed a tendency for poor prognoses. Mitral steno-regurgitation revealed the poorest prognoses. 3) 84.3 per cent of the living cases were found to be leading normal daily lives without any restriction. 4) The average death rate was 1.0% per year during the 20 years between 1958 and 1978. The death rate for age group between 9 and 17 years old was the highest (1.34% per year). 5) The leading cause of death in every group including all the cases under our program was a recurrence of rheumatic fever. However in groups older than 18 years of age chronic congestive heart failure and unsuccessful cardiac surgery were leading causes.

Fukuda ECP-100 computer assisted ECG analysis system was introduced into the heart disease program for school children and high school students in Osaka City in 1979. This analysis system was used as screening tool and 39,532 of 4th graders of primary schools were examined during the first year. To evaluate and improve this analysis system a "pilot study" was organized and 52 school physicians and 10 specialists made up a "working group". "Urgent reference codes" were set to be printed out so that the limitation of the present system of the Heart Disease Program should be compensated. Problems of the ECG analysis system were as follows. The Q wave registered too wide and there were same difficulties in recognizing the end point of the T wave. Recognition ot tiny "r" wave seemed to be impossible and base line sway seemed responsible for numerous erroneous outputs. Some cases corresponding to code "4-n-n" were found to be normal after further examination. This system can be said to be useful as a screening tool. Using this system at least 4 cases of serious lesion were newly detected, one case of myocarditis and 3 cases of myocardial diseases.