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The 2019 guidelines of the European Society of Cardiology (ESC) rename stable coronary heart disease to chronic coronary syndrome (CCS). Under CCS, six different scenarios have been defined, which take its heterogeneity into account. An important part of the current guideline plays the diagnostic assessment of the pre-test probability in the event of the possible presence of stenosing coronary heart disease. The addition of dyspnea and clinical probability as additional variables for better estimation of the pre-test probability are two important new features. Imaging techniques such as CT angiography have been significantly upgraded as diagnostic procedures for the detection of CHD, while exercise ECG is no longer routinely recommended in this regard. Invasive coronary angiography with revascularization option remains a central diagnostic and therapeutic procedure. In addition to antianginal, lipid-lowering and antithrombotic therapy, the current CCS guideline places special emphasis on prevention by means of lifestyle modification., Competing Interests: Die Autorinnen/Autoren geben an, dass kein Interessenkonflikt besteht., (Thieme. All rights reserved.)

Against the background of drastically increased cardiovascular comorbidity in patients with chronic kidney disease (CKD), an effective cardiovascular diagnostic approach appears essential. However, patients with CKD are often underdiagnosed. Prospective randomized studies showing an improved outcome for cardiovascular diagnostic in patients with CKD are limited. Special attention is paid to stress diagnostics in CKD patients. Guidelines recommend cardiovascular diagnostic evaluation prior to inclusion on the transplantation waiting list.

A 47-year-old man presented with angina pectoris complaints in the chest pain unit. Due to psoriasis and psoriatic arthritis he had been systemically treated for 4 years. Because of an increased cardiovascular risk profile, coronary heart disease (CHD) was suspected and an invasive coronary diagnosis was performed. In the cardiac catheterization, CHD could be detected and treated in the same session. The risk of CHD in patients with psoriasis is increased due to a higher incidence of risk factors but also the disease itself. Patients with psoriasis should regularly undergo cardiovascular risk screening.

Heart failure with "mid-range" ejection fraction: a new clinical entity? Abstract. The new entity of heart failure with mid-range ejection fraction (HFmrEF) is defined as clinical syndrome characterized by typical symptoms and signs of heart failure (HF), an EF of 40 - 49 %, elevated natriuretic peptides and documentation of structural heart disease. Prevalence has been estimated at 10 - 20 % of all patients with HF. Compared to the populations with reduced (HFrEF) and preserved (HFpEF) EF, patients with HFmrEF show in general intermediate clinical characteristics. However, coronary disease as aetiology of HF is similar in HFmrEF and HFrEF and significantly more prevalent than in HFpEF. Outcome is poor as in the other HF categories. Frequently, HFmrEF seems to be a transitory stage from or to HFrEF and HFpEF respectively. Preliminary data suggest a potential benefit of evidence-based drug treatment for HFrEF also in HFmrEF.

The Old-Age Heart Abstract. Knowledge of cardiovascular changes in old age and their therapeutic options is important. Old age can lead to hypertrophy of the left ventricle, diastolic dysfunction, heart valve changes and pulmonary hypertension. Patients often develop arterial hypertension. Valvular changes are common in people over 100 years of age (aortic stenosis and mitral insufficiency). The risk of coronary heart disease is 35 % for men and 24 % for women. In old age, sinus node dysfunction and atrial fibrillation are common. 25 % of all strokes are cardiac embolisms in atrial fibrillation. Cardiac interventions in the elderly are increasingly frequent and include coronary catheter revascularization or valve interventions (percutaneous aortic valve replacement or MitraClip). Optimal therapy in old age includes not only cardiovascular interventions also include drugs and a lifestyle modification and mainly serves to improve the quality of life.

Cardiovascular diseases are common; therefore, adequate and guideline-based diagnostics and treatment are essential. In addition to an electrocardiogram (ECG) and (treadmill) exercise tests, echocardiography plays the pivotal role in functional cardiac testing. It is permanently available at the bedside and has a high diagnostic accuracy; however, examinations such as cardiac magnetic resonance imaging (MRI) and computed tomography (CT) as well as nuclear medical imaging, e.g. single proton emission CT (SPECT) and positron emission tomography (PET) are becoming more and more common in clinical practice. This is due to the wide range of additional information and the high diagnostic accuracy. In the following article, the individual possibilities of non-invasive cardiac functional testing are presented and their meaningful application will be discussed; however, studies on the meaningful application of non-invasive diagnostics are scarce.

Remote follow-up of patients with implantable electronic cardiac devices (IECD) is a scientifically well-evaluated and technically mature method. Advantages over conventional follow-up include rapid detection of clinically relevant events (i. e. arrhythmias) and of technical problems. Additionally, telemetric follow-up of IECDs has a high degree of acceptance among both patients as well as health care professionals and carries the potential to reduce health care costs. The implementation of a remote follow-up programme is associated with organisational, infrastructural and legal aspects, which are reviewed.

The goals of cardiac rehabilitation are (re-)conditioning and secondary prevention in patients with heart disease or an elevated cardiovascular risk profile. Rehabilitation is based on motivation through education, on adapted physical activity, instruction of relaxation techniques, psychological support and optimized medication. It is performed preferably in groups either in outpatient or inpatient settings. The Swiss working group on cardiac rehabilitation provides a network of institutions with regular quality auditing. Positive effects of rehabilitation programs on mortality and morbidity have been established by numerous studies. Although a majority of patients after cardiac surgery are being referred to rehabilitation, these services are notoriously underused after catheter procedures.

Non cardiac chest pain (NCCP) are recurrent angina pectoris like pain without evidence of coronary heart diesease in conventional diagnostic evaluation. The prevalence of NCCP is up to 70% and may be detected in this order at all levels of the medical health care system (general practitioner, emergency department, chest pain unit, coronary care). Reduction of quality of life in NCCP is comparable, partially even higher compared to cardiac chest pain. Reasons for psychological strain are symptom recurrence in app. 50%, nonspecific diagnosis with resulting uncertainty and insufficient integration of other medical disciplines in diagnostic work-up. Managing of patients with NCCP has to be interdisciplinary because non cardiac causes of chest pain may be found frequently. This are musculosceletal in app. 40%, gastrointestinal in app. 20%, psychiatric in app. 10% and pulmonary and mediastinal diseases in app. 5% of cases. Also gastroenterological expertise is required because here gastroesophageal reflux disease (GERD) in app. 60%, hypercontractile esophageal motility disorders with nutcracker, jackhammer esophagus or distal esophageal spasmus or achalasia in app. 20% and other esophageal alterations (e. g. infectious esophageal inflammation, drug-induced ulcer, rings, webs, eosinophilic esophagits) in app. 30% of cases may be detected as cause of chest pain may. This implicates that regular interdisciplinary round wards and interdisciplinary management of chest pain units are mandatory., (© Georg Thieme Verlag KG Stuttgart · New York.)

Non cardiac chest pain (NCCP) are recurrent angina pectoris like pain without evidence of coronary heart disease in conventional diagnostic evaluation. The prevalence of NCCP is up to 70 % and may be detected in this order at all levels of the medical health care system (general practitioner, emergency department, chest pain unit, coronary care). Reduction of quality of life in NCCP is comparable, partially even higher compared to cardiac chest pain. Reasons for psychological strain are symptom recurrence in app. 50 %, nonspecific diagnosis with resulting uncertainty and insufficient integration of other medical disciplines in diagnostic work-up. Managing of patients with NCCP has to be interdisciplinary because non cardiac causes of chest pain may be found frequently. Especially gastroenterological expertise is required because in 50 - 60 % of cases gastroesophageal reflux disease (GERD), in 15 - 18 % hypercontractile esophageal motility disorders with nutcracker, jackhammer esophagus or distal esophageal spasmus or achalasia and in 32 - 35 % other esophageal alterations (e. g. infectious esophageal inflammation, drug-induced ulcer, rings, webs, eosinophilic esophagitis) as cause of chest pain may be detected. This implicates that regular interdisciplinary round wards and management of chest pain units are mandatory., (© Georg Thieme Verlag KG Stuttgart · New York.)

All women of child-bearing age suffering from congenital cardiac valve malformations or acquired valvular disease, pulmonary hypertension or arterial hypertension and who are at risk for coronary heart disease should receive early counseling and optimal treatment before pregnancy. They should be treated by an interdisciplinary team composed of gynecologists, cardiologists, geneticists and, if necessary, cardiac surgeons. This interdisciplinary approach should be used for all pregnant women with cardiac disease in order to minimize maternal and fetal mortality. As physicians will only rarely be confronted with such critically ill patients, guidelines and access to worldwide information from databanks are particularly important (http://www.safetus.com und http://www.emryotox.de).

In patients with coronary heart disease the further course of the disease can be substantially influenced by means of a targeted treatment of risk factors. A reduction of hospital referrals, an improvement in quality of life and an extension in life expectation by secondary prophylactic measures have been well documented. In addition to an optimized medicinal therapy, an often drastic change in lifestyle with a focus on a consistent abstinence from nicotine, a healthy diet and regular physical exercise is necessary. Data from healthcare research show that these targets are only insufficiently achieved. The implementation of current guidelines should therefore be rigorously applied. There is a need for research particularly with respect to the prognostic significance of beta blocker therapy for patients with stable coronary heart disease and preserved left ventricular function, the prognostic significance of targeted weight loss for overweight or obese coronary heart disease patients, the effectiveness of psychosocial interventions in the various patient groups and their implementation into routine care. Research is also necessary with respect to optimization of structured rehabilitation programs and improvement in patient compliance.

Patients with coronary heart disease are subject to an increased risk for sudden cardiac death (SCD). Within the first 30-90 days after the myocardial infarct the risk is particularly high. In times of implantable cardioverter-defibrillator (ICD) on the one hand and the ability to bridge high-risk periods with e. g. wearable defibrillator vests on the other, adequate risk stratification is essential. Currently, the main parameter for this is the left ventricular ejection fraction (LVEF). However, risk stratification by measurement of the LVEF has severe limitations, especially since the majority of patients suffering from SCD have a normal LVEF. Various other methods like ventricular ectopy, signal-averaged ECG, QRS width, microvolt T-wave alternans and programmed ventricular stimulation have been previously evaluated. None of these methods alone or in combination with a left ventricular function assessment was capable of improving the predictability of arrhythmic events significantly. Considering the multiple mechanisms that can lead to SCD, a single risk stratifier seems unrealistic. However, patients with chronic total occlusion of a coronary artery and residual or provocable ischemia have an increased risk for SCD. Therefore a combination of clinical and angiographic parameters seems reasonable. Advanced echocardiographic parameters e.g. mechanical dispersion could be used on a complementary role.

The prevalence of a major depressive disorder in patients after myocardial infarction is 20%. Depression is a risk factor for incident coronary heart disease and poor prognosis after myocardial infarction. Poor lifestyle habits and adherence to cardiac therapy as well as metabolic and pathophysiologic changes may partially explain this link. The threatening experience of an acute coronary event and immune and inflammatory changes may be unique features contributing to incident depression after myocardial infarction. While psychotherapy, antidepressants, and physical exercise may alleviate depressive symptoms in patients with coronary heart disease, cardiac rehabilitation additionally reduces mortality risk. Attempts are being undertaken to identify the cardiotoxic characteristics of depression to develop even more effective therapies in the future.

Peripheral arterial disease (PAD) increases cardiovascular event rate in patients with coronary artery disease (CAD). Therefore PAD should be considered in patients with CAD with regard to diagnostic and therapeutic strategies. PAD may difficult diagnostic tests in CAD patients. Patients with PAD and CAD may be limited in stress testing by decreased leg perfusion. In addition, arterial puncture can be more difficult in sclerotic femoral arteries. Cardiovascular risk factors should be treated carefully in all manifestations of atherosclerosis. Target values from current guidelines are similar for PAD and CAD. Inhibitors of platelet aggregation are indication in both CAD and PAD. Exercise not only improves walking distance in patients with intermittent claudication but also improves cardiovascular prognosis in patients with atherosclerosis., (© Georg Thieme Verlag KG Stuttgart · New York.)

Background: Data on 1-year complication and follow-up intervention rates after coronary angiography (CA) and percutaneous coronary intervention (PCI) in German clinical routine are sparse. This analysis aims to determine these rates., Methods: The analysis uses 2009 AOK claims data. Patients were divided into 3 groups (CA, without cardiac surgery and without acute myocardial infarction (AMI) n=116.071; PCI with stenting, without AMI: n=36.685; PCI with stenting and with AMI: n=32.707). The frequency of the endpoints MACCE (mortality, AMI, stroke, TIA), CABG, PCI and CA was recorded for up to one year., Results: 1-year MACCE rates were 8.1 % (CA), 9.9 % (PCI without AMI) and 17.9 % (PCI with AMI). Quality-relevant follow-up intervention rates in the CA group were 2.5 % for CABG (after 31-365 days), 1.7 % for PCI within 90 days and 3.5 % for follow-up CA within 1 year. In the PCI groups, the frequencies were 1.6 % (without AMI) and 2.7 % (with AMI) for CABG (after 31-365 days), and 10.2 % (without AMI) and 10.1 % (with AMI) for PCI after 91-365 days., Conclusion: This is the first cross-sectoral routine analysis of cardiac catheters and sequential events up to one year in Germany. The actual medical care situation revealed information particularly with regard to the second and follow-up inventions, which cannot be derived directly from medical guidelines. Beyond clinical trials, knowledge can be gained which is important both for medicine as well as the politics of health services., (© Georg Thieme Verlag KG Stuttgart · New York.)

During the last years the indications of Cardiac Magnetic Resonance Imaging (CMRI) have been continuously expanded. However, the acceptance of the method by cardiologists and radiologists does not correlate with respect to the diagnostic potential. Several factors, such as expensive equipment, relatively long examination times, high technical know how and lack of remuneration, limit the application of CMRI in everyday clinical practice. Furthermore, doctors tend to apply more conventional, well established diagnostic procedures, the access to the method is still limited and there exist difficulties in the interdisciplinary collaboration. The interdisciplinary Austrian approach to Cardiac Imaging is aimed to improve the aforementioned problems and to support the implementation of CMRI in the diagnostic tree of cardiac diseases thus enabling a cost efficient management of patients in cardiology., (© Georg Thieme Verlag KG Stuttgart · New York.)

The technological advances of recent decades have produced a large armamentarium of cardiac noninvasive imaging tools for the diagnosis of coronary artery disease (CAD), including stress echocardiography, myocardial perfusion radionuclide imaging, cardiac computed tomography (cardiac CT) and cardiac magnetic resonance imaging. The high diagnostic accuracy of these techniques has been documented by single center and occasionally larger multicentric studies. Hence, the choice of the appropriate technique in a given patient is based upon the particular clinical scenario, the patient's clinical characteristics, local availability and expertise, and upon other factors such as costs, radiation and potential contrast agent toxicity. Cardiac CT is by nature an anatomical technique (much like invasive angiography) with a high negative predictive value, therefore it has established itself as a useful tool to rule out CAD in patients with low to intermediate pretest likelihood of CAD. The remaining techniques, on the other hand, are functional tests for the detection of myocardial ischemia and are suitable to improve risk stratification in patients with known CAD or at higher cardiovascular risk. By this means, non-invasive cardiac imaging is an accurate and established tool in the diagnostic algorithm for CAD, and a cost-effective gatekeeper of invasive angiography.

An increasing number of elderly people and diabetes patients with myocardial infarction go unrecognized because of painless ischemia and regression of major Q-waves over time. An increased awareness of diagnostic electrocardiogram (ECG) abnormalities other than Q-waves should allow physicians to optimize patient management. Particularly emphasized is the R-peak delay in V6, i.e. the R-peak in V6 being later than the S-peak in V2, as a sign of masked anterior myocardial infarction and ECG findings if infarcts are masked by left ventricular hemiblocks and left bundle branch block (LBBB). In left anterior hemiblocks dramatically decreased R-waves in leads II, III and AVF in conjunction with disappearance of Q-waves in leads I and aVL help to identify posterodiaphragmatic infarction. The left posterior hemiblock is itself a potent indicator of underlying posterodiaphragmatic infarction not recognized by Q-waves. In LBBB Cabrera's sign, RSR' morphology in the left-sided or inferior leads, inverse R-progression from V1 to V3 and primary repolarization abnormalities overlying the secondary T-wave changes are specific indicators of myocardial infarction. QRS-prolongation greater than 150 ms independently identifies ventricular function impairment in chronic coronary heart disease.

Despite technical innovations of non-invasive coronary imaging modalities, coronary angiography still remains the standard of reference for the assessment of CAD.The advances in interventional cardiology require also increased imaging capabilities, which cannot be fully addressed by conventional coronary angiography. Intravascular ultrasound (IVUS) and optical coherence tomography (OCT) as well as near infrared spectroscopy (NIRS) are important developments and will be covered in this review article.IVUS was already around in interventional cardiology since the 90ies. It was the first to offer a high resolution tomographic image of the coronary arteries in vivo. Beyond that, it is also frequently used for peri- and postprocedural imaging. Furthermore, the radiofrequency information ("virtual histology") can be applied to perform a basic tissue characterization.Using near coherent light instead of ultrasound, optical coherence tomography (OCT) is able to deliver a 10 fold higher resolution compared to IVUS when imaging coronary plaques.This allows also for the detection of potential vulnerable lesions as well as for the detection of neo-intimal stent strut coverage following stent placement.Using near infrared spectroscopy (NIRS) even insights into the chemical composition of coronary plaques can be achieved.The development of advanced image acquisition technologies enables us to combine modern intravascular imaging technologies and conventional coronary angiography and hereby achieve additional benefit., (© Georg Thieme Verlag KG Stuttgart · New York.)

The main treatment goals of conservative treatment of patients with stable coronary heart disease are prevention of symptoms, prevention of myocardial infarction, and heart failure and reduction of mortality. Lifestyle changes (smoking cessation, physical activity) are essential to reduce risk factors. For symptomatic treatment and prevention of angina pectoris, beta-blockers, calcium channel blockers, nitrates, I((f)) (funny channel) blockers and ranolazine are effective. Cornerstones of pharmacological prevention are drugs with prognostic effects, specifically aspirin and statins, as well as treatment of co-existing disorders such as hypertension and diabetes.

Actually myocardial perfusion scintigraphy (MIP) is best evaluated imaging modality in patients with coronary artery disease. It detects flow-limiting coronary artery disease with high sensitivity and specificity, enables recognition of the grade of severity and extensiveness of myocardial ischemia, and furthermore enables assessment of future cardiac events independently of clinical and diagnostic parameters. Due to rapid technical evolution in diagnostic tools there is need of comparison between MIP and other concurrent imaging modalities such as stress echocardiography, Cardio-CT and Cardio-MRI in patients with coronary artery disease., (© Georg Thieme Verlag KG Stuttgart · New York.)

Cardiac monitoring with ECG and blood pressure recording is routinely performed during a stress test and blood pressure response is an important part of its interpretation. Unfortunately, the latter is not straightforward, partly because of the inconsistent definition of a pathologic blood pressure response, the different populations included in the studies and divergent test modalities. An exaggerated blood pressure response in normotensive subjects without coronary heart disease is associated with an increased risk of future arterial hypertension, whereas in patients with known or suspected coronary heart disease, prognosis is not worse than in patients with normal blood pressure response. By contrast, exercise induced hypotension, particularly in patients with coronary artery disease indicates an increased risk for cardiac events and should be investigated further, usually by performing coronary angiography.

The aim of this article is to provide an overview on depression as a risk factor for the onset and follow-up of cardiovascular disease (CVD). In brief, the current state of psychobiological mechanisms bridging the gap between affective states and somatic consequences are presented. Four meta-analyses dealing with depression as a CVD risk factor in apparently healthy populations with >100,000 participants included, extracted an adjusted effect estimator of 1.60-1.90. Depressed subjects present with an unhealthier lifestyle (nutrition, smoking, physical activity). Three major psychobiological pathways directly acting on the circulatory system are under discussion: (1) hyperregulation of the autonomic nervous system (e.g., increased mean heart rate, increased heart rate responses, impaired heart rate variability), (2) overshooting stress responses of the endocrine system with impaired feedback mechanisms (e.g., for cortisol release), and (3) the immune system with dysregulated release of acute phase proteins and proinflammatory cytokines, all involved in a bidirectional crosstalk with the patient's affective state and leading to platelet activation and flow mediated endothelial (dys-)function. Nonadherence and adverse side effects of medications also contribute to the lethal properties of depression in CVD.

Coronary heart disease (CHD) poses a special challenge for risk assessments. Various kinds of diagnostic or therapeutic procedures, concomitant diseases, risk factors and symptoms need to be connected logically in order to assess the risk of each individual applicant. "Reinsurance manuals" are available to risk assessors in life insurance for this purpose. Using these manuals, the risk assessor can calculate the risk loadings for applicants with specific pre-existing conditions, e.g., CHD. Various tasks thus fall to the reinsurer, which must be able to give grounds for the increased risk loadings, provide the manuals with a process-oriented structure and simultaneously support the primary insurer's business objectives via an intelligent risk assessment. Taking CHD as an example, the following article explains how these tasks can be solved with the aid of medical and mathematical approaches, and how the insurability of applicants with CHD can be extended via the re-evaluation of risks.