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The cultural and natural scientific ambivalence of the heart and alcohol has long been the subject of philosophical, artistic, intellectual and emotional discussions, not uncommonly in a romanticizing manner. The indulgence of alcoholic beverages in moderation is contrasted by the inestimable risks and dangers of alcohol abuse with many cardiovascular implications, such as cardiac arrhythmia, cardiomyopathy and arterial hypertension. The inspirational mental effects of alcohol have been emphasized in many citations from Classical Antiquity through the Middle Ages and even in modern times. In addition to wine and beer many alcoholic drinks, such as Champagne, sparkling wines, whisky (or whiskey), brandy (Cognac) and fruit brandies have a nearly ritual culture of traditions and customs, without which social life would be unthinkable. The interplay between enjoyment and displeasure is emphasized in the year 2016 with the 500-year jubilee of the German purity requirements for beer with countless events, including the Bavarian State Exhibition 2016. Recently, evidence of a neuroprotective effect of alcohol was reported with an improvement of intellectual capacity, which could counteract the widely occurring dementia syndrome. Millions of people could profit from this effect.

There is hardly a symptom that has impressed patients and physicians since ancient times more than an irregular heartbeat. In most cases, atrial fibrillation is the cause of the rhythm disturbance. However, it took many centuries before we were able to clearly understand fibrillation and to counteract it efficiently. The history of arrhythmia therapy with drugs is long and fascinating. Digitalis was probably the first “antiarrhythmic”. It was discovered by Leonhart Fuchs in the 16th century and introduced in the clinical practice by William Withering from Birmingham. Today's rhythm agents are of a much later date. Quinidine, an optical isomer of quinine, became clinically available in 1918. Other antiarrhythmic drugs were only developed in the 60s and 70s of the previous century, e.g. disopyramide, beta-receptor blockers, propafenone, flecainide, amiodarone, adenosine, ibutilide, and dofetilide. Among the latest commercially available antiarrhythmic substances are dronedarone and vernakalant, which were clinically introduced in 2009 and 2010, respectively. Thanks to the further development of innovative pharmaceuticals and modern electrotherapeutic methods, it can be expected that the previously therapy-resistant cases of atrial fibrillation will be lastingly reduced.

Das Herz ist mit Abstand das bekannteste und seit langer Zeit identifizierte Organ. Die myogene Herzmuskelpumpschwache mit linksventrikularer Dysfunktion ist nach wie vor die Herzerkrankung mit der schlechtesten Prognose bei zunehmender Pravalenz und Inzidenz. Neben verschiedenen mystischen Behandlungsversuchen und dubioser Krautermedizin etablierte sich schon fruh der Aderlass als ein uberragendes Heilmittel, das bei nahezu allen kardialen Erkrankungen Verwendung fand. Die erste und vielleicht wichtigste Herzdroge war Digitalis, das Glykosid des roten und mehr noch des weisen Fingerhuts, im Jahr 1552 beschrieben durch Leonhart Fuchs. In den 1980er Jahren erganzten Vasodilatatoren und Inotropika die klassischen Arzneimittel Digitalis und Diuretika. In den 1990er Jahren kamen ACE-Hemmer und Betarezeptorenblocker hinzu. Um die Jahrtausendwende wurden die kardiale Resynchronisationstherapie (CRT) und Linksherzunterstutzungssysteme entwickelt; letzthin ergaben sich zellulare bzw. genetische Ansatze sowie die Xenotransplantationen. Erste Resultate mit der Stammzelltechnologie sind ermutigend, jedoch werden bis zur klinischen Anwendung – wenn uberhaupt – noch Jahre vergehen.

There is a risk of atrial fibrillation for 1 in 4 adults over the age of 40 years. In most cases the cause of atrial fibrillation is an underlying organic disease. Approximately 2.5 million mostly elderly male patients in Europe are affected by this dysrhythmia and it is expected that the number of patients will more than double by the year 2050. With a few exceptions every form of fibrillation should be treated regarding the underlying disease, the risk of thrombo-embolization and the arrhythmogenic symptoms. However, it must be questioned whether every case of atrial fibrillation must be anti-arrhythmically treated or in which cases rate control of ventricle function is adequate or whether rhythm control, i.e. conversion into sinus rhythm, is necessary. Arguments for conversion into a sinus rhythm are improved cardiac output, decreased risk of thrombo-embolization and hypercoagulability as well as a reduction of tachycardiomyopathies. A decline in clinical symptoms leads to improvement in the quality of life and also in many cases brain function.

Vorhofflimmern ist die haufigste anhaltende Herzrhythmusstorung des Erwachsenen. Bei Vorhofflimmern ohne organisches Herzleiden gelten die 1 c-Antiarrhythmika Flecainid und Propafenon als Mittel der Wahl. Bei vorbestehender koronarer Herzkrankheit waren Betablocker als erstes anzuwenden, bei ausgepragter linksventrikularer Dysfunktion ist Amiodaron angezeigt. Bei einer Tachyarrhythmia absoluta ist zunachst eine Normalisierung der Kammerfrequenz durch den Einsatz von Kalziumantagonisten, Betarezeptorenblockern, Digitalsglykosiden oder Amiodaron sowie anderen Antiarrhythmika zur Senkung der AV-nodalen Leitungskapazitat anzustreben. Sprechen die Patienten auf die medikamentose Therapie nicht an, so steht als wirksame Masnahme die Ablation des AV-Knotens mit konsekutiver Schrittmacherimplantation zur Verfugung. – Bei der haufigen Form des anfallsweisen – also paroxysmalen – Vorhofflimmerns hat das neue Konzept der Pill-in-the-pocket-Strategie besonderes Interesse gefunden. Diese besagt, dass die in der Tasche mitgefuhrte antiarrhythmische Medikation anfallsbezogen einzunehmen ist. Das Prinzip besteht darin, bei paroxysmalem Vorhofflimmern keine dauerhafte Medikation zu verabreichen, sondern Rhythmusmittel ereignisbezogen durch den Patienten selbst einnehmen zu lassen mit dem Ziel der unmittelbaren Regularisierung der Herzschlagfolge. Hier werden vor allem Flecainid und Propafenon empfohlen. Von speziellem Interesse ist auch die Kombination von pharmakologischen und elektrotherapeutischen Behandlungsstrategien, wie sie bei der sog. Hybridtherapie Verwendung finden. Die modernen elektrischen sowie medikamentosen, in standiger Weiterentwicklung befindlichen Therapieoptionen dienen dem Ziel, den Patienten durch individuell angepasste therapeutische Masnahmen die Ruckkehr in das gewohnte soziale Umfeld zu ermoglichen, verbunden mit der gebotenen Alterskompetenz bei hoher Lebensqualitat.

Die Moglichkeiten der antiarrhythmischen Therapie von Vorhofflimmern sind heute vielfaltiger und effektiver, aber auch komplizierter als noch vor wenigen Jahren. Dies gilt gleichermasen fur die Indikation zur Therapie allgemein wie fur den Entschluss zu einer bestimmten therapeutischen Masnahme und die Kontrolle der antiarrhythmischen Behandlung selbst. Bei einer Tachyarrhythmia absoluta ist eine Normalisierung der Kammerfrequenz uber den Einsatz von Calciumantagonisten, β-Blockern, Digitalis, Glykosiden oder Amiodaron zur Senkung der AV-nodalen Leitungskapazitat anzustreben. Sprechen die Patienten auf die medikamentose Therapie nicht an, steht als wirksame Masnahme die Ablation des AV-Knotens mit konsekutiver Schrittmacherimplantation (meist VVIR-Stimulation) zur Verfugung. Bei medikamentoser Therapieresistenz und ausgepragter Symptomatik stehen auch die praventive Schrittmachertherapie sowie kathetergestutzte Ablationstechniken zu Gebote. Bei ausreichender Kenntnis der medikamentosen und interventionellen antiarrhythmischen Moglichkeiten durften therapieresistente Formen von Vorhofflimmern und Risiken der Arrhythmiebehandlung auf ein Minimum zu reduzieren sein.

An antiarrhythmic treatment was done in 56 patients with recurrent ventricular tachycardias using amiodarone. The dosage was 400 to 600 mg/d following a loading dosage of 1000 mg for 8 to 12 days. Amiodarone and desethylamiodarone concentration in serum (control group n = 33) and in erythrocyte haemolysate (control group n = 13) were determined in relapses of ventricular tachycardias (n = 7) and in pulmonary fibrosis as serious side effect (n = 3). It was shown that amiodarone levels rise continuously during loading treatment until the 8th to 12th day and that desethylamiodarone can be demonstrated after the 3rd day of treatment. The mean concentrations (+/- standard deviation) of amiodarone and desethylamiodarone were 2.21 +/- 0.89 microgram/ml and 1.3 +/- 0.74 microgram/ml in serum and 0.97 +/- 0.65 microgram/ml and 1.95 +/- 1.9 micrograms/ml in erythrocyte haemolysate. Amiodarone levels did not correlate with efficacy and with incidence of side effects. However, in pulmonary fibrosis high desethylamiodarone concentrations in serum (greater than 2.5 micrograms/ml) and in erythrocyte haemolysate (greater than 4 micrograms/ml) were found. Four out of 7 patients with recurrent ventricular tachycardia showed relatively low desethylamiodarone concentrations in serum (desethylamiodarone/amiodarone ratio less than 0.4). Thus control of amiodarone treatment can be enlarged by determination of desethylamiodarone levels as its concentrations correlate with relapses of ventricular tachycardias and serious side effects.

In einer randomisierten Doppelblindstudie bei 116 Patienten mit leichter bis mittelschwerer chronischer Herzinsuffizienz (NYHA II-III) wurde die Wirksamkeit einer Kombination von Captopril und Diuretika (Gruppe I) mit der einer Kombination von Digitalis und Diuretika (Gruppe II) verglichen. Die Therapie wurde uber zwolf Monate mit einer Kombination von 50 mg Captopril (zweimal 25 mg/d per os) oder 0,2 mg Digoxin (zweimal 0,1 mg/d per os) und Hydrochlorothiazid (HCT) durchgefuhrt. In einer Vorbehandlungsphase uber 3-4 Wochen erhielten die Patienten der Gruppe I eine mittlere HCT-Dosis von 37,7 mg, in der Gruppe II von 34,9 mg taglich. Nach 12 Monaten waren in Gruppe I der echokardiographisch bestimmte Ventrikeldurchmesser und die Belastungstoleranz gegenuber den Ausgangswerten sowie im Vergleich mit Gruppe II signifikant gebessert. Die klinische Bewertung der Herzinsuffizienz nach der NYHA-Klassifizierung zeigte in Gruppe I eine Verbesserung um im Mittel einen Schweregrad bei 51,8 % (n = 61) und in Gruppe II bei 40,7 % (n = 47) (P

Lymphocyte subpopulations in peripheral blood and bronchoalveolar lavage fluid (BAL) were examined in 29 patients with AIDS (26 men, three women; median age 32 [16-55] years). Patients in group 1 (n = 12) had no lung disease, in group 2 (n = 11) had Pneumocystis carinii pneumonia, in group 3 (n = 6) had other lung disease. There were 13 men and two women (median age 48 [21-80]) in the control group (bronchoscoped for mild pulmonary symptoms: no abnormal findings in the BAL). Compared with the control group, patients with AIDS had a significant deficiency in helper cells, both in blood (7-23% vs 50%; P < 0.01) as well as in the BAL (7-24% vs 52%; P < 0.001). There was a correlation of the percentage helper cell proportion in peripheral blood and BAL (for both group 1 and 2, rs = 0.75; P < 0.05). The proportion of helper cells in peripheral blood and BAL in AIDS patients was significantly lower in those with than without lung disease (group 1: 23% blood, 24% BAL vs group 2: 9% blood, 7% BAL; group 3: 7% blood, 7% BAL; P < 0.02 blood, P < 0.004 BAL). The percentage proportion of suppressor cells was greater in both blood and BAL in AIDS patients (group 1: blood 47%, BAL 63%; group 2: blood 44%, BAL 76%; group 3: blood 52%, BAL 75%) than in the controls (blood 28%, BAL 33% [P < 0.01], but there was no correlation between peripheral blood and BAL. In addition, the absolute number of suppressor cells in the lavage (30 cells/microliters in group 1 and 3, 65 cells/microliters in group 2) was significantly higher than in the controls (8 cells/microliters).--In AIDS patients there occurs a lymphocytosis in the BAL, while in blood there is a lymphopenia. The concordant decrease in helper cells in blood and BAL is decisive for the severity of any pulmonary infections.

AIM OF STUDY: To investigate how medical permission to drive in patients with a cardioverter defibrillator is handled in various European countries. METHODS: A specially developed questionnaire was sent to all 46 delegates of the pacemaker groups of the European Society of Cardiology. They were asked to provide information on the procedures and criteria used in the various countries regarding a driving ban after cardioverter defibrillator implantation (ICD). RESULTS: 39 answers (83%) were received from representatives of 24 countries. 22 (56%) of those replying advised their patients not to drive. A permanent driving ban was recommended by 13 (33%), a temporary one of 3-18 (mean 9 +/- 4) months by 26 (67%). Presyncope was named as a criterion for a ban by 15 (38%), syncope by 13 (33%) and multiple defibrillator shocks by two (5%). Contrary to medical advice not to drive about one third of patients resumed driving, half of them after 6 months. 12 months after implantation most of the patients were again driving. Defibrillator discharges occurred in 2 patients, without consequence. One patient had a fatal car accident, unrelated to loss of consciousness or defibrillator shock. CONCLUSIONS: 1. ICD discharges are an extremely rare cause of driving accidents. 2. About half of the cardiologists recommended a driving ban for a mean of 9 months after ICD. 3. Despite medical ban about half of the patients resumed driving after 6 months. 4. There are as yet no uniform criteria in Europe for judging fitness to drive. Language: de

PURPOSE To evaluate the independent prognostic impact of the chest radiograph for mortality from community-acquired pneumonia requiring hospitalization. METHODS Chest radiographs of 67 patients with hospital-treated community-acquired pneumonia were analyzed with regard to the prognostic implications of radiographic patterns, extent and density of infiltrates, and its evolution during treatment. RESULTS Non-survivors had a significantly higher extent of infiltrates (p = 0.008), density of infiltrates (p = 0.05), and radiographic spread during follow-up within 48-75 hours (p = 0.0001). In multivariate analysis, persistent or progressive infiltrates were associated with a 47-fold increase, and persistent or progressive density of infiltrates with an 18-fold increase in risk of mortality. The presence of both parameters could correctly predict 96% of survivors and 90% of non-survivors. CONCLUSIONS The chest radiograph is an independent predictor of the severity of pneumonia. Both persistent or progressive infiltrates and persistent or progressive density of infiltrates are independently associated with mortality from community-acquired pneumonia.

Die Moglichkeiten der antiarrhythmischen Therapie von Vorhofflimmern sind heute vielfaltiger und effektiver, aber auch komplizierter als noch vor wenigen Jahren. Dies gilt gleichermasen fur die Indikation zur Therapie allgemein wie fur den Entschluss zu einer bestimmten therapeutischen Masnahme und die Kontrolle der antiarrhythmischen Behandlung selbst. Bei einer Tachyarrhythmia absoluta ist eine Normalisierung der Kammerfrequenz uber den Einsatz von Calciumantagonisten, Betablockern, Digitalis, Glykosiden oder Amiodaron zur Senkung der AV-nodalen Leitungskapazitat anzustreben. Sprechen die Patienten auf die medikamentose Therapie nicht an, steht als wirksame Masnahme die Ablation des AV-Knotens mit konsekutiver Schrittmacherimplantation (meist VVIR-Stimulation) zur Verfugung. Bei medikamentoser Therapieresistenz und ausgepragter Symptomatik stehen auch die praventive Schrittmachertherapie sowie kathetergestutzte Ablationstechniken mit linearen atrialen Lasionen oder Isolation von Pulmonalvenenarealen bei fokal induziertem Vorhofflimmern zu Gebote. Bei ausreichender Kenntnis der medikamentosen und interventionellen antiarrhythmischen Moglichkeiten durften therapieresistente Formen von Vorhofflimmern und Risiken der Arrhythmiebehandlung auf ein Minimum zu reduzieren sein.

Last year was the 20th anniversary of the first defibrillator implantation in a human being. Since then, the number of new defibrillator implants has gradually increased following an exponential curve. In 1998, nearly 50 000 new ICD implants were carried out worldwide. This tremendous increase was due to technological improvements in the device and the effectiveness of ICD therapy. Technological improvements in devices and leads included a gradual reduction in the size of the device, the introduction of the endocardial approach in 1988, the biphasic waveform and antitachycardia pacing in 1991, pectoral implantation in 1995, inclusion of DDD pacing in 1996 and finally, inclusion of DDDR and also atrial defibrillation in 1998. Efficacy assessment started with observational studies. In 1985, FDA approval for ICD implantation was obtained. Results of prospective randomized studies, which assessed the effectiveness of ICDs, were obtained in the late 1990s. The first reported trial was essentially an analysis of cost-effectiveness, which compared ICD implantation as first-choice therapy vs conventional strategy starting with antiarrhythmic drugs in postinfarct sudden death survivors. If drugs failed, the patient was treated with endocardial resection or a late defibrillator implant. The cost-effectiveness ratio, defined as costs per day of life, was significantly in favour of early ICD implantation. However, because the number of patients was relatively small, total mortality showed only a trend in favour of early ICD implantation.

Die Arbeit fasst die wesentlichen kardiopulmonalen Risiken im Alter knapp zusammen und gibt einen Uberblick uber die therapeutischen Moglichkeiten bei Herzinsuffizienz, chronischem Cor pulmonale, koronarer Herzkrankheit, Herzrhythmusstorungen sowie pulmonal-respiratorischen Erkrankungen und arterieller Hypertonie.

Bei typischem Vorhofflattern handelt es sich um eine intraatriale Tachykardie mit singularem Makroreentry um die Trikuspidalklappe. Verantwortlich fur den stabilen Reentrykreis sind anatomische Strukturen mit leitungsblockierender Wirkung. Bei der Katheterablation wird durch eine lineare Lasion zweier gegenuberliegender Barrieren der kreisformige Wiedereintritt unterbunden. Etabliert ist die Ablation zwischen V. cava inferior und Trikuspidalklappe. Aufgrund einer geringeren Myokarddicke und einer relativ kurzeren Wegstrecke wird alternativ die lineare Lasion zwischen Eustachischer Klappe und Trikuspidalklappe empfohlen. Um eine lineare Lasion zu erzeugen, werden zwischen beiden Barrieren konsekutiv Radiofrequenzimpulse abgegeben. Durch Verwendung langer Fuhrungsschleusen, anatomisch angepaster Ablationskatheter, groserer oder gekuhlter Ablationselektroden kann die Produktion der notwendigen transmuralen Lasionen erleichtert werden. Insgesamt wird heute eine akute Erfolgsrate von uber 90% erreicht. Fur den Langzeiterfolg ist die Dokumentation der Kontinuitat der linearen Lasionen notwendig. Dies erfolgt durch den Nachweis von Doppelpotentialen an der Ablationslinie und durch endokardiales Aktivierungsmapping im Bereich der Trikuspidalklappe. Neuere dreidimensionale Mapping-Systeme konnen bei der Dokumentation eines kompletten Leitungsblockes bzw. zur Lokalisation persistierender Erregungsubertritte hilfreich sein.

Auch bei guter Langzeitprognose stellt die Therapie einer deutlich symptomatischen ventrikularen Extrasystolie im klinischen Alltag ein haufiges Problem dar. Studienziel: Ziel dieser Untersuchung war es, den Stellenwert der Katheterablation als kurative Therapie bei medikamentos therapierefraktaren, deutlich symptomatischen ventrikularen Extrasystolen zu uberprufen. Methoden: Bei 65 hochsymptomatischen Patienten mit einer therapierefraktaren, ventrikularen Extrasystolie wurde eine Katheterablation durchgefuhrt. Folgende Mappingverfahren wurden eingesetzt: Pace-Mapping, fruheste endokardiale Aktivierung, unipolares Mapping. Bei 5 Patienten wurde zusatzlich der neue “non-contact” Multielektrodenkatheter eingesetzt. Ergebnis: Der Ursprung des ektopen Zentrums lag bei 37 Patienten im rechtsventrikularen Ausflustrakt, bei 28 Patienten im linken Ventrikel. Bei 48/65 Patienten (75%) konnte die ventrikulare Extrasystolie erfolgreich abladiert werden. Bei einem Patienten kam es interventionsbedingt zu einer peripheren AV-Fistel. Wahrend der Nachbeobachtung von im Mittel 13 ± 11 Monaten kam es bei 9/49 Patienten (18%), die inital erfolgreich abladiert wurden, zu einem Rezidiv. Schlusfolgerung: Die Katheterablation stellt eine mogliche Therapiealternative bei haufigen, medikamentos therapierefraktaren ventrikularen Extrasystolen dar. Bei strenger Indikationsstellung kann diese Methode eine signifikante Besserung bei sonst therapierefraktaren hochsymptomatischen Patienten erreichen.

BACKGROUND: Metoprolol can improve haemodynamics in chronic heart failure, but survival benefit has not been proven. We investigated whether metoprolol controlled release/extended release (CR/XL) once daily, in addition to standard therapy, would lower mortality in patients with decreased ejection fraction and symptoms of heart failure. METHODS: We enrolled 3991 patients with chronic heart failure in New York Heart Association (NYHA) functional class II-IV and with ejection fraction of 0.40 or less, stabilised with optimum standard therapy, in a double-blind randomised controlled study. Randomisation was preceded by a 2-week single-blind placebo run-in period. 1990 patients were randomly assigned metoprolol CR/XL 12.5 mg (NYHA III-IV) or 25.0 mg once daily (NYHA II) and 2001 were assigned placebo. The target dose was 200 mg once daily and doses were up-titrated over 8 weeks. Our primary endpoint was all-cause mortality, analysed by intention to treat. FINDINGS: The study was stopped early on the recommendation of the independent safety committee. Mean follow-up time was 1 year. All-cause mortality was lower in the metoprolol CR/XL group than in the placebo group (145 [7.2%, per patient-year of follow-up]) vs 217 deaths [11.0%], relative risk 0.66 [95% CI 0.53-0.81]; p=0.00009 or adjusted for interim analyses p=0.0062). There were fewer sudden deaths in the metoprolol CR/XL group than in the placebo group (79 vs 132, 0.59 [0.45-0.78]; p=0.0002) and deaths from worsening heart failure (30 vs 58, 0.51 [0.33-0.79]; p=0.0023). INTERPRETATION: Metoprolol CR/XL once daily in addition to optimum standard therapy improved survival. The drug was well tolerated.

Atrial fibrillation, a commonly encountered arrhythmia, has in recent years, been the subject of increased interest and intensive clinical research. There is also increasing awareness that atrial fibrillation is a major cause of embolic events which in 75% of cases are complicated by cerebrovascular accidents[1,2]. Atrial fibrillation is often associated with heart disease but a significant proportion of patients (about 30%) have no detectable heart disease[3]. Symptoms, occasionally disabling, haemo-dynamic impairment and a decrease in life expectancy are among the untoward effects of atrial fibrillation, resulting in an important morbidity, mortality and an increased cost for the health care provider[4]. The Working Group of Arrhythmias of the European Society of Cardiology created a Study Group on Atrial Fibrillation in order to establish recommen-dations for the better management of this arrhythmia and to promote multicentre studies. The purpose of this paper is to briefly outline the state of our knowledge on the clinical presentation, the causes, the mechanisms and therapeutic approaches currently available and to propose recommendations for management. Although atrial flutter can coexist with atrial fibrillation, it is considered a different arrhythmia and will not be covered in the present paper.

Vorhofflimmern, die haufigste anhaltende Herzrhythmusstorung, ist durch Vorhofflimmernwellen mit einer Frequenz >300/min und unregelmasige Kammeraktionen charakterisiert. Es findet sich bei ca. 0,4% der gesamten und ca. 3–5% der uber 65jahrigen Bevolkerung. Hier wird uber die elektrische externe bzw. interne Konversion des Vorhofflimmerns referiert. Hinsichtlich der internen Konversion konnen die Autoren in diesem Zusammenhang uber ein umfangreiches eigenes Krankengut berichten. Das technische Vorgehen bei der externen Kardioversion mittels Defibrillationselektroden darf bei unseren Lesern als allgemein bekannt vorausgesetzt werden. Bei der internen Kardioversion, die neuerlich wieder starker an Bedeutung gewonnen hat, werden 3 Elektroden in das Herz des Patienten eingefuhrt, von denen die 1. im rechten Vorhofohr, die 2. im Sinus coronarius und die 3. in der Spitze des rechten Ventrikels plaziert werden. Wahrend bei externer Kardioversion Energiedosen zwischen minimal 50 und maximal 400 J angewendet werden, kommt man bei interner Kardioversion mit Energiedosen zwischen 0,5 und 20 J aus.

An increase in platelet aggregability is associated with unstable angina and myocardial infarction. Platelet size and activity correlate and mean platelet volume was found to be increased before acute myocardial infarction. We measured the mean platelet volume and platelet count in patients with stable angina, unstable angina and non-cardiac chest pain.We studied 981 patients (734 men; 247 women) defined clinically as stable angina (n = 688), unstable angina (n = 108) and unstable angina requiring immediate angioplasty (n = 52). After coronary angiography the patients were subdivided into single (n = 269), double (n = 304) and triple-vessel disease (n = 311) and the control group of non-cardiac chest pain (n = 97). There was no significant difference in platelet count between the control group and patients with 1, 2, or 3-vessel disease. However, the platelet size in patients with coronary artery disease was significantly larger (single: 8.7 +/- 1.19 fl; double: 8.7 +/- 1.12 fl; triple-vessel disease: 8.8 +/- 1.18 fl) than the control group (8.2 +/- 0.95 fl) (P0.01). Patients with stable angina similarly had no, significant difference in platelet count compared to the control group but did have a significantly increased mean platelet volume (8.7 +/- 1.13; P0.01). In contrast, patients with unstable angina had a decreased platelet count (245 +/- 56 x 10/l) compared to either stable angina (262 +/- 62 x 10/l; P0.05) or the control group (261 +/- 58 x 10/l; P0.05); furthermore, the mean platelet volume (9.4 +/- 1.23 fl) was significantly greater than for stable angina (P0.01). Patients with unstable angina requiring immediate PTCA had an even lower platelet count (231 +/- 55 x 10/l) and higher mean platelet volume (10.4 +/- 1.03 fl) (P0.01) than the rest of the population with unstable angina.In stable angina the platelet count is unchanged compared to patients with normal coronary arteries but the platelet size is increased. However, in unstable angina there is a decrease in platelet count and an even larger increase in platelet size. We interpret this as meaning that unstable angina might be associated or preceded by an increase in platelet destruction rate that is not completely compensated for by an increase in platelet production rate. The large, more reactive platelets might be causally related to an ongoing coronary artery obstruction in unstable angina.

Intravenous application of magnesium was suggested for the management of persistent ventricular tachycardia. In patients with torsade de pointes tachycardia the injection of magnesium controlled the life threatening arrhythmias reliably, thus magnesium became the treatment of choice in this setting. The results in patients with persistent monomorphic ventricular tachycardia are controversial. In one study, ventricular tachycardias could be controlled in 8 of 10 patients by 2,000 mg magnesium sulfate. In a randomized trial with 43 patients, termination of the ventricular tachycardia could be accomplished in 6 of 20 patients under the influence of 4,000 mg magnesium sulfate, whereas 3 of 24 patients exhibited termination of the tachycardia following placebo; the difference did not reach statistical significance. In our study 4 patients with torsade de pointes tachycardia could be controlled by the application of magnesium glutamate (2 x 1,000 mg intravenously). Of 25 patients with persistent monomorphic ventricular tachycardia, the arrhythmia ended in 8 patients under the influence of magnesium. No significant change of the RR intervals and the QRS duration during ventricular tachycardia could be demonstrated following magnesium injection. Cardiac index during ventricular tachycardia increased from 2.0 +/- 0.6 l/min x m2 to 2.5 +/- 0.1 l/min x m2 (p < 0.05). In a further investigation the dose of magnesium was increased to 2 x 9 mmol. To detect possible interactions with antiarrhythmic agent, 10 patients under chronic antiarrhythmic therapy with class-III-agents were compared with 10 patients without such treatment. Plasma levels of magnesium increased from 0.79 +/- 0.1 mmol/l to 1.87 +/- 0.5 mmol/l. In 5 of the 20 patients ventricular tachycardia ended under the influence of magnesium: 2 patients were on chronic antiarrhythmic agents, whereas 3 had no chronic therapy. There were no significant differences in the RR intervals and the duration of the monophasic action potentials during the ventricular tachycardia under the influence of magnesium. These data indicate that the bolus therapy of magnesium controls persistent monomorphic ventricular tachycardia in a minority of patients only. Therefore, magnesium injection cannot be recommended for treatment of monomorphic ventricular tachycardia in the emergency setting. On the other hand, magnesium application can be considered the therapy of choice for patients with torsade de pointes tachycardia.

The heart is by far the organ that is best known and has been identified for a long time. Myogenic weakness of the heart muscle pump with left-ventricular dysfunction remains the cardiac disease with the poorest prognosis while increasing in prevalence and incidence. Aside from all sorts of mystic treatment attempts and dubious herbal medicine, bloodletting was established early on as a superior remedy, which was applied in response to almost all cardiac illnesses. The first and perhaps most important cardiac drug was digitalis, the glycoside of the red and even more so of the white foxglove, described in 1552 by Leonhart Fuchs. In the 1980s, vasodilators and inotropic drugs supplemented the classical medications digitalis and diuretics. ACE inhibitors and beta-receptor blockers were added in the 1990s; at the turn of the millennium, the cardiac resynchronization therapy (CRT) and left-heart assist systems were developed; lately, there have been cellular and genetic approaches as well as xenotransplants. Preliminary results with stem cell technology are encouraging; however, it will be years until a clinical application-if it will happen at all.

There is a risk of atrial fibrillation for 1 in 4 adults over the age of 40 years. In most cases the cause of atrial fibrillation is an underlying organic disease. Approximately 2.5 million mostly elderly male patients in Europe are affected by this dysrhythmia and it is expected that the number of patients will more than double by the year 2050. With a few exceptions every form of fibrillation should be treated regarding the underlying disease, the risk of thrombo-embolization and the arrhythmogenic symptoms. However, it must be questioned whether every case of atrial fibrillation must be anti-arrhythmically treated or in which cases rate control of ventricle function is adequate or whether rhythm control, i.e. conversion into sinus rhythm, is necessary. Arguments for conversion into a sinus rhythm are improved cardiac output, decreased risk of thrombo-embolization and hypercoagulability as well as a reduction of tachycardiomyopathies. A decline in clinical symptoms leads to improvement in the quality of life and also in many cases brain function.

Summary Aim: This study was performed to compare the myocardial uptake of Tc-99m-furifosmin (Q12) versus Tc-99m-sestamibi (MIBI) in correlation to the whole-body uptake under resting conditions. Methods: 21 patients with coronary artery disease and no rest ischemia were examined. A whole-body scan was performed 60 min. p.i. under resting conditions. A quantification of the uptake (whole-body, heart and right lung) was done by ROI technique. Results: The heart-to-lung ratio of Q12 (1.56 ± 0.191) was significantly lower as compared to MIBI (1.94 ± 0.197; p

To assess acute myocardial uptake of antiarrhythmic drugs, we measured drug concentrations simultaneously in the aorta and in the coronary sinus during diagnostic cardiac catheterization. Measurements were taken 1, 2, 3, 4, 5, 7, and 10 minutes after intravenous bolus application of lidocaine (n= 10, 25 mg), mexiletine (n= 5, 25 mg andn= 10, 100 mg), or amiodarone (n= 10, 25 mg). Drug levels were measured by high-pressure liquid chromatography. Maximal concentrations were observed after 2–5 min. After 3–5 min coronary sinus levels exceeded aorta levels, indicating the end of net myocardial drug uptake. In contrast to lidocaine and amiodarone, no mexiletine was found in the coronary sinus 15 s after the end of drug application, obviously indicating a high myocardial drug content. Furthermore, the data provide an explanation for the acute efficacy of amiodarone. The myocardial uptake may result in various pharmacodynamic effects of antiarrhythmic drugs.

The implantable cardioverter/defibrillator (ICD), which uses antitachycardia pacing or shock, is the only adequate therapeutic option for life threatening ventricular tachyarrhythmias. The results of prospective, randomised ICD trials show that the indications for primary and secondary prevention of sudden cardiac death have changed in a relevant manner. After the identification of a patient at risk, the implantation of an ICD reduces cardiac and total mortality significantly. A clear diagnostic procedure and the parameters needed for the identification of this risk are essential. We report on the indications for the implantation of an ICD following current guidelines in order to enable the physician to provide his patients with an adequate ICD therapy in everyday practice.

Bis zu Beginn des 18. Jahrhunderts war die aus dem klassischen Altertum und aus der chinesischen Kultur erwachsene Pulslehre hierzulande noch nicht zu einem Instrument der arztlichen Praxis geworden. Vielmehr fand die Prufung des Pulses nur innerhalb der physiologischen Forschung ihre Bedeutung. Erst die Entwicklung der Elektrokardiographie fuhrte zur eigentlichen rationalen Rhythmologie.

The treatment of atrial fibrillation still remains challenging in everyday practice. Even after the introduction of catheter ablation, the decision-making process about the type of therapy became more complex. The recently published guidelines of the American Heart Association, the American College of Cardiology, and the European Society of Cardiology clearly show therapeutic approaches for different types of atrial fibrillation. The fear of thromboembolism still forces the physician to restore sinus rhythm and achieve optimized anticoagulation. Based on large studies, we are able to decide for each patient individually whether oral anticoagulation or ASA is required. Future studies in a large cohort of patients are still necessary to clarify the value of interventional therapy in conjunction with antiarrhythmic drug therapy. These will provide patients with safe therapy and high quality of life despite presenting paroxysmal or persistent atrial fibrillation.

A diagnostic and therapeutic approach of supraventricular and ventricular tachyarrhythmia is always challenging. Several criteria serve to discriminate correctly between these two types of tachycardia. Cardiac arrhythmias are terminated reliably by intravenous (IV) application of antiarrhythmic drugs: adenosine for supraventricular arrhythmia, amiodarone or ajmaline for ventricular tachycardia. Furthermore, AV-nodal tachycardia, atrioventricular reciprocating tachycardia, and typical atrial flutter is treated curatively by radiofrequency ablation during an electrophysiological study. This interventional therapy is well established in patients suffering from ventricular premature contractions or tachycardia originating in the right or left ventricular outflow tract. Aside treatment with an implantable defibrillator, patients with coronary artery disease highly benefit from adjusted pharmaceutical treatment.

Actual therapy of atrial fibrillation follows either the rate or rhythm control strategy. To stabilize sinus rhythm after cardioversion or in case of paroxysmal atrial fibrillation, medical treatment is currently first line therapy. In patients who develop drug-refractory atrial fibrillation, further invasive treatment modalities like preventive pacing, hybrid therapy or catheter-based ablation techniques including pulmonary vein ablation or linear atrial lesion are available. However, interventional atrial fibrillation therapy should be reserved for the highly symptomatic patient due to its limited efficacy and risk of complication. Due to the higher relevance of the AF substrate in elderly patients, ablation therapy will be of limited use until substrate modification in addition to trigger elimination will reach an established stage as a clinical procedure. Hybrid therapy however, with ablation of the cavotricuspid isthmus is as suitable in elderly patients as in the young or middle-aged.