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Elevated blood pressure remains a major cause of cardiovascular disease, disability, and premature death in Austria, with suboptimal rates of detection, treatment and control also in recent years. Management of hypertension is a common challenge for physicians with different spezializations. In an attempt to standardize diagnostic and therapeutic strategies and, ultimately, to increase the rate of patients with controlled blood pressure and to decrease the burden of cardiovascular disease, 13 Austrian medical societies reviewed the evidence regarding prevention, detection, workup, treatment and consequences of high blood pressure in general and in various clinical scenarios. The result is presented as the first national consensus on blood pressure. The authors and societies involved are convinced that a joint national effort is needed to decrease hypertension-related morbidity and mortality in our country.

High blood pressure is a major modifiable risk factor for all clinical manifestations of coronary artery disease (CAD). In people without known cardiovascular disease, the lowest systolic (down to 90-114 mmHg) and the lowest diastolic (down to 60-74 mmHg) pressures are associated with the lowest risk for developing CAD. Although diastolic blood pressure is the strongest predictor of CAD in younger and middle-aged people, this relationship becomes inverted and pulse pressure shows the strongest direct relationship with CAD in people above 60 years of age.Pathophysiological mechanisms of blood pressure as a risk factor for CAD are complex and include the influence of blood pressure as a physical force on the development of the atherosclerotic plaque, and the relationship between pulsatile hemodynamics/arterial stiffness and coronary perfusion. Treatment of arterial hypertension has been proven to prevent coronary events in patients without clinical CAD. In patients with established CAD, the effect of blood pressure lowering per se is beneficial, probably more than specific drugs or drug classes. The important exceptions are beta blockers (BBs), which are superior to all other drug classes for use after a recent myocardial infarction. Blood pressure targets in patients with established CAD have created controversy in the light of the so-called J-curve phenomenon, which describes an increase in coronary events at lower diastolic blood pressures. One explanation for this observation is that perfusion of the left ventricle occurs predominantly during diastole, and that coronary autoregulation may be exhausted with low diastolic blood pressure in the setting of left ventricular hypertrophy and atherosclerotic narrowing of the epicardial coronaries. The worst situation is a high systolic blood pressure in the presence of a low diastolic blood pressure, both a hallmark of increased aortic stiffness. However, the lowering of systolic blood pressure is clearly beneficial in this setting, even at the price of further lowering diastolic pressure. Primary blood pressure goal in patients with established CAD is below 140/90 mmHg. Recent studies suggest that a lower systolic blood pressure may be appropriate, whereas caution is advised with diastolic blood pressure below 60 mmHg.

Die von den aktuellen Guidelines empfohlenen tiefen Zielwerte fur die Hochdruckbehandlung, besonders fur Patienten mit Diabetes oder mit anderen Hochrisikokonstellationen, fanden in der Vergangenheit durch die Ergebnisse von Therapiestudien wenig empirische Unterstutzung. Ziel dieses Reviews ist es auf Basis rezenter Therapiestudien und post hoc Analysen alterer Studien die Zweckmasigkeit und Sicherheit tiefer Blutdruckwerte zu analysieren. ERGEBNISSE: Sowohl bei Patienten mit KHK oder KHK-Aquivalent als auch mit Diabetes war mit einer systolischen Blutdrucksenkung auf 130 bis 135 mmHg uberwiegend eine Reduktion von primaren oder sekundaren kardiovaskularen Endpunkten nachweisbar. Zwischen 120 und 129 mmHg liesen sich bei KHK Patienten teilweise positive Effekte zeigen, nicht so bei Patienten mit Diabetes oder metabolischem Syndrom. Unter 120 mmHg war in mehreren Studien eine Verschlechterung der Prognose feststellbar. Fur Patienten mit diabetischer oder anderer Nephropathie inklusive solchen mit erheblicher Proteinurie liegen keine uberzeugenden Daten vor, die einen Vorteil einer Senkung des systolischen Blutdrucks unter 130 gegenuber unter 140 mmHg zeigen. Allerdings wurde sowohl in der primaren wie in der sekundaren Schlaganfallprophylaxe wiederholt gezeigt, dass das Risiko kontinuierlich bis zu einem systolischen Wert von etwa 120 mmHg oder sogar etwas darunter abnimmt. Bei 70 bis 80 Jahre alten Patienten spricht die derzeitige Datenlage fur eine systolische Blutdrucksenkung auf 135 bis 145 mmHg, bei uber 80 Jahrigen auf 145 bis 155 mmHg. Fur diastolische Werte scheint unabhangig von zusatzlichen Erkrankungen ein Zielbereich zwischen 70 und 85 mmHg am gunstigsten zu sein. Limitierung der Aussagekraft vieler Hochdruckstudien ist ihre kurze Laufzeit, ihre geringen Ereignisraten und/oder die geringen Druckunterschiede zwischen den Vergleichsgruppen, die Langzeitwirkungen nicht verlasslich beurteilen lassen. FAZIT: Fur die Sinnhaftigkeit einer systolischen Blutdrucksenkung unter 130 mmHg liegen mit Ausnahme einer Reduktion von Schlaganfallen bis zu etwa 120 mmHg derzeit nur sparlich evidenzbasierten Ergebnisse vor. Vorbehaltlich, dass echte Langzeitergebnisse fehlen, ist vermutlich fur alle Hochdruckkranken mit Ausnahme von Jugendlichen und sehr Alten eine Drucksenkung auf 130 bis 140 systolisch und 70 bis 85 mmHg diastolisch ausreichend. Eine starkere Senkung durfte bestenfalls eine geringe weitere Risikoreduktion nach sich ziehen, diastolische Senkung unter 70mmHg kann das Risiko erhohen.

GRUNDLAGEN: Unter Standard-Statintherapie lassen sich etablierte Zielwerte fur das LDL-Cholesterin (LDL-C) bei kardiovaskularen Risikopatienten haufig nicht erreichen. Das zusatzliche lipidsenkende Potenzial einer Ezetimib/Simvastatin-Fixkombination wurde in einer osterreichweiten Anwendungsbeobachtung evaluiert. METHODIK: 3.156 Personen erfullten mit klinisch manifester Atherosklerose und/oder Diabetes mit hohem kardiovaskularen Risiko und LDL-C-Spiegeln >113 mg/dl trotz Statinbehandlung die Einschlusskriterien und 2.903 dieser Patienten wurden bei niedergelassenen Arzten, in Krankenhausern und Rehabilitationzentren mit 10 mg Ezetimib und 10–40 mg Simvastatin pro Tag in Fixkombination (Inegy) behandelt. ERGEBNISSE: Im Beobachtungszeitraum von 4–12 Wochen sank das LDL-C, weitgehend unabhangig von der Statin-Vortherapie (Rosuvastatin, Atorvastatin, Simvastatin, Pravastatin, Fluvastatin, Lovastatin) und deren Dosierung (gepoolte Medianwerte), um median 27–31 % der Ausgangswerte (Mittelwert 153,1 ± 33,5 mg/dl). Insgesamt erreichten 45,3 % (10/10 mg), 43,9 % (10/20 mg) und 62,7 % (10/40 mg Ezetimib/Simvastatin) den LDL-C-Zielwert von

Within four years ten patients (six women and four men) under 50 years of age (13-49 years) were observed who presented occlusions of the vertebrobasilar artery. Eight patients were admitted from other hospitals, on an average 41 hours after the acute occlusion; only in one case had a correct first diagnosis been made. In all cases diagnosis was confirmed by means of selective angiography. Conservative treatment comprised in two patients low-molecular dextranes and heparin, in another two prostaglandin E1. In the remaining six patients local fibrinolysis was performed. In the group receiving conservative treatment a 33-year-old female patient survived and her neurological deficits subsided except for an organic psychosyndrome of minor degree. Local fibrinolysis yielded complete recanalization in three cases and partial recanalization in two. Three patients survived, in two patients near-complete recovery was achieved.

For 17 years a now 45-year-old man had suffered from progressively more severe flaccid paresis of the arms and thoracic muscles, spastic paralysis of the legs and kyphoscoliosis. Artificial ventilation was required when he contracted pneumonia. Although it was being treated with antibiotics, frequent bronchoalveolar lavage had to be done because of repeated atelectases. After 6 weeks clonuses developed in the legs, predominantly on the right, stretch synergisms and opisthotonos. The pupils were small with sluggish reaction to light, and there was a positive "doll's head" phenomenon. The level of consciousness alternated between somnolence and sleepiness. Magnetic resonance imaging demonstrated cavities in cervical and thoracic spinal cord, supporting the diagnosis of an abnormal cerebrospinal circulation due to gliosis in syringomyelia. To secure cerebrospinal fluid drainage, the cerebellar tonsils were resected, together with a duraplasty and partial resection of the atlas. Following this he became fully conscious and the spastic state improved. During the following 8 weeks it became possible gradually to wean him from the artificial ventilation and achieve satisfactory mobilization so that he could be discharged to domiciliary care.

One or several syncopes were the reason for hospitalization in 31 of 155 in-patients with proven pulmonary embolism. In all of them there were at least two further pointers to acute pulmonary embolism: all had tachypnoea, 28 had dyspnoea, 25 had sinus tachycardia (more than 100 beats/min), 24 had congested neck veins and 16 had deep leg-vein thrombosis. In 21 patients the ECG had signs of right heart strain, in 15 of 20 in whom it was measured the arterial oxygen partial pressure was below 70 mm Hg. In 23 patients the chest X-ray was largely unremarkable despite dyspnoea. In 23 patients there had been a massive embolus and 16 patients had died. Although syncope is only rarely caused by pulmonary embolism, its ominous significance in this connection should stimulate a search for further diagnostic pointers to such an occurrence.

The balance of the 2 cytokines, osteoprotegerin (OPG) and the receptor activator of nuclear factor κ B ligand (soluble (s)RANKL), is known to have considerable influence on bone formation and degradation. Plasma concentrations of OPG and (s)RANKL were determined in a total of 31 long-distance runners before and immediately after running distances of either 15 or 42.195 km, respectively. In both groups of endurance runners, a significant decrease of sRANKL was observed during the run, the extent of which correlated to the running distance. Furthermore, OPG increased only in runners covering the marathon distance of 42.195 km. We hypothesize that the known positive effect of long-distance running on the skeletal mass may be mediated by the OPG/sRANKL system.

Whether diabetes mellitus affects the prognosis of stroke patients, and whether admission hyperglycemia influences prognosis similarly in diabetic as in non-diabetic patients is assessed controversially. The aims of the study were: 1) to compare the course of diabetic and non-diabetic acute stroke patients, and 2) to assess the influence of admission serum glucose levels on case fatality.In 57 Austrian medical departments the hospital course of consecutive stroke patients was documented prospectively between June 1999 and October 2000.Two hundred and ninety-six (30%) of 992 patients had a history of diabetes mellitus. Intracerebral hemorrhage was more frequent in non-diabetic patients than diabetic (13% versus 5%, P=0.0001). Coronary heart disease was more frequent in diabetic than in non-diabetic patients (35% versus 24%, P=0.0003). The case fatality was 18% among non-diabetic and 16% among diabetic patients (P=0.3559). Among patients who were discharged alive, the Barthel Index increased from 50 to 90 in non-diabetic and from 45 to 75 in diabetic patients (P=0.0403). In non-diabetic patients, admission serum glucose9.2 mmol/L was associated with a more than 4-fold increase in case fatality, compared with patients with serum glucose5.7 mmol/L (P0.0001).Diabetic stroke patients need special care since they tend to have a poorer recovery than non-diabetic patients. Admission hyperglycemia in non-diabetic acute stroke patients predicts a poor prognosis.

Stroke patients with atrial fibrillation (AF) have a poorer neurological outcome than stroke patients without AF. Whether stroke patients with AF also have a higher rate of medical complications is unknown. The aim of the study was to compare the in-hospital course of acute stroke patients with and without AF.The Austrian Stroke registry was a prospective multi-centre study involving 57 medical departments documenting the hospital course of consecutive stroke patients from June 1999 to October 2000. AF was diagnosed in 304 (31%) of 992 patients. Patients with AF were older (79 versus 75 years, p0.0004) than no-AF patients. There were more cases of pneumonia (23% versus 9%, p0.0004), pulmonary oedema (12% versus 6%, p0.0004) and symptomatic intracerebral haemorrhage (8% versus 2%, p0.0004) in AF compared to no-AF. In-hospital mortality was higher in AF (25% versus 14%, p0.0004), and neurological outcome was poorer (65 versus 90 Barthel index, p0.0004). On multivariable logistic regression analysis, however, AF was no predictor for mortality, but a Barthel index of zero (odds ratio 5.30, 95% CI 3.10-9.08, p0.0001), a National Institutes of Health Stroke Scale21 or comatose (odds ratio 3.13, 95% CI 2.26-4.32, p0.0001), age75 years (odds ratio 3.15, 95% CI 1.85-5.37, p0.0001), heart rate100 min(-1) (odds ratio 2.15, 95% CI 1.26-3.66, p = 0.0049), obstructive pulmonary disease (odds ratio 2.58, 95% CI 1.03-6.48, p = 0.0442) and creatinine125 micromol/l (odds ratio 1.84, 95% CI 1.00-3.37, p = 0.0479).Stroke in AF is associated with a poor prognosis, an increased rate of medical and neurological complications and a higher in-hospital mortality than in no-AF.

Zusammenfassung: Bei 19 Marathonlaufern (2F, 17M) wurde vor und unmittelbar nach dem Lauf die Plasmakonzentration der Parameter Gesamt-CK-Aktivitat, CK-MB-Masse, Myoglobin und Troponin I bestimmt. Unter dem Einflus der Laufbelastung sind bei allen Probanden Gesamt-CK und Myoglobin im Plasma signifikant angestiegen, wobei keine Korrelation mit dem Alter der Laufer und deren Laufzeit feststellbar war. Bei einigen der Laufer ist auch CK-MB auf Werte angestiegen, die sonst fur das Bestehen myokardialer Nekrosen sprechen. Es gibt jedoch keinen uberzeugenden Hinweis dafur, das diese Befunde wirklich durch Nekrosen im Myokard verursacht werden. Sie konnten auch Folgen einer zellularen Permeabilitatsstorung durch die Laufbelastung sein, die bei gesunden Laufern durch die Belastung der Muskulatur, etwa so wie das ,,stunning‘‘ des Myokards, lokal auftreten und – so eindrucksvoll die Befunde auch sein mogen – keine gesundheitlich nachteiligen Folgen zeitigen. Ihre Bedeutung fur einen Trainingseffekt der Muskulatur erscheint gegenwartig nicht beurteilbar. Muscle Cell Proteins are Selectively Released into the Blood Stream by Marathon Running Summary: In 19 marathon runners of both sexes, plasma concentrations of total creatine kinase (CK) activity, CKMB mass, myoglobin and troponin I were determined before and immediately after the race. Total CK activity and myoglobin increased significantly in all runners and showed neither a correlation with the individual age of the runners nor with the time they needed to reach the goal. In 12 of the runners, CKMB mass increased during the race to a level suggesting myocardial necrosis. However, the runners did not show any detectable deterioration of cardiac function after the race. The appearance of considerable amounts of muscle proteins in plasma precipitated by the muscle strain during the race seems explained by damage of skeletal muscle detected by histological studies. These phenomena may also be a consequence of profoundly disturbed cellular permeability, perhaps due to a kind of local stunning of muscle tissue by prolonged muscular strain.

OBJECTIVE: Intracranial pressure (ICP) monitoring is frequently used in intensive care treatment of patients with intracranial hemorrhage. Data demonstrating an improved outcome from this intervention are lacking. We analyzed standardized mortality ratios in patients with and without ICP monitoring to determine its efficacy. DESIGN: A nonrandomized study of case records of consecutively admitted intensive care unit (ICU) patients with intracranial hemorrhage. SETTING: General and medical ICU of a 900-bed tertiary-care hospital. PATIENTS: A total of 225 patients with intracranial hemorrhage (mainly nontraumatic) admitted consecutively between April 1997 and March 2000. MEASUREMENTS: Simplified Acute Physiology Score (SAPS) II, diagnosis, age, sex, use of ICP monitoring, and in-hospital mortality rates were collected from the hospital's ICU database. Expected mortality was provided by means of SAPS II. Standardized mortality ratios were calculated and compared in 119 patients with ICP monitoring and 106 patients without ICP monitoring. MAIN RESULTS: The case mix-adjusted hospital mortality in the group with ICP monitoring was in the expected range (standardized mortality ratio, 1.09 [95% confidence interval (CI), 0.87-1.31]). Patients without ICP monitoring had a significantly higher standardized mortality ratio than expected (1.26 [95% CI, 1.06-1.46]). CONCLUSIONS: A beneficial effect of ICP monitoring in patients with intracranial hemorrhage may be reflected in an improved standardized mortality ratio.

Background: If problems, interventions and complications occurring during oral anticoagulation (OAC) are related with age, indication for OAC, hypertension, diabetes, previous stroke, and number of additional drugs. Material and Methods: Clinical characteristics, additional drugs, problems, interventions and complications of outpatients whose OAC was controlled between two years were registered. Potential gastrointestinal and urologic bleeding sources were eliminated prior to initiation of OAC. Five-hundred-seventy-nine patients (mean age 65 years, 44% female) were observed for 590 patient-years. Results: Medical problems occurred in 352/100 patient-years (% p-y), organisational problems in 276% p-y, interventions in 636% p-y and complications in 13.8% p-y. Patients >65 years had less organisational problems (254 vs. 302% p-y, p = 0.0092) and interventions (574 vs. 713% p-y, p = 0.0003) than patients ≤65 years. The 35 patients with heart valve prosthesis had more life-threatening and fatal complications (12% p-y) than the 360 patients with atrial fibrillation (1.0% p-y), 128 patients with venous thromboembolism or 56 patients with other indications (0.0% p-y, p = 0.0024). Problems, interventions and complications were not related with hypertension (n = 297), diabetes (n = 97) or previous stroke (n = 90). Patients with >3 additional drugs/day had a higher complication rate than patients with ≤3 drugs/day (21 vs. 8.7% p-y, p = 0.0238). Patients with complications had more headache (27 vs. 20% p-y, p = 0.0036), chest pain (45 vs. 27% p-y, p = 0.0150), abdominal pain (25 vs. 15% p-y, p = 0.0350) and pain in the limbs (55 vs. 42% p-y, p = 0.0044) than patients without complications. Conclusions: By careful monitoring, eliminating potential bleeding sources, treating pain adequately and minimizing additional drugs the complications of OAC can be kept low. Abbreviated abstract. Aim of the study was to assess if problems, interventions and complications occurring during oral anticoagulation (OAC) in 579 outpatients (mean age 65 years, 44% female) are related with age, indication for OAC, cardiovascular risk factors and number of additional drugs. During 590 patient-years medical problems occurred in 352/100 patient-years (% p-y), organisational problems in 276% p-y, interventions in 636% p-y and complications in 13.8% p-y. Patients >65 years had less organisational problems (254 vs. 302% p-y, p = 0.0092) and interventions (574 vs. 713% p-y, p = 0.0003) than patients ≤65 years. Patients with heart valve prosthesis had more life-threatening and fatal complications (12% p-y) than atrial fibrillation (1.0% p-y) or venous thromboembolism (p = 0.0024). Problems, interventions and complications were not related with cardiovascular risk factors. Patients with >3 additional drugs/day had a higher complication rate than patients with ≤3 drugs/day (21 vs. 8.7% p-y, p = 0.0294). By careful monitoring the complications of OAC can be kept low.

To the Editor: In the February issue of Stroke , Jorgensen and coworkers1 report that treatment of stroke patients in a stroke unit (SU) compared with a general ward (GW) offers benefits on the order of odds ratios of 0.17 to 0.66. Consistently, their conclusion is that all patients with acute stroke should be treated in a dedicated SU. Moreover, their findings raise serious considerations of whether further treatment of stroke patients in GWs is ethically justifiable. In an earlier publication of the same investigation,2 Jorgensen and coworkers described an inhospital mortality of 23% in patients treated in the SU, which was 21% lower than that in patients treated in a GW. That is in fair agreement with the findings of the meta-analysis presented by the SU Trialists,3 which depended on studies predominantly performed in the 1980s. Logistic multiple regression analysis blew up this benefit to an odds ratio for poor outcome of 0.50 for the total stroke population and 0.17 for patients with severe stroke treated in the SU. …

Fragestellung: Ziel unserer Erhebung war es, zu erfassen, 1. wie vielen Patienten mit Vorhofflimmern eine antithrombotische Therapie bei der Entlassung aus osterreichischen Krankenhausabteilungen empfohlen wurde; 2. ob Schlaganfall-/Embolie-Risikofaktoren (Alter > 65 Jahre, arterielle Hypertonie, Diabetes mellitus und fruherer Schlaganfall) und Kontraindikationen fur orale Antikoagulanzien (Demenz, Alkoholabusus) die Wahl der antithrombotischen Therapie beeinflusten und 3. ob zwischen den Krankenhausabteilungen Unterschiede bei der Therapieempfehlung bestanden. Patienten: Eingeschlossen wurden 1566 Patienten (841 Frauen 725 Manner, mittleres Alter 76 Jahre) mit permanentem oder paroxysmalem Vorhofflimmern und Herzinsuffizienz. Methoden: Bei Entlassung aus dem Krankenhaus wurden Schlaganfall-/Embolie-Risikofaktoren, Kontraindikationen und die empfohlene antithrombotische Medikation erfast. Ergebnisse: Orale Antikoagulanzien wurden 26 %, Azetylsalizylsaure (ASS) 31 %, eine Kombination von oralen Antikoagulanzien mit ASS 2 % und keine antithrombotische Therapie 41 % der Patienten empfohlen. Das Vorliegen von Schlaganfall-/Embolie-Risikofaktoren beeinfluste nicht die Wahl der antithrombotischen Therapie. Das Vorhandensein von Demenz, nicht aber von Alkoholabusus, beeinfluste die Empfehlung der antithrombotischen Therapie. Aus kardiologischen oder Rehabilitationsabteilungen entlassenen Patienten wurden haufiger orale Antikoagulanzien empfohlen als denen, die aus anderen Krankenhausabteilungen entlassen wurden. Konklusion: Unsere Ergebnisse zeigen, das in der medizinischen Praxis die Empfehlungen fur eine antithrombotische Therapie bei Vorhofflimmern zu selten berucksichtigt werden, insbesondere wenn zusatzliche Schlaganfall-/Embolie-Risikofaktoren vorhanden sind.

Adipositas zeigt eine starke Assoziation mit Hypertonie, wobei das viszerale Fett uber eine Vielzahl von para- und endokrin wirksamen Peptiden eine Schlusselrolle in der Pathogenese des erhohten Blutdrucks und der akzelerierten Atherothrombose ubergewichtiger Personen spielt. Pathophysiologisch kommt der erhohten Aktivitat des RAAS und des sympathischen Nervensystems eine zentrale Bedeutung zu; neben dem erhohten peripheren Widerstand ist die Kreislaufsituation durch hohes Herzminutenvolumen und Hypervolamie charakterisiert. Der Hypertonus des Ubergewichtigen ist salzsensitiv und spricht medikamentos auf Hemmung des RAAS in der Regel gut an. Vorrangig in der Behandlung sind Lebensstilverbesserungen mit mehr Bewegung und weniger Kalorienzufuhr als wichtigste Masnahmen und Mitbehandlung der haufigen begleitenden Risikofaktoren im Sinne des heute geforderten totalen Risiko Managements.

Background: When examining the left atrial appendage by transesophageal echocardiography, differences in size and shape of the left atrial appendage are to be observed. The study was carried out with the aim of investigating the morphology of the left atrial appendage and to find associations with pathologic cardiac findings. Methods and results: In 220 cases (106 female, 114 male, mean age 72 ± 13 years) a cast of the left atrial appendage was made after the post mortem examination by using synthetic resin. In 198 cases an ECG was available (sinus rhythm n = 143, atrial fibrillation n = 55). The casts were described in respect to course and ramifications of the principal axis. The casts were measured concerning orifice diameters, outline, and volume. Most frequently (42%) the course of the principal axis was angulated below 100°. More than five ramifications of the principal axis were found in 56% of the casts. The volume ranged from 770–19,270 mm3 (mean 5,220 ± 3,041). When comparing the clinical and autopsy-data of the patients with the morphology of the casts, associations could be found between the volume of the casts and atrial fibrillation (7,060 mm3 as compared to 4,645 mm3 in sinus rhythm, P < 0.01), left ventricular hypertrophy (5,740 mm3 as compared to 4,639 mm3 without hypertrophy, P < 0.01), myocardial scars (5,923 mm3 as compared to 4,891 mm3 without scars, P < 0.05), closed foramen ovale (5,515 mm3 as compared to 4,037 mm3 with patent foramen ovale, P < 0.01), and left atrial appendage thrombi (8,566 mm3 as compared to 5,027 mm3 without thrombi, P < 0.01). Conclusion: Left atrial appendages are formations greatly varying in volume and shape. This variability should be considered when interpreting images of the left atrial appendage, and in particular when diagnosing thrombi. © 1995 Wiley-Liss, Inc.

The study was performed to determine whether age, cardiovascular risk factors or the stroke syndrome might define patients with embolic stroke for whom transoesophageal echocardiography (TEE) would prove to be useful. Of 256 patients from the Klosterneuburg Stroke Data Bank, 105 (40%) were included because of suspected embolic stroke (59 female, 46 male, mean age 64 years). A positive TEE finding was defined as the presence of left heart thrombus, valvular vegetation, right to left shunting or spontaneous echo contrast. TEE detected potential sources for embolism in 35 of the 105 patients. These were left atrial/appendage thrombi (n = 18), valvular vegetations (n = 4), right to left shunting (n = 10), and spontaneous echo contrast (n = 5). Only the presence of atrial fibrillation showed a significant association with the presence of a cardiac source of embolism (18/35 versus 22/70,P < 0.02). Age, cardiac disease, cardiovascular risk factors and the stroke syndrome did not help in distinguishing stroke patients with and without a positive TEE finding.

To assess the feasibility of intravascular ultrasound imaging during carotid endarterectomy. Intravascular ultrasound imaging was performed during carotid endarterectomy in eight patients using an over-the-wire catheter system with a 30-MHz ultrasound probe. In vitro studies were carried out before the intraoperative application, paying special attention to visualization of the wall layers of normal carotid arteries, structures of more or less diseased vessels, and surgically placed materials such as patch, suture material, and fibrin glue. Although intravascular ultrasound failed to distinguish between intima and media in areas of normal intima, fibrotic and calcified plaques were detected clearly. Dacron patch as well as sutures were identified as highly reflective structures. In seven of the eight patients studied, intravascular ultrasound yielded cross-sectional images of good quality allowing identification of the vessel layers and the structures at the endarterectomy site. In all patients the three layers of the vessel wall were clearly differentiated and the transition zone between the site of endarterectomy and the genuine vessel appeared smooth without intimal flaps or residual arteriosclerotic plaques. In one patient severe eccentric thickening of the media was detected in the distal internal carotid artery. Neither damage of the vessel layers by the shunt nor thrombus formation in the operating area and the internal carotid artery were detected. Intravascular ultrasound lends itself as a potentially valuable method of quality control during carotid endarterectomy. The method seems to enable an accurate evaluation of the endarterectomy site and the search for residual plaques.

Paradoxical embolism should only be diagnosed if three conditions are present: arterial embolism, a cardiac right-toleft shunt, and venous thrombosis. Whereas diagnosis of peripheral or cerebral arterial embolism is facilitated by computed tomography, angiography, and Duplex sonography, and cardiac right-to-left shunts is reliably diagnosed by transesophageal contrast echocardiography or transcranial Doppler sonography, there are only a few studies with a small number of patients that evaluate the role of the venous system in patients with suspected paradoxical embolism (Table 1) [1–8]. Several authors do not even mention screening for venous thrombosis as useful investigation in patients with suspected paradoxical embolism [9,10]. From a diagnostic prerequisite for paradoxical embolism, venous thrombosis has been degraded to one of several ‘‘risk factors’’ [11–13 14]. Confirming or excluding venous thrombosis in patients with suspected paradoxical embolism, however, is of therapeutic relevance and not only a matter of academic interest, because

BASIC CONCEPTS AND METHODOLOGY: Acceptance of the ESH/ESC 2007 hypertension guidelines and their reappraisal 2009 are not known by Austrian practitioners. Therefore, within the frame of a noninterventional trial we investigated 3,488 ambulatory hypertensive patients. Primary goal was the evaluation of the assignment to cardiovascular risk categories according to the ESH/ESC charts by office-based physicians compared to an independent risk adjudication using the same data and method. Further goals were assessment of compliance with the recommendation to start combination treatment in grade 2 and 3 hypertension and efficacy and tolerability of treatment with candesartan. RESULTS: The comparison revealed incorrect physicians' risk assessment for approximately 60% of the patients with a strong tendency for underestimation. Despite guidelines recommending an initial combination therapy for hypertension ≥160/90 mmHg, 15.4% of these patients still received candesartan as a monotherapy. Target blood pressure ≤140/90 mmHg could be well achieved (in 81.6%) with candesartan as monotherapy or combined with hydrochlorothiazide (HCTZ) for hypertension grade 1–3. CONCLUSIONS: Guidelines for assessment of individual risk and derived therapy algorithms should be better communicated in the outpatient setting. Candesartan alone or combined with HCTZ is an effective and well tolerated therapeutic option to control blood pressure in the majority of patients.

Venous thrombosis is a very common complication of central venous catheters inserted via the jugular or subclavian vein. The aim of this prospective study is to test the suitability of duplex sonography in detecting thrombi in the internal jugular vein after catheter removal and to analyze the number and extent of such thrombus formations. The study group comprised 64 consecutive patients with an average age of 59 +/- 16 years admitted to an internal intensive care unit. In 54 cases the catheters were removed under sonographic control. In 10 cases duplex sonography was carried out within 24 h after removal of the catheters. The data of 63 patients were evaluated. In 40 patients (63.5%), thrombi of varying extent were present in the jugular vein. No significant correlations were found between thrombus formation and the basic disease, duration of cannulation, the type of catheters used, and the mode of heparinization (therapeutic vs. low-dose). Local inflammation signs and local hematoma showed a significantly higher incidence (p < 0.01) in patients with thrombus formation. Duplex sonography lends itself as a valuable diagnostic tool in the diagnosis of thrombus formation in the internal jugular vein after removal of central venous catheters. Sonographic examinations should be carried out in all long-stay patients at an intensive care unit, in whom central venous catheters are inserted repeatedly via the internal jugular vein.

There is little evidence from controlled prospective studies to support the low blood pressure goals stipulated for the treatment of hypertension by present guidelines, especially in high-risk patients with diabetes, renal insufficiency or coronary heart disease. Aim of this review is to scrutinize the potential benefit and risk of low blood pressure on the basis of recent studies and secondary analyses of older studies.In patients with coronary heart disease or equivalent or with diabetes lowering systolic blood pressure to 130 to 135 mmHg reduced primary or secondary cardiovascular endpoints in the majority of studies. Between 120 and 129 mmHg some positive effects could be shown in patients with coronary heart disease but not in patients with diabetes or metabolic syndrome. In patients with diabetic or nondiabetic nephropathy including those with proteinurea no convincing data exist which show a better outcome with systolic blood pressure below 130 versus below 140 mmHg. However, several studies suggest that the risk of stroke may decrease by lowering systolic pressure to 120 mmHg or even lower. Below 120 mmHg an increased risk of cardiac and noncardiac events or death was shown in quite a number of studies. In patients between 70 and 80 years, current evidence suggests lowering systolic blood pressure to 135 to 145 mmHg and in those above 80 years to 145 to 155 mmHg. No evidence was found to justify different diastolic pressure goals for different groups of patients; optimal values fall between 70 and 85 mmHg. Limitations of recent studies are short follow-up, few event rates and small differences in achieved pressure between groups leaving uncertainty about long-term effects.Apart from prevention of stroke there is sparse evidence that lowering systolic blood pressure below 130 mmHg may be beneficial. Current evidence suggests that lowering systolic and diastolic pressure into a range of 130 to 140/70 to 85 may be adequate for all patients with the exception of children, adolescents and patients over 80 years. Further lowering of systolic pressure seems to offer little additional benefit and lowering diastolic pressure below 70 mmHg might increase risk.

In patients at risk for cardiovascular complications, established LDL cholesterol (LDL-C) target levels are frequently not achieved using standard statin therapy regimens. The additional lipid-lowering efficacy of the fixed combination ezetimibe/simvastatin was evaluated in a countrywide non-interventional observational study in Austria.About 3,156 subjects with clinically manifest atherosclerosis and/or diabetes at high cardiovascular risk and with LDL-C-levels113 mg/dl under statin therapy met the inclusion criteria and 2,903 of these patients were treated by primary care physicians, in hospitals and in rehabilitation centers with 10 mg ezetimibe and 10-40 mg simvastatin daily in a fixed-combination tablet (Inegy).During the follow-up period of 4-12 weeks, LDL-C levels were reduced by a median of 27-31% of baseline values (mean 153.1 +/- 33.5 mg/dl) mainly regardless of previous statin therapy (rosuvastatin, atorvastatin, simvastatin, pravastatin, fluvastatin, and lovastatin) and dosing (pooled median values). LDL-C reduction correlated proportional with baseline LDL-C values and increased with increasing simvastatin dosage. Overall, 45.3% (10/10 mg), 43.9% (10/20 mg) and 62.7% (10/40 mg ezetimibe/simvastatin) achieved LDL-C target levels of100 mg/dl.The fixed combination therapy with ezetimibe/simvastatin showed a clinically significant additional lipid-lowering potential as compared with established statin monotherapies and enabled more patients at cardiovascular risk to reach the LDL-C target level of100 mg/dl.

Hypertension, diabetes and visceral adiposity are very common co-morbidities with an exceedingly high risk of cardiovascular and renal complications. Therefore, emphatic treatment is necessary. Blood pressure goal is recommended below 130/80 mmHg with office measurements, and less than 7 out of 30 values below 135/85 mmHg with home measurements. Strict blood pressure control reduces macro- and microvascular morbidity. Usually combination of different drugs is necessary to achieve a satisfactory blood pressure control. First line should be an inhibitor of the RAS, commonly combined with a calcium channel blocker and/or a diuretic. Fixed-dose combinations are recommended. If indicated or necessary, newer generation betablockers may be given as an adjunct. Life style measures and active reduction of further risk factors are essential.

Obesity shows a strong association with hypertension, primarily due to secretion of an abundance of para- and endocrine peptides by the visceral adipose tissue that play a key role in the pathogenesis of high blood pressure and are responsible for the accelerated atherothrombosis encountered in overweight individuals. Increased activity of the RAAS and the sympathetic nerve system are the main pathophysiologic factors; hypertension in obese subjects is characterized by increased peripheral arterial resistance, high cardiac output, hypervolemia and salt sensitivity. Medical therapy sees blockade of the RAAS in front. Priority in treatment should be given to improvements in life style, primarily in increasing physical activity and decreasing caloric intake, and to medical treatment of associated risk factors according to the modern concept of global risk management.

OBJECTIVE: In view of ethical considerations and the limited resources in intensive care medicine, the present investigation aims to give a descriptive overview of the prognosis and therapeutic activity for the oldest age group of elderly patients admitted to an intensive care unit (ICU) in comparison with younger ICU patients. PATIENTS AND METHODS: 3069 patients admitted to the ICU during a seven-year period were categorized into four age groups: under 65 years (48%), 65 to 74 years (26%), 75 to 85 years (22%) and 85 years or older (5%). Type and reason for ICU admission, length of ICU stay, severity of illness as measured by the simplified acute physiology score (SAPS)-II, level of provided care as measured by the simplified therapeutic intervention scoring system (TISS)-28, and vital status at the date of ICU discharge were recorded. RESULTS: The ICU mortality rate of patients aged 85 years or older was significantly higher than in patients under 65 (OR of mortality: 1.8, p < 0.001). Non-survivors had higher SAPS II levels (even when excluding age points) in all age groups, but higher daily average TISS points only in patients under 85. The daily average TISS score was negatively correlated to age (r = −0.03; p < 0.001) and was significantly lower in the oldest group when compared with all the younger groups (p < 0.001). The oldest patients had a significantly shorter length of stay (median: 2; interquartile range [IQR] 1–3, p < 0.001) than the younger patient groups. CONCLUSIONS: Within the very elderly population, age is an important and independent predictor of mortality, but acute severity of illness is even more strongly associated with mortality. Consequently, age alone may be an inappropriate criterion for allocation of ICU resources.

Background Aneurysm of the ascending aorta is rarely reported as the source of emboli. We report a patient with a minor stroke in whom a saccular aneurysm of the left sinus of Valsalva was diagnosed as the presumed source of cerebral embolism. Case Description A 49-year-old right-handed woman presented 10 days after sudden onset of right-sided hemiparesis. Her history was uneventful apart from an acute inflammation of the subcutaneous tissue in the right leg 20 years earlier. A diastolic murmur was heard best over the third left intercostal space. Results of duplex ultrasound investigation of the cerebral vessels, chest x-ray, and electrocardiography and biochemical and hematological variables were normal. CT of the brain showed a small hypodense area in the left frontal region. Transthoracic and transesophageal echocardiography detected moderate aortic regurgitation and a saccular aneurysm originating from the left sinus of Valsalva. The aneurysm had calcified walls and contained thrombotic material. Surgical closure of the aneurysm with a pericardial patch was performed to prevent recurrent embolism and rupture. Coaptation of the aortic valves was achieved, and no residual aortic regurgitation could be detected. Conclusions We conclude that an unruptured sinus of Valsalva aneurysm should be included in the list of sources of embolism. Transthoracic echocardiography establishes the diagnosis. Transesophageal echocardiography provides additional information about the origin and size of the aneurysm and presence of thrombotic material. Surgical closure of the aneurysm prevents rupture and recurrent embolism and possibly corrects aortic regurgitation.

Objective: Long-distance running results in considerable stress. Little evidence exists about the role of the atrial and brain natriuretic peptides, ANP and BNP, deriving from the myocardium. The aim of our study was to investigate the influence of running 42.195 km on changes in circulating natriuretic propeptides and adrenocortical steroids. Design and methods: We studied 17 male and 2 female runners (age: 28 – 62 years) participating in a marathon. Blood samples were obtained before and immediately after the competition. proANP(1 – 98) and proANP(1 – 30) as well as Nt-proBNP(8 – 29) were determined by enzyme immunoassays. Results: Runners finished the competition between 2 h 58 min and 4 h 25 min. We observed a more pronounced increase in proANP(1 – 98) (þ 58%) and proANP(1 – 30) (þ 99%, both P , 0.001) compared with Nt-proBNP(8 – 29) (þ 6%; P ¼ 0.005). Increases in proANP(1 – 30) positively correlated with runners’ age (r ¼ 0.53; P ¼ 0.02). We also observed a marked increase in cortisol (þ 73%) and especially in aldosterone (þ 431%, both P , 0.001). Conclusions: Cardiac strain during long-distance running may explain the pronounced increase in proANP. Other explanations for the observed rise in plasma levels might be a change in the permeability of myocardial cells and an impaired clearance. A rise in adrenocortical steroids may compensate for the negative influence of ANP on natriuresis and blood pressure. Positive effects of ANP during a marathon could be the regulation of body temperature by influencing sweat glands as well as the stimulation of lipolysis compensating for the enormous energy demand.

To the Editor The Heart Outcomes Prevention Evaluation (HOPE) trial and Losartan Intervention For Endpoint Reduction in Hypertension Study (LIFE) have shown that ramipril and losartan lower the risk of ischemic vascular events, including strokes.1–3 This effect, which is independent of lowering blood pressure, is explained by pharmacological mechanisms, which are further consequences of inhibition of the renin-angiotensin system in the plasma and vascular wall. These potential mechanisms comprise reduction in proliferation of vascular smooth muscle cells, enhancement of endogenous fibrinolysis, stabilization of plaques, decrease in angiotensin II–mediated atherosclerosis, plaque rupture, and vascular occlusion.4 Atherosclerosis, however, is not the only cause of stroke. Stroke may also be due to embolism, vasculitis, or coagulation abnormalities. Stroke may …

BACKGROUND AND OBJECTIVES Some types of hypertrophic cardiomyopathy are due to cardiac Fabry's disease. Since left ventricular hypertrabeculation/noncompaction (LVHT) is regarded a subtype of hypertrophic cardiomyopathy, we looked for the alpha-galactosidase levels in blood leukocytes of LVHT patients. METHODS Included were male patients in whom LVHT was diagnosed between June 1995 and September 2002. Echocardiographic criteria for LVHT were 1) >3 trabeculations protruding from the left ventricular wall, apically to the papillary muscles, visible in 1 image plane, and 2) intertrabecular spaces perfused from the ventricular cavity, as visualised on colour Doppler imaging. Trabeculations were defined as structures with the same echogenicity as the myocardium and moving synchronously with the ventricular contractions. Excluded were patients with known neuromuscular disorders. All patients were asked for systemic manifestations of Fabry's disease and blood tests were taken. The alpha-galactosidase-A activity was determined by means of an established fluorometric assay in blood leukocytes. RESULTS Forty-one patients were invited and 26 accepted the invitation. The remaining patients had died (n=5), lived abroad (n=5) or were unwilling (n=5). Among the 26 patients, aged 28-78 years, who followed the invitation, one had renal failure due to renal shrinkage and one had suffered from a stroke 3 years previously. Leukocyte alpha-galactosidase levels ranged from 70 to 188 nM/mg Prot/h (normal: > or =42 nM/mg Prot/h). In none of the patients was the alpha-galactosidase level reduced. CONCLUSION LVHT does not seem to be a manifestation of cardiac Fabry's disease. To definitively exclude Fabry's disease, however, endomyocardial biopsy is required.

If problems, interventions and complications occurring during oral anticoagulation (OAC) are related with age, indication for OAC, hypertension, diabetes, previous stroke, and number of additional drugs.Clinical characteristics, additional drugs, problems, interventions and complications of outpatients whose OAC was controlled between two years were registered. Potential gastrointestinal and urologic bleeding sources were eliminated prior to initiation of OAC. Five-hundred-seventy-nine patients (mean age 65 years, 44% female) were observed for 590 patient-years.Medical problems occurred in 352/100 patient-years (% p-y), organisational problems in 276% p-y, interventions in 636% p-y and complications in 13.8% p-y. Patients65 years had less organisational problems (254 vs. 302% p-y, p = 0.0092) and interventions (574 vs. 713% p-y, p = 0.0003) than patientsor =65 years. The 35 patients with heart valve prosthesis had more life-threatening and fatal complications (12% p-y) than the 360 patients with atrial fibrillation (1.0% p-y), 128 patients with venous thromboembolism or 56 patients with other indications (0.0% p-y, p = 0.0024). Problems, interventions and complications were not related with hypertension (n = 297), diabetes (n = 97) or previous stroke (n = 90). Patients with3 additional drugs/day had a higher complication rate than patients withor =3 drugs/day (21 vs. 8.7% p-y, p = 0.0238). Patients with complications had more headache (27 vs. 20% p-y, p = 0.0036), chest pain (45 vs. 27% p-y, p = 0.0150), abdominal pain (25 vs. 15% p-y, p = 0.0350) and pain in the limbs (55 vs. 42% p-y, p = 0.0044) than patients without complications.By careful monitoring, eliminating potential bleeding sources, treating pain adequately and minimizing additional drugs the complications of OAC can be kept low.

The prevalence of a patent foramen ovale (PFO) as assessed by transesophageal contrast echocardiography varies considerably among echocardiographic laboratories (ranging from 8 to 54%). 1–3 This striking difference may be due to several reasons: (1) the population studied (age, healthy persons versus patients, history of embolism); (2) the technique used (contrast agent, provocative maneuvers, ultrasonic instrumentation including transducer frequency); and (3) the criteria applied for diagnosis. The aim of the present study was to clarify some of these factors by assessing the interobserver variability of 2 independent echocardiographic laboratories in diagnosing PFO by transesophageal contrast echocardiography.

The diagnosis of pulmonary embolism (PE) is still an unresolved problem. The aim of this prospective observational study was to derive and validate a prediction rule (PEscore) by which PE can be diagnosed by easily obtainable and rapidly available investigations. Included were consecutive patients with a clinical suspicion of PE admitted to a community hospital. Risk factors and clinical and instrumental investigations were registered. PE was diagnosed by angiography, scintigraphy, or autopsy. In 168 patients, PE was either diagnosed (angiography, n = 28; autopsy, n = 18) or excluded (angiography, n = 12; scintigraphy, n = 99; autopsy, n = 11). Based on the results of clinical and instrumental findings, a PEscore was derived by a multiple regression analysis, calculated as: [0.29 x proven leg vein thrombosis (0 = no, 1 = yes)] + [0.25 x ECG right heart strain (0 = no, 1 = yes)] + [0.22 x neck vein distension (0 = no, 1 = yes)] + [0.20 x dyspnoea (0 = no, 1 = yes)] + [0.13 x suspicious chest X-ray (0 = no, 1 = yes)] - [0.17 (constant)]. The PEscore was tested further in 139 subsequent cases. In these patients, the PEscore was 0.65+/-0.17 (diagnosed PE, n = 47) and 0.18+/-0.17 (excluded PE, n = 92), respectively (p = 0.0001). Depending on a given PE-score, the level of probability of PE can be assessed. Calculation of the PEscore can be helpful in clinical decisions when PE is suspected.

Coil embolization of tumor-related coronary arteries was successful in interrupting coronary supply to a cardiac metastasis from uterine leiomyosarcoma. In patients with cardiac metastases of highly malignant tumors this may be a palliative therapeutic approach.

The aim of this prospective noninvasive follow-up study was (1) to assess the progression of cardiac involvement (CI) in patients with myotonic dystrophy (MD), Becker’s muscular dystrophy (BMD) and mitochondrial myopathy (MMP), (2) to find out if CI and neurologic impairment are related and (3) to determine how often cardiac investigations should be performed. Clinical, electrocardiographic, echocardiographic and 24-hour ambulatory electrocardiographic examinations were performed at yearly intervals. CI was assessed qualitatively by the presence of pathologic examinations and quantitatively by the number of pathologic examinations. Qualitatively, CI was present at baseline in 36 of the 38 cases (18–68 years) and the number of cases did not change. Quantitatively, CI progressed after 1 (2) year in 50% (50%) of patients with MD (n = 16), 0% (43%) of patients with BMD (n = 7) and 27% (27%) of patients with MMP (n = 15). CI and neurologic impairment were not related (p = 0.54). Cardiac investigations should be repeated at yearly intervals irrespective of whether there is neurologic deterioration or not.

Embolic complications during ultrasound examinations are a rare cause of neurological deficits. The present case documents the occurrence of embolism by a nonobstructive compression maneuver during transcranial Doppler examination, resulting in a minor stroke. A 63-year-old man suffered from recurrent transient ischemic attacks. Duplex sonography showed a small echogenic plaque at the right carotid bifurcation. During transcranial Doppler studies with a reverberating compression maneuver of the right common carotid artery low in the neck, multiple emboli signals were detected, and the patient developed a left-sided hemiparesis with slurred speech. Funduscopy revealed cholesterol emboli in the inferior temporal arteriole of the right eye. These findings suggested embolization as the cause of the stroke. Compression maneuvers should not be performed in patients with recent neurological symptoms, even in the case of only small lesions in the extracranial carotid territory.

The aim of this trial was to evaluate the effectiveness of extracranial-intracranial bypass with respect to vasomotor reactivity in patients with internal carotid artery occlusions and absent vasomotor reactivity, comparing them with a control group treated conservatively. To test vasomotor reactivity in 104 patients with unilateral occlusion of the internal carotid artery, we measured blood flow velocity in the middle cerebral artery by transcranial Doppler sonography both at rest and after injection of acetazolamide. Among the 39 patients who failed to show increased mean blood flow velocity after the acetazolamide test distal to an occluded internal carotid artery by greater than or equal to 10%, 14 subjects subsequently underwent extracranial-intracranial bypass surgery (group A) and 14 age- and sex-matched subjects in whom no such procedure was done composed the control group (group B). Follow-up examinations were performed 3-6 months postoperatively and in the control group 3-6 months after initial examination. Baseline values of the mean blood flow velocity at rest on the affected side were reduced in both groups compared with the contralateral healthy side (group A, 46.0 +/- 15.1 cm/sec; group B, 48.1 +/- 16.7 cm/sec) and revealed only a marginal increase after acetazolamide. The contralateral side showed a normal blood flow velocity at rest and an adequate response to acetazolamide in both groups. On the follow-up examination group A demonstrated a normalized vasodilatory capacity. Blood flow velocity increased significantly after acetazolamide from 41.9 +/- 13.1 cm/sec to 53.5 +/- 16.0 cm/sec (p less than 0.002). In group B, the compromised vasomotor reactivity remained unchanged. Our results demonstrate that transcranial Doppler sonography together with the acetazolamide test can identify subjects with reduced vasomotor reactivity distal to an occluded internal carotid artery, who may improve hemodynamically by an extracranial-intracranial bypass.

The results of recent studies suggest that paradoxical embolism through a right-to-left shunt may more often be the cause of stroke than was previously supposed. Especially in young patients with otherwise unexplained stroke, the prevalence of a patent foramen ovale has been significantly higher (54 and 56%) than in asymptomatic control subjects (10%). 1,2 Currently, contrast echocardiography together with a Valsalva maneuver is the only noninvasive method that reveals this defect. 3,4 Based on the accurracy of transcranial Doppler sonography in the detection of intracerebral emboli during carotid endarterectomy, 5 we investigated whether the route of paradoxical cerebral embolism through patent foramen ovale may be traced reliably by transcranial contrast Doppler sonography.

Cerebral blood flow was studied in 12 elderly patients with severe calcific aortic stenosis by means of transcranial Doppler sonography (TCD) during percutaneous transluminal aortic valvuloplasty (PTAV). In 8 of these 12 patients duplex sonography revealed a stenosis of the internal carotid artery (ICA) exceeding 50%. Frequency spectra of 10 patients showed a satisfactory quality and were analyzed. In 7 subjects balloon inflation was well tolerated and systolic blood pressure did not drop below 75 mmHg. In these patients, whether they had a stenosis of the ICA or not, blood flow velocity in the middle cerebral artery (MCA) did not decrease to a critical level. The authors defined "critical" as a reduction of mean blood flow velocity in the MCA exceeding 50% or a decrease below 35 cm/sec. Three patients showed a rapid decrease of systolic aortic pressure below 75 mmHg. In these subjects mean blood flow velocity in the MCA dropped to levels below 35 cm/sec. Deflation and retraction of the balloon resulted in a rapid increase of systemic blood pressure and flow velocity in the MCA. This report demonstrates TCD to be a useful monitoring method of determining residual perfusion in patients with aortic stenosis during PTAV.

The percutaneous implantation of vena caval filters has gained acceptance as a means of preventing pulmonary embolism in patients with contraindications to or inefficiency of oral anticoagulants. In the past years, we predominantly used the Guenther filter. Its stainless steel wires are formed into a helical basket and anchoring struts.1 Our experience with 62 patients showed that this device prevents pulmonary embolism effectively. However, cranial and caudal migration of the filter, perforation of the caval wall by the struts, and breakage of the struts have been reported. In 39% of cases, thromboemboli were found inside the filter by computed tomography, but computed tomographic imaging does not allow differentiation between trapped emboli and genuine thrombi.2 Intravascular ultrasound has demonstrated reliable implementation in the diagnosis of peripheral arterial diseases.3,4 McCowan et al5 examined 6 different vena caval filters in vitro and in vivo, and found this method to be superior to both external ultrasound and cavography in detecting thrombi in the filter or vena cava. The present study was performed to assess the implementation of intravascular ultrasound imaging of Guenther basket filters, while paying particular attention to both the detection of trapped or genuine thromboemboli, and the diagnosis of filter perforation and breakage of struts.

Background: Transesophageal echocardiography visualizes the left atrium and its appendage, thrombi, and spontaneous echocardiographic contrast. Objective: To assess the association of transesophage...