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This article provides an overview of the recommendations from the Sports Cardiology section of the European Association of Preventive Cardiology on sports participation in individuals with valvular heart disease (VHD). The aim of these recommendations is to encourage regular physical activity including sports participation, with reasonable precaution to ensure a high level of safety for all affected individuals. Valvular heart disease is usually an age-related degenerative process, predominantly affecting individuals in their fifth decade and onwards. However, there is an increasing group of younger individuals with valvular defects. The diagnosis of cardiac disorders during routine cardiac examination often raises questions about on-going participation in competitive sport with a high dynamic or static component and the level of permissible physical effort during recreational exercise. Although the natural history of several valvular diseases has been reported in the general population, little is known about the potential influence of chronic intensive physical activity on valve function, left ventricular remodelling pulmonary artery pressure, and risk of arrhythmia. Due to the sparsity of data on the effects of exercise on VHD, the present document is largely based on clinical experience and expert opinion.

When an athlete presents with acquired valve disease during pre-participation examination, this often leads to an intensive discussion among the medical staff. Up to now the knowledge of the influence of physical activity on the progression of valvular heart disease (VHD) and ventricular dysfunction is rare. The recommended type of activity (either isometric or dynamic) for a patient with VHD is crucial as it can influence the progression of valvular heart disease as well as ventricular function and the dimensions of heart chambers. Valve defects with a regurgitant component are often better tolerated than stenotic lesions. Dynamic exercise primarily causes increased volume load to the ventricle, whereas static exercise causes mainly a pressure load. Of course, all sports are a combination of these types of effort, but their proportion varies between disciplines. Following adequate clinical evaluation and symptomatic status, echocardiography is the key technique to confirm the diagnosis of VHD as well as to assess its severity and thus prognosis. Indices of left ventricular enlargement and function as well as pulmonary artery pressure are also strong prognostic factors. Transesophageal echocardiography and a stress test to evaluate functional capacity is also of utmost importance to find out if an individual can tolerate the level of exertion expected from the type of sport wished to be engaged in.

Background Recently it has been demonstrated that elevated lipoprotein (a) (LPA) levels are associated with an increased risk of cardiovascular disease across multiple ethnic groups. However, there is only scanty data about the incidence of elevated LPA levels in different patient cohorts. As a consequence, we aimed to examine whether patients with elevated LPA levels might be seen more often in a cardiovascular center in comparison to the general population. Methods We reviewed LPA concentrations of 52,898 consecutive patients who were admitted to our hospital between January 2004 and December 2014. We subdivided them into different groups according to their LPA levels. Data was compared to available information in medical literature. Results 26.4% of the patients had LPA levels >30 mg/dl which is in line with the data from literature. Mean level of LPA concentration in our study was twice as high in comparison to the general population (25.8% vs. 13.3%). 4.6% had LPA levels >98 mg/dl (general population 30 mg/dl is comparable to the general population but mean levels over all are twice as high and the proportion of patients with LPA levels of >98 mg/dl is extremely higher.

Die familiare homozygote Hypercholesterinamie ist mit einer fruhen Manifestation der koronaren Herzkrankheit verbunden. Trotz einer Therapie mittels Lipidapherese und der aktuell zur Verfugung stehenden lipidsenkenden Medikation werden die Zielwerte fur LDL-Cholesterin zur Ver-meidung einer Progression nicht immer erreicht. Liegt wie in dem vorgestellten Fall eine homozygote Nullmutation des LDL-Rezeptors vor, ist die Behandlung mit einem PCSK9-Inhibitor ohne therapeutischen Effekt. Der MTP-Inhibitor Lomitapid bietet einen neuen pharmakologischen Ansatz, das LDL-Cholesterin effektiv zu senken. In der vorgestellten Kasuistik, bei der dieses Medikament erstmalig in Deutschland auserhalb einer Studie eingesetzt wurde, konnte eine deutliche Verbesserung der klinischen Symptomatik dokumentiert werden. Zusammenfassend zeigt sich der personalisierte Einsatz von Lomitapid in Kombination mit einer Lipidapherese als hocheffektive Therapie, da bei nachgewiesener homozygoter LDL-Rezeptor Nullmutation der Nutzen von Statinen und PCSK9-Inhibitoren erheblich eingeschrankt ist.

A consensus document from the Study Group of Sports Cardiology of the Working Group of Cardiac Rehabilitation and Exercise Physiology and the Working Group of Myocardial and Pericardial Diseases of the European Society of Cardiology.

The aim of this study is to evaluate the cost-effectiveness of ECG in combination with family and personal history and physical examination in order to detect cardiovascular diseases that might cause sudden death in athletes. The study was conducted on a cohort of 6,634, mainly young professional and recreational athletes, 1,071 from Algeria and 5,563 from Europe (France, Germany and Greece). Each athlete underwent medical history, physical examination, and resting 12-lead ECG. 293 athletes (4.4 %), 149 in Europe (2.7 %) and 144 in Algeria (13.4 %) required further tests, and 56 were diagnosed with cardiovascular disease and thus disqualified. The cost-effectiveness ratio (CER) was calculated as the ratio between the cost of screening and the number of statistical life-years saved by the intervention. The estimated reduced risk of death deriving from treatment or disqualification resulted in the saving of 79.1 statistical life-years in Europe and 136.3 in Algeria. CER of screening was 4,071 purchasing-power-parity-adjusted US dollars ($PPP) in Europe and 582 $PPP in Algeria. The results of this study strongly support the utilisation of 12-lead ECG in the pre-participation screening of young athletes, especially in countries where secondary preventive care is not highly developed.

Electromyostimulation (EMS) of thigh and gluteal muscles is a strategy to increase exercise capacity in patients with chronic heart failure (CHF). The aim of this non-randomised pilot study was to investigate the effects of different stimulation strategies in CHF patients using a newly developed stimulation suit also involving trunk and arm muscles [extended electromyostimulation (exEMS)] in comparison with EMS therapy limited to gluteal and leg muscles (limEMS). 60 individuals joined the EMS training programme. Stable CHF patients (NYHA class II–III) received either exEMS (22 patients, 15 males, mean age 59.95 ± 13.16 years) or limEMS (12 patients, 9 males, 62.75 ± 8.77 years). 26 participants served as healthy control group (CG) receiving exEMS. Training was performed for 10 weeks twice weekly for 20 min, and the level of daily activity remained unchanged. Effects on exercise capacity, oxygen uptake, left ventricular function (EF) and biomarkers were evaluated. There was a significant increase of oxygen uptake at aerobic threshold in all groups (exEMS: 13.7 ± 3.9–17.6 ± 5.1 ml/kg/min (+28.46 %, p

Homozygous hypercholesterolemia is an extremely rare genetic disorder caused by mutations in the LDL receptor gene or occasionally by mutations in other genes like proprotein convertase subtilisin / kexin 9 (PCSK9). Gold standard of homozygous hypercholesterolemia therapy is apheresis, accompanied by high-dose statin and ezetimibe therapy. The cholesterol-lowering effect can be supported by new agents like inhibitors of microsomal triglyceride transfer protein (lomitapide), or by enhancing LDL catabolism through inhibition of the PCSK9 activity. We present the case of a young woman with homozygous hyperlipidemia due to a mutation c.1200 CA(p.Tyr400*) in the LDLR gene that introduces a stop-codon at amino acid position 400. This truncated LDLR cannot mediate a membrane-bound uptake of LDL cholesterol. A combined therapy including simvastatin, ezetimibe and apheresis did not lead to satisfactory LDL levels. By adding lomitapide, a dramatic receptor-independent reduction of LDL was achieved.

OBJECTIVE Cardiac adaptation to sports activity in endurance athletes is considerably different from that in power athletes. The effects of a high-level team sport like handball, one of the most popular sports in the world, performed at a younger age, on cardiac rhythm in individuals above the age of 50 have not been investigated to date. METHODS Thirty-three former top-level handball players from the first German league (6 former world champions and numerous Olympians) (57.5 +/- 5.5 y) joined our screening programme for former athletes and underwent electrocardiography, echocardiography and spiroergometry. Data were compared to 24 sedentary healthy controls. RESULTS Ten of the 33 athletes suffered from atrial fibrillation (AF). Left ventricular diameter was 53.68 +/- 4.88 mm in the athletes group and 50.58 +/- 4.12 mm in the healthy controls. Analysing the subgroups of handball players ('AF group' and 'non-AF group'), spiroergometry showed oxygen consumption at the anaerobic threshold of 27.54 +/- 6.77 ml/kg/min in the AF group and 31.24 +/- 10.33 ml/kg/min in the non-AF group (P = 0.228). Absolute left atrial diameter was 44.34 +/- 4.41 mm in the AF group (non-AF group 38.94 +/- 3.77 mm, P < 0.001) (healthy controls 37.54 +/- 4.34 mm, compared with all athletes P = 0.015). In all individuals left ventricular wall thickness was within normal limits. However, myocardial walls were thicker in the AF group (11.28 +/- 1.83 mm) than in the non-AF group (9.44 +/- 1.26 mm, P = 0.002). Athletes in the AF group (187.6 +/- 6.42 cm) were significantly taller than in the non-AF group (180.91 +/- 7.31 cm, P = 0.018). CONCLUSION Not only endurance training, but also sports activity with a relevant static component, like team handball, might predispose for AF above the age of 50. LA size, height and myocardial wall thickness seem to affect the risk of developing AF. More data in non-endurance sports are mandatory to confirm this hypothesis.

Contains fulltext : 89482.pdf (Publisher’s version ) (Closed access) Cardiovascular remodelling in the conditioned athlete is frequently associated with physiological ECG changes. Abnormalities, however, may be detected which represent expression of an underlying heart disease that puts the athlete at risk of arrhythmic cardiac arrest during sports. It is mandatory that ECG changes resulting from intensive physical training are distinguished from abnormalities which reflect a potential cardiac pathology. The present article represents the consensus statement of an international panel of cardiologists and sports medical physicians with expertise in the fields of electrocardiography, imaging, inherited cardiovascular disease, cardiovascular pathology, and management of young competitive athletes. The document provides cardiologists and sports medical physicians with a modern approach to correct interpretation of 12-lead ECG in the athlete and emerging understanding of incomplete penetrance of inherited cardiovascular disease. When the ECG of an athlete is examined, the main objective is to distinguish between physiological patterns that should cause no alarm and those that require action and/or additional testing to exclude (or confirm) the suspicion of an underlying cardiovascular condition carrying the risk of sudden death during sports. The aim of the present position paper is to provide a framework for this distinction. For every ECG abnormality, the document focuses on the ensuing clinical work-up required for differential diagnosis and clinical assessment. When appropriate the referral options for risk stratification and cardiovascular management of the athlete are briefly addressed. 01 januari 2010

Out-patient groups of hypertensives were organized in an effort to improve long-term treatment results with greater attention to general measures and to increase compliance. Under supervision of a doctor and a physiotherapist 45 patients (aged 54 +/- 10 years) with mild or moderately severe hypertension were enrolled in a sports training programme after thorough examination. At the same time they were given advice and instructions on self-measurement of blood pressure, diet, medication, general life style and relaxation techniques. In the first 20 patients (observation period of more than one year) a significant reduction in both resting (systolic of -9%) and exercise (systolic of -12%) blood pressures was noted. At the same time exercise tolerance was raised (+18%), while body-weight and total cholesterol concentrations were lowered. It was possible to reduce drug dosage in seven patients, in three more it was discontinued. Left-ventricular wall thickness fell slightly but not significantly. There were no complications. It is concluded that group therapy with sport as a vehicle and advice on general life style are satisfactory means for controlling hypertension and achieve better compliance.

The chest roentgenogram in a 46-year-old woman with dyspnoea for several months revealed global cardiac enlargement. Echocardiography demonstrated a tumour in the right atrium, about 4 x 5 cm, as well as circular pericardial effusion. Septic temperatures occurred in the further course, and blood cultures grew Staphylococcus aureus. Recurrent pulmonary emboli and cerebral emboli with hemiparesis, especially of the brachiofacial region, occurred despite heparinization. Shortly after hospitalization a chest roentgenogram revealed a round shadow, about 1 cm in diameter, in the left upper lobe. The patient died in cardiogenic shock on the 16th hospital day. Autopsy showed the tumour to be a poorly differentiated round-cell sarcoma, originating from the wall of the right atrium, infiltrating the myocardium through to the epicardium and extending to the tricuspid orifice. The foramen ovale was open, making paradoxical emboli at atrial level possible.

In patients with type 2 diabetes mellitus (T2DM) exercise training is recommended to improve glycemic control. Electrical myostimulation (EMS) of skeletal muscles is a new method to increase exercise capacity in patients with chronic heart failure. The aim of this study was to investigate the effects of EMS in T2DM on glucose metabolism, body composition, and exercise performance using a newly designed stimulation suit that involves trunk, leg, and arm muscles.Fifteen individuals (nine males; 61.7±14.8 years old) were trained for 10 weeks twice weekly for 20 min with EMS. Effects on glucose, glycosylated hemoglobin (HbA(1c)), oxygen consumption, and body composition were evaluated.There was a significant increase of oxygen uptake at the aerobic threshold from 12.3±0.8 to 13.3±0.7 mL/kg/min (P=0.003) and of maximal work capacity from 96.9±6.4 to 101.4±7.9 W (P=0.046), with a concomitant trend for improved maximal oxygen uptake (from 14.5±0.9 to 14.7±0.9 mL/kg/min [P=0.059]). Fasting blood glucose level decreased from 164.0±12.5 to 133.4±9.9 mg/dL (P=0.001), and HbA(1c) level decreased from 7.7±0.3% to 7.2±0.3% (P=0.041), whereas mean total weight (from 101.5±4.0 to 103.1±4.3 kg) and proportion of body fat (from 38.8±3.2% to 40.3±3.4%) remained statistically unchanged.EMS can improve glucose metabolism and functional performance in T2DM patients. These data suggest that EMS might emerge as a novel additional therapeutic mode of exercise training and might help patients to overcome their sedentary lifestyle.

Elevated lipoprotein(a) (Lp(a)) levels are an accepted risk factor for coronary heart disease. The role of Lp(a) in the development of extracardiac arteriosclerosis like peripheral arterial disease (PAD) and stenosis of the arteria carotis (ACIS) has hardly been documented so far. We aimed to investigate the incidence of extracardiac arteriosclerosis in individuals with elevated Lp(a) values.In our center, we measured Lp(a) levels in 31,734 consecutive patients over 5 years. Of these, 1411 patients were selected retrospectively for the presented analysis. Patients were matched according to age, sex, and other accepted cardiovascular risk factors and were assigned to 6 groups according to their Lp(a) values. Retrospectively, we analysed the incidence of PAD and ACIS.In the group with Lp(a) values 2 mg/dl the incidence of PAD was 1.9 % (ACIS 2.8 %), in the group with Lp(a) 23-29 mg/dl 7.3 % (6.1 %), 30-60 mg/dl 9.0 % (8.3 %), 60-91 mg/dl 11.4 % (7.9 %), 91-110 mg/dl 8.6 % (6.0 %) and 110 mg/dl 12.7 % (10.9 %). None of the patients had LDL levels 130 mg/dl or HbA1c 6.1 %.Elevated Lp(a) levels seem to be associated with an increased incidence of PAD and ACIS. Even Lp(a) concentrations between 23 and 29 mg/dl show a threefold increased risk of PAD when compared to patients with Lp(a) 2 mg/dl. However, these findings have to be verified in large prospective studies. In this context cut-off values have to be reevaluated as well.

The 1996 American Heart Association consensus panel recommendations stated that pre-participation cardiovascular screening for young competitive athletes is justifiable and compelling on ethical, legal, and medical grounds. The present article represents the consensus statement of the Study Group on Sports Cardiology of the Working Group on Cardiac Rehabilitation and Exercise Physiology and the Working Group on Myocardial and Pericardial diseases of the European Society of Cardiology, which comprises cardiovascular specialists and other physicians from different European countries with extensive clinical experience with young competitive athletes, as well as with pathological substrates of sudden death. The document takes note of the 25-year Italian experience on systematic pre-participation screening of competitive athletes and focuses on relevant issues, mostly regarding the relative risk, causes, and prevalence of sudden death in athletes; the efficacy, feasibility, and cost-effectiveness of population-based pre-participation cardiovascular screening; the key role of 12-lead ECG for identification of cardiovascular diseases such as cardiomyopathies and channelopathies at risk of sudden death during sports; and the potential of preventing fatal events. The main purpose of the consensus document is to reinforce the principle of the need for pre-participation medical clearance of all young athletes involved in organized sports programmes, on the basis of (i) the proven efficacy of systematic screening by 12-lead ECG (in addition to history and physical examination) to identify hypertrophic cardiomyopathy-the leading cause of sports-related sudden death-and to prevent athletic field fatalities; (ii) the potential screening ability in detecting other lethal cardiovascular diseases presenting with ECG abnormalities. The consensus document recommends the implementation of a common European screening protocol essentially based on 12-lead ECG.

Die koronare Vasodilatationskapazitat ist bei Hypercholesterinamie infolge der Endotheldysfunktion (ED) vermindert. Eine medikamentose Cholesterinsenkung kann die ED weitgehend normalisieren. Es ist jedoch strittig, wie schnell dieser Effekt eintritt. Bisher wird ein Zeitintervall von Wochen bis Monaten angenommen. Mittels LDL-Apherese ist eine bedeutsame LDL-Senkung innerhalb von Stunden moglich. Die vor und nach LDL-Apherese durchgefuhrte dynamische quantitative Positronenemissionstomographie ermoglicht die Messung der gemittelten globalen Myokardperfusion in Ruhe und nach pharmakologischer Vasodilatation mittels Dipyridamol unter Verwendung von N-13-Ammoniak als Tracersubstanz. Bei 35 Patienten (11 Frauen und 24 Manner) mit dokumentierter koronarer Herzkrankheit und Hypercholesterinamie wurde unmittelbar vor der LDL-Apherese und innerhalb von 18–20 h danach eine Positronenemissionstomographie durchgefuhrt. Parallel zur Senkung des LDL-Cholesterins (von 175±50 auf 77±25 mg/dl) und des Fibrinogens (von 287±75 auf 155±52 mg/dl) konnte eine signifikante Verbesserung des myokardialen Blutflusses unter Dipyridamolstimulation (177±59 vs. 217±82 ml/min 100 g, p

Bei familiarer Hypercholesterinamie erfordert die koronare Herzkrankheit im Kindesalter sowohl eine medikamentose Therapie als auch den Einsatz der LDL-Apherese. Im vorgestellten Fall konnte bei einem 10-jahrigen Patienten ein Verschluss des Ramus descendens anterior der linken Koronararterie nachgewiesen werden. Wegweisend war die pathologische Ergometrie. Mit Hilfe der LDL-Apherese wird die maximal erreichbare Senkung der Lipidparameter und des Fibrinogens bei Senkung der Plasmaviskositat angestrebt. Erstaunlicher Weise wird diese Behandlung auch von Kindern gut toleriert, die notigen Gefaszugange sind ausreichend, Shunt-Operationen nicht unbedingt erforderlich. Die Effizienz dieses Verfahrens zeigte sich an den beeindruckenden Veranderungen der Hauteffloreszenzen. Die weiteren angiographischen Kontrollen und der klinische Verlauf werden Aufschluss geben uber den Nutzen der Behandlungsstrategie der maximalen Lipidtherapie und die erhoffte Prognoseverbesserung.

An acute Lyme carditis affects about 0.3-4% of patients with Lyme borreliosis. The acute period of the disease may be associated with critical atrioventricular conduction abnormalities (complete heart block), supraventricular and ventricular arrhythmias as well a left ventricular failure. Normally, Lyme carditis is completely reversible. Therefore the prognosis largely depends on the management of the acute complications and early antibiotic therapy. Even if the symptoms are spontaneously reversible, antibiotic therapy should be applied to prevent a chronic cardiomyopathy and other manifestations of Lyme borreliosis. We report on a 47-year old patient with acute ECG changes initially suggesting an acute coronary syndrome. However, case history and the erythema migrans indicated an acute Lyme carditis which was confirmed serologically and by myocardial biopsy later.

Zusammenfassung: In vielen Sportarten wird ein regelmäßiges, richtliniengetreues kardiales Screening zur Verhinderung des plötzlichen Herztods noch immer nicht gewährleistet. Wir nahmen die Handball Europameisterschaften, welche 2010 in Wien und weiteren Städten in Österreich stattfanden, zum Anlass, die aktuelle Situation bei Toplevel-Handballern zu untersuchen: Ein standardisierter Fragebogen wurde vor dem Turnier an alle qualifizierten Teams und Spieler versandt. Eine Rücklaufrate von 42,7 % kann zum Schluss führen, dass das Problem des plötzlichen Herztods bei den Spielern und Verantwortlichen unterschätzt wird. Die überwiegende Mehrzahl der Spieler (82 %) wurde gemäß der Auswertung der Fragebögen korrekt, entsprechend der aktuellen Screening-Richtlinien untersucht. In gut der Hälfte der Teams wurde das Screening jedoch "inhomogen" durchgeführt. 5 Spieler (4,1 %) wurden zumindest nicht innerhalb der letzten Jahre untersucht, bei 1 Spieler (0,8 %) wurde kein EKG durchgeführt. Während 69 % der Handballer ihr erstes Screening erst nach dem Alter von 18 Jahren durchliefen, wurden 16 Spieler (13,1 %) gar niemals zuvor einer kardialen Vorsorgeuntersuchung unterzogen. Schließlich identifizierten wir aufgrund der Fragebögen 17 Athleten (13,9 %) mit einer hoch suspekten Anamnese, wovon 2 Athleten (1,6 %) niemals zuvor kardiologisch abgeklärt wurden

Echocardiographic tissue Doppler imaging (TDI) has been proposed for the differentiation of physiologic left ventricular hypertrophy and pathologic left ventricular hypertrophy in athletes. In addition, cutoff values for systolic (S'9 cm/s) and early diastolic (E'9 cm/s) myocardial velocities had been defined. The aim of our study was the analysis of the morphologic cardiac changes by standard echocardiography, and the myocardial velocities S' and E' by TDI in top-level handball players with respect to the predefined cutoff values.Pulsed-wave TDI of the systolic and early diastolic velocities was performed at the lateral and septal mitral annulus (MA) in the four-chamber view in 100 athletes (100 Caucasian men; professional handball players of the first German handball league and the German national team; mean age 25.8+/-4.8 years).Global and regional left ventricular systolic function was normal in all athletes. They showed an eccentric hypertrophy of the left ventricle (LV), which was characterized by an increased mass of the LV (287.3+/-58.4 g), and an increased end diastolic diameter of the LV (LVEDD: 58+/-5.9 mm), but no echomorphologic signs of pathologic hypertrophy or hypertrophic cardiomyopathy. TDI showed a systolic velocity S' of the MA of 9.3+/-1.5 cm/s at the septal and 10.5+/-2.1 at the lateral MA. Ten of the 100 athletes showed a S'9 cm/s at both sides of the MA. TDI showed an early diastolic velocity E' of the MA of 13.2+/-2.8 cm/s at the septal and of 16.6+/-3.4 cm/s at the lateral MA. None of the 100 athletes showed reduced systolic or early diastolic velocities below the proposed cutoff values (S' and E'9 cm/s) at any sides of the MA.Our study provides further insights into systolic and diastolic function as assessed by TDI in top-level handball players. Owing to the large cohort of individuals, our findings might be helpful as reference values for the echocardiographic assessment of handball players, who are performing a moderate static and high dynamic sport.

Current guidelines concerning the treatment of patients with chronic congestive heart failure (CHF) include ergospirometry-directed dynamic exercises on a daily basis. Several prospective, randomized trials have confirmed its positive influence on clinical symptoms and prognosis of the disease. Patients with stable coronary artery disease (CAD) can benefit from a 27% reduction of mortality, as shown in meta-analyses of several studies. By contrast, patients with CHF have traditionally been discouraged from physical activities, which may have had detrimental consequences. They became even less able to participate in daily activities that in turn hastened the disease-driven atrophies of skeletal muscles. On the other hand, well-adjusted endurance training at 50-70% of maximum oxygen uptake was shown to improve overall fitness. In a recent metaanalysis, the mortality of patients with CHF was reduced by 35% by sports, and the rate of hospitalizations dropped by 28%. It is a well-perceived clinical problem that successful treatment is not possible without intensive guidance and a close therapeutic relationship. Being left in their routine situation and circumstances, the majority of patients cannot cope with the day-to-day challenge of an independent, active lifestyle. Among the primary reasons not to sustain physical activity are mental, psychological or social barriers.The authors have begun, in a cohort of patients with CHF, a prospective pilot study to investigate the impact of, and attitude to, electromyostimulation (EMS). Unique features of this treatment include its passive nature that remains independent of mental attitude.An up to 96% increase of peak oxygen uptake at the anaerobic threshold could be shown (pre- vs. posttraining phase, VO(2at) 19.39 [+/- 5.3] ml/kg vs. 24.25 [+/- 6.34] ml/kg). The diastolic blood pressure decreased significantly. A 14% gain in muscle volume was observed, while overall body weight remained unchanged. All patients kept up the training until the conclusion of the study and found their overall fitness to be considerably improved.The results may indicate the enormous potential of EMS for the treatment of patients within the cardiologic arena, especially those with CHF.

Physical check-ups among athletes with valvular heart disease are of significant relevance. In athletes with mitral valve stenosis the extent of allowed physical activity is dependant on the size of the left atrium and the severity of the valve defect. Patients with mild-to-moderate mitral valve regurgitation can participate in all types of sport associated with low and moderate isometric stress and moderate dynamic stress. Patients under anticoagulation should not participate in any type of contact sport. Asymptomatic athletes with mild aortic valve stenosis can take part in all types of sport, as long as left ventricular function and size are normal, a normal response to exercise at the level performed during athletic activities is present and there are no arrhythmias. Asymptomatic athletes with moderate aortic valve stenosis should only take part in sports with low dynamic and static stress. Aortic valve regurgitation is often present due to connective tissue disease of a bicuspid valve. Athletes with mild aortic valve regurgitation, with normal end diastolic left ventricular size and systolic function can participate in all types of sport. A mitral valve prolapse is often associated with structural diseases of the myocardium and endocardium. In patients with mitral valve prolapse Holter-ECG monitoring should also be performed to detect significant arrhythmias. All athletes with known valvular heart disease, a previous history of infective endocarditis and valve surgery should receive endocarditis prophylaxis before dental, oral, respiratory, intestinal and genitourinary procedures associated with bacteraemia. Sport activities have to be avoided during active infection with fever.

Hypercholesterolemia impairs endothelial function and subsequently decreases coronary vasodilatatory capacity. We examined the quantitative effects of one single LDL apheresis on vasodilatatory capacity. Using N-13 ammonia as a tracer for dynamic quantitative positron emission tomography (PET), mean myocardial perfusion measurements were carried out before and 20 h later after LDL apheresis, both under resting conditions and after pharmacological vasodilatation with dipyridamole. LDL apheresis was carried out using the heparin induced extracorporeal LDL precipitation (H.E.L.P.) procedure. We examined 47 patients (12 women and 35 men), with angiographically-proven coronary artery disease. All of them suffered from hypercholesterolemia. Of the patients, 35 received a chronic weekly H.E.L.P. procedure (group A), while H.E.L.P. procedure treatment was started for the first time in 12 patients, who were subsequently enrolled in a chronic apheresis program (group B). H.E.L.P. apheresis was combined with cholesterol lowering drugs in all patients. Both groups underwent positron emission tomography twice (prior to LDL apheresis and 20 h later). In group A, LDL cholesterol levels decreased from 175 +/- 50 mg/dL to 60 +/- 21 mg/dL immediately after H.E.L.P. (77 +/- 25 mg/dL before the second PET). Corresponding values for fibrinogen levels were 287 +/- 75 mg/dL to 102 +/- 29 mg/dL (155 +/- 52 mg/dL), minimal coronary resistance dropped from 0.56 +/- 0.20 to 0.44 +/- 0.17 mm Hg x 100 g x min/mL (P < 0.0001). Plasma viscosity decreased by 7.8%. In group B, LDL cholesterol decreased from 187 +/- 45 mg/dL to 75 +/- 27 mg/dL (85 +/- 29 mg/dL) and fibrinogen from 348 +/- 65 mg/dL to 126 +/- 38 mg/dL (168 +/- 45 mg/dL). Minimal coronary resistance was reduced from 0.61 +/- 0.23 to 0.53 +/- 0.19 mm Hg x 100 g x min/mL (P < 0.01). Plasma viscosity was observed to decrease by 7.6%. The strong LDL drop in patients under chronic H.E.L.P. treatment has a significant impact on coronary vasodilatatory capacity within 20 h leading to an improved overall cardiac perfusion. Nearly the same effect can be seen in patients after their first H.E.L.P. treatment.

The key challenge in athlete's screening is the distinction between abnormal and normal which is hindered by the fact that the adaptation to sports activity in endurance athletes is different to that in power athletes. Especially cardiomyopathies provoke changes in ECG and echocardiography (echo) at an early stage when clinical symptoms are absent. ECG and echo data and their relationship to fitness peculiar to top handball players have never been described. We studied 291 male first league handball players (32 Olympians/47 national players) (25.3±4.4 years). Check up consisted of ECG, spiroergometry and echocardiography. None had T-wave inversions, 3.1% showed early repolarisation abnormalities in the precordial leads. Sokolow-Lyon voltage criterion for left ventricular hypertrophy was positive in 19.3%. Spiroergometry showed a maximum oxygen uptake (peakVO₂) of 50.3±7.7 ml/min/kg body weight. LVmass was increased in comparison to normal values. There was a correlation between peakVO₂ and LVindex (p

LDL-Cholesterin gilt als eine Schlusselsubstanz fur die Ausbildung und Progredienz eines atherosklerotischen Prozesses und stellt einen Risikofaktor erster Ordnung fur die Atherogenese dar. Ein linearer Anstieg des Plasmacholesterins ist verbunden mit einer exponentiellen Erhohung des koronaren Risikos (1, 2).

Die H.E.L.P.-Apherese ist ein etabliertes Verfahren zur Therapie einer schweren Hypercholesterinamie bei Patienten in fortgeschrittenen Stadien der koronaren Herzkrankheit. Es ist jedoch bekannt, dass sowohl die Hypercholesterinamie selbst als auch die Behandlung mittels extrakorporaler Zirkulation mit vermehrtem oxidativem Stress verbunden sind. Das Gleichgewicht zwischen Antioxidanzien und Oxidanzien im Rahmen der H.E.L.P.-Apherese wurde von mehreren Arbeitsgruppen untersucht. Die Untersuchungen belegen eine gesteigerte Resistenz von LDL gegen oxidativen Stress nach der H.E.L.P.-Behandlung. Wir untersuchten den Einfluss einer einmaligen H.E.L.P.-Apherese auf die Plasmakonzentrationen von Parametern der Lipidperoxidation bei 12 Patienten mit heterozygoter familiarer Hypercholesterinamie und koronarer Herzkrankeit, die sich einmal wochentlich einer Apherese unterzogen. Eine einmalige H.E.L.P.-Apherese reduzierte die Plasmakonzentrationen von oxidiertem LDL und Malondialdehyd, ohne einen Einfluss auf die zellulare Cu/Zn-Superoxiddismutase (Cu/ZnSOD) zu haben. Die antioxidative Serumkapazitat nahm nach der Apherese tendenziell ab. Dagegen sind die Plasmakonzentrationen von 8-Isoprostan- PGF2α angestiegen. Bei der H.E.L.P.-Apherese uberwiegen die antioxidativen Effekte. Dem Benefit der LDL-Senkung wirkt die Oxidation von Lipiden bzw. die bedeutsame Modifikation der enzymatischen und nichtenzymatischen Antioxidanzien wahrend extrakorporaler Zirkulation nicht entgegen.

Ein Zusammenhang zwischen erhohten Lp(a)-Werten und der Inzidenz der KHK ist eindeutig belegt. Die Bedeutung einer Lp(a)-Erhohung fur die Entstehung einer Arteriosklerose mit extrakardialer Manifestation ist bisher nur wenig untersucht. Inwieweit ein erhohter Lp(a)-Wert als eigenstandiger Risikofaktor fur das Auftreten einer peripheren arteriellen Verschlusskrankheit (pAVK) und einer Stenose der Arteria carotis interna (ACIS) gesehen werden kann, war Ziel der vorliegenden Untersuchung. In unserer Klinik wurde uber 5 Jahre bei 31.734 konsekutiven Patienten ein Lp(a)-Wert bestimmt. Hiervon wurden 1411 Patienten retrospektiv fur diese Studie rekrutiert. Die Patienten wurden nach Matching hinsichtlich Alter, Geschlecht und ubriger Risikofaktoren in sechs etwa gleich grose Gruppen gemas des erhobenen Lp(a)-Wertes eingeteilt. Wir bestimmten die Haufigkeit einer pAVK und einer ACIS. Keiner der Patienten hatte ein LDL > 130 mg/dl oder ein HbA1c ≥ 6,1 %. In der Gruppe mit Lp(a)-Werten 110 mg/dl 12,7 % (10,9 %). Es besteht ein Zusammenhang zwischen der Lp(a)-Konzentration und dem Auftreten einer nichtkardialen Arteriosklerose. Bereits Lp(a)-Konzentrationen

Introduction Low density lipoprotein (LDL-C) apheresis is a last treatment option for hypercholesterolemic patientsresistant to conservative lipid-lowering therapy. In a retrospective analysis of 8,533 heparin-induced extra-corporeal LDL precipitation apheresis treatments (HELP), we evaluated the efficacy of LDL reduction, the rate of adverse events, and the progression of atherosclerosis. Methods Between July 1992 and April 2009, we performed 8,533 HELP apheresis therapies in patients with familial hypercholesterolemia (FH). Inclusion criteria were FH with insufficient lipidological status under optimal drug therapy and diet, and at least 50 HELP therapies. Left ventricular function and valvular status was checked prior to the first apheresis therapy and at the end of the individual HELP program. Blood samples were taken directly before and after each therapy. Blood count, electrolytes, total cholesterol, LDL–C, high density lipoprotein (HDL–C), triglycerides, lipoprotein (a) (Lp(a)), and fibrinogen were measured. Adverse events were documented weekly. Results We evaluated 27 patients (19 men) with FH (age 49.2 ± 12.5 years (range 10–67 years)). The number of HELP treatments once weekly was between 50 and 790 applications. Mean follow-up time was 7.0 ± 5.2 years (range 1.3–16.6 years). Prior to the individual apheresis program, 44.4% of the patients had a three vessel disease (VD; 25.9% two VD, 25.9% one VD) and 7.4% had a peripheral arterial occlusive disease. During the time of HELP treatment, none of the patients had a myocardial infarction; 3.7% had one percutaneous coronary intervention (PCI), 11.1% two PCI, 14.8% three PCI, 11.1% ³ four PCI. The patients received 1.2 ± 1.6 (range 0–5) PCI during follow-up time. Adverse events directly associated with HELP therapy were very rare (