Search

Objectives Cardiovascular diseases (CVDs) occur more often in people living with HIV (PLWH) than in the general population. It has been reported that CVD risk scores developed for the general population underestimate the CVD risk in PLWH. Performances of the Framingham Risk Score (FRS), the Systematic Coronary Risk Evaluation (SCORE) and the atherosclerotic cardiovascular disease (asCVD) risk score in PLWH were compared with the general population to quantify score-specific differences in risk prediction. Methods HIV-positive outpatients from the HIV-HEART (HIVH) study (n = 567) were compared with participants from the population-based Heinz Nixdorf Recall (HNR) study (n ~ 4440) both recruited from the German Ruhr area. During a follow-up time of around 5 years, the associations between the FRS and incident CVD and peripheral artery disease (CVD_pAD), SCORE and coronary heart disease (CHD), and asCVD and incident CVD were examined using logistic regression. Score performances were assessed by comparing the areas under the curve (AUCs). Results The mean ages were 52.9 ± 6.7 and 59.1 ± 7.7 years in the HIVH and HNR studies, respectively. There were fewer incident CVD events in the HNR study than in the HIVH study (CVD_pAD: 3.9% vs. 12.1%; CHD: 2.1% vs. 7.8%; CVD: 3.5% vs. 9.9%). Age- and sex-adjusted CVD risk was greater with increasing FRS, SCORE and asCVD in both cohorts, but the scores performed more accurately in the HNR than in HIVH study (AUCs FRS: 0.71 vs. 0.65; SCORE: 0.70 vs. 0.62; asCVD: 0.74 vs. 0.62). Conclusions Associations between risk scores and future CVD were observed in both cohorts, but the score performances were less reliable in PLWH than in the general population.

Hintergrund: Ob Diabetiker mit Übergewicht oder moderater Adipositas eine geringere Mortalität aufweisen als Diabetiker mit Normalgewicht, wird kontrovers diskutiert. Während einige Autoren ein solches Adipositasparadox bei Diabetikern für plausibel halten, vermuten andere methodische[zum vollständigen Text gelangen Sie über die oben angegebene URL], 64. Jahrestagung der Deutschen Gesellschaft für Medizinische Informatik, Biometrie und Epidemiologie e.V. (GMDS)

In contrast to the situation in the 1960s and 1970s, the mortality risk for patients with myocardial infarction has been clearly reduced, particularly for those with myocardial infarction with cardiogenic shock (MICS). Approximately 5‑10 % of patients with a myocardial infarction are affected by a MICS and the mortality risk is between 30 % and 50 %. The primary percutaneous coronary intervention with stent implantation should be carried out as quickly as possible in order to reduce the mortality to around 20 %. This article gives an overview of the currently available options for conservative and fibrinolytic treatment of MICS, of the interventional treatment of cardiogenic shock in the era of intravenous and intracoronary infarct treatment as well as without thrombolysis. In addition, the currently available mechanical support systems and the possibilities for surveillance and monitoring of patients are presented.

Aortic diseases include not only the thoracic but also the abdominal part of the aorta. In the etiology cardiovascular risk factors, such as hypertension, smoking and hyperlipoproteinemia play a major role, but more and more genetic diseases with familiar predisposition are being identified. Even large aneurysms remain asymptomatic as long as other organs in the neighborhood are not damaged and no acute aortic event occurs including aortic dissection, intramural hematoma, penetrating aortic ulcer, and traumatic aortic injury. Standardized algorithms allow precise and rapid diagnosis for initiating medicinal therapy or operative and/or endovascular interventions (thoracic/endovascular aortic repair, TEVAR/EVAR) in this emergency situation. Specialized aortic centers are recommended to form localized regional networks.

The tricuspid valve and the right ventricle are hemodynamically closely related. Pathological changes of the valve or of the ventricle itself and also various diseases beyond that can result in a downward spiral of mutual interference, which is of prognostic importance for the patient. The development of a functional tricuspid regurgitation is of great importance. Especially with the help of 3D-echocardiography, more and more changes and mechanisms have been identified that are crucial in this process. This article provides a review of the relationship between the tricuspid valve and the right ventricle emphasizing the current knowledge of the causes, the pathophysiological concepts, the underlying structural changes and the therapeutic approaches based on this.

The article reviews the state of vascular-platelet hemostasis in patients with coronary heart disease and diabetes mellitus type 2. It was shown the less efficiency and the higher incidence of resistance to the classic double antiplatelet therapy in these patients after coronary stenting.

Background: The complexity of the heart failure with preserved ejection fraction (HFPEF) syndrome makes that the best approach towards diagnosis is still not fully established. According to recent studies stress echocardiography may be useful to improve the diagnosis, but its exact place in clinical practice is still unproven. Methods: Tissue Doppler velocity traces were acquired from 55 subjects at rest and during submaximal exercise (semi- supine bicycle) at the basal septum and lateral wall, and temporally aligned to a common reference for comparison. This population consisted of 19 HFPEF patients (diagnosed by the HFA of ESC criteria), 14 controls with unexplained breathlessness (EF>50%, did not fulfill HFA criteria) and 22 healthy controls. Each stage of the stress protocol was independently analyzed by an unsupervised machine learning algorithm that spread the data according to their most relevant characteristics. Results: The use of exercise data resulted in a better separation of healthy controls and HFPEF subjects than using rest data (spec=86.3% vs. spec=81.8% while the sensitivity does not substantially change). Notably, the stress protocol identified critical breathless subjects, which during exercise get close to the HFPEF subgroup while they were not differentiated from controls at rest (p-value in the figure). Conclusion: The characterization of HFPEF is significantly improved by analyzing velocities acquired during exercise. The method has strong clinical potential to identify critical breathless subjects at an early stage.

Hintergrund Soziale Ungleichheiten im Ernahrungsverhalten sind belegt, die Ursachen hierfur jedoch nicht ausreichend untersucht. Die vorliegende Arbeit bezieht sich auf ausgewahlte Ernahrungseinstellungen als Vermittlungsfaktor. Es wird pruft, ob diese Einstellungen bei Mannern und Frauen sozial ungleich verteilt sind und ob sie soziale Ungleichheiten des Ernahrungsverhaltens erklaren.

Infective endocarditis is an endovascular infection usually caused by bacteria. Mortality rate is still approximately 20 %. To improve patients' prognosis by implementation of current diagnostic and therapeutic evidence, the European Society of Cardiology published an updated version of the guidelines for management of infective endocarditis in 2015. It strengthens the role of imaging modalities like PET/CT for detection of infectious foci when echocardiography remains negative and highlights the use of modern tests for identification of possible pathogens. New diagnostic criteria were introduced to integrate these methods for improved diagnostic sensitivity. Complicated cases should be treated in reference centers with on-site cardiac surgery. The antibiotic and early surgical management should be discussed in a multidisciplinary endocarditis team. A few years ago, the indication for endocarditis prophylaxis was limited to high-risk patients. These recommendations were confirmed in current guidelines.

Purpose The aim of this study was to introduce population-based sex and age-stratified distributions of carotid intima media thickness (CIMT), to compare fixed cut-off and percentile values for subjects with and without known coronary heart disease (CHD) and to describe CIMT percentiles. Methods Between 2000 and 2003, a total of 4,814 subjects aged 45-75 years were recruited into the Heinz Nixdorf recall study (HNR). Ultrasound examination of extracranial arteries was performed and the CIMT was measured manually over a distance of 1 cm proximal to the bulb in the common carotid artery (CCA). Both sides were measured and the average of the right and left artery were calculated (mean CIMT). Results The CIMT was measured for 1,749 men and 1,802 women without prevalent CHD and 177 men and 50 women with prevalent CHD. Mean CIMT values were higher in men compared to women (men 0.71 ± 0.14 mm vs. women 0.65 ± 0.11 mm, p ≤ 0.0001) and in subjects with CHD compared to those without (men with and without CHD: 0.76 ± 0.14 mm and 0.70 ± 0.14 mm, p ≤ 0.0001, respectively; women with and without CHD: 0.73 ± 0.15 mm and 0.64 ± 0.11 mm, p ≤ 0.0001, respectively). In men the mean CIMT increased from 0.62 ± 0.10 mm in the youngest (45-49 years old) up to 0.79 ± 0.13 mm in the highest age group (≥ 70 years) (0.57 ± 0.08 mm up to 0.71 ± 0.12 mm in women, p ≤ 0.0001 for both). Conclusions Compared to international studies similar CIMT distributions were found in this study using both continuous and percentile distributions. However, lower CIMT values were observed in older participants, which can be explained by exclusion of carotid plaque formation in CIMT measurements.

Eine effektive orale Antikoagulation mit Vitamin-K-Antagonisten ist der aktuelle Goldstandard bei der Behandlung von Patienten mit Vorhofflimmern. Durch eine Anwendung mit INR-Werten zwischen 2,0 und 3,0 kann das Schlaganfallrisiko verglichen mit Placebo um 60–70% reduziert werden. Vitamin-K-Antagonisten haben allerdings eine Vielzahl von Problemen in der praktischen Anwendung, was die geringe Einnahmefrequenz und eine unzureichende INR-kontrollierte Einstellung erklart. Neue orale Antikoagulanzien wie direkte Thrombininhibitoren (Dabigatran) oder direkte Faktor-Xa-Hemmer wie Rivaroxaban und Apixaban zeigten eine im Vergleich zu Warfarin mindestens ebenburtige, wenn nicht hohere Wirksamkeit und zum Teil auch eine niedrigere Inzidenz an schwerwiegenden Blutungskomplikationen sowie Vorteile in der praktischen Handhabung. Die neuen Substanzen sind sowohl in der Sekundar- als auch in der Primarpravention von Schlaganfallen bei Patienten mit Vorhofflimmern wirksam und stellen daher eine gute Alternative dar, die sich im klinischen Alltag zunehmend etablieren wird.

Als mogliche Alternative zu einer dauerhaften oralen Antikoagulation mit Vitamin-K-Antagonisten bei Patienten mit Vorhofflimmern hat sich der interventionelle Verschluss des linken Vorhofohrs als nicht unterlegen in Bezug auf die neurologische Ereignisrate gezeigt. Gerade im Hinblick auf die neuen Moglichkeiten, direkte orale Faktor-II- oder Faktor-Xa-Inhibitoren zur Schlaganfallprophylaxe einsetzen zu konnen, ist eine individuelle Entscheidung, die das jeweilige Blutungs- und Schlaganfallrisiko mit dem periinterventionellen Risiko abwagt, erforderlich. Hier konnen etablierte Risiko-Scores hilfreich sein.

In 12 patients with severe congestive heart failure due to ischaemic heart disease (n = 6) and due to congestive cardiomyopathy (n = 6) the haemodynamic effects of a new beta 1-agonist, prenalterol, were studied. Left ventricular (LV) function was studied before and 20 min after infusion of 12 mg prenalterol. Heart rate was kept constant by atrial pacing at a rate of 100 min-1 unless intrinsic heart rate exceeded it. As a sign of positive inotropic support, prenalterol enhanced peak rate of LV pressure development (dP/dt) from 1160 +/- 100 mm Hg/s to 1590 +/- 190 mm Hg/s (p less than 0.005). In the mean LV end-diastolic and end-systolic volume determined by cineventriculography and two-dimensional echocardiography decreased. LV stroke work index measured with both methods increased with 4 ml/m and 5 ml/m, respectively (p less than 0.02). LV ejection fraction was improved by 6% and 8% (p less than 0.005). Increase of peak fall of left ventricular pressure (dP/dt) (1050 +/- 60 mm Hg/s to 1270 +/- 100 mm Hg/s, p less than 0.005) and shortening of time constant (T) of pressure fall from 64.5 +/- 5.0 ms to 44.5 +/- 6.0 ms (p less than 0.005) demonstrated the improved LV relaxation. Analysis of LV volume and myocardial compliance revealed decrease of left ventricular stiffness. Thus, LV filling pressure was reduced from 22.1 +/- 4 mm Hg to 14 +/- 3.5 mm Hg (p less than 0.001). Pressure volume analysis showed a significant increase of LV power and work, as well as a slight decrease of wall stress. Our study could demonstrate, even in patients with severe heart failure, a sustained positive inotropic effect of prenalterol leading to an improved left ventricular contractility, relaxation and compliance. LV power and work was enhanced. The increase of oxygen demand seemed to be counterbalanced by an improved perfusion of particularly subendocardial layers indicated by an increased transmyocardial pressure gradient.

It is well established, that the increased mortality in patients with acromegaly is due to cardiac diseases. Cardiomyopathy is the predominant cardiac alteration in patients with acromegaly. There are less data about coronary heart disease or coronary calcifications. Electron beam computed tomography (EBCT) is the standard imaging modality for identification of coronary artery calcifications (CAC) and can determine the extent and severity of coronary atherosclerosis. Coronary risk was evaluated by the Framingham risk score (FRS). The prospective study included 30 patients with acromegaly (mean age 53+/-14 year; 16 females, 14 males; BMI 28.1+/-3.6 kg/m (2); mean+/-SD), 12 patients had active disease (IGF-1 751+/-338 microg/L; GH 25.6+/-36.4 microg/L), 9 were well-controlled (IGF-1 157+/-58 microg/L; GH 1.8+/-1.1 microg/L) under somatostatin analogue octreotide (n=5), dopamine agonists (n=2), and the GH receptor antagonist pegvisomant (n=2; GH levels were not determined in this subgroup) and 9 were cured IGF-1 (148+/-57 microg/L; GH 0.5+/-0.2 microg/L). Increased left ventricular muscle mass index (LVMI >132 g/m (2)) was focused in 53%, hypercholesterinemia in 63%, hypertension in 43%, diabetes mellitus/impaired glucose tolerance in 27%, and smokers in 53% (pack per year 9+/-15 yr). For quantification of CAC the EBCT was used and the Agatston calcium score was determined. Results were composed to established age and sex adjusted percentile distribution of CAC. CAC was present in 53%, high CAC score (75 (th) percentile) in 37% and were categorized as cardiovascular high risk patients. FRS was related to the CAC score (p=0.008, r (2)=0.22) and the disease duration (p=0.002, r (2)=0.29). The CAC score correlated with LVMI (p=0.02, r (2)=0.17), the disease duration of acromegaly (p=0.004, r (2)=0.36), and the FRS (p=0.008, r (2)=0.22). Patients with a high CAC score had a longer disease duration of 9.6+/-4.7 versus 5.4+/-2.8 years with CAC

Every year about 100,000 persons die from sudden cardiac death (SCD) in Germany. Although many efforts have been undertaken, mortality remains high. Only 2 - 10% of patients with out-off hospital SCD can finally be discharged from hospital after resuscitation. Observational studies show that ventricular fibrillation and ventricular tachycardia are the primary arrhythmias underlying SCD. For both arrhythmias the main determinant for survival is the time between onset and termination by defibrillation. The chance of survival declines by 10% for every minute of delay. These findings prompted the concept of early defibrillation by first responders. Many studies have shown that non-medical professionals, like police men, firemen or security officers, often arrive at the patient more early than emergency medical service. Thus, "smart" automated external defibrillators (AEDs), designed to identify VT/VF and prompt the user when to deliver a shock were introduced. These devices allow lay rescuers to terminate ventricular arrhythmias before the arrival of medical professionals. By this approach the time to defibrillation could be reduced and a significant reduction in mortality could be documented in selected situation. These encouraging results initialled the installation of AED at public places like aircrafts, airports, underground stations and shopping males. Due to the success of this approach doctors are more and more confronted with questions about technical details, reliability and cost effectiveness of these devices. The present review should give an overview about the current studies and guidelines.

Die koronare Herzkrankheit manifestiert sich haufig durch ein akutes Koronarsyndrom als Indexereignis. Vor dem Hintergrund der Entwicklung von Adipositas und Diabeteshaufigkeit fallt die Inzidenzrate der Erkrankung nicht weiter ab und wird moglicherweise sogar wieder ansteigen. Angesichts der hohen Letalitat des akuten Myokardinfarkts in der Prahospitalphase kommt die medizinische Versorgung fur viele Patienten zu spat. Die Koronarkalkbestimmung kann eine wichtige Hilfe zur Identifizierung asymptomatischer Personen mit erhohtem Koronarrisiko und zur Einleitung einer Behandlung zur Risikoreduktion sein. Koronarkalk ist ein weitgehend spezifischer Ausdruck der koronaren Atherosklerose und korreliert mit dem koronaren Gesamtplaquevolumen. Aufgrund der komplexen Gefaswandbiologie mit kompensatorischem Remodeling zeigt Koronarkalk nicht notwendigerweise eine signifikante Stenosierung an. Eine Vielzahl unabhangiger Studien in Kollektiven mit gesunden, durch Werbung, Uberweisung und Selbsteinweisung gewonnenen Teilnehmern beschreibt ubereinstimmend die pradiktive Wertigkeit der Koronarkalkbestimmung im Hinblick auf koronare und kardiovaskulare Ereignisse. Nach Adjustierung fur die etablierten Risikofaktoren sind erhohte Kalkscores mit einem 5- bis 10fach erhohten Risiko kardialer Ereignisse assoziiert. In jungster Zeit wurden auch Ergebnisse aus strikt unselektierten, bevolkerungsweiten Kollektiven bekannt, welche die pradiktive Wertigkeit der Koronarkalkbestimmung bestatigen. In Deutschland bietet dazu die bevolkerungsbasierte Heinz-Nixdorf-Recall-Studie im Ruhrgebiet eine wichtige Datengrundlage. In Ubereinstimmung mit den aktuellen Empfehlungen der amerikanischen und europaischen Fachgesellschaften wird die Koronarkalkbestimmung insbesondere bei Patienten eingesetzt, die ein intermediares Risiko auf der Basis der klinischen Befunde und Risikofaktorenanalyse aufweisen. Deutlich erhohte Kalkscores geben dem behandelnden Arzt eine Rationale zur intensiven Risikotherapie. Dies gilt auch fur altere Patienten, bei denen die etablierten Risikofaktoren einen Teil ihrer pradiktiven Wertigkeit verlieren. Die Anwendung des Verfahrens bei Selbsteinweisern oder als primares Mittel der Risikostratifizierung kann nicht empfohlen werden.

History and admission findings A 71-year-old man was admitted because of treatment-resistant orthostatic hypotension of unknown aetiology. When aged 64 years he developed some impotence and later urinary incontinence and urinary frequency. At 68 years he noted vertigo on physical activity, and a year later he had signs of reversible cerebral ischaemia. At this point the Schellong test demonstrated vasovagal circulatory dysfunction. After his 70th birthday the unsteadiness on walking and standing got worse and he had recurrent syncopes. He was in a wheel-chair when hospitalized and even the unsteady walk he could maintain for only a few seconds. Investigations Plasma and urinary concentrations of catecholamines were at the lower limit of normal but failed to increase during orthostasis. Hormonal, cardiological and infectious causes of the orthostatic hypotension were excluded. Orthostatic tests after Schellong and with the tilting table showed orthostatic hypotension without increased sympathetic activity but hypertensive blood pressure levels during the recumbent period. Intravenous infusion of norepinephrine produced an excess rise in blood pressure (raised norepinephrine sensitivity). The recurrent urinary infection was shown to be due to a hypotonic bladder detrusor muscle. Neurological examination revealed cerebellar dysfunction, signs of pyramidal tract abnormality and sensory polyneuropathy. A Shy-Drager syndrome was diagnosed on the basis of the history, absent blood pressure rise and lack of catecholamine release during orthostasis with increased epinephrine sensitivity and characteristic neurological signs. Treatment and course Physiotherapy and elastic stockings with administration of mineralocorticoids as well as of one direct (norfenefrine) and one indirect (amezinium) sympathomimetic drug failed to improve adequately the abnormal orthostatic response. But on additional administration of an alpha 2-receptor antagonist (yohimbine) the patient was able to stand and walk for a few minutes, but the urinary incontinence and the other neurological signs remained treatment-resistant. Conclusion If orthostatic hypotension occurs together with neurological symptoms, a Shy-Drager syndrome should be taken into account.

History and clinical findings A 54-year-old man was urgently admitted because of sudden onset of progressively worsening angina pectoris, his first attack. Physical examination was unremarkable. Investigations Electrocardiography and laboratory tests excluded acute myocardial infarction. With the exception of hypercholesterolemia (total cholesterol 247 mg/dl) laboratory tests were normal. Coronary angiography revealed a 60% eccentric narrowing in the proximal part of the interventricular branch with adjacent aneurysmatic dilatation. Intravascular ultrasound (IVUS) showed a coronary pseudoaneurysm, its cavity communicating with the empty atheroma hole of an adjacent ruptured coronary plaque. Treatment and course A 19 mm stent graft was implanted, via a percutaneously inserted balloon-catheter system, in the region of the stenosis and the pseudoaneurysm. Subsequent angiography demonstrated a smooth nonstenotic lumen. The membrane of the graft (made of polytetrafluoroethylene [PTFE]), fixed between two thin metal stents, had occluded the pseudoaneurysm. Occlusion of an immediately distal septal branch briefly produced an asymptomatic rise of creatine kinase to maximally 173 U/l. Oral medication included ticlopidine hydrochloride (2 x 250 mg daily for 4 weeks). The patient was symptom-free after the procedure and was discharged 5 days later. Conclusion Implantation of a new type of stent-graft provides quick and uncomplicated treatment of a coronary aneurysm. The membrane fixed between two stents prevents wash out of any thrombi. The method may also be applicable to other potentially thrombus-containing lesions.

HISTORY AND FINDINGS A 60-year-old man underwent a continence-preserving anterior rectal resection for a high rectal carcinoma. After mobilisation on the 5th postoperative day dyspnoea and cyanosis suddenly developed requiring emergency intubation and mechanical ventilation. INVESTIGATIONS His heart rate was 160/min, blood pressure 80/50 mmHg, mean pulmonary artery pressure by indwelling catheter was 70 mmHg. The electrocardiogram had the classical signs of acute right-heart overload. Transoesophageal echocardiography (TOE) demonstrated marked right-heart and pulmonary artery dilatation. TREATMENT AND COURSE Despite thrombolytic treatment (bolus of 50 mg r-TPA; one day later bolus of 1 million IU urokinase followed by 100,000 IU/h) a new thromboembolus was seen by TOE to straddle the pulmonary artery bifurcation. After the urokinase dosage had been raised to 200,000 IU/h TOE on the 6th day no longer showed the embolus and documented a reduction in right-heart dilatation associated with improved haemodynamics. CONCLUSION TOE is an ideal method for the rapid diagnosis and for monitoring the response to treatment of fulminant pulmonary arterial embolism. As it can also diagnose thromboembolism without significant haemodynamic consequences it is possible to adjust fibrinolytic treatment accordingly.

127 patients, admitted within six hours of onset of symptoms of acute transmural myocardial infarction, received at first 250 000 U streptokinase intravenously over 20 min, followed by an intracoronary infusion of 250 000 U after coronary angiographic demonstration of the infarct vessel. Those in whom the infarct vessel was closed were randomized into two groups. An attempt at recanalization was made either by thrombolysis alone, through a specially developed 3F catheter (group I, 64 patients), or by thrombolysis and dilatation with 4F Gruntzig balloon catheter (group II, 63 patients). There was no significant difference between the two groups with regard to sex, age, infarct site, creatine-kinase level and interval between onset of symptoms and treatment. Re-perfusion rate for group I was 92% (59 patients), for group II 89% (56 patients). Re-occlusion during the hospital stay occurred in 10 of 59 patients in group I, in 9 of 55 in group II. Re-occlusion occurred in only 8% (3 patients) after successful dilatation, but in 35% (6 patients) after failed dilatation. In the subsequent six months further occlusions were observed in seven group I and two group II patients. Combined drug-mechanical recanalization thus increased the re-perfusion rate, shortened the infarction time and made possible full revascularization by subsequent dilatation which led to a reduction in the re-occlusion rate.

OBJECTIVE The extent of coronary calcification demonstrated by electron beam tomography was correlated with the individual cardiac risk profile. PATIENTS AND METHODS The possible presence of coronary calcifications was studied by electron beam tomography (EBT) in 650 patients (526 men, 124 women; mean age 54 +/- 10 [28-81] years) with known or suspected coronary heart disease. Depending on the degree of density and the size of the lesion a score was calculated according to an international standard. RESULTS No calcification was shown to be present in 202 patients (score of 0). A score of more than 0 was calculated in 73.8% of men and 48.4% of women. The average score was 227.8 +/- 24.8 in men, compared with 65.3 +/- 26.5 in women (P < 0.001). There were significantly more calcifications in older patients: Men aged 71-75 years had the highest score, 859.4, while the lowest, 9.6, was in those aged 36 to 40 years. The most important variables for the presence of calcification were age (relative risk per age group: 1.6), male sex (relative risk: 4.3), hypertension (relative risk: 2.4) and nicotine consumption (relative risk: 1.8). The median point score in patients without known risk factors was 1.3, with one known factor it was 7.2, and with three it was 48.0. The vessel segment most affected with calcification was the anterior interventricular branch with an average score of 84. CONCLUSION Together with an evaluation of the risk profile EBT provided a better assessment of individual risk than conventional examination.

HISTORY AND CLINICAL FINDINGS A 37-year-old woman who was not wearing a seat-belt while driving a car had a head-on collision at 70 km/h. On arrival of the emergency physician she was awake and responsive but complained of pain with bruising over the sternum and the epigastrium. Pressure on the sternum was painful. Arterial pressure was 95/60 mm Hg, heart rate 112/min. On admission the heart sounds were unremarkable and peripheral pulses normal. Vesicular sounds were heard over both lungs. In addition to multiple facial abrasions voluntary movements were impaired and the right knee-joint was swollen. INVESTIGATIONS The ECG showed sinus tachycardia (103 beats/min) with left axis deviation, but was otherwise unremarkable. Initially the haemoglobin was 12.6 g/dl with normal white cell and platelet counts. Clotting tests, serum transaminases, creatine kinase, lactate dehydrogenase and other routine laboratory tests were within normal limits. TREATMENT AND COURSE Because the haemoglobin level had fallen to 7.7 g/dl within the first 4 hours erythrocytes concentrate was infused. The chest radiogram and subsequent computed tomography showed a mediastinal and paraaortic haematoma of unclear origin. Transoesophageal echocardiography (TEE) demonstrated rupture of the descending aorta with free floating intraluminal parts of the intima in the isthmal region, just distal to the origin of the left subclavian artery, which was not occluded. Colour Doppler echocardiography revealed abnormal flow into mediastinal and paraaortic tissues. At operation the echocardiographic findings were confirmed and part of the descending aorta was replaced by a 3 cm dacron tube during an aortic crossclamping time of 37 min. The patient was discharged after a postoperative stay of average length, during which her other injuries were treated. CONCLUSION After blunt thoracic or deceleration trauma earliest possible TEE is indicated, because it can at once provide details of extent and degree of injury to heart and/or aorta.

HISTORY AND CLINICAL FINDINGS A 51-year-old man, having experienced sudden retrosternal pain was admitted to another hospital with suspected myocardial infarction. He also had dysaesthesia and later paresis of the left leg. There was no sign of acute infarction in the ECG. However, computed tomography revealed aortic dissection, type III (DeBakey). The left pedal pulses were diminished. The patient was transferred to our hospital for further diagnosis and treatment. At a blood pressure of 110/60 mm Hg the occlusion pressure of the leg artery was 55 mm Hg on the left and 95 mm Hg on the right. INVESTIGATIONS Transoesophageal echocardiography detected no abnormality of the aortic valve and ascending aorta. But distal to the origin of the left subclavian artery it demonstrated a free floating membrane of an aortic dissection and computed tomography showed its extension to the aortic bifurcation. TREATMENT AND COURSE At first, because of the incomplete ischaemia syndrome affecting the left leg, a percutaneous fenestration of the dissection membrane was performed. After conventional angiography intravascular ultrasound imaging was also undertaken; it revealed that the membrane was almost completely occluding the left iliac artery. Under ultrasound monitoring a puncture needle and two balloon catheters were introduced across the membrane and thus a window created in it. The clinical findings quickly disappeared and the patient was discharged without further operation. CONCLUSION Monitoring with intravascular ultrasound imaging makes it possible to perform safely a percutaneous fenestration of the membrane of an aortic dissection and to obtain immediate evidence of its success.

BACKGROUND AND OBJECTIVE Early evidence of drug-induced cardiomyopathy (CMP) is of great importance in haematological treatment, especially with anthracyclines. Stress echocardiography (SEC) has proved of value in determining left ventricular function at rest and under stress in patients with heart disease. The study was undertaken to assess the value of SEC in comparison with radionuclide ventriculography (RNV). PATIENTS AND METHODS 63 unselected patients with malignant tumour (20 women, 43 men; mean age 49 +/- 15 years) underwent SEC and RNV. No chemotherapy had yet been started in 17 of them, 43 had received anthracyclines as main component of the chemotherapy (mean anthracycline dose 339 +/- 251 mg/m2). Left ventricular ejection fraction (LVEF) was measured by both SEC and RNV at rest and during standardized stress (recumbent ergometry). Both methods were applied and results measured independently by two examiners. RESULTS The time interval between the two tests averaged 1 = 2 days. EC could be performed at rest in 62 of 63 and under stress in 59 of 63 patients (RNV: 63 of 63 and 54 of 63, respectively). Resting LVEF was 61 +/- 8% by SEC and 64 +/- 9% by RNV (P < 0.05). LVEF during stress, measured by SEC, was 71 +/- 11% and 73 +/- 10% by RNV (not significant). Mean LVEF increase between rest and stress was 9 +/- 10% by SEC and 9 +/- 8% by RNV (not significant). CONCLUSION SEC is a satisfactory alternative to RNV in the assessment of ventricular function in patients receiving chemotherapy. It is less involved and more cost-effective than RNV, avoids radiation exposure and provides additional information on heart size and segmental contraction abnormalities.

Between March 1980 and July 1984, coronary angiography was performed on 461 consecutive patients (no age limit) with acute myocardial infarction, and the partially or completely obstructing thrombus lysed by selective intracoronary infusion of streptokinase. At the time of first coronary angiography 96 patients (21%) had a high degree of stenosis but no total occlusion of the infarct vessel (group A). In 365 patients (79%) there was complete occlusion which in 315 patients (86%) was removed successfully after an occlusion period of 213 +/- 87 minutes (group B). In 50 patients (14%) (group C) attempts at reperfusion failed. In 129 of 163 patients (79.1%) with one-vessel disease, PTCA (percutaneous transluminal coronary angioplasty) was successful. Patients with multiple-vessel disease and an occlusion time of less than four hours, on the other hand, were treated surgically within the first ten days (78 patients). In the remaining 254 patients conservative treatment was practised. Within the first 30 days there were seven deaths (14%) in group C, while among group A and B patients, under conservative treatment, 16 died (7.8%). After successful PTCA four patients (3.1%) died. The lowest mortality was among patients with a short occlusion time and early bypass operation (2.6%). The most frequent cause of death was cardiogenic shock (20 of 29 patients), more rarely ventricular fibrillation (3) or other causes (4). Ventricular rupture occurred in three patients, one of whom was saved by pericardial tap. One year later the mortality among the conservative group was 21.2%, after successful PTCA or bypass operation 9.3% and 6.4%, respectively.

A fundamental improvement in the diagnosis of acquired valvular defects has been achieved by the introduction of two-dimensional echocardiography. For the first time, it has now become possible to visualize the underlying morphological changes direct and true to anatomy. Additional information is supplied by a detailed study of the dynamics of the affected valve. At present, limited information only can be obtained in respect of the haemodynamic severity of the defect. In the near future, however, we may expect advances also in quantitative respect, from a combination of this method with Doppler echocardiography or contrast echocardiography.

Left ventricular volumes and the ejection fraction can be determined by two-dimensional echocardiography. Because of methodological problems, cineventriculographic normal values can not be transferred to two-dimensional echocardiography. Therefore, normal values for two-dimensional echocardiographically determined left ventricular volumes and the ejection fraction were established in 55 normal controls. Basing on these volumes, the sensitivity and specificity of two-dimensional echocardiography for detection of impaired left ventricular function was analysed and compared with results from cineventriculography. Sensitivity for detection of a reduced ejection fraction was 84%, specificity 89% and predictive accuracy 98%. Thus, two-dimensional echocardiography can be used as a screening method for analysing left ventricular function. Analysis of beat-to-beat variation revealed that for two-dimensional echocardiography 3 consecutive beats should be analysed because evaluation of 5 instead of 3 beats increased reliability only by less than 1%. It was necessary to analyse the day-to-day variations. To separate a random error from a non-random error for an individual change, an absolute change of volumes of more than 10-12% and of ejection fraction of more than 10% had to be observed. Group changes can of course be smaller and yet significant. Intraobserver variation was not significant and below 5%. However, interobserver variability must be considered. This depends on observer experience. For a 4-chamber view no significant variability was observed, but for the RAO-equivalent view the observer variation was significant for end-diastolic and end-systolic volume. For the ejection fraction no significant difference was found. Two-dimensional echocardiography can be used for pharmacodynamic studies if percentage changes instead of absolute changes are listed.

Andreas Grüntzig can be regarded as the pioneer of modern cardiology. Based on the previous experiences of Charles Dotter in Portland, Oregon, and after many years of preparation as a young 38-year-old physician and consultant he carried out the first percutaneous transluminal coronary angioplasty (PTCA) in a 38-year-old patient in Zurich in 1977, supported by the cardiac surgeons A. Senning and M. Turina. Despite high ranking publications and early preparedness to share his experiences the development of PTCA stagnated and was met with great scepticism. The technique was new, technically difficult and aimed at aortocoronary bypass surgery, which was itself still in its infancy 10 years after the introduction in Cleveland in 1968. Even after several years only two patients per week were admitted for treatment in Zurich. In a similar way the young cardiac surgeon H.R. Andersen was a pioneer in Denmark whose ideas and own experiments with a balloon catheter-assisted aortic valve implantation were not initially taken up by the leading companies of the time and publication of the data suffered lengthy delays. It took 10 years before Prof. A. Cribier in Rouen followed up his ideas and carried out the first valve implantation again in pioneer work after many years of preparation in 2002. Again, the new method for treatment of very old and high risk patients needed many years before it was accepted. The breakthrough only became possible when this new technique began to be used in cardiac surgery after the introduction of hybrid cardiac catheter operating rooms. Despite evidence-based studies innovative methods are not subject to the same criteria throughout Europe with respect to the timely introduction of innovative and validated procedures also in consideration of reimbursement and this has become an important initiative of the European Society of Cardiology (ESC).

Die nichtinvasive Abklarung von symptomatischen Patienten mit Verdacht auf koronare Herzkrankheit (KHK) erfolgt stufenweise. Zunachst werden die Risikofaktoren quantifiziert. Das Ruhe-EKG liefert erste diagnostische und prognostische Hinweise. Bei fehlendem Ausschluss von Kontraindikationen und guter Belastbarkeit sollte bei Patienten mit intermediarer Vortestwahrscheinlichkeit ein Belastungs-EKG durchgefuhrt werden. Bei eingeschrankter Interpretierbarkeit des Belastungs-EKG ist eine weiterfuhrende Diagnostik zu erwagen. Traditionell werden Methoden eingesetzt, mit denen durch korperliche oder pharmakologische Belastung mit Vasodilatanzien (Adenosin, Dipyridamol) oder positiv inotropen Substanzen (Dobutamin) eine Myokardischamie nachgewiesen werden kann. Hierfur sind die Stressechokardiographie, die Myokardszintigraphie und seit kurzem die Stress-MRT indiziert und in der Nationalen Versorgungsleitlinie „Chronische KHK“ verankert. Diese Verfahren haben Sensitivitaten und Spezifitaten zwischen 80–89% bzw. 75–86% fur signifikante Koronarstenosen >50% und liefern zusatzlich prognostische Informationen. Ein sicherer Ausschluss einer fortgeschrittenen Arteriosklerose ist jedoch nicht moglich. Die ischamieanzeigenden Methoden werden dagegen erst bei hohergradigen Stenosen positiv, da ein Remodeling der Herzkranzgefase oft erst im Spatstadium der Erkrankung zu einer funktionell relevanten Stenose fuhrt. Der Patient kann jedoch schon im asymptomatischen Stadium gefahrdet sein. Als erganzendes Konzept wurde in den letzten Jahren daher die morphologische Diagnostik durch direkte Visualisierung und Quantifizierung der Arteriosklerose und von Koronarstenosen in die klinische Routine eingefuhrt. Mit steigendem Kalkscore und zunehmender Zahl der kalzifizierten Gefase steigt die Wahrscheinlichkeit fur das Vorliegen einer stenosierenden KHK. Ein Ruckschluss auf eine Stenose im kalzifizierten Segment ist jedoch nicht moglich. Durch zusatzliche Kontrastmittelgabe konnen in modernen Mehrzeilen-CT-Geraten auch nichtkalzifizierte Plaques quantifiziert werden und hochgradige Stenosen mit einer Sensitivitat und Spezifitat von >90% ausgeschlossen werden. Wahrend hochgradige proximale Stenosen direkt einer interventionellen Therapie zugefuhrt werden konnen, sollte sich bei Plaquenachweis mit unklarer funktioneller Relevanz eine konventionelle Ischamietestung anschliesen. Unter Berucksichtigung der Kontraindikationen und Limitationen der einzelnen Methoden kann durch Integration der morphologischen Bildgebung in die Evaluation von Patienten mit Verdacht auf KHK die individuelle Diagnostik optimiert werden. Bei der Wahl der bildgebenden Verfahren sollte in jedem Fall die Verfugbarkeit und Erfahrung der Einrichtung mit in Betracht gezogen weren, um die bestmogliche Bildqualitat und Information fur den jeweiligen Patienten anzupassen.