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Structured AbstractBackgroundAssessment of left ventricular (LV) function and volume after ST-segment elevation myocardial infarction (STEMI) is recommended to guide clinical decision within and after hospitalization. Early after STEMI, initial LV reshaping and hypokinesia may affect analysis of LV function. A comparative evaluation of left ventricular ejection fraction (LVEF) and stroke volume (SV) by different imaging modalities to assess LV function early after STEMI has not been performed so far.MethodsLV function was assessed by LVEF and SV using serial imaging within 24h and 5 days after STEMI with cineventriculography (CVG), 2-dimensional echocardiography (2DE), 2D and 3D cardiovascular magnetic resonance (2D/3D) in 82 patients. Respective parameters were compared between modalities and to 3D gold standard CMR.Results2D analyses of LVEF using CVG and 2DE as well as 2D CMR yielded uniform results within 24h and 5 days of STEMI. SV assessment between CVG and 2DE at day 1 after STEMI was comparable, whereas values for SV were higher using 2D CMR on all occasions (pConclusionsEarly after STEMI, 2D analysis of LVEF yielded robust results across all imaging techniques implying that CVG, 2DE, and 2D CMR can be used interchangeably in this setting. SV measurements to assess cardiac function differed substantially between imaging techniques due to higher intermodality-differences of absolute volumetric measurements.

Risk factor control of diabetes mellitus (DM) and especially dyslipidemia remains unsatisfactory in patients with atherosclerotic cardiovascular disease (ASCVD). We aimed to analyze the knowledge of low-density lipoprotein cholesterol (LDL-C) and glycated hemoglobin (HbA1c) treatment goals, subjective level of information, and information needs in very high-risk patients with ASCVD.ASCVD patients (n = 210; 75 ± 9 years; 71.4% male; 89.5% coronary disease) with DM (96.7% type 2) completed a questionnaire assessing knowledge of HbA1c and LDL-C treatment goals and subjective level of information and information needs on disease-related topics of DM and ASCVD. Serum LDL-C and HbA1c were measured.HbA1c goal (7.0% in 60.6%) was attained more frequently than LDL-C goal (70 mg/dl in 39.9%; p .01). Significantly more participants named the correct goal for HbA1c compared to LDL-C (52.9% vs. 2.4%; p .01). Subjective levels of information were higher and information needs were lower for DM than for ASCVD (p .01 for all topics). No associations of knowledge of treatment goals and level of information with the attainment of treatment goals for HbA1c and LDL-C were found. However, in multivariate regression, higher levels of education were associated with knowledge of treatment goals (HbA1c: odds ratio [OR] 1.32, 95% confidence interval [CI] 1.01-1.72, p = .04; LDL-C: OR 2.32, 95% CI 1.07-5.03; p = .03).In very high-risk patients with ASCVD, a deficit of knowledge of treatment goals to control dyslipidemia exists when compared to DM, patients felt significantly better informed for topics of DM than for ASCVD and display higher information needs for topics of ASCVD.

Patient safety is one of the most important issues in healthcare. High-risk percutaneous coronary interventions (HR-PCIs) offer well-established treatment options for patients with complex coronary artery disease and multiple comorbidities. Whether process standardization using standard operating procedure (SOP) management and checklists improves HR-PCI is still unknown.This retrospective study analyzed procedural characteristics, in-hospital outcomes, and length of hospital stay in patients who received HR-PCI in a German heart center 12 months before the introduction of process standardization using SOP management-the SOP (-) group-and after the introduction of process standardization using SOP management-the SOP (+) group. A total of 192 patients were included, with 77 patients in the SOP (-) group and 115 patients in the SOP (+) group. The mean age in the SOP (-) group was 72.0 ± 10.2 years and 81.8% were male; mean age in the SOP (+) group was 75.2 ± 10.4 years and 68.7% were male. Acute kidney events were significantly lower in the SOP (+) group than in the SOP (-) group (7.0% vs 10.4%; P=.04). Bleeding was the most common adverse event and significantly lower in the SOP (+) group than in the SOP (-) group (13.1% vs 31.2%, respectively; Plt;.01). There were trends toward shorter length of hospital stay in the SOP (+) group compared with the SOP (-) group (9.3 ± 6.4 days vs 10.9 ± 7.3 days, respectively; P=.10) and days of hospital stay in the intensive care unit (3.7 ± 4.0 days vs 4.7 ± 4.3 days; P=.07). SOP management was independently associated with shorter length of hospital stay in multivariate regression analysis.This retrospective study shows significantly better quality of care measures after the introduction of process standardization techniques using SOP management in HRPCIs, with a lower risk of adverse outcomes and shorter length of hospital stay.

ZusammenfassungDie zunehmende Inzidenz der Herzinsuffizienz, als häufigste zur Krankenhausaufnahme führende Gesundheitsstörung, bedarf in einer demografisch alternden Gesellschaft eines optimierten und ressourcensparenden Diagnostik- und Therapieplans in hierfür spezialisierten sektorenübergreifenden Herzinsuffizienz-Netzwerken (HF-NET), wo nicht nur die häufigen Komorbiditäten und Komplikationen, sondern auch die zunehmende Anzahl zur Verfügung stehender medikamentöser und interventioneller Therapiemöglichkeiten einen interdisziplinären und intersektoralen Versorgungsansatz bei limitierten Ressourcen ermöglicht. Insbesondere vor dem Hintergrund, dass der Verlauf der Herzinsuffizienz durch rezidivierende Dekompensation (meist Volumenretention etc.) charakterisiert ist, ermöglichen die im HF-NET optimierten Versorgungs- und Kommunikationsstrukturen der bei Herzinsuffizienz betroffenen Leistungserbringer, drohende Dekompensationen frühzeitiger und prognostisch relevant zu erkennen und zu behandeln.

ZusammenfassungDeutschlandweit werden über 20.000 Patienten in integrierten Herzinsuffizienz-Versorgungsmodellen betreut (Bundesverband Niedergelassener Kardiologen, persönliche Kommunikation, 16. Juli 2020). Durch eine damit einhergehende, leitliniengerechte Pharmakotherapie und regelmäßige Kontrolluntersuchungen lässt sich die Lebensqualität von herzinsuffizienten Patienten deutlich verbessern. Darüber hinaus lassen sich Krankenhauseinweisungen und daraus resultierend Kosten für die Krankenversicherungen minimieren. Eine enge Kooperation (in einem Netzwerk) zwischen Klinikkardiologen, niedergelassenen Kardiologen und Hausärzten ermöglicht eine optimale Herzinsuffizienz-Behandlung in allen Herzinsuffizienz-Schweregraden. Integrierte Versorgungmodelle wie CorBene oder KardioExpert tragen dazu bei, neben einer optimalen Patientenbetreuung, wissenschaftliche Auswertungen vorzunehmen und harte Endpunkte wie Re-Hospitalisierung oder kardiovaskuläre Mortalität zu reduzieren. Das hier vorgestellte KHAD-Modell (Kölner Herzen Atmen durch") ist ein integriertes Versorgungsmodell in dem die aktuellen Leitlinienempfehlungen zur poststationären Versorgung von Herzinsuffizienzpatienten in der Region Köln umgesetzt werden sollen. Fast allen Krankenkassen unterstützen das Modell. Es nehmen alle Kölner Krankenhäuser und einige der niedergelassenen Kölner Kardiologen teil, um eine optimale Herzinsuffizienz-Versorgung gewährleisten zu können. Solche Modelle für eine Herzinsuffizienz-Betreuung könnten in allen deutschen Großstädten praktiziert werden. Zum Wohle der Patienten, zur Einsparung von Potenzialen bei den Krankenkassen, für eine angemessene Honorierung der behandelnden Ärzte und zur Entlastung der Krankenhäuser – ein Gewinn für unsere Patienten und alle Beteiligten im Gesundheitssystem.

ZusammenfassungVon der Volkskrankheit „koronare Herzkrankheit“ (KHK) ist jeder zehnte 40- bis 79-Jährige in Deutschland betroffen. Basierend auf den Leitlinien der Europäischen Gesellschaft für Kardiologie zu chronischen Koronarsyndromen (CCS) und zur Myokardrevaskularisation sowie der Nationalen VersorgungsLeitlinie (NVL) „Chronische KHK“ werden evidenz- und expertenbasierte Empfehlungen zur Diagnosestellung sowie zur Behandlung und Betreuung der KHK-/CCS-Patienten dargestellt, mit Fokus auf nichtinvasive und invasive Myokardischämiediagnostik sowie medikamentöse und myokardrevaskularisierende Maßnahmen. Voneinander abweichende Empfehlungen der einzelnen Leitlinien in seltenen Fällen erweitern den Ermessensspielraum des Arztes. Das Aufzeigen des Notwendigen und Angemessenen sind wesentliche Intentionen dieser Leitlinien, mit dem Ziel, die Qualität der Patientenversorgung auf bestmöglichem Niveau zu halten.

ZusammenfassungUm der wachsenden Anzahl von Herzinsuffizienz-Patienten besser gerecht zu werden, empfehlen die Europäischen Behandlungsleitlinien für das Syndrom Herzinsuffizienz strukturierte Nachsorgeprogramme. In diesen Programmen können wesentliche Aufgaben (wie Beratung, Monitoring, Kommunikation, Organisation, Dokumentation) an nichtärztliches Fachpersonal delegiert werden. Das hier beschriebene, durch die Deutsche Gesellschaft für Kardiologie konsentierte Fortbildungscurriculum „Spezialisierte Herzinsuffizienz-Assistenz“ will zur Verbesserung der Versorgung von Herzinsuffizienz-Patienten beitragen.

Guidelines recommend adjunct glycoprotein IIb/IIIa inhibitors (GPIs) only in selected patients with acute ST-segment elevation myocardial infarction (STEMI). This study aimed to evaluate routine GPI use in STEMI treated with primary percutaneous coronary intervention.Online databases were searched for randomized controlled trials of routine GPI vs control therapy in STEMI. Data from retrieved studies were abstracted and evaluated in a comprehensive meta-analysis. Twenty-one randomized controlled trials with 8585 patients were included: 10 trials randomized tirofiban, 9 abciximab, 1 trial eptifibatide, and 1 trial used abciximab+tirofiban; only 1 trial used dual antiplatelet therapy with prasugrel/ticagrelor.Routine GPI use was associated with a significant reduction in all-cause mortality at 30 days (2.4% [GPI] vs 3.2%; risk ratio [RR], 0.72; P = 0.01) and 6 months (3.7% vs 4.8%; RR, 0.76; P = 0.02), and a reduction in recurrent myocardial infarction (1.1% vs 2.1%; RR, 0.55; P = 0.0006), repeat revascularization (2.5% vs 4.1%; RR, 0.63; P = 0.0001), thrombolysis in myocardial infarction flow3 after percutaneous coronary intervention (5.4% vs 8.2%; RR, 0.61; P0.0001), and ischemic stroke (RR, 0.42; P = 0.04). Major (4.7% vs 3.4%; RR, 1.35; P = 0.005) and minor bleedings (7.2% vs 5.1%; RR, 1.39; P = 0.006) but not intracranial bleedings (0.1% vs 0%; RR, 2.7; P = 0.37) were significantly increased under routine GPI.Routine GPI administration in STEMI resulted in a reduction in mortality, driven by reductions in recurrent ischemic events-however predominantly in pre-prasugrel/ticagrelor trials. Trials with contemporary STEMI management are needed to confirm these findings.

Background: Patients with chronic kidney disease (CKD) and atrial fibrillation have increased risks for stroke and bleeding under oral anticoagulation (OAC). We investigated an alternative therapy of percutaneous left atrial appendage occlusion (LAAO) in CKD patients in this study.Methods: Consecutive patients undergoing LAAO were included in a retrospective analysis and stratified for kidney function into CKD/Non-CKD groups (cutoff eGFR 60 ml/min). Procedural characteristics, in-hospital and follow-up events were analysed and compared between groups.Results: LAAO was performed in 146 patients (81 CKD; 65 Non-CKD), mean follow-up was 391 days. Groups differed in eGFR (40.1 (CKD) vs. 75.1 (Non-CKD) ml/min) and CHA2DS2VASc scores (4.65 ± 1.3 (CKD) vs. 4.06 ± 1.4 (Non-CKD)). Procedural success was 98.6%, contrast-induced acute kidney injury was significantly more frequent in CKD patients (11.1% vs. 0%; p = .004). Follow-up mortality was higher in CKD (10.5/100 PY vs. 4.2/100 PY; p = .156). Follow-up stroke rates were 2.3/100 (CKD) patient-years (PY) and 1.4/100 PY (Non-CKD) (p = 1.000), corresponding to a relative risk reduction (RRR) of 60% (all), 68% (CKD) and 71% (Non-CKD) compared to expected stroke rates. Follow-up major bleeding rates were 3.5/100 PY (CKD) and 4.2/100 PY (Non-CKD), corresponding to RRR of 57% (all), 61% (CKD) and 53% (Non-CKD) compared to OAC.Conclusions: Left atrial appendage occlusion shows comparable efficacy for stroke and bleeding prevention in CKD and Non-CKD patients. CKD patients experience more adverse events during follow-up and a significantly increased risk for periprocedural contrast-induced acute kidney injury.

ZusammenfassungDie Sicherung des medizinischen Nachwuchses in Kliniken und Praxen stellt eine Herausforderung für die Weiterentwicklung der medizinischen Versorgung in Deutschland dar. Die aktuelle Entwicklung ist gekennzeichnet durch eine Überalterung der Ärzteschaft, eine zunehmende Inanspruchnahme von Teilzeitarbeit sowie durch die Tatsache, dass mehrheitlich Frauen das Medizinstudium abschließen und in die kurative Tätigkeit eintreten („Feminisierung“ der Medizin). Dieser Entwicklung muss mit der Entwicklung flexibler Arbeitszeitmodelle, modernisierten organisatorischen Abläufen sowie Maßnahmen zur Steigerung der Attraktivität sowohl von Niederlassungsmöglichkeiten als auch von Möglichkeiten einer klinischen Karriere bis in leitende Positionen unter Gewährleistung der Vereinbarkeit von Beruf und Familie sowohl für Männer als auch Frauen begegnet werden.

Objective Early diagnosis of atrial fibrillation (AFib) is a priority for stroke prevention. We sought to test four commercial pulse detection systems (CPDSs) for ability to distinguish AFib from normal sinus rhythm using a published algorithm (Zhou et al., PLoS One 2015;10:e0136544), compared with visual diagnosis by electrocardiogram inspection. Methods BAYathlon was a prospective, non-interventional, single-centre study. Adult cardiology patients with documented AFib or sinus rhythm who were due to have a routine 5-min electrocardiogram were randomized to undergo a parallel 5-min pulse assessment with a Polar V800, eMotion Faros 360, TomTom heart rate monitor, or Adidas miCoach Smart Run. Results 144 patients (73 with AFib, 71 with sinus rhythm (based on electrocardiograms); median age: 73 years; 53.5% male) were analysed. Algorithm sensitivities (primary endpoint) and specificities for AFib when applied to CPDS recordings were 93.3% and 94.1% with the Polar V800, 90.0% and 84.2% with the eMotion Faros 360, and 0% and 100% with the other CPDSs (analysis period: 127 heart rate signals + 2 min). When applied to routine electrocardiograms, the algorithm correctly detected AFib in 71/73 patients. Different analysis periods (127 heart rate signals +1 or 3 min) only slightly changed the sensitivities with the Polar V800 and eMotion Faros 360 and had no effect on the sensitivities with the other CPDSs. Conclusion AFib screening using the applied algorithm is feasible with the Polar V800 and eMotion Faros 360 (which provide RR interval data) but not with the other CPDSs (which provide pre-processed heart rate time series). ClinicalTrials.gov identifier: NCT02875106

Koordinierte Prozessablaufe bei der Erstuntersuchung von Patienten mit akutem, unklarem Brustschmerz spielen eine zentrale Rolle fur eine verbesserte Prognose. Dies gelingt in erster Linie nur dann, wenn eine Standardisierung mittels Zertifizierung und verbesserter Kooperation der daran beteiligten Versorgungseinheiten erreicht wird.

Background and purpose The risk of major cardiovascular events (MACE) is increased in patients with diabetes mellitus. Recently published clinical trials of three different pharmacological classes (DPP4 inhibitors (DPP4i), SGLT2-inhibitors (SGLT2i), GLP-1-receptor-antagonists (GLP1RA)) of new anti-diabetic agents (ADA) showed potential benefits for cardiovascular (CV) outcomes. We thus aimed to perform a meta-analysis of randomized controlled trials (RCTs) of these ADA to elucidate benefits on CV outcomes in diabetic patients. Methods Following a systematic online database search, all RCTs reporting CV outcomes of DPP4i, SGLT2i or GLP1RA vs. Placebo in diabetic patients up until December 2018 were eligible for inclusion in the meta-analysis. Studies including patients with acute coronary syndrome (ACS) were excluded. Data were abstracted and analyzed with the inverse-variance method and a random-effects model, hazard ratios (HR) with 95% confidence intervals (CI) were used as summary statistics. CV outcomes of MACE, myocardial infarction (MI), stroke, heart failure (HF), CV death and all-cause mortality were analyzed. Results Eleven RCTs (DPP4i: SAVOR, TECOS, CARMELINA; GLP1RA: LEADER, SUSTAIN-6, EXSCEL, Harmony; SGLT2i: EMPA-REG OUTCOME, CANVAS Program, DECLARE) with 109,316 patients were selected for inclusion. ELIXA and EXAMINE were excluded due to their inclusion of patients with ACS, CAROLINA was excluded for lack of placebo-control. In the pooled meta-analysis of all trials, ADA significantly reduced the risk for MACE (Hazard ratio (HR) 0.91, CI 0.86–0.96, p=0.0004), MI (HR 0.91, CI 0.85–0.96, p=0.02), CV death (HR 0.9, CI 0.82–0.99, P=0.02) and all-cause mortality (HR 0.92, CI 0.85–0.99, p=0.03). There was no difference in the risk for stroke (HR 0.94, CI 0.87–1.02, p=0.16) and HF (HR 0.88, CI 0.76–1.02, p=0.08). In agent-specific subgroup analyses, GLP1RA and SGLT2i showed significant reductions in MACE (GLP1RA: HR 0.85, CI 0.78–0.92, p Conclusions This meta-analysis lends evidence to GLP1RA and SGLT2i benefits for MACE, MI and all-cause mortality, while DPP4i failed to show superiority in cardiovascular outcomes. Individualized medication for diabetic patients depending on CV disease status should be considered.

Background and purpose Although endovascular thrombectomy (EVT) in acute ischemic stroke (AIS) is guideline-recommended to improve functional recovery, thus far there are only inconclusive data from underpowered singular trials of EVT vs. medical therapy (MT) on mortality. We here aimed to perform a meta-analysis on short-term mortality in guideline-relevant EVT vs. MT randomized controlled trials (RCTs). Methods All randomized controlled trials (RCT) reporting EVT vs. MT in the latest 2018 American Stroke Association/American Heart Association (ASA/AHA) Guidelines were eligible for inclusion. Data were abstracted by two independent investigators and double-checked by four others. Study data were integrated using the Cochran-Mantel-Haenszel method and a random-effects model to compute summary statistics of risk ratios (RR) with 95% confidence intervals (CI). Ninety-day mortality and intracranial hemorrhage (ICH) were analyzed. Results Ten of the twelve guideline-relevant EVT vs. MT RCTs (DAWN, DEFUSE 3, ESCAPE, EXTEND-IA, MR CLEAN, MR RESCUE, REVASCAT, SWIFT PRIME, THERAPY, THRACE) with 2,313 patients were selected for inclusion. Studies IMS III and SYNTHESIS were excluded due to their very infrequent use of EVT. Stent retrievers (Trevo, Solitaire, Merci) were most frequently applied, followed by thrombus aspiration (Penumbra). Intravenous thrombolysis was administered in addition to EVT in the majority of patients. In the pooled meta-analysis of all eligible RCTs, EVT significantly reduced the risk for 90-day mortality by 3.7% compared to MT (15.0% vs. 18.7%; RR 0.81 with CI 0.68 to 0.98; p=0.03), accounting for a number-needed-to-treat of 27 to prevent one all-cause death. Trends were similar in early-window (RR 0.83) and late-window trials only (RR 0.76). There was no difference in the risk for ICH in EVT vs. MT (4.2% vs. 4.0%; RR 1.11 with CI 0.71 to 1.72; p=0.65). All included trials were published in high-quality journals and risk of bias was judged low. Conclusions This meta-analysis lends evidence to EVT benefits for survival already during the first 90 days after acute ischemic stroke. These results further highlight the evolution of interventional techniques in this setting.

The National Cardiovascular Data Registry (NCDR) risk scores for mortality, bleeding and acute kidney injury (AKI) are accurate outcome predictors of coronary catheterization procedures in North American populations. However, their application in German clinical practice remained elusive and we thus aimed to verify their use. NCDR scores for mortality, bleeding and AKI and corresponding clinical outcomes were retrospectively assessed in patients undergoing catheterization for ST-segment elevation myocardial infarction (STEMI), non-ST-segment elevation myocardial infarction (NSTEMI) or for elective coronary procedures at a German Heart Center from 2014 to 2017. Risk model performance was assessed using receiver-operating-characteristic curves (discrimination) and graphical analysis/logistic regression (calibration). A total of 1637 patients were included, procedures were performed for STEMI (565 patients, 34.5%), NSTEMI (572 patients, 34.9%) and elective purposes (500 patients, 30.5%); 6% (13% of STEMI and 5% of NSTEMI patients) presented in cardiogenic shock and 3% with resuscitated cardiac arrest. Radial access was used in 38% of procedures and cross-over was necessary in 5%; PCI was performed in 60% of procedures. In-hospital mortality was 6.3% (STEMI 14.5%; NSTEMI 3.7%; elective 0%) and major bleedings occurred in 5.6% (STEMI 10.6%; NSTEMI 5.4%; elective 0.2%); AKI was detected in 18.1% of patients (STEMI 23.7%; NSTEMI 27.3%; elective 1.4%), amounting to KDIGO stage I/II/III in 11.5%/3.5%/3.2%. NCDR risk models discriminated very well for mortality [AUC 0.93 with 95% confidence interval (CI) 0.91–0.95] and well for major bleeding (AUC 0.82, CI 0.78–0.86) and any AKI (AUC 0.83, CI 0.81–0.86). Discrimination in the subgroup of patients with PCI was comparable (mortality: AUC 0.90; major bleeding: AUC 0.78; any AKI: AUC 0.79). However, calibration showed considerable underestimation of mortality and AKI in high-risk patients, while major bleeding was consistently overestimated (Hosmer–Lemeshow p

Introduction In the prospective, open-label, non-interventional, multicenter RESPONSIfVE study, the effectiveness, response rates and tolerability of ivabradine with or without beta blocker (BB) were evaluated in patients with chronic stable angina pectoris (AP) in daily clinical practice. Methods In patients with AP, ivabradine was given twice daily in flexible doses for 4 months. Resting heart rate (HR), number of angina attacks, short-acting nitrate use, severity of symptoms [by Canadian Cardiovascular Society (CCS) score] and tolerability with or without existing BB therapy were documented and analyzed using descriptive statistical methods. Results In total, 1250 patients with AP (mean age 66.0 ± 10.9 years, 59.6% male, 31.9% previous myocardial infarction) and an indication for ivabradine were included. Sixty-five percent of all patients received BB. Further concomitant standard medication included aspirin (74.2%), statins (69.3%), angiotensin-converting enzyme inhibitors/angiotensin receptor blockers (84.2%), diuretics (40.0%), long-acting nitrates (15.7%), and calcium antagonists (21.4%). After 4 months of ivabradine treatment (mean daily dose 11.0 ± 2.7 mg), mean HR was reduced from 82.4 ± 11.8 beats per minute (bpm) to 67.1 ± 8.4 bpm. The average number of angina attacks/week decreased from 1.2 ± 1.9 to 0.1 ± 0.6 and the average use of short-acting nitrates/week from 1.5 ± 2.8 units to 0.2 ± 1.0 units. CCS classification of patients improved from 76% classified in CCS grades II or III and 24% in CCS grade I to 66% classified in CCS grade I and only 35% remaining in CCS grades II or III at study end. Response rate to ivabradine (defined as HR

Previous randomized controlled trials (RCT) failed to demonstrate benefits of patent foramen ovale (PFO) closure (PFO-C) over medical therapy (MT) for secondary prevention of cryptogenic ischemic stroke. Three recently published RCTs, however, turned out positive for PFO-C and warrant an updated meta-analysis. Data from all available RCTs on PFO-C vs. MT for secondary prevention of cryptogenic ischemic stroke up until October 2017 were abstracted and analyzed in a comprehensive meta-analysis. Clinical efficacy outcomes were recurrent stroke, recurrent TIA, and their combination; safety outcomes were mortality, major bleeding, venous thromboembolism (VTE), and new-onset atrial fibrillation/flutter (NOAF). Five trials including a total of 3440 patients were included in the meta-analysis. PFO-C significantly reduced recurrent stroke [odds ratio (OR) 0.41, 95% confidence interval (CI) 0.19–0.90; p = 0.03] and the combination of recurrent stroke + TIA (OR 0.53, CI 0.36–0.80; p = 0.002) compared to MT; recurrent TIA alone showed no differences (OR 0.77; CI 0.51–1.14; p = 0.19). NOAF was significantly more frequent after PFO-C (OR 5.75, CI 3.09–10.70; p

Since 2008, the German Cardiac Society (DGK) has been establishing a network of certified chest pain units (CPUs). The goal of CPUs was and is to carry out differential diagnostics of acute or newly occurring chest pain of undetermined origin in a rapid and goal-oriented manner and to take immediate therapeutic measures. The basis for the previous certification process was criteria that have been established and published by the task force on CPUs. These criteria regulate the spatial and technical requirements and determine diagnostic and therapeutic strategies in patients with chest pain. Furthermore, the requirements for the organization of CPUs and the training requirements for the staff of a CPU are defined. The certification process is carried out by the DGK; currently, 225 CPUs are certified and 139 CPUs have been recertified after running for a period of 3 years. The certification criteria have now been revised and updated according to new guidelines.

Importance Although endovascular thrombectomy (EVT) in acute ischemic stroke is recommended by guidelines to improve functional recovery, thus far there are insufficient data on its association with mortality. Objective To identify guideline-relevant trials of EVT vs medical therapy reporting 90-day mortality and perform a meta-analysis. Data Sources All randomized clinical trials cited for recommendations on EVT vs medical therapy in the latest 2018 American Stroke Association/American Heart Association guidelines. Study Selection Ten American Stroke Association/American Heart Association guideline–relevant randomized clinical trials of EVT vs medical therapy were selected for inclusion. Two EVT trials were excluded owing to infrequent use of EVT. Data Extraction and Synthesis Data were abstracted by 2 independent investigators and double-checked by 4 others. Singular study data were integrated using the Cochran-Mantel-Haenszel method and a random-effects model to compute summary statistics of risk ratios (RR) with 95% CIs. Main Outcomes and Measures Risk of 90-day mortality and 90-day intracranial hemorrhage was analyzed; sensitivity analyses were performed in early-window EVT trials (which included patients from the onset of symptoms onward) vs late-window EVT trials (which included patients from 6 hours after onset of symptoms onward). Results In 10 trials with 2313 patients, EVT significantly reduced the risk for 90-day mortality by 3.7% compared with medical therapy (15.0% vs 18.7%; RR, 0.81; 95% CI, 0.68-0.98;P = .03). Trends were similar in early-window (RR, 0.83; 95% CI, 0.67-1.01;P = .06) and late-window trials only (RR, 0.76; 95% CI, 0.41-1.40;P = .38). There was no difference in the risk for intracranial hemorrhage in EVT vs medical therapy (4.2% vs 4.0%; RR, 1.11; 95% CI, 0.71-1.72;P = .65). Limitations of the studies include trial protocol heterogeneity and bias originating from prematurely terminated trials. Conclusions and Relevance This meta-analysis of all evidence on EVT cited in the 2018 American Stroke Association/American Heart Association guidelines shows significant benefits for survival during the first 90 days after acute ischemic stroke compared with medical therapy alone.

Increasing utilization rates of implantable cardioverter-defibrillators (ICDs) tend to overburden follow-up resources at the implanting electrophysiological centres (ECs). Remote monitoring technology allows physicians from different institutions to simultaneously review ICD data of shared patients. We studied if an integrated follow-up care involving ECs and general cardiologists (GCs) may reduce the frequency of in-office follow-ups at ECs by using remote monitoring data to identify routine checks that may be conducted at GCs.The analysis included 109 patients (aged 63 +/- 11 years, 84.4% male) followed for a cumulative study duration of 155 patient-years. The patients underwent 436 in-office controls after hospital discharge: 143 (33%) at two ECs and 293 (67%) at two GCs (each cooperating with one EC). The mean duration of in-office follow-up sessions was 13.7 min (EC) and 10.3 min (GC). The average distance between patients' homes and follow-up sites was 31.6 km (EC) vs. 16.2 km (GC). Investigators considered a follow-up to be of'high or medium'importance in 78% (EC) vs. 45% (GC) of all in-office follow-ups. At one EC, the integrated follow-up care concept appeared highly successful, with 97% of follow-ups transferred to the corresponding GC and, on average, 103.8 km shorter patient trips per follow-up.Integrated follow-up care guided by remote monitoring allows to direct the more significant follow-ups towards ECs and routine follow-ups towards GCs.This concept may contribute to the needed adaptations of the health-care system to the rising numbers of patients with implanted devices.

Hintergrund: Das Home-Monitoring ermoglicht es Arzten unterschiedlicher Institutionen, Daten und Informationen von implantierten Kardioverter-Defibrillatoren gemeinsamer Patienten gleichzeitig zu prufen. Untersuchungsgegenstand war hier ein integriertes Nachsorgekonzept, bei dem jedes Implantationszentrum mit einer speziell zugewiesenen kardiologischen Praxis zusammenarbeitete. Die Nachsorgeverantwortung lag dabei sowohl bei den Elektrophysiologen in den Zentren als auch bei den niedergelassenen Kardiologen in den Praxen. Anhand von Home-Monitoring-Daten wurde vorab zwischen Routineuntersuchungen, die unproblematisch bei niedergelassenen Kardiologen erfolgen konnten, und komplexen Analysen unterschieden, die die Expertise eines Implantationszentrums erfordern. Methoden und Ergebnisse: Von 142 in die Studie eingeschlossenen Patienten (Alter: 63 ± 12 Jahre, 82,4 % mannlich) wurden 109 Patienten aus 2 Implantationszentren in die Auswertung einbezogen. Nach Entlassung der Patienten wurden im Verlauf von durchschnittlich 652 ± 213 Tagen 436 Untersuchungen in der Sprechstunde durchgefuhrt: 143 (33 %) in den Implantationszentren und 293 (67 %) in den kardiologischen Praxen. Die durchschnittliche Dauer der Nachsorgeuntersuchungen (10 vs. 14 min) sowie die von den Prufarzten beigemessene Bedeutung der Nachsorgen (45 vs. 78 % mittel bzw. hoch) lagen bei den kardiologischen Praxen insgesamt niedriger als bei den Implantationszentren. Fazit: Der Einsatz eines integrierten Nachsorgesystems fur ICD-Patienten, das von niedergelassenen Kardiologen und erfahrenen Elektrophysiologen zur Verfugung gestellt wird, erwies sich als machbar und zuverlassig, wobei die graduelle Tendenz dahin ging, schwierigere Nachsorgen in den Implantationszentren und Routinenachsorgen eher durch die niedergelassenen Kardiologen durchzufuhren. Vor diesem Hintergrund kann dieses Nachsorgekonzept einen Beitrag zu den erforderlichen Anpassungen im Gesundheitswesen an die steigenden Zahlen von Implantattragern leisten.

Objectives: The efficacy of ivabradine has been demonstrated in different subpopulations of stable angina patients in randomized clinical trials. This study explored its effectiveness in subpopulations seen in clinical practice as they often differ from those of randomized trials. Methods: Data were pooled from three German observational studies with similar inclusion criteria (stable angina and heart rate ≥60 bpm). All patients received 2.5, 5, or 7.5 mg b.i.d. of ivabradine for 4 months, with or without concomitant beta-blocker. Antianginal effectiveness was analyzed in subpopulations defined by gender, age, heart rate, angina severity, use of concomitant beta-blocker, previous percutaneous coronary intervention procedure, and comorbidities (including previous myocardial infarction and diabetes). Results: Treatment data were available on 8,555 patients, where therapy with ivabradine was associated with a significant reduction in the frequency of angina attacks and consumption of short-acting nitrates of 87%. Effectiveness was maintained in all investigated subpopulations, with a reduction in antianginal parameters of 82-90%. Clinical status (Canadian Cardiovascular Society class) and quality of life were also improved. Ivabradine was well tolerated in all subgroups. Conclusions: Ivabradine is effective and safe in all subpopulations of angina patients seen in clinical practice, independent of age, comorbidities, and use of beta-blocker.

Die US-amerikanische Gesundheitsbehorde FDA hat der neuen Apple Watch ihren „Segen“ fur eine EKG-Funktion und als Methode zur Erkennung von Vorhofflimmern gegeben. Teils hat dieses Urteil fur Erstaunen gesorgt — ein Kommentar.

Das Verhaltnis von Systolen- und Diastolendauer wird als eine wichtige Determinante der Herzfunktion angesehen. Bei Kindern mit dilatativer Kardiomyopathie (DCM) konnte eine abnorme Verkurzung der Diastolendauer beobachtet werden. In der vorliegenden Studie wurde untersucht, ob sich dieser Befund bei Erwachsenen reproduzieren lasst und welches Verhalten der diastolische Anteil des Herzzyklus unter stufenweiser ergometrischer Belastung zeigt. Die Untersuchung schloss konsekutiv 61 Patienten mit DCM im NYHA-Stadium (New York Heart Association) II–III ein. Bei diesen wurde unter ergometrischer Belastung eine Radionuklidventrikulographie mit hoher zeitlicher Auflosung durchgefuhrt. Aus der Zeit-Aktivitats-Kurve wurde neben der linksventrikularen Ejektionsfraktion die Dauer von linksventrikularer Systole und Diastole abgeleitet. Als Vergleichskollektiv dienten 26 Patienten, bei denen eine normale linksventrikulare Pumpfunktion mittels Radionuklidangiographie vor geplanter Chemotherapie sichergestellt wurde. Der Vergleich der relativen Systolendauer ergab bei Patienten mit DCM bereits in Ruhe eine signifikante Verlangerung gegenuber Herzgesunden (23,9 vs. 21,5 s/min; p = 0,006). Dieser Befund blieb unter maximaler Belastung signifikant (29,2 vs. 26,7 s/min; p = 0,01), obwohl der Herzfrequenzanstieg in der Patientengruppe vermindert war (118 vs. 127/min; p = 0,04). Um den Einfluss der Herzfrequenz auf die Diastolendauer der DCM-Patienten zu eliminieren, wurden die beobachteten Werte mit den rechnerisch aus der Regressionsgleichung Herzgesunder ermittelten Werten verglichen. Dieses Vorgehen bestatigte eine signifikante Verkurzung der Diastolendauer auf maximaler Belastungsstufe und eine Zunahme des Verlusts an diastolischer Zeit pro Herzschlag gegenuber dem Ruhewert. Patienten mit fortgeschrittener DCM weisen eine abnorme Verkurzung der linksventrikularen Diastolendauer auf. Diese ist unter korperlicher Belastung besonders ausgepragt und kann die kardiale Effizienz durch Restriktion von ventrikularer Fullung und Perfusion beeintrachtigen.

Objectives We sought to determine the incidence of arteriovenous fistulas (AVF), identify risk factors for AVF, and follow up the clinical outcome of femoral AVF. Background Arteriovenous fistulas are a potential harmful complication of cardiac catheterization. Incidence and clinical outcome of iatrogenic AVF are unknown so far, although important for risk stratification and treatment. Methods A total of 10,271 consecutive patients undergoing cardiac catheterization were followed up prospectively over a period of three years. Diagnosis of AVF was performed by duplex sonography. Results The incidence of AVF was 0.86% (n = 88). The following significant and independent risk factors for AVF were identified: high heparin dosage (odds ratio [OR]) = 2.88), coumadin therapy (OR = 2.34), puncture of the left groin (OR = 2.21), arterial hypertension (OR = 1.86), and female gender (OR = 1.84). Within 12 months 38% of all AVF closed spontaneously. No signs of cardiac volume overload or limb damage were observed in patients with persisting AVF. None of the risk factors for AVF influenced the incidence or the rate of AVF closure. Only intensified anticoagulation showed a tendency to extend AVF persistence. Conclusions Almost 1% of patients undergoing cardiac catheterization acquire femoral AVF, for which patient- and procedure-related risk factors could be identified. One-third of iatrogenic AVF close spontaneously within one year. Cardiac volume overload and limb damage are highly unlikely with AVF persistence. Thus, a conservative management for at least one year seems to be justified.

Aims/Hypothesis: Early determination of myocardial manifestations of diabetes mellitus is of major importance, since myocardial involvement considerably influences the prognosis of diabetic patients. The aim of this study was to investigate whether young patients with insulin-dependent diabetes mellitus and normal systolic left ventricular (LV) function already show a diastolic LV dysfunction and an increased risk of arrhythmias. Methods: Echocardiography was performed in 87 patients suffering from type I diabetes mellitus, without known cardiac disease and in 87 controls. Patients with a known manifest cardiac disease or a long-term diabetic syndrome were excluded. Morphological parameters were determined using M-mode echocardiography. Doppler echocardiography was used to evaluate parameters of LV diastolic function. The risk of arrhythmia was assessed by means of electrocardiography, heart rate variability, and late potential analysis. Results: The left atrial and ventricular dimensions and systolic functional parameters of all patients were normal. A diastolic dysfunction with a reduction in early diastolic filling, an increase in atrial filling, an extension of isovolumetric relaxation and deceleration time was documented in diabetic patients, as well as an increased number of supraventricular and ventricular premature beats. Conclusion: Even young patients with diabetes mellitus suffer from a diastolic dysfunction while systolic ventricular function is normal. Therefore, echocardiography with measurements of diastolic functional parameters appears to be a sensitive method for evaluating the manifestation and course of early diabetic cardiomyopathy.