[Bedside implantation of a new temporary vena cava inferior filter : German results from the European ANGEL registry]. / Bettseitige Implantation eines neuen passageren V.-cava-inferior-Filters : Deutsche Daten aus dem europäischen ANGEL-Register.

BACKGROUND: Pulmonary embolism (PE) is a frequently occurring complication in critically ill patients, and the simultaneous occurrence of PE and life-threatening bleeding is a therapeutic dilemma. Inferior vena cava filters (IVCF) may represent an important therapeutic alternative in these cases. The Angel® catheter (Bio2 Medical Inc., San Antonio, TX, USA) is a novel IVCF that provides temporary protection from PE and is implanted at bedside without fluoroscopy. MATERIAL AND METHODS: The European Angel® Catheter Registry is an observational, multicenter study. In our German substudy, we investigated patients from three German hospitals and four intensive care units, who underwent Angel® catheter implantation between February 2016 and December 2016. RESULTS: A total of 23 critically ill patients (68 ± 9 years, 43% male) were included. The main indication for implantation was a high risk for or an established PE, combined with contraindications for prophylactic or therapeutic anticoagulation due to either an increased risk of bleeding (81%) or active bleeding (13%). The Angel® catheter was successfully inserted in all patients at bedside. No PE occurred in patients with an indwelling Angel® catheter. Clots with a diameter larger the 20 mm, indicating clot migration, were detected in 5% of the patients by cavography before filter retrieval. Filter retrieval was uneventful in all of our cases, while filter dislocation occurred in 3% of the patients. CONCLUSION: The German data from the multicenter European Angel® Catheter Registry show that the Angel® catheter is a safe and effective approach for critically ill patients with a high risk for the development of PE or an established PE, when an anticoagulation therapy is contraindicated.

[Computer aided dosage management of phenprocoumon anticoagulation therapy. Clinical validation]. / Rechnergestützte Dosierung in der Antikoagulationstherapie mit Phenprocoumon. Validierung für den klinischen Einsatz.

UNLABELLED: A recently developed multiparameter computer-aided expert system (TheMa) for guiding anticoagulation with phenprocoumon (PPC) was validated by a prospective investigation in 22 patients. The PPC-INR-response curve resulting from physician guided dosage was compared to INR values calculated by "twin calculation" from TheMa recommended dosage. Additionally, TheMa was used to predict the optimal time to perform surgery or invasive procedures after interruption of anticogulation therapy. RESULTS: Comparison of physician and TheMa guided anticoagulation showed almost identical accuracy by three quantitative measures: Polygon integration method (area around INR target) 616.17 vs. 607.86, INR hits in the target range 166 vs. 161, and TTR (time in therapeutic range) 63.91 vs. 62.40 %. After discontinuation of anticoagulation therapy, calculating the INR phase-out curve with TheMa INR prognosis of 1.8 was possible with a standard deviation of 0.50 ± 0.59 days. CONCLUSION: Guiding anticoagulation with TheMa was as accurate as Physician guided therapy. After interruption of anticoagulant therapy, TheMa may be used for calculating the optimal time performing operations or initiating bridging therapy.

[Cannabinoid hyperemesis syndrome inducing acute prerenal failure and electrolyte disturbance]. / Akutes prärenales Nierenversagen und Elektrolytentgleisung durch das Cannabis-induzierte Hyperemesis-Syndrom.

HISTORY AND CLINICAL FINDINGS: A 36-year-old patient presented to the psychiatric clinic with presumed worsening of a chronic psychosis. INVESTIGATIONS: Laboratory values revealed acute renal failure and electrolyte imbalance. A further diagnostic work-up including urine analysis as well as abdominal und retroperitoneal sonography was normal. DIAGNOSIS, THERAPY AND CLINICAL COURSE: By exact history taking the clinical diagnosis of a cannabinoid hyperemesis syndrome (CHS) was established. Symptomatic treatment with intravenous fluids and electrolytes together with strict cannabis abstinence completely resolved all symptoms and normalized all pathologic values. CONCLUSION: Recreational use of cannabis is widespread. It may induce a widely unknown syndrome characterized by nausea, vomiting and crampy abdominal pain accompanied by frequent hot showers or bathing. This syndrome should be recognized as a potential cause of acute prerenal failure.

[41-year-old female patient with ST-elevation myocardial infarction and multiple arterial emboli]. / 41-jährige Patientin mit ST-Hebungsinfarkt und multiplen arteriellen Embolien.

A 41-year-old woman presented with acute angina in the emergency unit. Additionally, she reported pain in both legs and a weight loss of 5 kilograms within the last 10 days. ECG revealed an acute anterior myocardial infarction. However, immediate coronary angiography showed open arteries with minimal arteriosclerosis. A characteristic rise of cardiac enzymes together with an akinesis of the anterior wall and an adjacent mural thrombus was highly suggestive of a transient coronary thrombosis. Further investigations showed occlusion of multiple arteries in both legs and a splenic infarct. Although there was a typical risk profile including smoking, hyperlipidemia and regular estrogen medication, a further work-up was started. Urin analysis was decisive for the presence of proteinuria and a severe nephrotic syndrome. The definite diagnosis was made by direct biopsy of the kidney that revealed the characteristic findings of a minimal change glomerulopathy. Rapid remission could be induced by high-dose oral steroids. During routine work-up of coronary syndromes, especially in those with normal coronaries, rare but treatable causes of myocardial infarction and coagulopathy have to be thought of and should carefully be excluded.

[Renal and cardiac functions as prognostic factors after revascularization for myocardial infarction]. / Nieren- und Herzfunktion als prognostische Faktoren nach Revaskularisation bei Myokardinfarkt.

BACKGROUND AND OBJECTIVE: In the last few decades optimal treatment of myocardial infarction has been achieved by thrombolytic and interventional reperfusion as well as subsequent secondary pharmacological prevention. It remains a subject of debate what factors influence prognosis after such measures. PATIENTS AND METHODS: 939 patients who had sustained acute myocardial infarction (75.1% males, aged 62.5 10.1 years) were followed prospectively after revascularization, using a multicenter registry (PreSCD) registry. Date and site of infarction, reperfusion measures, cardiovascular risk factors, hemoglobin and creatinine, QRS duration, ventricular arrhythmias recorded by Holter ECG monitoring were recorded, as well as biplane left ventricular ejection fraction (LVEF). Multivariate logistic Cox regression analysis was used to determine the effect of these various factors on overall mortality, resuscitation outcome, ventricular tachycardia, re-infarction, syncope and interventional or surgical revascularization. RESULTS: Complete data were collected on 926 patients (98.6%). During the follow-up period of 578 47 days there were 39 deaths (4.2%), 29 of them due to cardiac reasons, predominantly sudden cardiac death (58.6%). The occurrence of left bundle branch block was associated overall with a sevenfold increase in the of death (hazard ratio [95% confidence interval, (CI) 6.940 (2.912-16.539); p<0.0001), while an increase of serum creatinine by 1 mol/l raised the overall mortality by 0.7% (Hazard ratio (95% CI) 1.007 (1.03-1.012); p<0.001]. Improvement of LVEF by 1 % was associated with a 5% reduction in mortality risk (Hazard ratio [95% CI] 0.946 (0.918-0.975); p<0.0001]. Conventional cardiovascular risk factors, previous revascularization measures, site of infarction and pharmacological treatment failed to show any significant influence on end-points. CONCLUSION: In patients who had revascularization measures after a myocardial infarction the mortality rate was less than 5%. The risk of death was determined by LVEF, occurrence of left bundle branch block and renal failure.

Implementation of evidence-based therapy in patients with systolic heart failure from 1998-2000.

BACKGROUND: In recent years, the incidence of systolic heart failure has increased. Besides a complete revascularization, guideline-based medication represents the most effective therapeutic approach. AIM: Analysis of adherence of guideline-recommended and actual medication during inpatient cardiac rehabilitation as well as under subsequent outpatient conditions. METHODS: From 01/1998 to 12/ 2000, 1346 consecutive patients (64 +/- 10 years, 73% male, LVEF 36.3 +/- 8%, 88% ischemic, 6.7% valvular cardiomyopathy, 5.3% other causes, 11.8% atrial fibrillation) were included in a singlecenter prospective register. Medication was recorded at discharge and after the follow-up period of 731 +/- 215 days. Trends in prescription rates were analyzed based on nonparametric correlations (Spearman's-Rho). Changes in medication from in- to outpatient settings were analyzed using exact McNemar test. RESULTS: At discharge 75.3% (67.9%/68.9%/ 86.6% in 1998/1999/2000, p <0.001) of the patients were treated as recommended. This rate dropped to 68.3% at followup (p <0.0001). Mortality within the follow-up period was low (12.6%). CONCLUSION: It could be shown that from 1998 to 2000 inpatient guideline conformity was implementable adequately. Outpatient conformity was significantly lower. Although a high proportion of correctly prescribed CHF medication could be demonstrated, a further effort to improve guideline adherence in the management of heart failure patients is desirable.

[Acceptance of a patient passport in secondary prevention of coronary heart disease]. / Akzeptanz eines Patientenpasses in der Sekundärprävention der koronaren Herzkrankheit.

BACKGROUND AND OBJECTIVE: Over the long term a large percentage of patients exhibit inadequately managed cardiovascular risk factors following an acute cardiac event. It remains unclear whether the patients would accept a health pass and which sociodemographic variables have an effect on the number of its users. PATIENTS AND METHODS: 437 patients (25% women, 69 +/- 10 years; 75% men 63 +/- 10 years) with diagnosed coronary heart disease were issued a health pass before being discharged from in-patient rehabilitation care. Besides their medical history, the passes contained the patients' latest values for hypertension, glucose, lipids, body mass index (kg/m(2)), and smoking. How many patients actually use the health pass was checked by the patients' physicians after 3, 6, and 12 months. In addition, cardioprotective drugs and cardiac events were logged. RESULTS: 185 (44%) of the patients used the pass continually over the course of one year. These patients tended to be older (> or = 60 years vs. < 60 years, p = 0.023), to be white-collar workers (white-collar vs. blue-collar, p = 0.043), and to have a higher level of education (> 10th class vs. < or = 10th class, p = 0.039) compared to "non-users". CONCLUSION: The acceptance of a passport is low, because fewer than half the patients used it in connection with the secondary prevention of coronary heart disease. Therefore the health pass in its present form did not show up as a useful device in patient care, particularly in single persons and those of a low sociodemographic status.

[Prognostic significance of ST segment change in acute myocardial infarct]. / Prognostische Bedeutung der ST-Strecken-Veränderung beim akuten Myokardinfarkt.

The extent of ST segment elevation resolution (STR) 180 minutes after initiation of streptokinase treatment for acute myocardial infarction within 6 hours after onset of symptoms is an excellent early prognostic indicator that can be easily determined in all patients. This presentation is based on a meta-analysis from 3 thrombolysis studies including 3,912 patients. About 50% of patients had complete STR (> or = 70%). They had small enzymatic infarct sizes and well preserved left ventricular function associated with an excellent chance of survival. Patients with partial STR (< 70 to 30%) developed larger infarcts, but had still a relatively low mortality. To assess the optimal cut-off point that best predicts an increased mortality risk, the squared standardized log odds ratio statistics as a function of the hypothetical cut-off points in STR was used. A cut-off point around 30% STR was associated with an extraordinarily strong predictive power. The 35-day cardiac mortality with STR < 30% was 12.7% as compared to 2.1% for patients who had complete STR and 4.2% for those who had partial STR. Based on STR, age, medical history, and simple parameters at admission, a low risk population can be defined that includes about 50% of all patients aged < or = 70 years, and 20% of older patients. The 35-day and 1-year mortality rates for the group of younger patients was 1.4% and 2.7%, respectively, and for the older age group 5.0% and 7.9%. It appears highly unlikely that aggressive testing and interventions would have any measurable beneficial effect on such a good outcome. In thrombolytic therapy comparative trials STR may perform well as a surrogate endpoint, since it is more powerful than 90 minutes post-thrombolytic patency rates and early mortality, in a statistical sense. This is especially true for Phase-II dose-finding studies and the use as a surrogate or even primary endpoint in phase-III trials. In addition, STR may be very helpful for safety monitoring, interim analyses, and subgroup analyses in megatrials with the endpoint mortality. Use of STR can result in a substantial reduction in the required sample size. However, at least 1 pivotal mortality trial cannot be replaced by STR trials, since STR does not reflect the risk of intracranial hemorrhages and other bleeding complications.

Risk stratification following myocardial infarction in the thrombolytic era: a two-step strategy using noninvasive and invasive methods.

OBJECTIVES: We prospectively performed a two-step risk assessment in patients in the early phase after acute myocardial infarction (MI). BACKGROUND: Noninvasive methods like Holter electrocardiographic monitoring (HM) and determination of the left ventricular ejection fraction (EF) as well as the invasive technique of programmed ventricular stimulation (PVS) have been used to identify patients in the late phase after MI as candidates for prophylactic implantation of a cardioverter/defibrillator. However, it is unclear whether these results can be transferred to patients following acute MI. METHODS: A series of 657 patients with acute MI (< or = 75 years) underwent HM and EF. If one of the two methods yielded abnormal findings (HM > or = 20 ventricular ectopic beats/h/> or =10 ventricular pairs/day/ventricular tachycardia; EF < or = 40%), PVS was done (abnormal PVS: induction of monomorphic ventricular tachycardia, duration >10 s, cycle length > or = 230 ms). RESULTS: Of 657 patients, 304 (46%) had either an abnormal HM or EF. The PVS performed in 146 of 304 patients was abnormal in 22. During a mean follow-up of 37 months, there were 106 (16%) deaths, being sudden in 24 (3.6%), nonsudden cardiac in 45 (6.8%). The incidence of arrhythmic events (sudden cardiac death, symptomatic ventricular tachycardia, cardiac arrest) was 18% (4/22) with an abnormal PVS and only 4% (5/124) with a normal PVS (odds ratio 4.0, p=0.032). CONCLUSIONS: The rate of arrhythmic events is low in post-MI patients in the 1990s. Nevertheless, a two-step risk stratification is helpful in selecting candidates for a defibrillator trial aiming at primary prevention of sudden cardiac death after MI.

[Effect of cardiac embolism sources on origin of territorial cerebral infarcts]. / Der Einfluss kardialer Emboliequellen auf die Genese territorialer Hirninfarkte.

BACKGROUND AND PURPOSE: To test the association of cardiac sources of embolism with territorial type brain infarcts. METHODS: From a prospective cerebral ischemia data base the 106 consecutive patients with territorial type cerebral infarcts on computerized tomography were analyzed. The 85 consecutive patients with lacunar lesions served as a comparison group. The association of cardiac sources of embolism with territorial types infarcts was assessed using univariate Chi Square tests and logistic regression models. Cardiac sources of embolism were defined as:atrial fibrillation, left cardiac thrombi, valvular vegetations, wall motion and valvular abnormalities, left atrial enlargement, open foramen ovale, septal aneurysm, mitral valve prolaps, and aortic arch atherothrombosis (all findings--except for atrial fibrillation--assessed by echocardiography). RESULTS: Atrial fibrillation was significantly associated with territorial type infarcts (odds ratio 2.2, 95% confidence interval 1.01-4.8). This effect was independent of additional cardiac diseases, other cardiac abnormalities, carotid artery stenosis, and patient age. Most likely due to the small sample size, left cardiac thrombi only showed a non-significant trend towards an association with territorial infarcts (odds ratio 3.0, 95% confidence interval 0.7-12.3). The rate of all other cardiac findings did not differ significantly between the comparison groups. CONCLUSION: Atrial fibrillation and cardiac thrombi showed an association with territorial type infarcts. Other so-called cardiac sources of embolism--except for mechanical valves and bacterial endocarditis which were not represented in our sample--revealed no clinically relevant association with embolic brain infarct pattern.

Estimation of enzymatic infarct size: direct comparison of the marker enzymes creatine kinase and alpha-hydroxybutyrate dehydrogenase.

BACKGROUND: Estimation of infarct size with serum-time activity curves of creatine kinase (CK) (or CKMB) or alpha-hydroxybutyrate dehydrogenase (HBDH) is widely used in clinical trials. However, an independent variable such as left ventricular function has not been directly compared with CK and HBDH infarct size measurements in the same group of patients. METHODS AND RESULTS: Infarct size was calculated by the CK area under the curve (AUC) and by the cumulative release of HBDH in 90 patients with acute myocardial infarction undergoing early thrombolysis. Infarct size estimates by CK AUC and HBDH release were closely correlated (r = 0.88, p < 0.0001). HBDH release was significantly better (p < 0.001) correlated to angiographically assessed ejection fraction 8 days after infarction (r = 0.74) than to CK AUC (r = 0.60), as was maximum HBDH (r = 0.71) compared with CK maximum (r = 0.59). In contrast to CK, maximum levels of HBDH only slightly overestimate myocardial damage in patients with early reperfusion. Data reanalyzed from the former placebo-controlled Intravenous Streptokinase in Acute Myocardial Infarction (ISAM) study revealed significant differences in favor of streptokinase for CK and CKMB AUC and for HBDH maximum, but no difference for CK and CKMB maximums. CONCLUSIONS: For comparative clinical trials HBDH appears to be the preferable marker enzyme for estimates of infarct size and measure of reperfusion effectiveness. In clinical practice one routine measure of HBDH serum activity on the second day after infarction may be a useful approximate value of infarct size.

Modification of the circadian pattern of ventricular tachyarrhythmias by beta-blocker therapy.

BACKGROUND: Sudden cardiac death exhibits a circadian variation and predominantly occurs during morning hours, Beta-adrenergic antagonists have shown to blunt this morning peak. However, previous reports studying the effects of beta blockers on the circadian variation did not analyze the underlying cause of sudden cardiac death. It thus remains unclear whether ventricular tachyarrhythmias are influenced by beta-blocker therapy. HYPOTHESIS: This study tested the hypothesis that beta-blocking agents blunt the morning peak of life-threatening ventricular tachyarrhythmias. METHODS: In 87 patients who were treated and monitored with an implantable cardioverter defibrillator, the circadian distribution of ventricular tachyarrhythmias terminated by appropriate shocks was analyzed and compared in those receiving beta blockers versus those not receiving beta-blocker therapy. RESULTS: Tachyarrhythmic episodes in the absence of beta-blocker therapy (n = 344) exhibited a circadian variation with a distinct morning peak (16, 38, 28, and 18% of episodes at 0-6, 6-12, 12-18, and 18-24 h, respectively, p < 0.001). In contrast, tachyarrhythmic episodes during beta-blocker therapy (n = 104) were equally distributed over time (22, 27, 24, and 27% of episodes at 0-6, 6-12, 12-18, and 18-24 h, respectively, p = 0.95). The circadian distribution of episodes was significantly different in patients with and those without beta blockade (p < 0.05). CONCLUSION: Beta-adrenergic antagonists influence the circadian distribution of malignant ventricular tachyarrhythmias in patients with an implantable cardioverter defibrillator. The blunted morning peak of tachyarrhythmic events during beta blockade supports the hypothesis that a sympathetic surge is involved in the circadian pattern of malignant arrhythmias.

Factors influencing the diagnostic accuracy of dobutamine stress echocardiography.

BACKGROUND: While Dobutamine stress echocardiography is a well established tool, the range of the diagnostic accuracy found in the literature is rather large. The main reason for this is the fact, that different test protocols were used. Aim of this study was to assess the effects of both addition of atropine as well as consideration of a hyperdynamic response while interpreting the stress echocardiogram on the diagnostic accuracy. METHODS AND RESULTS: 120 consecutive patients were examined and divided into the following groups: A) achieving their age predicted heart rate with dobutamine, B) termination of the test due to ischemia, C1) negative test without reaching the predicted heart rate, and C2) C1 following addition of atropine. All of the echocardiograms were analyzed twice: 1) regarding the lack of a hyperdynamic response to dobutamine as ischemia (Hyper analysis), and 2) ignoring the hypercontractility (Conventional analysis). The accuracy of A and B were 88% and 90% resp. Group C1 had a very poor accuracy of 60%. This rose significantly (p < 0.01) after atropine (C2 = 84%), without leading to an increase of adverse effects. Conventional wallmotion analysis lead to an overall accuracy of 87% (groups A, B, and C2), while Hyper analysis showed an accuracy of 90% (p < 0.01). CONCLUSIONS: To achieve a high accuracy Dobutamine stress echocardiography should always be combined with atropine to reach a target heart rate. The wallmotion analysis should be based on the assumption that a hyperdynamic response to dobutamine is normal, while its lack is indicative of ischemia.

[Diagnostic advantage by transthoracic and transesophageal echocardiography in acute ischemic infarct. A contribution to indications for transesophageal echocardiography]. / Diagnostischer Gewinn durch transthorakale und transösophageale Echokardiographie bei akutem ischämischen Insult. Ein Beitrag zur Indikationsstellung für die TOE.

The yield of TTE and TEE in identifying cardiac sources of embolism in patients with TIA or stroke was calculated from data from the Berlin Stroke Data Bank. High risk sources of embolism were detected by TTE in 4.2% with and in 1.6% of patients without evidence of cardiac disease from case history, clinical symptomatology, and ECG respectively. TEE yielded high risk sources of embolism in 10.6% of patients with and in 4.2% of patients without evidence of cardiac disease from case history, clinical symptomatology, ECG, and TTE respectively. Pathological findings were 12 atrial thrombi, 4 ventricular thrombi, and 1 atrial myxoma. 12 out of 14 atrial thrombi were only detected by TEE and not by TTE. There was a significant association of high risk cardiac sources of embolism with pial artery infarct pattern in CCT compared with lacunes. The yield of TEE in detecting high risk sources was not significantly associated with CCT infarct pattern probably due to the small numbers of investigations.

[Possible errors in diagnosis of left atrial thrombosis in transesophageal echocardiography]. / Fehlermöglichkeiten bei der Diagnose linksatrialer Thromben im transösophagealen Echokardiogramm.

The detection of thrombi in the left atrium and left atrial appendage by transesophageal echocardiography has significant diagnostic and therapeutic value. However, it requires high method accuracy in routine evaluation. In order to record the percentage of false positive findings, a reevaluation was performed by two experienced examiners using the video recordings of 51 patients, in whom a thrombus has been diagnosed during the routine evaluation. From 1988 to 1994, these thrombi were diagnosed in 726 patients in whom we looked for a source of possible cardiac embolism. In the reevaluation of the 43 cases with sufficient video recordings, in 26 (60%) the diagnosis was classified as false-positive and in 5 patients (12%) as questionable. Thrombus diagnosis was confirmed in only 12 (28%) cases. The incidence of false-positive findings decreased over the course of years with 8.3% (1988-1990), 2.9% (1991-1992) and 0.4% (1993-1994), p = 0.0001. The agreement in the reevaluation between the two examiners was high (interobserver variability 7%), whereby completely divergent evaluations did not occur. Typical diagnostic pitfalls included a prominent trabecular structure in the left atrial appendage (n = 10), the membranous structure between the left atrial appendage and the upper left pulmonary vein (n = 7), transition of the lower left atrium/left atrial appendage (n = 3) and branches within the apex of the left atrial appendage (n = 2). When searching for thrombi in the left atrium and left atrial appendage, there is a high risk of false-positive findings, especially for the unexperienced investigator. Attention must be paid to the typical causes of diagnostic pitfalls in the case of complex and variable anatomy.

Comparison of the diagnostic potential of four echocardiographic stress tests shortly after acute myocardial infarction: submaximal exercise, transesophageal atrial pacing, dipyridamole, and dobutamine-atropine.

This study assessed and compared the diagnostic potential of submaximal exercise, transesophageal atrial pacing, dipyridamole, and dobutamine-atropine stress echocardiography tests shortly after acute myocardial infarction. In 121 study patients, 325 digital echocardiographic stress tests were attempted 10 to 11 days after acute myocardial infarction: 83 submaximal exercise tests, 121 high-dose dipyridamole echocardiography tests (DET), 69 transesophageal atrial pacing tests (< 150 beats/min), and 52 dobutamine tests, starting at 10 microgram/kg per minute, increasing stepwise to 40 microgram kg/min, and coadministering atropine in 12 patients (dobutamine-atropine stress echocardiography [DASE]). Results were correlated to a coronary artery diameter stenosis > or = 50% as determined by quantitative angiography. Feasibility to perform submaximal exercise echocardiography, atrial pacing echocardiography, DET, and DASE was 89%, 52%, 98%, and 88%, respectively. Atrial pacing was not tolerated by 18 patients and refused by 6 (9%). Severe but not life-threatening side effects were hypotension in DET (2%) and tachyarrhythmias in DASE (6%). Test positivity in multivessel disease with submaximal exercise, DET, and DASE was 55%, 93%, and 90%, respectively, and in 1-vessel disease 47%, 65%, 71%, and for atrial pacing, 82%, respectively. We conclude that submaximal exercise has limited sensitivity and atrial pacing limited feasibility. The pharmacologic stressors provide a useful, safe diagnostic approach: DET with slightly lower sensitivity in 1-vessel disease and DASE with insignificantly less feasibility.

[Potential embolism sources in transesophageal echocardiography--prognostic value in patients with cerebral ischemia]. / Potentielle Emboliequellen im transösophagealen Echokardiogramm--prognostische Bedeutung bei Patienten mit zerebralen Ischämien.

To determine whether potential sources of embolism such as atrial septal aneurysm (ASA), patent foramen ovale (PFO), mitral valve prolapse and atherosclerotic aortic debris can influence the outcome of patients after first cerebral ischemic event (CIE), 214 patients (124 stroke, 21 RIND, 69 TIA) were examined by transesophageal echocardiography (TEE) up to 3 weeks after CIE and followed up for 12 months. For risk estimation, the patients were subdivided into group I = without and group II = with potential sources of embolism. We additionally took into account cardiovascular diseases and atherosclerotic risk factors (group la + IIa without, Ib + IIb with). Recurrence occurred in 14 out of 214 patients (6.5%). Univariate analysis demonstrated that the presence of ASA, PFO and aortic debris as well as cardiovascular diseases and atherosclerotic risk factors was associated with a twofold to threefold higher incidence of recurrent events. While potential sources of embolism alone had no influence on the recurrence rate (group I:8/111 = 7.2% versus group II: 6/103 = 5.8%, n.s.), this was significantly different in relation to cardiovascular diseases and atherosclerotic risk factors (groups Ia + IIa: 0/66 = 0%, groups Ib + IIb: 14/148 = 9.8%, p < 0.01). Our results show that potential sources of embolism do not appear to influence the recurrence rate in cardiac healthy subjects. In patients with cardiovascular diseases, however, potential sources of embolism are associated with a higher risk of recurrence, and should therefore be imaged by TEE.

Extent of early ST segment elevation resolution: a strong predictor of outcome in patients with acute myocardial infarction and a sensitive measure to compare thrombolytic regimens. A substudy of the International Joint Efficacy Comparison of Thrombolytics (INJECT) trial.

OBJECTIVES: This study was undertaken to assess prospectively the prognostic power of early ST segment elevation resolution in a large cohort of patients with myocardial infarction and to test the value of differences in ST segment resolution as a surrogate end point. BACKGROUND: Previous studies revealed that the use of two cutoff points for three groups of ST segment resolution within 3 h after the start of thrombolysis is most effective in predicting outcome. METHODS: The International Joint Efficacy Comparison of Thrombolytics (INJECT) trial compared mortality in 6,010 patients randomized to receive either reteplase or streptokinase. The 1,909 German patients form the basis of this substudy. The three groups of ST segment resolution were defined as complete (> or = 70%), partial (70% to 30%) and no resolution (< 30% to > or = 0%). RESULTS: In 1,398 patients presenting < or = 6 h from onset of acute myocardial infarction, the 35-day mortality rate for complete, partial and no ST segment resolution was 2.5%, 4.3% and 17.5%, respectively (p < 0.0001). Peak creatine kinase levels (fraction of normal) were 9.8, 13.4 and 14.0, respectively (p < 0.0001). When baseline characteristics were included, ST segment resolution was the most powerful independent predictor of 35-day mortality. The proportion of patients with complete ST segment resolution was larger, and that with no ST segment resolution smaller, with reteplase than with streptokinase (p = 0.006). CONCLUSIONS: No ST segment resolution, indicating failed thrombolysis, predicts very high early mortality, whereas complete resolution is associated with a small infarct area and low mortality. Partial ST segment resolution also predicts larger infarct areas, but early mortality is relatively low. Different extents of ST segment resolution may serve as a sensitive surrogate end point in clinical trials.

Circadian variation of sustained ventricular tachyarrhythmias terminated by appropriate shocks in patients with an implantable cardioverter defibrillator.

To determine the circadian variation of sustained ventricular tachyarrhythmias, 78 consecutive patients with an implanted cardioverter defibrillator were analyzed with regard to the occurrence of spontaneous shock episodes during a mean follow-up period of 18 +/- 12 months. In 39 patients 207 shock episodes that terminated potentially life-threatening ventricular tachyarrhythmias could be related to an exact time of onset. A circadian variation (p < 0.001) of these events was demonstrated, with a primary morning peak between 7 hours and 11 hours and a secondary, much smaller peak between 16 hours and 20 hours. This finding indicates the relevance of endogeneous or exogeneous triggers in the cause of malignant arrhythmias that potentially lead to sudden cardiac death. Subgroup analyses revealed an association of the circadian pattern to the New York Heart Association functional classification, indicating perhaps a different role of triggers in different patient populations.