Target organ damage and control of cardiovascular risk factors in hypertensive patients. Evidence from the multicenter ESTher registry.

AIMS: This study investigated the incidence of hypertensive target organ damage (TOD), control of cardiovascular risk factors, and the short-term prognosis in hypertensive patients under contemporary guideline-oriented therapy. PATIENTS AND METHODS: A total of 1,377 consecutive patients (mean age 58.2 ± 9.9 years, 82.2 % male) with arterial hypertension were included in the ESTher (Endorganschäden, Therapie und Verlauf - target organ damage, therapy, and course) registry at 15 rehabilitation clinics within the framework of the National Genome Research Network. Cardiovascular risk factors, medication, comorbidities, and glomerular filtration rate (GFR) were assessed. Left ventricular hypertrophy (LVH), left ventricular mass (LVM), left ventricular mass index (LVMI), and left ventricular ejection fraction (LVEF) were determined by two-dimensional echocardiography. The mean follow-up was 513 ± 159 days. Changes in continuous parameters were tested by the t test, changes in discrete characteristics are presented by means of transition tables and tested with the McNemar test. RESULTS: The mean LVEF was 59.3 ± 9.9 %, both mean LVM (238.6 ± 101.5 g) and LVMI (54.0 ± 23.6 g/m(2.7)) were increased while relative wall thickness (RWT, 0.46 ± 0.18) indicated the presence of concentric LVH. Of the patients, 10.2 % displayed renal dysfunction (estimated GFR < 60 ml/min/1.73 m(2)). The 1.5-year overall mortality was 1.2 %. Compared with discharge, at follow-up the proportion of patients with blood pressure (BP) values < 140/90 mmHg decreased from 68.7 % to 55.0 % (p < 0.001) and with low-density lipoprotein (LDL) values < 100 mg/dl from 62.6 % to 38.1 % (p < 0.001). At follow-up significantly more patients displayed a GFR value of < 60 ml/min/1.73 m(2) (10.2 % vs. 16.0 %, p < 0.001). CONCLUSION: A significant proportion of hypertensive rehabilitation participants displayed TOD including LVH and renal dysfunction. Even after stringent BP reduction, a considerable increase in nephropathy could be found after 18 months.

Effect of targeting normal fasting glucose levels with basal insulin glargine on glycaemic variability and risk of hypoglycaemia: a randomized, controlled study in patients with early Type 2 diabetes.

AIMS: The purpose of this sub-study of the Outcome Reduction with Initial Glargine Intervention (ORIGIN) trial was to determine efficacy and safety of targeting normal fasting plasma glucose (FPG) levels in patients with early Type 2 diabetes treated with insulin glargine in comparison with standard care. METHODS: Participants were randomly allocated to insulin or standard care. Insulin was titrated to reach FPG

[Rehabilitation of patients with cardiac pacemakers and implanted cardioverter-defibrillators: recommendations for training, physiotherapeutic procedures and re-employment]. / Rehabilitation von Patienten mit Herzschrittmachern und Kardioverter-Defibrillatoren: Empfehlungen zu Training, Physiotherapie und beruflicher Wiedereingliederung.

Rehabilitation of patients with cardiac pacemakers (CP) or implantable cardioverter defibrillators (ICD) comprises secondary prevention of underlying cardiac disease, conditioning training activities and psychological education and includes furthermore the assessment of aggregate function, detection of any device malfunction as well as the return to work efforts. The extent to which the physical activities can be permitted is determined by both cardiopulmonary capacity and the primary arrhythmic indication. Under consideration of upper frequency limit, left ventricular dysfunction and the avoidance of mechanical exposure on device can and leads, an individually designed training programme is acceptable even on a high load level. Likewise, electrotherapeutic procedures due to musculoskeletal pain syndrome are not generally contraindicated, if differentiated limitations are respected. Beside the assessment of aggregate function and, if necessary, parameter optimization, psychologic intervention programs play an important role particularly in ICD-patients and can be utilized as an additive therapeutic module. Personalized recommendations for driving with an ICD are determined by the time interval since idex arrhythmia and the rhythmological risk profile as well as by the motor vehicle class. The return to work rate of CP and ICD patients is resumably influenced by the underlying cardiac disease and to a lesser extend by the implanted device. Except industrial jobs the risk of electromagnetic interference during the working process is low and can be objected by working place analysis including noise field measurement. Thus cardiac of CP and ICD patients should be used to a large extend for the recovery of individual physical and psychological integrity as well as for the organisation of reemployment.

[Management of sleep-related abnormal breathing by cardiologists and hospital departments of cardiology]. / Versorgung von Patienten mit obstruktiver Schlafapnoe in kardiologischen Praxen und Kliniken.

BACKGROUND AND OBJECTIVES: In the general population there is a high prevalence of sleep-related disorders of breathing (sleep apnea). In addition to being leading symptom of excessive day-time sleepiness they are also important predictors are cardiovascular disease such as arterial hypertension, heart failure, cardiac arrhythmias and stroke. Are the cardiologists the specialists who recognize such patients and refer them to diagnostic procedures and treatment? METHODS: We sent out a questionnaires to cardiologists in private practice, to hospitals with cardiology departments and to cardiology rehabilitation units in Germany in order to assess the knowledge about sleep apnea and of the current diagnostic and therapeutic procedures in patients with suspected sleep apnea. All cardiology rehabilitation units and every other practice and cardiology department listed in the reference book 'Medführer' were approached. RESULTS: 98% of 388 cardiologists with private practice were found to know about the disorder sleep apnea. 94.3% routinely asked their patients about any sleep disorder and specifically about excessive day-time sleepiness. More than half of the cardiologists (59.3%) questioned patients about possible sleep apnea as part of their interview, but only 32.7% carried out tests with a portable sleep apnea monitor. Most patients were referred to a sleep center. In 60% of the cardiology departments a portable sleep apnea monitor was used. Further diagnostic investigation followed in collaborating sleep centers (66.4%), because only 22.4% of the departments had a sleep laboratories. The main focus was on the diagnosis of abnormal sleep due to central or obstructive disorders of breathing. More than two thirds of the cardiology departments initiate nocturnal ventilation treatment. CONCLUSION: Cardiologists in private practice and cardiologists in hospital departments know about sleep-related abnormal breathing. The use of portable sleep apnea monitors and of polysomnography in special as parts of sleep centers within cardiology departments should be improved.

[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.

Cardiac rehabilitation in patients with implantable defibrillators. Feasibility and complications.

OBJECTIVE: We examined patients with implantable cardioverter defibrillators (ICD) in order to demonstrate their safe participation in a standard rehabilitation program. DESIGN: Prospective cohort study of a consecutive series of patients after ICD implantation. Setting Inpatient rehabilitation center. PATIENTS AND METHODS: A total of 118 patients (73.7% male, mean age 60+/-11 years) took part for 23 +/- 4 days in a standard inpatient rehabilitation program including physical activity, psychological care, heart function seminars, and resuscitation exercises with family members. The following noninvasive tests were performed: symptomlimited exercise testing, two-dimensional echocardiography, Holter monitoring, telemetric ICD interrogation, optional fluoroscopy or X-ray examination of the thorax, and (in some patients) defibrillation threshold testing. RESULTS: Out of 118 patients 101 patients (85.6%) participated in regular ergometer training during which the initial workload of 23 +/- 11 Watts could be increased to 45 +/- 18 Watts. An individual conditioning program was assigned to 15% (n = 17) patients, thereby enabling the inclusion of all patients in the rehabilitation process. Under these conditions 12 patients (10%) experienced ICD malfunctions requiring therapy. As a consequence of all cardiac function tests, ICD reprogramming was necessary in 26 patients (22.1%). CONCLUSION: Following ICD implantation, patients may participate in a standard rehabilitation program without serious complications and with a significant increase in physical capacity. However, ICD malfunction occurs in approximately 10% of patients. Additional tests performed by skilled medical staff and appropriate technical equipment allows the ICD program to be optimized.

Hemodynamic effects of double bolus reteplase versus alteplase infusion in massive pulmonary embolism.

BACKGROUND: Thrombolytic agents are given in massive pulmonary embolism to dissolve or reduce the clot and normalize hemodynamics. Comparative clinical studies have shown that administration of a 2-hour infusion of alteplase is more effective than urokinase over a 12-hour period. Reteplase is a new generation thrombolytic with a longer half-life that can be administered more conveniently as a double bolus. We compared efficacy and safety of reteplase with the approved regimen of alteplase in massive pulmonary embolism. METHODS: Thirty-six patients were enrolled and randomly assigned: 23 received reteplase and 13 received alteplase along with intravenous heparin. Reteplase was administered as 2 intravenous bolus injections of 10 U 30 minutes apart, and alteplase was administered as an intravenous infusion of a total dose of 100 mg over a 2-hour period, including an initial 10-mg bolus. Diagnosis of pulmonary embolism was confirmed by selective pulmonary angiography. Hemodynamic monitoring was conducted during the first 24 hours after administration. The primary end point was change in total pulmonary resistance. Secondary variables were pulmonary pressure, cardiac index, clinical parameters, and adverse events. RESULTS: The primary parameter of total pulmonary resistance showed a significant decrease after just 0.5 hours in the reteplase group and after 2 hours in the alteplase group, with a further decrease persisting for up to 24 hours in both treatment groups. A similar pattern was seen in other directly measured hemodynamic parameters, especially mean pulmonary artery pressure and cardiac index; there was no significant difference between reteplase and alteplase. There was also no apparent difference between the treatment groups with respect to safety, and no stroke or intracranial hemorrhage occurred. The rate of bleedings and the incidence of nonhemorrhagic adverse events were as expected for patients with pulmonary embolism treated with a thrombolytic agent. CONCLUSIONS: Reteplase is suitable for treatment of massive pulmonary embolism with a standard double bolus 10 + 10 U. Efficacy of reteplase appeared to be at least as good at decreasing pulmonary vascular resistance as that of the approved alteplase regimen of 100 mg infusion over a 2-hour period.

Facilitation of DDD follow-up using the DDT mode.

To facilitate follow-up, modern dual chamber pacemakers provide a variety of diagnostic features like ECG interpretation channels and intracardiac electrograms. For evaluation of the sensing performance at rest and during exercise, for assessment of the presence of crosstalk, and for measurement of the retrograde conduction time, dual chamber triggered pacing, particularly the DDT mode, can be used alternatively or additionally in pacemakers equipped with this option. In contrast to ECG interpretation channels, ECG documentation is not required for evaluation of the sensing performance, because the triggered pulses serving as markers for sense events can also be seen on the monitor. Selection of the DDT mode not only as temporary but also as permanent program serves to facilitate pacemaker ECG interpretation for exercise tests and Holter recordings as well.

[Adenomyoma of the stomach (pancreatic heterotopia)--case report and review of the literature]. / Das Adenomyom des Magens (Pankreasheterotopie)--Kasuistik und Literaturübersicht.

A case report is given of a patient, who harbored a gastric adenomyoma; this is a special form of heterotopic pancreatic tissue including excessive formation of smooth muscle tissue. Size and localization of the tumor were unusual in our case. The case presented is discussed taking into account the literature available.

[ Food allergy ]. / Nahrungsmittelallergie.

Food allergies' following food incompatibilities, which are not caused immunologically. Mostly allergic symptoms are caused by cow's milk or chicken eggs. Allergic reactions are preceded by sensitizing events; certain characteristics of foodstuffs and conditions in the human body facilitate their development. Gastrointestinal symptoms very often are just accompanying signs. In differential diagnosis the so-called "pseudo-allergies' following food ingestion have to be separated. Most important diagnostic measures are clinical history, prick-/scratch test, RAST, gastrointestinal provocation and abstinence test. The therapeutic program consists of allergen abstinence, avoiding all allergy-arousing factors, oral desensitizing and pharmaceutical treatment.