Travelling with heart failure: risk assessment and practical recommendations.

Patients with heart failure are at a higher risk of cardiovascular events compared with the general population, particularly during domestic or international travel. Patients with heart failure should adhere to specific recommendations during travel to lower their risk of developing heart failure symptoms. In this Review, we aim to provide clinicians with a set of guidelines for patients with heart failure embarking on national or international travel. Considerations when choosing a travel destination include travel distance and time, the season upon arrival, air pollution levels, jet lag and altitude level because all these factors can increase the risk of symptom development in patients with heart failure. In particular, volume depletion is of major concern while travelling given that it can contribute to worsening heart failure symptoms. Pre-travel risk assessment should be performed by a clinician 4-6 weeks before departure, and patients should receive advice on potential travel-related illness and on strategies to prevent volume depletion. Oxygen supplementation might be useful for patients who are very symptomatic. Upon arrival at the destination, potential drug-induced photosensitivity (particularly in tropical destinations) and risks associated with the local cuisine require consideration. Special recommendations are needed for patients with cardiac implantable electronic devices or left ventricular assist devices as well as for those who have undergone major cardiac surgery.

[Syncope and fitness to drive]. / Fahreignung bei Synkope.

Although medical students are rarely instructed in traffic medicine in Germany, they are obliged to inform their patients about their fitness to drive after having become a medical doctor. This article gives an overview on the fitness to drive for patients with syncope by referring to the driving license regulation and the current guidelines released by the department of traffic. The driving license regulation distinguishes between group 1 and group 2 drivers. Group 1 drivers drive vehicles with a total weight less than 3.5 t, whereas group 2 drivers drive vehicles with a total weight above 3.5 t or provide commercial passenger transport. Since patients with syncope may suffer from different serious illnesses, the first approach is to clarify the cause of syncope. If no treatable cause of syncope (e. g., pacemaker, aortic valve replacement) is found, drivers of group 1 are not fit to drive for 6 months after a second unexplained syncope, whereas in this situation, drivers of group 2 are not fit to drive permanently. If, however, syncopes occur in conditions which cannot be expected to occur while driving (e. g. venipuncture, defecation, micturition) fitness to drive will persist. Syncope due to ventricular tachycardia in ischemic heart disease and reduced left ventricular ejection fraction are in general treated with an implantable cardioverter-defibrillator (ICD). Group 2 drivers with an ICD are normally unfit to drive. Group 1 drivers with an ICD are fit to drive when no syncope or adequate shock occurred within the last three months.

Fitness to Drive in Cardiovascular Disease.

BACKGROUND: Medical students are taught little or nothing about the medical considerations related to the driving of motor vehicles. Physicians treating patients with cardiovascular disease need to acquire competence in traffic medicine in order to be able to advise them about their fitness to drive. METHODS: We present the current governmental regulations and recommendations concerning fitness to drive in patients with cardiovascular disease. We also review pertinent publications that were retrieved by a selective search in PubMed with the search terms "cardiovascular disease and traffic accidents" and "cardiovascular disease and traffic deaths" for the decade 2007-2016, as well as further publications collected by us individually. RESULTS: Cardiovascular disease can make a driver lose control of a vehicle without warning and thereby lead to an accident. The main pathophysiological mechanisms of sudden loss of control are disturbances of brain perfusion (e.g., syncope with or without cardiac arrhythmia, sudden cardiac death due to ventricular fibrillation or asystole, stroke, aneurysm rupture) and marked general weakness (e.g., after major surgery or in cardiac insufficiency). CONCLUSION: Patients with cardiovascular disease should be advised by their physicians about their fitness to drive, and the discussion should be documented in writing. Because of the German law on the confidentiality of medical data, only the affected patient should receive this information, with very few exceptions.

[When to terminate resuscitation in adults?]. / Reanimation bei Erwachsenen: Wann kann eine Wiederbelebung beendet werden?

Resuscitation in cardiac arrest rarely results in survival with a good neurologic outcome. It is therefore a common problem to decide when resuscitation should not be initiated or an ongoing attempt has to be terminated. Resuscitation attempts should be withheld or terminated if there is a do not resuscitate order (DNR), if resuscitation is not in accordance with the presumptive will of the patient or does not have a chance to allow the patient to continue an independent living. As long as ventricular fibrillation or pulseless ventricular tachycardia are present, however, resuscitation should be continued. Also in pulmonary embolism prolonged resuscitation measures may be necessary. In out-of-hospital cardiac arrest resuscitation may be stopped when the three criteria are met: not witnessed arrest, no ventricular fibrillation or pulseless tachycardia, and no return of spontaneous circulation before arrival at the hospital. According to current guidelines in-hospital resuscitation can be terminated if the patient is in asystole for at least 20 minutes. In any case termination of a resuscitation attempt is an individual decision where all possible information on circumstances and on the patient should be taken into account.

[New guidelines on resuscitation in adults: What has changed?]. / Neue Reanimationsleitlinie bei Erwachsenen: Was hat sich geändert?

In October 2015, new guidelines for cardiopulmonary resuscitation (CPR) were published, which represent a revision of the guidelines 2010. The new recommendations are based on an update of knowledge on resuscitation, which was evaluated for the first time by GRADE (Grading of Recommendations Assessment, Development and Evaluation). The key messages of the guidelines 2010 were retained in 2015. Adult basic life support consists of a sequence of 30 chest compressions at a rate of 100-120/min with a depth of 5 to maximally 6 cm and 2 ventilations. As soon as possible, an automated external defibrillator (AED) should be applied. Interruptions of chest compressions should be minimized. To improve bystander CPR emergency medical dispatchers should diagnose cardiac arrest when informed about unconscious persons not breathing normally. In this case, emergency medical staff should inform bystanders to resuscitate with compression only CPR until the arrival of an emergency team. In postresuscitation care, mild hypothermia (body temperature 32-34 °C) has been replaced by targeted temperature management in unconscious patients. Now, the guidelines recommend a constant body temperature between 32-36 °C for at least 24 h. Fever should be prevented or treated.

Cardioversion in Non-Valvular Atrial Fibrillation.

BACKGROUND: Atrial fibrillation is the most common type of cardiac arrhythmia and is associated with elevated rates of stroke, heart failure, hospital admission, and death. Its prevalence in the overall population is 1.5% to 2%. To convert atrial fibrillation to sinus rhythm, cardioversion is needed. METHODS: This review is based on pertinent articles published from 2004 to December 2014 that were retrieved by a selective PubMed search employing the terms "atrial fibrillation" and "cardioversion." RESULTS: In electrical cardioversion, a defibrillator is used to pass a pulse of current between two electrodes. In pharmacological cardioversion, antiarrhythmic drugs are given intravenously or orally. Electrical cardioversion results in sinus rhythm in more than 85% of patients; pharmacological cardioversion results in sinus rhythm in about 70% of patients with recent-onset atrial fibrillation. As a rule, cardioversion should be carried out only under effective therapeutic anticoagulation with heparin, a vitamin K antagonist, or a new oral anticoagulant drug. If atrial fibrillation has been present for more than 48 hours, cardioversion must be preceded by transesophageal echocardiography to rule out blood clot in the left atrium, or else the patient is pretreated with an anticoagulant drug for at least 3 weeks. As cardioversion can transiently impair left atrial pumping function, anticoagulation is usually maintained for 4 weeks after the procedure. The decision whether to continue anticoagulation beyond this point is based on the risk of stroke, as assessed with the CHA2DS2-VASc score. CONCLUSION: The main risks of cardioversion-thrombo--embolism and clinically significant hemorrhage--occur in 1% of cases or less (in the first 30 days after treatment) if the procedure is carried out as recommended in therapeutic guidelines. Serious complications still occur, but they are rare.

Characteristics and clinical outcome of 458 patients with acute myocardial infarction requiring mechanical ventilation. Results of the BEAT registry of the ALKK-study group.

BACKGROUND: Information about the clinical course of patients with acute myocardial infarction requiring mechanical ventilation is scarce. We sought to evaluate the clinical outcome of a large cohort of such patients in clinical practice. METHODS: The German BEAT registry prospectively enrolled consecutive patients requiring mechanical ventilation who were admitted to an internal intensive care unit (ICU) of 45 participating German hospitals between September 2001 and June 2002. For this analysis, we created a subgroup of patients with acute ST-segment-elevation or non-ST-segment-elevation myocardial infarction. RESULTS: During the 9-month study period, 458 consecutive patients fulfilled our inclusion criteria. The mean age was 68 ± 8 years and 71% were men. 40% of the patients were already intubated in the prehospital phase. The initial reason for intubation was in 48% of the cases ventricular fibrillation/tachycardia or sudden cardiac death, in 39% congestive heart failure and in 13% of the cases non-cardiac. The median time of ventilation was 2 days (1-5) among survivors and 1 day (0-5) among non-survivors. Of the 458 patients, 256 (56%) had already or developed cardiogenic shock, 86 (19%) acute renal failure, 76 (17%) coma or brain damage, 64 (14%) severe infection, 46 (10%) sepsis and 28 (6%) multiorgan distress syndrome; 11% were treated with fibrinolysis, 39% with PCI and 6% with coronary artery bypass grafting. The overall hospital mortality rate was 48%. In patients with cardiogenic shock, mortality was even higher with 69%. CONCLUSIONS: Patients requiring mechanical ventilation during an acute myocardial infarction constitute a high risk group with a mortality of about 50%. Further research is necessary to improve the outcome of these patients.

Quantitative Doppler-echocardiographic determination of regurgitant volume in patients with aortic insufficiency.

BACKGROUND: The severity of aortic regurgitation (AR) can be determined by invasive or echocardiographic methods. We systematically compared quantitative invasive and echocardiographic data with semiquantitative invasive grades in a prospective series of patients. METHODS: Using Doppler-echocardiography we determined the cardiac output over the aortic, pulmonary and mitral valve in 27 patients (20 with, 7 without AR). Aortic regurgitant volume was calculated as the difference between the cardiac output over aortic and pulmonary valve/ mitral valve. During angiography the severity of AR was assessed semiquantitatively by aortography and the regurgitant volume was calculated invasively as the difference between the left- and right ventricular cardiac output. RESULTS: The echocardiographically and invasively determined regurgitant blood volume correlated closely (R approximately 0.8). The regurgitant volume increased with higher angiographic grade but there was significant overlap between adjoining qualitative grades. CONCLUSION: In patients with AR, quantitative echocardiographic and angiographic measurements of the regurgitant volume correlate closely.

[Cardiovascular changes during pregnancy]. / Physiologische Anderungen des Herz-Kreislauf-Systems in der Schwangerschaft.

Cardiovascular alterations during pregnancy are characterized by an increased vascular volume, cardiac output, and heart rate, with a marked fall in vascular resistance. Cardiac output is about 40-50% higher during the third trimester. Even higher values of cardiac output are observed during uterine contractions in labor. In general, arterial blood pressure remains unaffected or demonstrates some tendency toward lower diastolic pressure. The higher blood volume is associated with a slight increase in left ventricular dimensions. Left ventricular contraction force and its first derivative remain unchanged. Many symptoms and findings during pregnancy are caused by the described changes, such as dyspnea on exertion, presyncope due to pressure on the inferior vena cava resulting in a decreased venous return to the heart, prominent jugular venous pulsation, leg edema, and ejection murmurs over the aorta and pulmonary artery. Paroxysmal nocturnal dyspnea, anginal chest pain, syncopy, anasarca, and diastolic heart murmurs require further evaluation.