Influence of gender on treatment and short-term mortality of patients with acute myocardial infarction in Berlin.

AIMS: Previous studies have shown higher hospital mortality rates in women, especially younger women, than in men. In light of the fact that myocardial infarction therapy is rapidly developing, and since gender-specific aspects have been discussed in detail during recent years, it was our goal to re-evaluate factors influencing hospital mortality rate, especially those involving gender-specific differences, in the city of Berlin, Germany. METHODS: We prospectively collected data from 5133 patients (3330 men and 1803 women) with acute myocardial infarction who were treated in 25 hospitals in Berlin during the years 1999 to 2002. RESULTS: During hospitalization the overall mortality rate was 18.6% among women and 8.4% among men. Women were older (mean age for men 62 years; women 73 years) and less likely to be married (men 74.6%; women 36.9%) than men. Women generally took longer to arrive at the hospital after infarction than did men (median time: men 2.0 h; women 2.6 h). Women furthermore demonstrated a higher proportion of diabetes (men 22.8%; women 36.5%) and hypertension (men 58.0%; women 69.3%). Reperfusion therapy (men 68.8%; women 49.7%) and administration of beta-blockers (men 76.0%; women 66.0%) took place less often for women than for men. A multivariate analysis revealed the following factors to be independent predictors of hospital mortality: age, gender, diabetes mellitus, hypercholesterolemia, pre-existing heart failure, pre-hospital cardiopulmonary resuscitation, cardiogenic shock and pulmonary congestion on admission, admission to a hospital with >600 beds, ST-elevation in the initial ECG, reperfusion therapy, as well as beta-blocker and ACE inhibitor treatment within 48 h of hospitalization. CONCLUSION: Even after adjustment in multivariate analysis, women with acute myocardial infarction still demonstrate a higher risk for in-hospital death than men.

Preventable causative factors leading to hospital admission with decompensated heart failure.

OBJECTIVE: To determine the distribution and importance of various factors, especially the preventable ones, that contribute to cardiac decompensation and subsequent hospital admission for heart failure. METHODS: During a one year period patients were prospectively recruited and evaluated during their hospital stay by means of a structured personal interview by trained medical staff and through clinical examination and laboratory investigation. SETTING: The cardiological department at a teaching affiliated general community hospital in Berlin, Germany. PATIENTS: Consecutive sample of 179 patients admitted to hospital with acute decompensation of pre-existing heart failure. MAIN OUTCOME MEASURES: Proportional distribution of causative factors leading to hospital admission for heart failure; relative importance of preventable factors; details of patient compliance with diet and medication, and knowledge about medication. RESULTS: Mean (SD) age was 75.4 (9.9) years. Potential causative factors for decompensated heart failure were identified in 85.5% of patients. Lack of adherence to the medical regimen was the most commonly identified factor and was regarded as the cause of the cardiac decompensation in 41.9% of cases. Non-compliance with drugs was found in 23.5% of patients. Other factors related to hospital admission were coronary ischaemia (13.4%), cardiac arrhythmias (6.1%), uncontrolled hypertension (5.6%), and inadequate preadmission treatment (12.3%). In all, 54.2% of admissions could be regarded as preventable. CONCLUSIONS: Many hospital admissions for decompensation of chronic heart failure in patients at a district hospital in Berlin are preventable. Measures are necessary to improve this situation and evaluation of programmes that include patient education, patient follow up, and physician training is needed.

[Effect of physical activity on incidence of sudden cardiac death. Study of the Berlin-Reinickendorf and Berlin-Spandau population]. / Der Einfluss von körperlicher Aktivität auf die Inzidenz des plötzlichen Herztodes. Untersuchung in der Bevölkerung von Berlin-Reinickendorf und Berlin-Spandau.

AIM: Our investigation examined the influence of regular physical activity and sudden extrenious situations on the incidence of sudden cardiac death (scd) in two different Berlin districts with a total population of 219,251 in the examined age-groups. PATIENTS AND METHOD: All cases of scd which occurred outside of the hospital and were documented as been induced from ventricular fibrillation were examined over a time period of 18 months. For each case the amount of and the intensity of their regular physical activity was determined. In addition the stress of the sudden extrenious situations was survived. The study population was divided into various groups depending upon their level of regular physical activity. For each group the incidence of sudden cardiac death was determined. Then the relative risk for scd during strenuous activity compared to inactivity was determined for each group. The influence of preexisting disease was calculated. RESULTS: 77 patients with scd induced from ventricular fibrillation were included in our study. In the sedentary group we found an incidence of 4.69 scd per 10(5) person-years, in the group with a low level of regular physical activity we found an incidence of 4.25, in the group with a middle level of regular physical activity an incidence of 2.63 and in the most active group 0.92 scd per 10(5) person-years. We found the relative risk for scd during highly strenuous activity compared with inactivity to be 150 in the sedentary group as opposed to 4.0 in the most active group. The preexisting illness status of the case-groups had no influence on the outcome. CONCLUSIONS: The results show that the risk of scd for all persons regardless of their levels of regular physical activity and their preillness status is higher during strenuous activity than during inactivity. The increase of the risk for scd during activity is the highest for persons with sedentary lifestyles, whereas the risk increase for persons with active lifestyles is minimal. The protective effect of regular physical activity for scd by far exceeds the risk increase of the actual strenuous situation.

[The value of thallium myocardial scintigraphy (single photon emission computerized tomography, SPECT) for diagnosis of ischemia after myocardial infarct]. / Die Bedeutung der Thalliummyokardszintigraphie (Single-Photon-Emissions-computertomographie, SPECT) für die Ischämiediagnose nach Herzinfarkt.

BACKGROUND: Patients with prior myocardial infarction and additional stenosis in noninfarct-related coronary artery have a high risk of reinfarction. Angina pectoris and exercise electrocardiography have a low sensitivity und specificity in detection of such coronary artery stenosis. We assessed the diagnostic value of tomographic thallium scintigraphy for detection of ischemia in myocardium not supplied by the infarct-related coronary artery. PATIENTS AND METHOD: In 77 patients with prior myocardial infarction (59 patients with acute infarction, 18 patients with chronic infarction) sensitivity and specificity of angina pectoris, exercise electrocardiography and tomographic thallium scintigraphy was determined. Coronary arteriography was the gold standard method. The predictive value of tomographic thallium scintigraphy was assessed by serial testing. RESULTS: Tomographic thallium scintigraphy detected 40 of 51 patients with significant stenosis in noninfarct-related coronary artery (sensitivity: 78%; positive predictive value: 83%). In 18 of 26 patients with no additional significant stenosis tomographic thallium scintigraphy did not show ischemia at a distance (specificity: 69%; negative predictive value: 62%). In sequential testing tomographic thallium scintigraphy did not give any additional diagnostic information in patients with angina pectoris. In patients without angina pectoris exercise electrocardiography had a high positive predictive value (90%), tomographic thallium scintigraphy did not yield a higher positive result. Only in patients without angina pectoris and negative exercise electrocardiographic findings tomographic thallium scintigraphy was helpful: 16 of these patients had an additional coronary artery stenosis and were detected by tomographic thallium scintigraphy only (positive predictive value: 75%); in 13 of 17 patients without an additional coronary artery stenosis thallium scintigrams were negative (negative predictive value: 76%). CONCLUSION: The presence of significant coronary artery stenosis in noninfarct-related vessels can be predicted by serial noninvasive testing. Tomographic thallium scintigraphy has its place in postinfarction patients without angina and with negative exercise electrocardiographic findings.

[Glossopharyngeal neuralgia with syncope]. / Glossopharyngeusneuralgie mit Synkope.

Eleven years after treatment of a tonsillar carcinoma by neck dissection, chemotherapy and radiotherapy, a now 26-year-old man had several syncopes, all preceded by burning pain in the area of the left ear with radiation to the throat and left tonsil. ECG monitoring revealed 3 degrees atrioventricular block with a slow idioventricular rhythm (34/min), as well as an asystole lasting 13 seconds. There were renewed syncopes even after pacemaker implantation. 24-hour blood pressure monitoring recorded pressures of 65/50 mm Hg, coinciding with symptoms of pain and dizziness. Being diagnosed as having glossopharyngeal neuralgia with cardiovascular involvement he was given carbamazepine, 400 mg three times daily, but without improvement. Because of this treatment failure the glossopharyngeal nerve was surgically divided, with partial but not complete regression of the symptoms. The patient declined the suggested further bilateral division of the upper vagal branches.

[Postoperative peritonitis. A contribution on diagnosis]. / Die postoperative Peritonitis. Ein Beitrag zur Diagnostik.

Symptoms and signs of 18 patients with postoperative bacterial peritonitis were compared with the findings in uncomplicated postoperative cases. Their diagnostic values were examined: 1. Elevated temperature, hyperventilation, and somnolence are relevant, being indicative of bacterial peritonitis and already occurring before the typical findings on abdominal examination. 2. In those patients with peritonitis, hemodynamics, and metabolism are characterized by hyperdynamic circulation, premature arterial hypotension with dry warm skin, and lactate accumulation. 3. Laboratory data often reveal thrombocytemia, leucocytosis with shift to the left, and a relative and absolute hypophosphatemia.

[Prognosis for patients of an intensive care unit. Myocardial infarct, pulmonary edema, reanimation and severe infections]. / Prognose von Patienten einer Intensivstation. Myokardinfarkt, Lungenödem, Reanimation und bedrohliche Infektionen.

The prognosis of patients should influence diagnostic and therapeutic measurements. For this reason the survival time is shown of 516 patients with acute myocardial infarction, 200 patients with pulmonary edema, 553 patients in which resuscitation had become necessary and 201 with life-threatening infections. The survival time is correlated to clinical signs easily obtainable on admission. Small groups can be selected which with a high degree of probability will die during their stay in hospital. Intensive therapy should be withheld from those patients. But prognostic indices without the probability of error cannot yet be constructed.

[Lactic acidosis and biguanid therapy (author's transl)]. / Biguanidtherapie und Lactatacidose

Ten case histories of patients with lactic acidosis and biguanide therapy are presented. 6 patients received phenformin, 4 buformin. The symptomatology was characterized by somnolence or unconsciousness with hyperventilation, renal insufficiency, signs of infection occasionally with detection of gram negative rods and in later stages circulatory insufficiency with high central venous pressure. Glucose, insulin, bicarbonate, dialysis, antibiotics and katecholamines were the therapeutic measurements. It is the proposal of this communication to call attention again to the potential toxicity of biguanids which makes necessary the strict observation of contraindications.

[Consumption coagulopathy in a patient with metastatic renal carcinoma (author's transl)]. / Chronische Verbrauchskoagulopathie bei metastasierendem Hypernephrom

Chronic disseminated intravascular coagulation with secondary hyperfibrinolysis occurred in a patient with metastatic renal carcinoma. In the beginning the treatment with heparin was successfull. Heparindosage up to 35 000 E/day could never suppress this process completely. The value of determining thrombintime, concentration of fibrin splitting products, coagulation factors II, V, VII, IX, X and XIII, antithrombins II and III in controlling heparintherapy is discussed. Besides thrombintime and platelets the determination of fibrin splitting products is another substantial factor in controlling treatment of chronic intravascular coagulation. The patient died of myocardial rupture with heart tamponade, caused by a great intramyocardial metastasis.

[Hospital care of patients with myocardial infarction in West Berlin (author's transl)]. / Die Versorgung von Patienten mit Myokardinfarkt in West-Berlin

An inquiry with Berlin hospitals on the care of patients with acute myocardial infarction revealed that only 30% were treated on wards guaranteeing optimum supervision and treatment according to their equipment and staff. The inquiry further shows which procedures have gained ground in the treatment of dysrhythmias and heart failure and in the prevention of thrombosis. An improvement of the care is to a lesser extent to be expected from the further development of costly therapeutical specialities but rather from administrative measures ensuring disease-specific admission to appropriate hospitals. This calls for authorities to attend to this task.