Prognostic significance of present atrial fibrillation on a single office electrocardiogram in patients with atrial fibrillation.

BACKGROUND: Evidence for the association of atrial fibrillation (AF) present on the ECG and cardiovascular outcomes in AF patients is limited. OBJECTIVE: To investigate the prognostic significance of AF on a single surface ECG for cardiovascular outcomes in AF patients. METHODS: A total of 3642 AF patients were prospectively enrolled. Main exclusion criteria were rhythms other than sinus rhythm (SR) or AF. The primary end-point was a composite of all-cause death and hospitalizations for congestive heart failure (CHF). Secondary end-points were all-cause death, CHF hospitalizations, cardiovascular death, myocardial infarction, any stroke and stroke subtypes. Associations were assessed with multivariable Cox proportional hazards models. RESULTS: Mean age was 71 years, 28% were female, and mean follow-up was 3.4 years. Patients with SR on the ECG at study enrolment (56%) were younger (69 vs. 74 years, P < 0.0001), had more often paroxysmal AF (73 vs. 18%, P < 0.0001) and fewer comorbidities. The incidence of the primary end-point was 1.8 and 3.1 per 100 person-years in patients with SR and AF, respectively. The multivariable-adjusted hazard ratio was 1.4 (95% confidence intervals 1.1; 1.7; P = 0.001) for patients with AF on the ECG compared to patients with SR. The hazard ratios (95% confidence intervals) were 1.4 (1.1; 1.8; P = 0.006) for all-cause death, 1.5 (1.2; 1.9; P = 0.001) for CHF and 1.6 (1.1; 2.2; P = 0.006) for cardiovascular death. None of the other associations were statistically significant. CONCLUSIONS: The presence of AF in a single office ECG had significant prognostic implications with regard to mortality and CHF hospitalizations in patients with AF. These patients present a high-risk group and might benefit from intensified treatment.

A comparison of four risk models for the prediction of cardiovascular complications in patients with a history of atrial fibrillation undergoing non-cardiac surgery.

It is unclear how best to predict peri-operative cardiovascular risk in patients with atrial fibrillation undergoing non-cardiac surgery. This study examined the accuracy of the revised cardiac risk index and three atrial fibrillation thrombo-embolic risk models for predicting 30-day cardiovascular events after non-cardiac surgery in patients with a pre-operative history of atrial fibrillation. We conducted a prospective cohort study in 28 centres from 2007 to 2013 of 40,004 patients ≥ 45 years of age undergoing inpatient non-cardiac surgery who were followed until 30 days after surgery for cardiovascular events (defined as myocardial injury, heart failure, stroke, resuscitated cardiac arrest or cardiovascular death). The 2088 patients with a pre-operative history of atrial fibrillation were at higher risk of peri-operative cardiovascular events compared with the 34,830 patients without a history of atrial fibrillation (29% vs. 13%, respectively, adjusted odds ratio 1.30 (95%CI 1.17-1.45). Compared with the revised cardiac risk index (c-index 0.60), all atrial fibrillation thrombo-embolic risk scores were significantly better at predicting peri-operative cardiovascular events: CHADS2 (c-index 0.62); CHA2 DS2 -VASc (c-index 0.63); and R2 CHADS2 (c-index 0.65), respectively. Although the three thrombo-embolic risk prediction models were significantly better than the revised cardiac risk index for prediction of peri-operative cardiovascular events, none of the four models exhibited strong discrimination metrics. There remains a need to develop a better peri-operative risk prediction model.

[Assessment, frequency, causes, and prevention of medication errors - a critical analysis]. / Erfassung, Häufigkeit, Ursachen und Präventionvon Medikationsfehlern - eine kritische Analyse.

Medication errors are responsible for up to 50% of errors in healthcare. Therefore, they are an important target for the improvement of patient safety. The application of evidence-based methods for the analysis of institution-specific medication safety hotspots is crucial. Recommended methods for the identification of medication safety problems have individual strengths and weaknesses, but there is little overlap. Consequently, a combination of methods is recommended. While the analysis of critical incident reporting systems preferentially identifies serious medication errors, trigger tool represents an effective and cost-efficient approach. Evidence-based data for improvement methods is limited. However, the implementation of clinical pharmacy services, IT tools (electronic prescribing, barcoding) and standardized double-check showed a significant impact on error reduction. In addition, the support of institutional leadership is an important prerequisite.

[Measures to enhance patient safety. Importance of efficiency evaluation]. / Maßnahmen zur Verbesserung der Patientensicherheit. Bedeutung einer Wirksamkeitsevaluation.

Over the last 10 years, there has been increasing awareness of medical errors and harm to patients in healthcare. There is now widespread acceptance of the problem of medical harm and a determination to tackle major patient safety problems. Safety is defined as freedom from accidental injury. Thus, clinical risk management has been increasingly requested by professionals and their professional organizations to make healthcare safer. Clinical risk management is one of a number of organizational systems or processes aimed to improve the quality of healthcare, but one which is primarily concerned with creating and maintaining safe systems of care. A definition of this form--identifying, analyzing, and controlling risks--fits more comfortably with the culture and mission of healthcare organizations and is more likely to achieve the support and involvement of clinical professionals because it better reflects their purpose and values. Patient safety needs to become embedded in the culture of healthcare, not just in the sense of individual high standards, but a widespread acceptance of understanding of risk and safety and the need of everyone to actively promote patient safety. Measures taken to enhance patient safety encompass a wide range of activities with regard to the errors in the process of medication, to surgical errors and surgical outcome ("safer surgery saves lives"), and to hospitalism and hospital-acquired infections taking into consideration adherence to hand hygiene. An evaluation of the added value to patient safety, when processes are systematically changed and the patients become involved in making healthcare safer, is needed.

Twenty-four hour ambulatory blood pressure for the management of antihypertensive treatment: a randomized controlled trial.

The aim of this study was to assess whether the use of 24-h blood pressure (BP) measurement in the management of antihypertensive therapy improves BP in patients with sustained hypertension. Patients with sustained hypertension (office BP > or =140/90 mm Hg, and 24-h systolic BP > or =130/80 mm Hg) were randomly assigned to a strategy using 24-h BP to manage antihypertensive treatment (target <130/80 mm Hg) or to a standard strategy using office BP (target <140/90 mm Hg). The primary end point was change in 24-h systolic BP at 1 year of follow-up. We included 136 patients in the primary analysis. After 1 year of follow-up, the change in 24-h systolic BP was significantly greater in the ambulatory BP group compared with the office BP group (mean difference (95% confidence interval) -3.6 (-7.0, -0.3), P=0.03). Intention-to-treat analysis revealed essentially unchanged results. The mean number of antihypertensive drugs per participant at 1 year of follow-up was 1.76+/-1.1 and 1.95+/-0.9 in the ambulatory and office BP group, respectively (P=0.049). The benefit of ambulatory BP monitoring was mainly seen in patients with previously known hypertension (mean difference -7.2 (-11.6, -2.8), P=0.002), but not in those with newly detected hypertension (mean difference 0.2 (-4.9, 5.4), P=0.93). In conclusion, using 24-h BP for the management of antihypertensive therapy in patients with sustained hypertension leads to a greater BP reduction compared with a standard treatment strategy using office BP, although fewer antihypertensive drugs were used in the ambulatory BP group.

Epidemiology of atrial fibrillation.

Atrial fibrillation is the most common sustained cardiac arrhythmia in the general population. Unfortunately, current treatment strategies aiming at the elimination of atrial fibrillation have limited long term success rates and significant risks. In this context, recent publications have provided many insights on potentially treatable risk factors for the occurrence of atrial fibrillation, such as alcohol, blood pressure, obesity, inflammation and nutritional factors. In this review, we summarise the current evidence on these risk factors and indicate areas in need of further investigation. The current evidence shows that blood pressure, hypertension and obesity seem to play a key role in the pathogenesis of atrial fibrillation. Preliminary evidence also suggests that inflammation is an important mediator of these associations. Knowledge of these interrelationships may eventually help to develop new treatment strategies and decrease the burden of atrial fibrillation in the general population.

The quest for indicators of paroxysmal atrial fibrillation in sinus rhythm - the DETECT AF trial.

Background: Atrial fibrillation (AF) is related to an increased stroke risk. At present, differentiation between patients with paroxysmal AF (pAF) and without is only possible during AF episodes and not during sinus rhythm. If AF could be diagnosed more quickly and reliably, anticoagulation therapy may be administered and prevent from cardioembolic strokes. The DETECT AF trial evaluated the hypothesis that propagation of electric activities in patients with pAF differs from propagation in healthy atria and that this can be detected with a three-dimensional electrocardiogram in patients during sinus rhythm. Methods: We conducted a case-control study including patients with a history of pAF and a control group with no history of AF. Vectorcardiographic beat-to-beat variability of atrial activation in sinus rhythm was tested and compared between the two groups. Results: One hundred and eight patients with a history of pAF in sinus rhythm and 121 controls in sinus rhythm were included. With a combination of specific vectorcardiographic beat-to-beat variability parameters discrimination between the two groups was possible with a specificity of 82% and a sensitivity of 71% (p≤.01). Using heart rate independent parameters, both specificity and sensitivity were reduced to 70%. Conclusions: Analysis of atrial vectorcardiographic beat-to-beat variability indicates that atrial conduction variability in patients with pAF differs from patients without AF and may be used as an indicator to estimate the risk for pAF in patients during sinus rhythm. Further studies to investigate the potential of this parameter are needed. Clinical trial registration number: NCT02270112.

Renin-angiotensin and endothelial nitric oxide synthase gene polymorphisms are not associated with the risk of incident type 2 diabetes mellitus: a prospective cohort study.

OBJECTIVE: The renin-angiotensin system and endothelial function have both been implicated in the pathogenesis of type 2 diabetes. The aim of this study was to assess the relationship between a set of well-characterized genetic variants of the renin-angiotensin system and the endothelial nitric oxide synthase (NOS3) gene and the incidence of type 2 diabetes. DESIGN: Prospective cohort study. SETTING: Women's Health Study, United States. SUBJECTS: A total of 24,309 Caucasian women free of diabetes at baseline. MAIN OUTCOME MEASURES: Six previously characterized single nucleotide polymorphisms (NOS3 rs1800779, NOS3 rs3918226, NOS3 rs1799983, ACE rs1799752, AGT rs699 and AGTR rs5186) were genotyped. Cox proportional-hazards models were constructed to compare the incidence of type 2 diabetes according to the different genotypes. RESULTS: During a median follow-up of 10.2 years (interquartile range 9.6-10.6 years), 999 women developed type 2 diabetes. The age-adjusted incidence rates across the six genotypes were very similar, and ranged from 3.7 to 4.8 cases/1000 person-years of follow-up. The multivariable adjusted hazard ratios (95% confidence intervals) for rs1800779, rs3918226, rs1799983, rs1799752, rs699, and rs5186 were 1.01 (0.92-1.10), 1.09 (0.93-1.27), 0.95 (0.86-1.05), 1.04 (0.95-1.14), 1.08 (0.98-1.18), 1.01 (0.91-1.11), confirming the lack of association between the genotypes and incident type 2 diabetes. Stratification by body mass index revealed essentially unchanged results. Finally, there was no association between NOS3-haplotypes and incident type 2 diabetes. CONCLUSION: We did not find an association between six well-characterized genetic polymorphisms of the renin-angiotensin system or the NOS3 gene and the occurrence of type 2 diabetes.

Substantial intraindividual variability of BNP concentrations in patients with hypertension.

Plasma concentrations of B-type natriuretic peptides (BNP) independently predict the risk of death and cardiovascular events. In the present study, we investigated the intraindividual variability of BNP concentrations, a potential confounder of risk prediction. Consecutive outpatients with blood pressure (BP) values of at least 140/90 mm Hg and not taking BP lowering therapy were asked to participate. Exclusion criteria were renal insufficiency, structural heart disease on echocardiography, except left ventricular hypertrophy and any other severe concomitant illness. Plasma BNP levels were determined on two different days using the same assay. In total, 77 patients were included. Mean age was 54+/-12 years, 55% were male and mean systolic/diastolic BP was 163+/-16/96+/-8 mm Hg. Mean creatinine was 70+/-14 micromol/l. The median interval between the two BNP assays was 10 days (interquartile range 1-23 days). Median BNP concentrations were 17 and 16 pg/ml for the first and second visit, respectively (P=0.48). However, there was a wide range of differences in BNP values among individual patients, 34 patients (44%) having an absolute difference of at least 10 pg/ml. When patients were categorized according to tertiles of BNP levels, 25 (32%) changed from one tertile at the first visit to another at the second visit. In conclusion, these data indicate that BNP levels may be used on a population level. However, the high intraindividual variability seems to preclude useful risk stratification in the individual patient. Care should be taken in the interpretation of single BNP values below the currently accepted thresholds for heart failure.

C-reactive protein and echocardiography have little impact on risk stratification in never-treated hypertensive patients.

The aim of this study was to assess the contribution of increased concentrations of high-sensitivity C-reactive protein (hsCRP) and echocardiography to risk stratification according to the 2003 European guidelines for the management of arterial hypertension in patients with untreated hypertension. A total of 207 consecutive medical outpatients with untreated hypertension were included. History and clinical examination, electrocardiography, laboratory analyses including the measurement of hsCRP and echocardiography were performed in all patients. Patients were classified into four risk groups with and without using echocardiography and hsCRP concentrations of at least 10 mg/l according to the 2003 guidelines for the management of hypertension. The majority of the 207 patients (81%) were at moderate or high cardiovascular risk before adding echocardiography and/or hsCRP to the risk stratification process. When echocardiography was included, only three patients were reclassified from the moderate added risk to the high added risk group. Adding hsCRP concentrations of at least 10 mg/l had no impact on risk stratification. Using an hsCRP cutoff level of 3 mg/l, one patient was at moderate instead of low added risk, eight patients were at high instead of moderate added risk and one patient was at very high instead of high added risk. We conclude that hsCRP at the proposed cutoff level of 10 mg/l has no impact on risk stratification in outpatients with untreated hypertension. An hsCRP cutoff level of 3 mg/l may be more suitable for risk stratification. Finally, our data suggest that depending on the population studied, there is minimal impact of echocardiography on risk stratification.

Is routine replacement of peripheral intravenous catheters necessary?

BACKGROUND: Guidelines developed by the Centers for Disease Control and Prevention, Atlanta, Ga, recommend that peripheral intravenous catheters be changed every 3 days. However, routine replacement of central venous catheters is no longer supported in their latest update. OBJECTIVE: To evaluate the risk to patients of having peripheral intravenous catheters left in place for as long as they are clinically indicated. METHODS: This observational study in a university-affiliated, 700-bed hospital was designed to evaluate the day-specific risk (incidence density) for phlebitis, catheter infection, and obstruction with catheters remaining in place as long as clinically indicated. All consecutive patients who required peripheral intravenous catheterization for 24 hours or more were enrolled during a 10-week period. Outcome variables are phlebitis, catheter-related infections, and obstruction. Evaluated risk factors include age, sex, underlying disease, anatomical insertion site, catheter diameter, first or subsequent catheter, duration of catheterization, type of admission, hospital location, type of infusate, and antibiotic therapy. RESULTS: A total of 609 catheters that were in place for 1 to 28 days were evaluated. Phlebitis, catheter-related infection, and obstruction occurred in 19.7%, 6.9%, and 6.0% of catheters, respectively. We were unable to demonstrate an increased risk after 3 days of catheterization. The day-specific risk indicated a linear function of all outcome variables. CONCLUSIONS: The hazard for catheter-related complications--phlebitis, catheter-related infections, and mechanical complications--did not increase during prolonged catheterization. The recommendation for routine replacement of peripheral intravenous catheters should be reevaluated considering the additional cost and discomfort to the patient.

Effects of antihypertensive treatment on cerebral perfusion.

Antihypertensive treatment reduces the risk of ischemic strokes and cerebral hemorrhage as complications of excessive or long-standing hypertension. However, neurologic dysfunction and brain damage may also accompany short-term, and under certain conditions, even long-term antihypertensive treatment. Therefore, treatment should be instituted restrictively and cautiously. Special regard should be given to the action of antihypertensive drugs on cerebral perfusion in patients with an increased risk for the development of treatment-induced cerebral ischemic complications, such as patients with hypertensive encephalopathy or autonomic dysfunction, and elderly patients with suspected sclerotic stenosis of cerebral or neck arteries. The structural and functional lesions of cerebral vessels observed in acute and chronic hypertension are reviewed, as are the effects of antihypertensive drugs on cerebral blood flow. Calcium channel blockers and angiotensin-converting enzyme inhibitors may have advantages as first-line drugs in the treatment of patients with an elevated risk of cerebral hypoperfusion, because of the selective action of these agents on vasoconstricted vessels and their differential effects in varying regional vascular beds. The excellent efficacy of these drugs in the short- and long-term treatment of hypertension may lead to changes in the traditional management of hypertensive emergencies as well as in management strategies for other patients at risk for treatment-induced complications.

Antibody response in six HACEK endocarditis cases under therapy.

The antibody response to bacteria of the so-called HACEK group, i.e. Haemophilus spp., Actinobacillus actinomycetemcomitans, Cardiobacterium hominis, Eikenella corrodens and Kingella kingae, was measured in sera of six patients with endocarditis. The corresponding isolates from their blood cultures were identified by conventional methods, including reactions for nitrate reduction and catalase as well as acid production from sugars. Crude antigens were prepared by glycine extraction and sonification of the blood culture isolates, and used to determine titers by complement fixation. A patient with Haemophilus parainfluenzae bacteremia received a short course of antibiotic therapy, and relapsed with spondylitis and endocarditis 5 months later. Titers of sera against his own isolate rose from 1:40 to 1:320 and fell to 1:40 after therapy within one year. A patient with C. hominis endocarditis had a similarly prolonged course. The complement fixation titer against his own isolate was already 1:240 before antibiotics were administered. Another patient with C. hominis endocarditis presented a titer of 1:320 2 weeks after the diagnosis. These three patients revealed C-reactive protein values over 50 mg/l in the first serum sample. Decrease of both antibody titers and C-reactive protein values correlated with clinical improvement. Two patients with prosthetic valve replacement 5 months earlier developed C. hominis and K. kingae endocarditis, respectively. At admission, C-reactive protein values were 64 and 82, respectively, and therapy was instituted immediately. The first sera were received 3 and 6 weeks, respectively, after isolation of the corresponding blood culture isolates and revealed already low titers, i. e. 1:80 and 1:60, respectively. A woman with A. actinomycetemcomitans endocarditis received immediate therapy and did not develop titers against her own isolate. CRP was 100 at admission and remained over 50 5 weeks later. We conclude that the complement fixation assay with individual antigen preparations was easy to perform and allowed monitoring of the antibody response in 5 of 6 HACEK endocarditis cases under therapy, but the usefulness of this method to find culture-negative HACEK endocarditis needs to be established.

Women's experiences with low-risk singleton in-hospital delivery in Switzerland.

OBJECTIVE: To assess maternal and neonatal clinical short-term outcomes and women's experiences with singleton low-risk in-hospital deliveries in a routine care setting. METHODS: In 13 community hospitals in the Cantons of Zurich (10), St. Gallen (2) and Schwyz (1), participating in the "Canton of Zurich Outcomes Project", trained hospital staff recorded clinical outcome data. Patients completed a questionnaire at the end of the hospital stay. Over two measurement cycles, 3395 eligible women entered the study and 2079 (61%) returned the questionnaire. RESULTS: Sixty-seven percent of women had spontaneous and 11% had assisted vaginal deliveries, 12% delivered by emergency, and 10% by elective Caesarean section. The episiotomy rate in vaginal deliveries was 46% (95% CI 44-48%). Ten percent of neonates had umbilical cord artery pH < or =7.15 (95% CI 9-11%) and Apgar scores at five minutes were < or = 7 in 3% (95% CI 2.5-3.6%). Reporting negative experiences with hospital care and an insufficient state of knowledge at discharge were strongly associated with mode of delivery. The top three issues new mothers were most likely to report about feeling little or not informed about were postpartum pelvic floor exercises (22%), management of vaginal bleedings (12%), and alternatives of infant feeding (10%). CONCLUSION: In a setting of routine care poor short-term outcomes were rare in women giving birth in hospitals, and neonates and most mothers were discharged with a level of information that at least ensured a smooth transition to follow-up maternal care. Poor clinical results and patient-reported negative experiences concentrate in few individuals. Restrictive approaches that reduce the frequency of instrumental vaginal delivery, and routine episiotomy remain an important objective for quality improvement.

Prevalence of hyperuricemia and relation of serum uric acid with cardiovascular risk factors in a developing country.

BACKGROUND: The prevalence of hyperuricemia has rarely been investigated in developing countries. The purpose of the present study was to investigate the prevalence of hyperuricemia and the association between uric acid levels and the various cardiovascular risk factors in a developing country with high average blood pressures (the Seychelles, Indian Ocean, population mainly of African origin). METHODS: This cross-sectional health examination survey was based on a population random sample from the Seychelles. It included 1011 subjects aged 25 to 64 years. Blood pressure (BP), body mass index (BMI), waist circumference, waist-to-hip ratio, total and HDL cholesterol, serum triglycerides and serum uric acid were measured. Data were analyzed using scatterplot smoothing techniques and gender-specific linear regression models. RESULTS: The prevalence of a serum uric acid level >420 micromol/L in men was 35.2% and the prevalence of a serum uric acid level >360 micromol/L was 8.7% in women. Serum uric acid was strongly related to serum triglycerides in men as well as in women (r = 0.73 in men and r = 0.59 in women, p < 0.001). Uric acid levels were also significantly associated but to a lesser degree with age, BMI, blood pressure, alcohol and the use of antihypertensive therapy. In a regression model, triglycerides, age, BMI, antihypertensive therapy and alcohol consumption accounted for about 50% (R2) of the serum uric acid variations in men as well as in women. CONCLUSIONS: This study shows that the prevalence of hyperuricemia can be high in a developing country such as the Seychelles. Besides alcohol consumption and the use of antihypertensive therapy, mainly diuretics, serum uric acid is markedly associated with parameters of the metabolic syndrome, in particular serum triglycerides. Considering the growing incidence of obesity and metabolic syndrome worldwide and the potential link between hyperuricemia and cardiovascular complications, more emphasis should be put on the evolving prevalence of hyperuricemia in developing countries.

[Sex- or symptom-specific behavior of male residents? An analysis of diagnosis and therapy of ambulatory female and male patients with abdominal pain]. / Geschlechts- oder symptomspezifisches Verhalten männlicher Assistenzärzte? Eine Analyse von Diagnostik und Therapie bei ambulanten Patientinnen und Patienten mit Bauchschmerzen.

We investigated the influence of the patient's gender for diagnostic and therapeutic approach of physicians at the outpatient clinic of the university hospital of Basle. In a prospective study 13 male residents in their second and third year of medical training were observed in their management of 25 female and 25 male patients presenting with the leading complaint of abdominal pain with regard to taking of the medical history, the physical examination and the performed diagnostic and therapeutic procedures, without informing the participating physicians. The time spent for the first consultation and the number of follow ups performed were registered. Following differences in the management of female and male patients were observed: The time spent at the first consultation was 59 +/- 5 minutes in female and 45 +/- 3.5 in male patients (p less than 0.03). Fundoscopic examination was three times more often performed in female patients. Endoscopic examinations were more often observed in male patients (p less than 0.01). Antacids and H2-antagonists were more frequently prescribed in male (p less than 0.01). Spasmolytics and laxatives more frequently in female (p less than 0.01). In summary in male patients the diagnosis of functional disease was predominantly made after exclusion of an organic disease what does explain the use of more diagnostic procedures and the induction of a more specific therapy.

[Quality management: internal guidelines and critical pathways for patients]. / Qualitätsmanagement: Interne Leitlinien und Patientenpfade.

BACKGROUND: The construction and implementation of "Practice Guidelines" was one of the most important developments in American medicine of the last 15 years. There is ongoing controversy about the effectiveness of these guidelines to get introduced into practice. It has been proved, however, that guidelines developed by care organizations themselves, will show a higher effectiveness and acceptance and will achieve more positive results (Internal Guidelines, "Locally Owned" Standards). "Mipp": Internal Guidelines are also the starting point for the patient pathways of the model of integrated patient pathways "mipp", developed at the Kantonsspital Aarau in the last 7 years. The model is presented with its main features: Construction and Implementation of Pathways, Path-Controlling, Path-Benchmarking and Path-Visualization. "Mipp" Pathways share with Clinical Pathways the interdisciplinary perspectives for an efficient quality management. The description of processes is combined with an integrated calculation of costs, which is the basis of standard cost accounting and even activity based-costing. CONCLUSION: In the field of upcoming prospective payment systems (PPS) like ARDRG, APDRG etc. it is of utmost importance for care organizations to have a clear view regarding the treatment processes and the possibilities of their improvement.

[Sense and usefulness of preventive diagnosis]. / Sinn und Nutzen präventiver Diagnostik.

The value of preventive screening tests is controversial. The predictive value of such testing depends on the incidence of the disease as well as of the sensitivity and specificity of the available tests. Cardiovascular and neoplastic diseases have been a model for preventive testing. We review the pertinent literature on preventive screening tests with special emphasis on the value of a thorough history and physical exam.

[Ambulatory transesophageal echocardiography. Diagnostic possibilities of a novel study method]. / Ambulante transösophageale Echokardiographie. Diagnostische Möglichkeiten einer neuen Untersuchungsmethode.

Transesophageal echocardiography has become now a routine outpatient method to augment the diagnostic power of transthoracic echocardiography in 10-15 minutes. Indications are native and prosthetic valvular heart disease and congenital heart disease, the evaluation of embolic events and suspicion of aortic dissection.

Cerebral blood flow and calcium antagonists in hypertension.

Antihypertensive treatment reduces the risk of ischaemic strokes and cerebral haemorrhage as complications of excessive or long-standing hypertension. However, neurological dysfunction and brain damage may also accompany acute and, under certain conditions, even chronic antihypertensive treatment. Treatment should therefore be instituted restrictively and cautiously, with special regard to the action of antihypertensive drugs on cerebral perfusion in patients with an increased risk for treatment-induced cerebral ischaemic complications, e.g. patients with hypertensive encephalopathy, patients with autonomic dysfunction or elderly patients with suspected sclerotic stenosis of cerebral or neck arteries. The present study is a review of the structural and functional lesions of cerebral vessels observed in acute and chronic hypertension, together with the effects of antihypertensive drugs on cerebral blood flow. Calcium channel blockers such as nifedipine, nitrendipine and verapamil may have advantages as first-line drugs in the treatment of patients with an elevated risk for cerebral hypoperfusion, because of their selective action on vasoconstricted vessels and their differential effects in different regional vascular beds. The particular efficacy of calcium antagonists in acute antihypertensive treatment, with a significant increase in cerebral blood flow in the case of nifedipine, and also in chronic antihypertensive therapy without decreasing cerebral blood flow, may change the traditional management of hypertensive emergencies, as well as of other patients at risk of treatment-induced complications.