[Less is more in cardiology and angiology]. / Weniger ist mehr in Kardiologie und Angiologie.

Cardiovascular medicine is one of the most resource-consuming parts of the healthcare system and many examples of overdiagnostic and overtreatment can be found. The present article presents just three of these, one from cardiology and two from vascular medicine. The topic of chronic coronary heart disease concerns the unequivocal proof of ischemia before a coronary intervention. The sections on Duplex sonography of the cervical blood vessels and the diagnostics of thrombophilia describe which valid clinical problems may justify the performance of these examinations at all. The potential for harm caused by overdiagnostics in both cases lies not only in the unnecessary use of resources but, more importantly, in the subsequent overtreatment. The few appropriate indications are described in detail.

Anticoagulation treatment of cancer patients with deep or superficial leg vein thrombosis - a retrospective observational study of German statutory health insurance claims data (the CERTIFICAT initiative).

Background: Thrombosis is a common complication of cancer with a negative impact on quality of life and overall prognosis. Guidelines recommend low-molecular-weight heparin (LMWH) as initial and prolonged anticoagulation treatment. Little is known about current treatment patterns of these patients in ambulatory care. Patients and methods: The current retrospective observational study interrogates a large German statutory health insurance claims database in order to understand which kind of data can be extracted and analysed. An age- and sex-adjusted sample of about 4.1 million insured people from 2011 to 2016 could be used. Cancer patients with incident deep and superficial leg vein thrombosis were identified. Patients with preexisting cancer were allocated to a normal risk group; those who suffered from simultaneously diagnosed cancer and thrombosis were classified as high-risk group. Results: We identified 322,600 patients with inpatient or outpatient documented cancer diagnosis in at least two different quarters within one year. 87,755 patients were identified with an incident deep or superficial vein thrombosis. 8,201 patients suffered from both cancer and incident thrombosis. 56.9% of the patients received an anticoagulation regimen with predominant LMWH prescription, 24.2% vitamin K antagonists, 17.2% direct oral anticoagulants; in 1.7% of patients, no predominant anticoagulant drug/regime could be identified. On average, patients were prescribed anticoagulants for 4.5 months. An estimate of clinically relevant gastrointestinal bleeding could be derived (1.8% of patients). Conclusions: The dataset allows assigning detailed information of anticoagulant prescriptions in ambulatory care to well-defined groups of cancer patients. A first analysis suggests that in Germany current medical care of patients with cancer-related deep or superficial vein thrombosis does not entirely comply with guideline recommendations regarding type and duration of anticoagulation.

[Management of pre-existing anticoagulation for timely treatment of proximal femoral fractures]. / Management vorbestehender Antikoagulation zur zeitgerechten Versorgung von hüftnahen Frakturen.

Proximal femoral fractures are urgent indications for surgery. In cases of delayed surgical treatment more than 48 h after hospital admittance, increased rates of general complications, local complications and mortality have been proven. Since 2015, the quality target for the external quality assurance by order of the Federal Joint Committee (G-BA) is surgical treatment within 24 h after hospital admittance for osteosynthesis and within 48 h for joint replacement. The foundations for these time intervals are the S2e guidelines for the treatment of femoral neck fractures of adults from the German Society of Trauma Surgery (DGU) and the Austrian Society of Trauma Surgery (ÖGU) and several other international guidelines. The distinction of the temporal specifications between osteosynthesis and joint replacement in Germany is unusual in comparison with other countries. For 15% of each group of patients a prolonged preoperative preparation is accepted. In the structured dialog within the external quality management anticoagulants are quoted as the most frequent reason for delayed surgery. The present review provides a way to achieve compliance with statutory provisions, to minimize the risks of both bleeding and thromboembolism and to achieve surgical treatment of proximal femoral fractures within the agreed time limit.

[Bridging anticoagulation in patients receiving vitamin K antagonists : Current status]. / Überbrückende Antikoagulation bei Patienten unter Vitamin-K-Antagonisten : Eine Bestandsaufnahme.

Approximately 30% of patients receiving oral anticoagulation using vitamin K antagonists (VKA) require surgery within 2 years. In this context, a clinical decision on the need and the mode of a peri-interventional bridging with heparin is needed. While a few years ago, bridging was almost considered a standard of care, recent study results triggered a discussion on which patients will need bridging at all. Revisiting the currently available recommendations and study results the conclusion can be drawn that the indications for bridging with heparin must nowadays be taken more narrowly and considering the individual patient risk of bleeding and thromboembolism. Bridging with heparin is only needed in patients with a very high risk of thromboembolism. This overview aims to give guidance for a risk-adapted peri-interventional approach to management of patients with a need for long-term anticoagulation using VKA.

[The conspicuous leg]. / Das auffällige Bein.

Symptoms of the leg or of both legs, may indicate a need for evaluation and/or treatment, which must be clarified urgently or even as an emergency situation. Among the diseases which must be considered from a vascular viewpoint are critical limb ischemia, suspicion of deep leg vein thrombosis and special forms of venous insufficiency. With respect to infections erysipelas and the syndrome of infected diabetic foot must be considered as well as peripheral and central leg paresis as orthopedic and neurological disorders, respectively. The current review summarizes the main clinical features of these diseases. Criteria are discussed as to which require the particular capabilities of a hospital and which patients can be managed in an outpatient setting.

[Abnormal laboratory results : Plausibility, reliability, and implications]. / Auffällige Laborwerte : Plausibilität, Aussagekraft und Konsequenzen.

In outpatient care or the emergency room laboratory tests oftentimes provide the first clues to the medical condition that made the patient seek medical help. Quite commonly, rapid medical decisions are required in these situations. Therefore, laboratory results must be evaluated immediately and interpreted within the broader context of the patient's presentation. During this process test results must be checked for plausibility, their positive and/or negative predictive values for the individual patient must be considered, and finally, the potential clinical implications need to be assessed. The latter in particular is of the utmost importance. This article discusses several laboratory tests commonly ordered for emergency patients and provides some guidance on their relevance in the decision to refer an outpatient to an emergency room or for inpatient care, or whether a patient can be safely diagnosed in the outpatient setting.

[Bridging anticoagulation in patients receiving vitamin K antagonists : Current status]. / Überbrückende Antikoagulation bei Patienten unter Vitamin-K-Antagonisten : Eine Bestandsaufnahme.

Approximately 30% of patients receiving oral anticoagulation using vitamin K antagonists (VKA) require surgery within 2 years. In this context, a clinical decision on the need and the mode of a peri-interventional bridging with heparin is needed. While a few years ago, bridging was almost considered a standard of care, recent study results triggered a discussion on which patients will need bridging at all. Revisiting the currently available recommendations and study results the conclusion can be drawn that the indications for bridging with heparin must nowadays be taken more narrowly and considering the individual patient risk of bleeding and thromboembolism. Bridging with heparin is only needed in patients with a very high risk of thromboembolism. This overview aims to give guidance for a risk-adapted peri-interventional approach to management of patients with a need for long-term anticoagulation using VKA.

[Imaging representation of the aorta]. / Bildgebende Darstellung der Aorta.

Depending on the type and acuteness, diseases of the aorta can be imaged by a variety of techniques. Modalities and quality of imaging have developed rapidly in recent years. In combination with the clinical assessment of patients, the results obtained by imaging determine the further management. They not only establish the underlying diagnosis but provide the information essential for indications, planning and reassessment of therapy, as well as for evaluation of the clinical course and surveillance. Whereas conventional catheter-guided angiography and intravascular ultrasound are only used in exceptional cases and then in conjunction with interventional therapy, cross-sectional imaging modalities, such as contrast-enhanced computed tomography (CT) angiography and magnetic resonance imaging (MRI) are nowadays the mainstay of diagnostics. Ultrasound techniques are improving steadily and are gaining increasing importance, e. g. for screening purposes and for pretherapeutic and posttherapeutic surveillance. Additional information of therapeutic relevance may be acquired by means of molecular imaging with positron emission tomography (PET) CT.

[Imaging representation of peripheral veins]. / Bildgebende Darstellung peripherer Venen.

Several techniques are available for imaging of the venous system of the legs and pelvic region. In cases of suspected deep leg vein thrombosis B­mode compression ultrasound is applied. Its accuracy is sufficient to either confirm or exclude the diagnosis with certainty. For examination of the iliac veins, however, flow information has to be added by pulsed wave (PW) Doppler or color Doppler sonography. In cases of suspected arm vein thrombosis, ultrasound is also the method of choice. The more proximal or the central parts of the venous system, i. e. brachiocephalic veins or the superior and inferior vena cava can be visualized by cross-sectional imaging procedures. Computed tomography (CT) angiography accurately shows the vessel lumen and magnetic resonance imaging (MRI) provides more details of the surrounding soft tissue. The use of classical contrast medium phlebography is nowadays restricted to interventions on proximal or central parts of the venous system. In addition, venous imaging is required in the field of chronic venous insufficiency. For both differential diagnostics and choice of treatment options, e. g. for varicose veins, the mainstay is venous ultrasound.

[Imaging of vessels supplying the brain]. / Bildgebende Darstellung hirnversorgender Gefäße.

Nowadays, several technically validated modalities are available for imaging both the extracranial and intracranial segments of arteries supplying blood to the brain. In the acute stroke setting, computed tomography (CT) angiography is of utmost importance because it provides the key diagnostic criteria indicative for the use of catheter-based recanalization techniques. Ultrasound imaging of extracranial arteries is most suitable for detecting an underlying stenosis of the internal carotid artery (ICA) in patients with stroke, transient ischemic attacks (TIA), retinal vessel occlusion and amaurosis fugax. Ultrasound imaging enables measurement of the methodologically most reliable criteria for grading stenosis of the ICA, which defines the indications for revascularization procedures in this territory. Magnetic resonance imaging (MRI) in the cross-sectional mode is of greatest value in confirming or excluding an arterial dissection even in short arterial segments, whereas MR angiography generates a more global view of the cerebral circulation. In most cases classical digital subtraction angiography (DSA) is no longer needed for diagnostic purposes only. Conversely, it is an indispensable component of any interventional approach and thus of growing importance. Ultrasound imaging is not indicated for the clarification of vertigo or syncope. In addition, there is no evidence that ultrasound screening of the ICA adds any value to the care of asymptomatic persons.

[Imaging of visceral vessels]. / Bildgebende Darstellung viszeraler Gefäße.

Visceral vessel processes are primarily or secondarily included in a multitude of clinical abdominal symptoms, with which the specialist in internal medicine is confronted. The spectrum ranges from more sharply outlined manifestations, such as chronic ischemic bowel disease up to dysfunctional disturbances of blood pressure regulation, such as high-grade renal artery stenosis. Sometimes diseases with prognostic implications, such as arterial aneurysms, are revealed as incidental findings. As a rule the B­mode and duplex ultrasound can often be complemented by computed tomography (CT) and magnetic resonance imaging (MRI), as in aneurysms or portal vein thrombosis or the indications for subsequent digital subtraction angiography (DSA) and catheter-based therapy can be directly obtained from duplex and Doppler ultrasound. The present review article focuses on the use of these methods in the most important diseases, with the exception of acute abdomen because this requires further detailed etiological and diagnostic systematization.

[Diseases of the peripheral vestibular system: contribution of ENT medical diagnostics and therapy]. / Erkrankungen des peripher-vestibulären Systems: HNO-ärztliche Diagnostik und Therapie.

The most common types of vertigo caused by diseases of the peripheral vestibular system are benign paroxysmal positional vertigo (BPPV), Meniere's disease and vestibular neuritis. A thorough examination of the medical history and clinical examination are usually sufficient for the differential diagnostics. Treatment includes differentiated repositioning maneuvers, medicinal treatment and physiotherapy.

[Cardiogenic syncope]. / Die kardiogene Synkope.

BACKGROUND: Cardiogenic syncope is a serious clinical event and the cause has to be clarified as rapidly and definitively as possible. DIAGNOSTICS: With knowledge of the pathophysiological background the reason for syncope can mostly be clarified by taking a thorough medical history. In most cases a physical examination, electrocardiogram (ECG) and echocardiography can provide sufficient evidence for most of the causes. Rhythmogenic syncope, however, often tends to be extremely difficult to diagnose which is why many different instruments have been developed for the detection of changes in heart rhythm. Several drugs can induce syncope by different modes of action and is the reason why particular attention should always be paid to this aspect.

[Reflex syncope and syncope secondary to orthostatic hypotension]. / Reflexsynkopen und Synkopen bei orthostatischer Hypotonie.

BACKGROUND: Reflex syncope predominantly occurs in younger patients and is the most common type of syncope. Typical contributors to reflex syncope are orthostatic stress, followed by a delayed and inadequate circulatory response consisting of bradycardia (cardioinhibitory type) and hypotension (vasodepressor type). Comparably, syncope may occur after direct activation of the vagus nerve, after emotional distress or pain, and in specific situations, such as coughing and post-micturition. The latter situations are mediated by indirect vagus nerve activation by usually unknown mediators. Syncope mediated by orthostatic hypotension occurs in elderly patients and is mediated by insufficient sympathoadrenergic vasoconstriction, occurring shortly after the onset of the orthostatic situation. DIAGNOSTICS: A thorough examination of the patient history is the mainstay of diagnostics. Specific testing is only required in uncertain and recurrent cases. In addition to standard diagnostics, tilt table testing can be helpful. A negative tilt test is, however, not definitive. Implanted loop recorders are helpful to diagnose the cardioinhibitory component of reflex syncope and are more sensitive than tilt testing. THERAPY: Treatment of both types of syncope consists of avoiding known situations leading to syncope, early reaction to prodromal syndromes, and physical counterpressure manoeuvers. Drug treatment (e.g. alpha-adrenergic agonists and fludrocortisone) are effective only in patients with orthostatic syncope. In selected patients with reflex syncope of a predominantly cardioinhibitory type, pacemaker implantation may be considered in selected patients.

[Vertigo and syncope: a clinically oriented introduction to the problem]. / Schwindel und Synkope: Eine klinisch orientierte Hinführung zum Problem.

Vertigo and syncope are frequently occurring clinical presentations in the physician's practice as well as in the emergency room. Therefore, many physicians and institutions have formulated diagnostic protocols that they follow when a patient with vertigo or syncope presents. This kind of blanket routine may lead to over-diagnosis in many cases, as well as to under-diagnosis in some. The purpose of the following article is to show that a well-focused history based on clear cut concepts of disease and a sound pathophysiological understanding will guide the physician precisely through the diagnostic process in both clinical presentations and will help to avoid manifold diagnostic procedures. Finally, a description of the most frequent pitfalls of the diagnostic work-up is given, along with measures to avoid these.

[Dyspnea. Profile of the most important diagnostic tests]. / Dyspnoe. Profile der wichtigsten diagnostischen Tests.

The diagnostic pathway for the evaluation of patients with dyspnea requires a thorough history taking and physical examination. Based on the results of these basic steps a broad variety of additional diagnostic tests are available. Each test can contribute valuable information when correctly indicated and performed. Among these are electrocardiography (ECG), laboratory parameters, X-ray examination, echocardiography, spirometry and whole body plethysmography and finally spiroergometry. This article presents a focused review of what each of these diagnostic modalities can contribute to the diagnostic process for dyspnea.

[Non-cardiac and non-pulmonary causes of dyspnea]. / Nichtkardiale und nichtpulmonale Ursachen der Dyspnoe.

In addition to cardiac and pulmonary diseases there is a broad variety of different underlying causes of dyspnea. The spectrum includes the different forms of anemia, all causes of upper airway obstructions, neuromuscular diseases and psychopathological disorders. This article gives a brief review of the entire spectrum by providing information about differential diagnostics as well as the main therapeutic principles. A field of growing interest is dyspnea in the context of palliative care.

[Importance of thrombophilia screening]. / Stellenwert des Thrombophilie-Screenings.

Thrombophilia testing denotes a test battery for inherited or acquired features associated with a tendency for clot formation. Currently, it is being used in a frequency and to an extent which is not supported by evidence. In order to protect patients from unnecessary worry and stigmatization, but also for reasons of cost effectiveness, thrombophilia testing should be reduced to a very small number of medically justifiable indications which are outlined in this review.Those indications include the following: secondary prevention of venous thromboembolism in patients from a thrombophilic family, i.e., with two or more first degree relatives with venous thromboembolism (VTE), or patients with suspected antiphospholipid syndrome; women prior to oral contraception or planning to become pregnant if they had no prior VTE but have one or more first-degree relatives with VTE-provided they are willing to follow the consequences of positive test results; women with recurrent miscarriage. The inappropriate indications are discussed as well.The test panel for inherited thrombophilias includes deficiencies of antithrombin, protein C and protein S, factor V Leiden and prothrombin 20210 mutation. Patients with suspicion of antiphospholipid syndrome have to be tested for lupus anticoagulans, anti-cardiolipin antibodies, and anti-ß2-glycoprotein I-antibodies. It is important to do the blood sampling at an appropriate point in time.

[New direct oral anticoagulants : Many advantages, but open questions]. / Neue orale direkte Antikoagulanzien : Viele Vorteile, aber offene Fragen.

In the past few years, the clinical field of anticoagulation has undergone dramatic changes due to the introduction of the new class of direct oral anticoagulants. All these agents share common features such as stable oral bioavailability, short half-life compared to vitamin K antagonists, paucity of drug-drug interactions, and fixed dosing without laboratory monitoring. However, the new agents differ regarding metabolism pathways, impact on routine clotting tests, availability of test systems for plasma concentration, and-of utmost clinical importance-dose regimens, clinical evidence, and approved indications.The present review outlines pharmacologic properties, clinical indications, different dose regimens, and preliminary clinical experience from their use in daily practice. Each of the four topics will be complemented by a compilation and in-depth discussion of open questions and lessons still to learn. The well-documented benefits of the direct oral anticoagulants as documented in clinical trials will translate to routine clinical practice only if all the rules regarding dosing and indications are obeyed, and if the experience with these agents is captured and communicated in a controlled manner.