[Premature complexes, anxiety and quality of life]. / Extrasystolen, Angst und Lebensqualität.

Premature complexes can be indicative of an increased cardiac risk or can contribute to the initiation or deterioration of heart failure in particular in the presence of organic heart disease. Most premature complexes are benign. The postextrasystolic pause or the augmented postextrasystolic premature beat may cause the following symptoms: feeling of a skipped beat or the sensation of a pounding heart beat causing the feeling "that something is seriously wrong". It is mentioned that premature beats cause an unconscious reaction of the autonomic nervous system. Symptoms related to premature complexes may cause uneasiness or franc anxiety which may itself intensify the symptoms. This may cause a panic reaction which may be associated with shortness of breath or angina of the chest mimicking dyspnea of heart failure of an acute coronary syndrome. Along the "vicious cycle of anxiety" it is demonstrated how patients may be comforted. In addition, the panic disorder itself should be treated by cognitive behavioral or psychodynamic therapy.

[Cardiac involvement in neurological diseases]. / Kardiale Beteiligung bei neurologischen Erkrankungen.

Not only can cardiac diseases have neurological sequelae, but neurological diseases can also affect the heart. In this paper, the effects of a primary neurological disease on the heart are reviewed. Rare genetic muscular disorders, systemic neurodegenerative diseases, special neurological syndromes and sequelae of brain disease are discussed. A case vignette is used to illustrate that an undiagnosed neurological disease can trigger cardiac disease. Brain imaging should therefore always be considered in cardiac disease.

Significance of psychosocial factors in cardiology: update 2018 : Position paper of the German Cardiac Society.

BACKGROUND: Psychosocial factors in cardiovascular diseases are increasingly acknowledged by patients, health care providers and payer organizations. Due to the rapidly increasing body of evidence, the German Cardiac Society has commissioned an update of its 2013 position paper on this topic. The German version was published in 2018 and the current manuscript is an extended translation of the original version. METHODS: This position paper provides a synopsis of the state of knowledge regarding psychosocial factors in the most relevant cardiovascular diseases and gives recommendations with respect to their consideration in clinical practice. RESULTS: Psychosocial factors such as low socioeconomic status, acute and chronic stress, depression, anxiety and low social support are associated with an unfavorable prognosis. Psychosocial problems and mental comorbidities should be assessed routinely to initiate targeted diagnostics and treatment. For all patients, treatment should consider age and gender differences as well as individual patient preferences. Multimodal treatment concepts should comprise education, physical exercise, motivational counseling and relaxation training or stress management. In cases of mental comorbidities, brief psychosocial interventions by primary care providers or cardiologists, regular psychotherapy and/or medications should be offered. While these interventions have positive effects on psychological symptoms, robust evidence for possible effects on cardiac outcomes is still lacking. CONCLUSIONS: For coronary heart disease, chronic heart failure, arterial hypertension, and some arrhythmias, there is robust evidence supporting the relevance of psychosocial factors, pointing to a need for considering them in cardiological care. However, there are still shortcomings in implementing psychosocial treatment, and prognostic effects of psychotherapy and psychotropic drugs remain uncertain. There is a need for enhanced provider education and more treatment trials.

[Syncope in hypertrophic (obstructive) cardiomyopathy]. / Synkope bei hypertropher (obstruktiver) Kardiomyopathie.

Hypertrophic cardiomyopathy is the most common genetic cardiac disease. The most important pathophysiological finding is dynamic (outflow tract) obstruction of the left ventricle in about 70% of affected patients. Especially in younger patients, an increased risk of sudden cardiac death has been observed. Syncope and presyncope-in addition to extremely variable cardiac symptoms (dyspnea and angina)-are common. The etiology of syncope is complex. The most important aspect for diagnosis is a detailed history regarding the accompanying circumstances of the syncope. In principle, an attempt must be made to distinguish between rhythmogenic and hemodynamic causes. Diagnostic work-up should be performed under the criteria of a possible prognostic-with implantation of an implantable cardioverter-defibrillator (ICD) in patients at increased risk of sudden cardiac death-and symptomatic therapy. Depending on the underlying morphology and the experience of the surgeon, percutaneous septal ablation and operative myectomy are complementary options for symptomatic treatment if medical therapy with beta-blockers and/or verapamil is inadequate.

Effect of additional temporary glycoprotein IIb/IIIa receptor inhibition on troponin release in elective percutaneous coronary interventions after pretreatment with aspirin and clopidogrel (TOPSTAR trial).

OBJECTIVES: The Troponin in Planned PTCA/Stent Implantation With or Without Administration of the Glycoprotein IIb/IIIa Receptor Antagonist Tirofiban (TOPSTAR) trial investigated: 1) the amount of troponin T (TnT) release after nonacute, elective percutaneous coronary intervention (PCI) in patients pretreated with aspirin and clopidogrel; and 2) the effect of additional glycoprotein (GP) IIb/IIIa receptor inhibiton on postinterventional TnT release. BACKGROUND: No data are available yet as to whether additional administration of a GP IIb/IIIa receptor antagonist might be beneficial in patients undergoing elective PCI already pretreated with aspirin and clopidogrel. METHODS: After bolus application of the study medication (tirofiban [T] or placebo [P]), PCI was performed followed by an 18-h continuous infusion of T/P. Primary end point of the study was incidence and amount of TnT release after elective PCI after 24 h. RESULTS: A total of 12 h after PCI troponin release was detected in 63% of the patients receiving P and in 40% of the patients receiving T (p < 0.05), after 24 h in 69% (P) and 48% (T) (p < 0.05) and after 48 h in 74% (P) versus 58% (T) (p < 0.08) of the patients. No differences were observed regarding major bleeding, intracranial bleeding or nonhemorrhagic strokes. After nine months a reduction of combined death/myocardial infarction/target vessel revascularization could be observed in the tirofiban group ([T] 2.3% vs. [P] 13.04%, p < 0.05). CONCLUSIONS: Troponin T release occurs after successful intervention in 74% of the patients undergoing elective PCI after 48 h even after pretreatment with aspirin and clopidogrel. The GP IIb/IIIa receptor antagonist tirofiban is able to decrease the incidence of troponin release significantly in this patient population.

[Exfoliative esophagitis while taking dabigatran]. / Exfoliative Ösophagitis unter Dabigatran.

History | A 77-year-old woman was admitted with severe chest pain, heartburn, dysphagia and odynophagia. She had been on dabigatran for 13 months due to atrial fibrillation and arterial hypertension. Investigations and findings | Endoscopy of the esophagus revealed sloughing of mucosal casts, predominantly in the upper half of the organ. Treatment and course | The patient was placed on pantoprazol, local anaesthetic antacid and i. v. fluids. Dabigatran was discontinued. The symptoms disappeared within 3 days. Control endoscopy after 12 days showed complete healing of the esophageal mucosa. Conclusion | The intake of dabigatran was associated with exfoliative esophagitis, possibly due to caustic tissue damage by prolonged drug contact.

[Diagnosis of atrial fibrillation. From the standard ECG to analysis of electrograms]. / Diagnose Vorhofflimmern. Vom Standard-EKG bis zur Elektrogrammanalyse.

The early diagnosis of asymptomatic atrial fibrillation is important because of the associated risk for arterial embolism. Routine ECG recording, however, is not effective in asymptomatic patients. The goal of this article is to show the general practitioner and internist how the search for atrial fibrillation can be made more efficacious. For example, recording an ECG in patients older than 65 years with irregularities in their pulse or repeated ECG recording in patients older than 75 years with hypertension shows improved results in this regard. It is interesting that elements of the CHA2DS2-VASc score, which was developed to predict risk for arterial embolism, are also effective for defining populations to screen for atrial fibrillation. In the subgroup of patients with a pacemaker or implantable converter-defibrillator (ICD), histograms or intracardiac electrograms can be used to identify previously undiagnosed atrial fibrillation. The general practitioner should take these results which are usually obtained by a cardiologist into consideration in the follow-up treatment of his or her patients.

Electrocardiography and outcome in patients with diabetes mellitus on maintenance hemodialysis.

BACKGROUND AND OBJECTIVES: In hemodialysis, applicable guidelines recommend regular electrocardiogram (ECG) recordings. However, respective systematic evaluations are absent. Thus, the authors investigated whether routine ECG findings add prognostic information to standard risk assessment in hemodialysis. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: The relationship between nine common baseline ECG variables and a combined cardiovascular endpoint (CVE; cardiac death, myocardial infarction, stroke), sudden death, stroke, MI, and all-cause death in 1253 patients from the German Diabetes and Dialysis Study was evaluated. All patients were on maintenance hemodialysis, had type 2 diabetes mellitus, and received randomized treatment with atorvastatin or placebo. RESULTS: During 4 yr of follow-up (March 1998 to March 2004), 469 patients reached the CVE, and 617 died. After adjustment for demographics, comorbidities, and biomarkers in multivariate analysis, patients presenting without sinus rhythm were 89% more likely to die, and the risk of CVE and stroke increased by 75% and 164%, respectively, compared with patients with preserved sinus rhythm. Left ventricular hypertrophy was associated with >2-fold increase in the risk of stroke and a 60% increase in the risk of sudden death. CONCLUSIONS: In hemodialysis patients with type 2 diabetes mellitus, the absence of sinus rhythm is a risk indicator for CVE, stroke, and all-cause death, and left ventricular hypertrophy is associated with stroke and sudden death. Thus, routine ECG recording adds prognostic information to standard risk assessment.