Perspectives on improving blood pressure control to reduce the clinical and economic burden of hypertension.

The clinical and economic burden of hypertension is high and continues to increase globally. Uncontrolled hypertension has severe but avoidable long-term consequences, including cardiovascular diseases, which are among the most burdensome and most preventable conditions in Europe. Yet, despite clear guidelines on screening, diagnosis and management of hypertension, a large proportion of patients remain undiagnosed or undertreated. Low adherence and persistence are common, exacerbating the issue of poor blood pressure (BP) control. Although current guidelines provide clear direction, implementation is hampered by barriers at the patient-, physician- and healthcare system levels. Underestimation of the impact of uncontrolled hypertension and limited health literacy lead to low adherence and persistence among patients, treatment inertia among physicians and a lack of decisive healthcare system action. Many options to improve BP control are available or under investigation. Patients would benefit from targeted health education, improved BP measurement, individualized treatment or simplified treatment regimens through single-pill combinations. For physicians, increasing awareness of the burden of hypertension, as well as offering training on monitoring and optimal management and provision of the necessary time to collaboratively engage with patients would be useful. Healthcare systems should establish nationwide strategies for hypertension screening and management. Furthermore, there is an unmet need to implement more comprehensive BP measurements to optimize management. In conclusion, an integrative, patient-focused, multimodal multidisciplinary approach to the management of hypertension by clinicians, payers and policymakers, involving patients, is required to achieve long-term improvements in population health and cost-efficiency for healthcare systems.

[Abdominal pain and signs of acute pancreatitis in a 60-year-old man]. / Bauchschmerzen und Zeichen einer akuten Pankreatitis bei einem 60-jährigen Patienten.

Spontaneous splenic rupture is an uncommon complication of acute pancreatitis. This report describes the case of a 60-year-old man with acute pancreatitis complicated by splenic rupture. The patient was admitted to the emergency department with pain in the upper abdomen that had been present for 2 days. He was diagnosed with acute pancreatitis of alcoholic etiology. The patient was admitted to the hospital for two recurrent episodes in the last 4 months of acute pancreatitis of alcoholic etiology. Magnetic resonance imaging of the abdomen revealed a suspicious area of necrosis. Seventy-two hours after admission, the patient had significant improvement in symptoms and the inflammation markers rapidly decreased. However, he showed clinical worsening on the seventh day of hospitalization, with increasing abdominal distension and reduced hemoglobin levels. A CT angiography showed a large amount of free fluid in the abdominal cavity, along with a large splenic hematoma. The patient subsequently underwent laparotomy, which showed hemoperitoneum due to rupture of the splenic parenchyma. A splenectomy was performed with resection of the pancreatic tail.

[Guidelines in Practice: The New S3 Guideline "Sleeping Disorders - Sleep-Related Abnormal Breathing"]. / Leitlinien in der Praxis: Die neue S3-Leitlinie "Nicht erholsamer Schlaf/Schlafstörungen" ­ Kapitel "Schlafbezogene Atmungsstörungen".

Sleep related breathing disorders include central sleep apnea (CSA), obstructive sleep apnea (OSA), sleep-related hypoventilation, and sleep-related hypoxia. These disorders are frequent and growing in clinical relevance. The related chapter of the S3 guideline "Non-restorative sleep/Sleep disorders", published by the German Sleep Society (DGSM), has recently been updated in November 2016. Epidemiology, diagnostics, therapeutic procedures, and classification of sleep related disorders have been revised. Concerning epidemiology, a considerably higher mortality rate among pregnant women with OSA has been emphasized. With regards to diagnostics, the authors point out that respiratory polygraphy may be sufficient in diagnosing OSA, if a typical clinical condition is given. For CSA, recommendations were changed to diagnose CSA with low apnea rates present. Significant changes for treating CSA in patients with left ventricular dysfunction have been introduced. In addition, there is now to be differentiated between sleep-related hypoventilation and sleep-related hypoxaemia. Obesity hypoventilation syndrome is discussed in more detail. This article sums up and comments on the published changes.

Non-CPAP therapies in obstructive sleep apnoea.

In view of the high prevalence and the relevant impairment of patients with obstructive sleep apnoea syndrome (OSAS) lots of methods are offered which promise definitive cures for or relevant improvement of OSAS. This report summarises the efficacy of alternative treatment options in OSAS. An interdisciplinary European Respiratory Society task force evaluated the scientific literature according to the standards of evidence-based medicine. Evidence supports the use of mandibular advancement devices in mild to moderate OSAS. Maxillomandibular osteotomy seems to be as efficient as continuous positive airway pressure (CPAP) in patients who refuse conservative treatment. Distraction osteogenesis is usefully applied in congenital micrognathia or midface hypoplasia. There is a trend towards improvment after weight reduction. Positional therapy is clearly inferior to CPAP and long-term compliance is poor. Drugs, nasal dilators and apnoea triggered muscle stimulation cannot be recommended as effective treatments of OSAS at the moment. Nasal surgery, radiofrequency tonsil reduction, tongue base surgery, uvulopalatal flap, laser midline glossectomy, tongue suspension and genioglossus advancement cannot be recommended as single interventions. Uvulopalatopharyngoplasty, pillar implants and hyoid suspension should only be considered in selected patients and potential benefits should be weighed against the risk of long-term side-effects. Multilevel surgery is only a salvage procedure for OSA patients.

[Are there alternative therapeutical options other than CPAP in the treatment of the obstructive sleep apnea syndrome]. / Gibt es Alternativen zum nCPAP-Verfahren in der Behandlung des obstruktiven Schlafapnoesyndroms?

Many patients with the obstructive sleep apnea syndrome (OSAS) look for alternative conservative or surgical therapies to avoid to be treated with continuous positive airway pressure. In view of the high prevalence and the relevant impairment of the patients lots of methods are offered which promise definitive cure or relevant improvement of OSAS. The working group "Apnea" in the German Society of Sleep Medicine and Research established a task force to evaluate the scientific literature on non-CPAP therapies in the treatment of OSAS according to the standards of evidence-based medicine. This paper summarizes the results of the task force. The data were unsatisfactorily for most of the methods. Sufficient data were available for intraoral appliances (IOA) and the maxillomandibular osteotomy (MMO). IOA's can reduce mild to moderate respiratory disturbances, MMO are efficient in the short and long term but are performed only in special situations such as craniofacial dysmorphias. Weight reduction and body positioning cannot be recommended as a single treatment of OSAS. Most surgical procedures still lack sufficient data according to the criteria of evidence based medicine. Resections of muscular tissue within the soft palate have to be strictly avoided. But even success following gentle soft palate procedures is difficult to predict and often decreases after years. Results in other anatomical regions seem to be more stable over time. Today combined surgeries in the sense of multi-level surgery concepts are of increasing interest in the secondary treatment after failure of nasal ventilation therapy although more data from prospective controlled studies are needed. There is no evidence for any other treatment options.

Pulmonary hypertension in patients with obstructive sleep apnea syndrome.

BACKGROUND: Obstructive sleep apnea syndrome (OSAS) is associated with an increased cardiovascular morbidity, including pulmonary hypertension. Little is known about factors influencing the degree of pulmonary hypertension and left ventricular dysfunction in patients with OSAS, especially in the absence of concomitant lung disease. METHODS: Right heart catheterization, arterial blood gas analysis, and pulmonary function tests were performed in 92 consecutive patients (81 men and 11 women; mean +/- SD age, 53.1 +/- 11.0 years) with polysomnographically verified OSAS, in whom clinically significant lung disease was excluded. RESULTS: Eighteen patients (20%) had mild pulmonary hypertension; 8 (44%) of them also had increased pulmonary capillary wedge pressures (Ppew). Left ventricular dysfunction was associated with arterial hypertension. Only Ppcw (r = 0.51; P < .001) and the percentage of time during sleep spent with an oxygen saturation below 90% (as an indicator of the severity of OSAS) (r = 0.34; P = .003) were significantly and independently associated with pulmonary artery pressure. CONCLUSIONS: Obstructive sleep apnea syndrome can cause mild pulmonary hypertension, even in the absence of pulmonary disease. In these patients, pulmonary hypertension is of the postcapillary type, or-in patients with normal left ventricular function-strongly related to the severity of OSAS. Our findings indicate that OSAS may constitute an important, and independent, risk factor for pulmonary hypertension.

Use of conventional and self-adjusting nasal continuous positive airway pressure for treatment of severe obstructive sleep apnea syndrome: a comparative study.

STUDY OBJECTIVES: To compare conventional and self-adjusting nasal continuous positive airway pressure (nCPAP) therapy in patients with severe obstructive sleep apnea syndrome with respect to suppression of respiratory disturbances, quality of sleep, mean mask pressure, and patient compliance. DESIGN: Cohort study of consecutive patients with obstructive sleep apnea syndrome, single-blinded. SETTING: Clinical sleep laboratory in Germany. PATIENTS: Fifty patients (44 men, 6 women who ranged in age from 35 to 71 years) with polysomnographically confirmed severe obstructive sleep apnea syndrome (respiratory disturbance index [RDI], >20/h). MEASUREMENTS AND INTERVENTIONS: After baseline polysomnography, patients were randomly treated with nCPAP either in conventional (group 1) or in automatically adjusting (group 2) mode. Three to 6 months after adjustment, all patients underwent polysomnography again. They also were examined with a portable monitoring device and received a questionnaire on subjective well-being and device evaluation. RESULTS: Anthropometric and respiratory data were comparable in both groups; body mass index had not changed significantly in the follow-up. RDI dropped by 91.5% (from 38.3+/- 13.9/h to 3.6+/-4.4/h) in conventional and by 93.6% (from 35.5+/-9.6/h to 2.4+/-1.6/h) in self-adjusting mode (statistically not significant [NS]). Sleep efficiency decreased by 4.0% in conventional and increased by 2.0% in self-adjusting mode (NS). In both groups, normal sleep structure was largely restored. Mean mask pressure was 8.1+/-2.5 cm H2O in group 1 and 6.5+/-1.7 cm H2O in group 2 (p<0.01). Patient compliance in terms of nights per week of mask appliance was better in the self-adjusting mode (5.7+/-0.7 to 6.5+/-0.4; p<0.01). CONCLUSION: Self-adjusting nCPAP demonstrates the same reliability in suppression of respiratory disturbances as fixed-mask pressure therapy. Sleep quality is slightly superior, patient compliance is highly significantly better.

Self-adjusting nasal continuous positive airway pressure therapy based on measurement of impedance: A comparison of two different maximum pressure levels.

STUDY OBJECTIVE: Automatic titration using the forced oscillation technique (FOT) has recently been developed for the treatment of obstructive sleep apnea syndrome (OSAS). So far, it is not known if therapy with automatic nasal continuous positive airway pressure (nCPAP) using a preset upper pressure limitation or a free range (which might lead to higher mean pressure) is preferable with regard to obstructive events, sleep stages, and pressure characteristics. DESIGN: After diagnostic polysomnography, patients were randomly assigned to two settings with the self-adjusting nCPAP (APAP) device based on the FOT. In mode 1, the pressure variation ranged from 4 to 15.5 cm H(2)O, and in mode 2, the pressure variation ranged from 4 cm H(2)O to an individual upper pressure limit. PATIENTS: Eleven men, aged 53.0 +/- 6.8 years with a body mass index of 32.4 +/- 5.1 kg/m(2) and an apnea-hypopnea index (AHI) of 31.6 +/- 26.6/h. MEASUREMENTS AND RESULTS: Manually titrated pressure was at 9.3 +/- 2.1 cm H(2)O, the mean pressure in mode 1 was 5.4 +/- 1.0 cm H(2)O (p < 0.01), and the mean pressure in mode 2 was 5.1 +/- 0.7 cm H(2)O (p < 0.01). A reduction of respiratory events (baseline AHI, 31.6 +/- 26.6/h; AHI in mode 1, 3.4 +/- 4.5; AHI in mode 2, 5.0 +/- 7.2; each with p < 0.001) and an increase in the "rapid eye movement" stage of sleep (baseline, 13.0 +/- 5.5%; mode 1, 22.0 +/- 7.7 [p < 0. 05]; mode 2, 23.0 +/- 7.9 [p < 0.01]) were achieved. In mode 1, the mean pressure was below the manual pressure 91.7 +/- 9.3% of the time, and in mode 2, the mean pressure was below the manual pressure 90.4 +/- 6.3% of the time. The manual pressure was exceeded by 5.5 +/- 7.4% (mode 1) and by 5.2 +/- 3.1% (mode 2). CONCLUSION: We conclude that nCPAP therapy based on the FOT permits the adequate treatment of OSAS with significantly lower pressure than manually titrated nCPAP therapy does. A presetting of an upper pressure limit has no advantage compared to free range.

Clinical significance of ventricular late potentials in patients with obstructive sleep apnoea.

Patients with obstructive sleep apnoea (OSA) have an increased cardiovascular mortality and probably also an increased incidence of sudden cardiac death. Thus the question arises whether ventricular late potentials can constitute markers for an increased electric vulnerability in these patients. Signal-averaged electrocardiograms were recorded in 64 patients (6 female, 58 male; mean age 53.2 y) with OSA (mean apnoea-hypopnoea index (AHI) 41.7 h-1 +/- 24.3 h-1). Furthermore, a continuous ambulatory electrocardiogram and gated radionuclide ventriculography were performed. Ventricular late potentials were recorded in 5 men out of 64 patients. Two of them had coronary artery disease (1 patient post-myocardial infarction), 2 hypertension, and 1 nocturnal hypertension. No correlation could be traced between left ventricular ejection fraction, severity and extent of ventricular premature beats, or severity of OSA and occurrence of ventricular late potentials. It was noticeable, however, that the patients with ventricular late potentials had severe OSA (mean AHI 50.2/h vs. 40.9/h). Although OSA may lead to structural myocardial changes that could be the basis for re-entrant circuits, ventricular late potentials were found in only 7.8% of these patients. The results of this study demonstrate that at present ventricular late potentials and signal-averaged electrocardiograms do not prove useful as screening methods for risk stratification of patients with OSA.

Multiple myeloma involving the stomach with vitamin B12 deficiency.

Involvement of the gastrointestinal tract by plasmocytoma is rare. In a 78-year-old man with IgA lambda multiple myeloma stage IIIB, the evaluation of a megaloblastic anaemia revealed a subnormal vitamin B12 level. Urinary excretion of isotope-labelled vitamin B12 was reduced. Tests for gastric parietal cell and intrinsic factor antibodies were negative. There were no clinical signs of an insufficient absorption in the ileum. Biopsy specimens of the stomach showed a dense, diffuse infiltrate of malignant plasma cells in the lamina propria of fundus and corpus. A urease test for Helicobacter pylori was positive. There was a minor haematological improvement when vitamin B12 was given parenterally. Several combinations of cytostatic drugs had no effect on the manifestations of the multiple myeloma. In our patient the vitamin B12 deficiency may be related to a displacement or destruction of parietal cells by malignant plasma cells.

[Cine-MRT in the functional and morphological diagnosis of the heart after a myocardial infarct/ A comparison with angiocardiography, 2-dimensional echocardiography, intracardiac scintigraphy and enzymatic infarct size estimation]. / Cine-MRT in der funktionellen und morphologischen Diagnostik des Herzens nach Myokardinfarkt. Vergleich zur Angiokardiographie, zweidimensionalen Echokardiographie, Herzbinnenraumszintigraphie und enzymatischen Infarktgrössenbestimmung.

PURPOSE: The aim of the study was to test the reliability of cine magnetic resonance imaging (cine-MRI) on the infarction heart with its altered geometry. MATERIAL AND METHODS: 61 patients (17 women, 44 men, 36-83 years, 32 with anterior, 29 with posterior wall infarction) received Cine-MRI in the true long and short axis of the heart and two-dimensional echocardiography one and 4 weeks post infarction. Two-level angiocardiography (ACG) and radionuclide ventriculography (RNV) were performed 4 weeks p.i. The size of myocardial infarction was determined enzymatically with the CK integral method. Left ventricular volume indices (EDVI, ESVI, SVI), ejection fraction (EF) and infarction weight (IW) were compared. RESULTS: Excellent correlations existed between cine-MRI in the long and short axis for the volume indices and EF. Between cine-MRI in the short axis and ACG all correlations were excellent as well. They were significantly less satisfactory between cine-MRI and 2DE due to the inhomogeneity of echo quality. Cine-MRI and RNV produced similar EF results (r = 0.884), and a comparison of IW in cine-MRI and CK integral method also showed a good correspondence (r = 0.967). CONCLUSION: Cine-MRI is a reliable method for the morphological and functional examination of post-myocardial infarction.

Sleep-Disordered breathing in patients referred for angina evaluation--association with left ventricular dysfunction.

BACKGROUND: Clinical observations have linked sleep-disordered breathing to cardiovascular morbidity and mortality, and especially to coronary artery disease. HYPOTHESIS: The study was undertaken to determine the prevalence of sleep-disordered breathing in consecutive patients referred for angina evaluation, and analyzed the parameters influencing the severity of sleep-disordered breathing. METHODS: In all, 68 consecutive patients (53 men, 15 women, aged 63.4 +/- 10.0 years) referred for angina evaluation were studied. Coronary angiography, selective left ventriculography, and a polygraphic study with a validated six-channel monitoring device were performed. Full-night polysomnography was used to reevaluate patients with an apnea/hypopnea index > or = 10/h. RESULTS: Sleep-disordered breathing as defined by an apnea/hypopnea index > or = 10/h was found in 30.9% of patients; its prevalence was not increased in patients with and without coronary artery disease (26.5 vs. 42.1%). Multiple stepwise linear regression analysis revealed that the severity of sleep-disordered breathing was significantly and independently associated with left ventricular ejection fraction (r = -0.38; p = 0.002), but not with age, body mass index, gender, diabetes mellitus, hypertension, hyperuricemia, hypercholesterolemia, smoking habits, or coronary artery disease. In this group of patients, multiple logistic regression analysis could not demonstrate sleep-disordered breathing to be an independent predictor of coronary artery disease. CONCLUSIONS: Sleep-disordered breathing is common in patients referred for angina evaluation. The degree of sleep-disordered breathing is mainly determined by the extent of left ventricular dysfunction.

Influence of tissue affinity of angiotensin-converting enzyme inhibitors on left ventricular remodeling after myocardial infarction.

BACKGROUND: The demonstration of local renin-angiotension systems has raised the question of whether angiotensin-converting enzyme (ACE) inhibitors with different tissue affinities differ with regard to their effects on postinfarction remodeling. HYPOTHESIS: The study was undertaken to investigate the influence of ACE inhibitors with different tissue affinity on morphology and function of the infarcted left ventricle. METHODS: In all, 52 patients (17 women, 35 men, 38-73 years) with large acute myocardial infarction were randomized to receive either 25-75 mg/day captopril or 10-20 mg/day fosinopril beginning on the Day 7 after infarction. Of these, 28 had anterior and 24 had posterior wall infarctions. Infarct size was determined by the creatine kinase integral method. Fifty patients were examined by cinemagnetic resonance imaging (CMRI) 1 and 26 weeks after infarction. The following parameters were determined: left ventricular end-diastolic and end-systolic volume index (LVEDVI, LVESVI), ejection fraction (LVEF), infarct weight, and muscle mass (LVMM). The volume-to-mass ratio (VMR) was calculated and the clinical status according to the guidelines of the New York Heart Association (NYHA) was documented at each examination time. The results were compared with those of a historical sample without ACE-inhibitor therapy examined in an identical manner (n = 31, 10 women, 21 men, 36-75 years). RESULTS: LVEDVI and LVESVI increased in the first 6 months after infarction by 24.9 and 36.6%, respectively, in the historical sample; by 11.0 and 7.8%, respectively, under captopril; and by 13.1 and 10.7%, respectively, under fosinopril. LVEF decreased by 14.9% in the untreated sample, by 3.7% under captopril and by 5.0% under fosinopril. Infarct weight and LVMM increased by 12.7 and 15.3%, respectively, without ACE inhibition, by 5.7 and 10.1%, respectively, in patients treated with captopril, and by 6.1 and 9.3%, respectively, in patients treated with fosinopril. The VMR increased by 7.4% in the historical sample, by 3.5% in the captopril group, and by 1.8% in the fosinopril group. The NYHA clinical status improved by 18.2% without ACE inhibition, by 42.9% in the captopril group, and by 26.3% in the fosinopril group. The differences between the two ACE-inhibitor groups and the reference group were all significant, while the differences between the captopril group and the fosinopril group were significant only for VMR (p < 0.01) and NYHA class (p < 0.05). CONCLUSIONS: Both captopril and fosinopril have a comparable positive influence on postinfarction remodeling and on clinical status. Lipophilicity and tissue affinity do not seem to play a clinically important role in ACE-inhibitor therapy after infarction.

Prevalence of ventricular late potentials in patients with obstructive sleep apnea syndrome.

BACKGROUND: It is known from various cardiac disorders that the presence of ventricular late potentials (VLP) in the signal-averaged electrocardiogram (ECG) is associated with an increased risk of sudden cardiac death. HYPOTHESIS: In view of the increased cardiovascular mortality of patients with obstructive sleep apnea syndrome (OSAS), we assessed the prevalence of VLP in these patients. METHODS: In all, 118 consecutive patients with polysomnographically verified OSAS were prospectively studied; 21 snorers without evidence of a sleep-related breathing disorder served as a control group. Signal-averaged ECG and 24-h Holter ECG were performed in all patients and controls, and left ventricular function was determined by radionuclide ventriculography in the OSAS group. Furthermore, patients and controls were followed for up to 45.5 months for arrhythmic events, syncopes, or sudden cardiac death. RESULTS: An abnormal signal-averaged ECG was seen in seven patients (5.9%) and in one snorer (4.8%). Patients with and without VLP did not differ with respect to age, body mass index, left ventricular ejection fraction, or ectopic activity in the 24-h Holter ECG, but the former had significantly higher mean (standard deviation) apnea/hypopnea indices [55.4 (25.2)/h vs. 37.4 (22.6)/h; p < 0.05]. Of the 118 patients, 110 could be followed for 26.7 (7.9) months. During this period, two patients had syncopes and one patient had sudden cardiac death. The seven patients with VLP remained free of events during the follow-up period, as did the 21 snorers. CONCLUSIONS: Patients with OSAS have a low prevalence of VLP in the signal-averaged ECG, not exceeding that in normal subjects. Moreover, abnormal signal-averaged ECGs do not appear to be useful as a prognostic marker.

Changes of the left ventricle after myocardial infarction--estimation with cine magnetic resonance imaging during the first six months.

BACKGROUND: In recent years, the interest of cardiologists has focused increasingly on the morphologic and functional changes of the left ventricle after myocardial infarction (MI), due to their great prognostic significance for the patient. HYPOTHESIS: The aim of this study was to evaluate changes in left ventricular morphology and function during the first 6 months following MI. METHODS: In all, 61 patients (17 women, 44 men, age 36-83 years) were examined with cine magnetic resonance imaging (CMRI) 1, 4, and 26 weeks after myocardial infarction. Thirty-two patients had anterior MI and 29 patients had posterior MI. According to enzyme-derived infarct weight, 15 patients had small infarcts (< 20 g), 19 had intermediate-sized infarcts (20-40 g), and 27 patients had large infarcts (> 40 g). CMRI was performed in the true short axis of the left ventricle. In each examination, left ventricular end-diastolic and end-systolic volume indices (LVEDVI, LVESVI), stroke volume index (LVSVI), ejection fraction (LVEF), and regional thickness, mass, and motility of the myocardial wall-diastolic thickness (IDdia), infarct mass (IM) and motility (IMOT) of the infarct area and diastolic and systolic thickness (VDdia, VDsys), muscular mass (VM), and motility (VMOT)-were determined. In addition, patients were divided into subgroups according to New York Heart Association (NYHA) functional status at baseline. RESULTS: In the total group, LVEDVI increased from 73.9 +/- 23.5 ml/m2 to 85.4 +/- 28.1 ml/m2 (p < 0.001) and LVESVI from 40.5 +/- 19.4 ml/m2 to 51.2 +/- 29.0 ml/m2 (p < 0.001). In the subgroups the development depended on infarct size and location. LVSVI and LVEF remained more or less constant except for large anterior infarctions. All changes of the myocardial wall depended on infarct size and location: In all patients IDdia decreased from 10.4 +/- 1.6 mm to 8.9 +/- 1.7 mm (p < 0.001), IMOT from 2.0 +/- 1.6 mm to 0.5 +/- 2.9 mm (p < 0.001). IM increased from 41 +/- 21 g to 45 +/- 25 g (p < 0.001). In the total group, VDdia increased from 11.9 +/- 1.6 mm to 12.4 +/- 1.8 mm (p < 0.05), VDsys from 16.6 +/- 2.5 mm to 17.2 +/- 3.1 mm (p < 0.05). In the subgroups changes varied: VDdia and VDsys decreased markedly in large anterior wall infarctions. VM increased in the total cohort from a mean of 246 +/- 66 g to 276 +/- 80 g (p < 0.001). VMOT decreased from 7.1 +/- 2.4 mm to 6.3 +/- 2.7 mm (p < 0.05). Loss of motility was most pronounced in anterior infarctions. The volume-mass ratio, a measure of the success of compensation of volume increase by myocardial hypertrophy, decreased in small infarcts, remained unchanged in intermediate infarcts, and increased in large infarcts. There was a trend toward improvement of the NYHA functional status during the observation period. CONCLUSIONS: Changes of the left ventricular chamber during the first 6 months following MI are dependent on its size and location, with large anterior infarctions having the worst course. Myocardial wall remodeling is also dependent on infarct size and location, and the volume-mass ratio increases in the presence of large areas of necrosis, indicating the non-compensatory effect of myocardial hypertrophy. However, these changes have no clinical effect during the first half year after MI.

[Complications of nasal CPAP therapy. Consequences for general practice]. / Komplikationen bei der nasalen CPAP-Therapie. Konsequenzen für die Praxis.

BACKGROUND: The prevalence of the obstructive sleep apnea syndrome is about 5% in the entire population. The amount of treatment-indications grows for this particular sleep-related breathing disorder due to the increasing usage of diagnostic screening tests. In most cases, the positive-pressure ventilation, PPV (nCPAP, nBiPAP) is considered as a highly effective form of treatment, in comparison to other treating methods. The residential polysomnographic supervised adjustment of the treatment is optimally applied to most of the patients. Due to the increasing number of the treated patients, the reports about the appearance of short-termed side effects during the adjustment of the PPV become more frequent. PATIENTS AND RESULTS: We report on 9 patients who showed complications during the initial stage of treatment. The most common one, during the nCPAP-therapy, was the increase of central apneas. Because of this complication, a rapid optimization of the respiratory pressure or a change to a nBiPAP-therapy was necessary in 5 of the patients. 2 of the patients showed cardiac arrhythmias, some of which were severe. One patient produced a remarkable central hypoventilation during the initial phase of a nCPAP-therapy. The nBiPAP-titration combined with right-heart-catheter monitoring could demonstrate in another patient a possible cardiac decompensation through an increased ventilatory pressure. CONCLUSION: The risk of a positive-pressure ventilation is higher in patients with accompanying cardiac, pulmonary, neuropsychiatric and/or otorhinolaryngologic disorders. Considering the various predisposing factors of the patients we suggest an intensive apparative monitoring as well as stuff-supervision during the introduction to a respiratory treatment. If complications appear, a rapid improvement of the ventilatory pressure or a change to another respiratory treatment is indicated.