[Climate Crisis: What Gastrointestinal Complications of this Medical Emergency Should We Be Aware Of?] / Klimakrise: Welche gastroenterologischen Folgeerkrankungen dieses medizinischen Notfalls sollten wir kennen?

INTRODUCTION: The climate crisis has serious consequences for many areas of life. This applies in particular to human health - also in Europe. While cardiovascular, pneumological and dermatological diseases related to the climate crisis are often discussed, the crisis' significant gastroenterological consequences for health must also be considered. METHODS: A literature search (Pubmed, Cochrane Library) was used to identify papers with relevance particularly to the field of gastroenterology in (Central) Europe. Findings were supplemented and discussed by an interdisciplinary team. RESULTS: The climate crisis impacts the frequency and severity of gastrointestinal diseases in Europe due to more frequent and severe heat waves, flooding and air pollution. While patients with intestinal diseases are particularly vulnerable to acute weather events, the main long-term consequences of climate change are gastrointestinal cancer and liver disease. In addition to gastroenteritis, other infectious diseases such as vector-borne diseases and parasites are important in the context of global warming, heat waves and floods. DISCUSSION: Adaptation strategies must be consistently developed and implemented for vulnerable groups. Patients at risk should be informed about measures that can be implemented individually, such as avoiding heat, ensuring appropriate hydration and following hygiene instructions. Recommendations for physical activity and a healthy and sustainable diet are essential for the prevention of liver diseases and carcinomas. Measures for prevention and the promotion of resilience can be supported by the physicians at various levels. In addition to efforts fostering sustainability in the immediate working environment, a system-oriented commitment to climate protection is important.

[Rehabilitation for Post-COVID Syndrome covered by the German Pension Insurance in 2021]. / Rehabilitationen bei Post-COVID-Syndrom der Deutschen Rentenversicherung 2021.

AIM OF THE STUDY: The present work is intended to give an overview of rehabilitation of patients with post COVID-19 condition covered by the German Pension Insurance in 2021. METHODS: Cross-sectional analysis of medical rehabilitation completed in 2021, in which COVID-19 sequelae were coded in first or second place in the uniform discharge report according to the International Statistical Classification of Diseases and Related Health Problems was carried out. The codes U08(.9), U09(.9) and U10(.9) as well as the corresponding codes from 2020 were taken into the evaluation as COVID-19-related diseases. Children's rehabilitation and oncological rehabilitation for pensioners and their relatives were excluded. Statistically, relative and absolute frequencies are given for nominal and ordinal variables, and median and quartiles for continuous, skewed distributed variables. RESULTS: 9,666 rehabilitations with one of the codes mentioned in first or second place remained. 54.8% of the patients were women and 43.2% men. The median age was 54 and 55 years (women/men). In all, 64.4% of the rehabilitations were carried out in the pulmonary medicine department. Owing to somatic indications, almost 50% of these patients in rehabilitation remained in the clinic beyond the regular approval period. The most common other diagnoses were diseases of the respiratory system. In 80.7% of those affected, the treating physicians considered the post-COVID-19 condition-associated symptoms as improved through rehabilitation. Furthermore, employment was subject to social security contributions for 88.0% of these patients, and 30.5% were employed in the fields of health, social affairs, teaching, and education. Of those affected, 63.8% were on sick leave when they were admitted, 63.0% when they were discharged. With regard to performance in the last job or on the general job market, over 90.0% received a prognosis for 6 hours and more. CONCLUSION: The importance of post-COVID-19 condition in the context of medical rehabilitation increased significantly over the course of 2021. The disease causes long periods of disability. With regard to performance, the available analyses give a positive picture; only 6.5% of those individuals undergoing rehabilitation were assessed as having a reduced capacity to earn of less than 3 hours on the general labor market.

S2k-Leitlinie SARS-CoV-2, COVID-19 und (Früh-) Rehabilitation ­ eine Kurzfassung mit allen Empfehlungen im Überblick.

The consensus-based SARS-CoV-2, COVID-19, and Rehabilitation Practice Guideline provides recommendations that take both infection prevention and the pursuit of therapeutic goals in rehabilitation settings during the coronavirus pandemic into account. The Practice Guideline provides guidance how to prevent SARS-CoV-2 infections in rehabilitation settings in a first part. The guideline's second part addresses rehabilitation for patients affected by COVID-19 starting with interventions on intensive care units, during early rehabilitation, post-acute rehabilitation, in outpatient and community rehabilitation settings, as well as long-term care, e. g. for COVID-19 survivors with Long- or Post-COVID.The updated second version of the Practice Guideline (dating from 01.11.2021) is a consensus-based guideline developed by a representative panel of healthcare professionals from 15 medical societies covering various rehabilitation disciplines, infectious diseases, hospital hygiene, and epidemiology. The abbreviated version provides an overview of all recommendations given.

[Rehabilitation with coronavirus disease with SARS-CoV-2 (COVID-19)]. / Rehabilitation bei Coronavirus-Erkrankung mit SARS-CoV-2 (COVID-19).

The Coronavirus disease with SARS-CoV-2 viral infection (COVID-19) and its diverse courses of disease from mild to critical illness frequently is not only an acute disease, but will - in a proportion of those affected - lead to organ structure and body function deficits that still exist or become apparent after the acute stage of disease. When clinically relevant symptoms or functional deficits (impairments) are documented more than four weeks after COVID-19 onset, the syndrome is called "Long-COVID", from 12 weeks after onset onwards "Post-COVID".In such cases and when everyday life functioning and return to work are affected by persisting deficits specialized rehabilitation treatment is indicated. An individual medical, frequently multi-professional diagnostic evaluation is mandatory in that situation: For adequate treatment, it is important to identify and objectify the individually underlying health conditions based on knowledge about the diverse potential consequences of COVID-19, to assess type and severity of functional consequences (impairments, activity limitations, and restrictions of participation) of Long-/Post-COVID individually, and then to decide on the treatment necessities and plans. With regard to rehabilitation, need and decision for either pulmonary, neurological, cardiac, or psychosomatic rehabilitation depends on the individual medical presentation.

Polymorphism of CD14 Gene Is Associated with Adverse Outcome among Patients Suffering from Cardiovascular Disease.

BACKGROUND: The biological link between severe periodontitis and cardiovascular disease is well established. Both complex inflammatory diseases are influenced by genetic background. Therefore, the impact of genetic variations of receptors of the innate immune system-(Toll-like receptors (TLRs)) TLR2, TLR4, cluster of differentiation 14 (CD14), and the transcription factor nuclear factor-κΒ (NF-κB)-was investigated. MATERIALS AND METHODS: In this study (ClinicalTrials.gov identifier: NCT01045070), 1002 cardiovascular (CV) patients were included. In a 3-year follow-up period, new vascular events were assessed. SNPs in CD14 (rs2569190), NF-κΒ (rs28362491), TLR2 (rs5743708), and TLR4 (rs4986790) were genotyped. The impact of these genetic variants on severe periodontitis as well as on CV outcome was assessed. RESULTS: All investigated genetic variants were not associated with preexisting CV events or severe periodontitis in CV patients. In Kaplan-Meier survival analyses, the CT genotype of CD14 single-nucleotide polymorphism (SNP) rs2569190 was shown to be an independent predictor for combined CV endpoint (log rank: p = 0.035; cox regression; hazard ratio: 1.572; p = 0.044) as well as cardiovascular death (log rank: p = 0.019; cox regression; hazard ratio: 1.585; p = 0.040) after three years of follow-up. CONCLUSIONS: SNPs in CD14, NF-κΒ, TLR2, and TLR4 are no risk modulators for preexisting CV events or severe periodontitis in CV patients. The CT genotype of CD14 SNP rs2569190 provides prognostic value for further CV events within 3 years of follow-up.

[Postacute care after transcatheter aortic valve implantation (TAVI)]. / Nachsorge nach kathetergestütztem perkutanen Aortenklappenersatz (TAVI).

With increasing age valvular heart disease is among the most frequent diseases of the heart. Relevant valvular disease impairs not only the long-term prognosis but also physical resilience, activities of daily living and the quality of life. In cases of middle to high-grade symptomatic cardiac defects, valve replacement or valve reconstruction is still the surgical procedure of choice; however, in recent years the transcatheter percutaneous aortic valve replacement (TAVI) procedure has become more prominent for the most frequent defect, aortic valve stenosis. This article provides an overview of the aftercare and rehabilitation of patients following a TAVI intervention.

ANRIL polymorphisms (rs1333049 and rs3217992) in relation to plasma CRP levels among in-patients with CHD.

BACKGROUND: Single nucleotide polymorphisms (SNPs) in long non-coding RNA ANRIL (antisense noncoding RNA in the INK4 locus) were shown to be associated with coronary heart disease (CHD). The biological background for this association is not fully understood. The primary aim of this study was to investigate whether two leading ANRIL SNPs, namely, rs133049 and rs3217992, were associated with plasma levels of C-reactive protein among a large cohort of in-patients with CHD (n = 933). MATERIAL AND METHODS: CHD was defined as previous or current detection of 50% stenosis of a main coronary artery. Severe periodontitis was diagnosed if proximal attachment loss of at least 5 mm was found in at least 30% of teeth. For genotyping rs1333049 we applied PCR using sequence-specific primers and for rs321799 restriction fragment length polymorphism analyses. C-reactive protein (CRP) plasma levels were determined using a particle-enhanced immunological turbidity test. In addition, interleukin (IL)-6, low-density lipoprotein (LDL), total cholesterol, high-density lipoprotein (HDL), triglycerides, and number of leukocytes were determined. RESULTS: Genotype CC of rs1333049 was significantly associated with both elevated CRP levels and decreased HDL concentrations after univariate (p = 0.028, p = 0.012) and multivariate analysis (p = 0.041, p = 0.023) stratified for age, gender, body mass index, smoking, diabetes, and severe periodontitis. Furthermore, severe periodontitis (p = 0.031), but not SNP rs3217992, was associated with CRP plasma concentrations. CONCLUSIONS: Among patients with CHD, ANRIL SNP rs1333049 is an independent risk indicator for both elevated CRP plasma levels and reduced HDL concentrations. ClinicalTrials.gov Identifier: NCT01045070.

Periodontal pathogens and their role in cardiovascular outcome.

AIM: Periodontitis has been identified as a moderate but independent risk factor for cardiovascular (CV) disease and progression. The objective of this study (ClinicalTrials.gov Identifier: NCT01045070) was to assess subgingival colonization with selected periodontal pathogens on the occurrence of further adverse CV events in a cohort of CV patients. METHODS: The prevalence of severe periodontitis including the detection of 11 periodontal pathogens (Aggregatibacter actinomycetemcomitans, Porphyromonas gingivalis, Prevotella intermedia, Tannerella forsythia, Treponema denticola, P. intermdia, Peptostreptococcus micros, Fusobacterium nucleatum, Campylobacter rectus, Eubacterium nodatum, Eikenella corrodens, Capnocytophaga sputigena, Capnocytophaga gingivalis, Capnocytophaga ochracea; HAIN-Diagnostica® ) was analysed in 1,002 CV patients The prognostic impact of periodontal pathogens for combined CV endpoint (stroke/TIA, myocardial infarction, CV death, death from stroke) was evaluated after a 3-year follow-up period. Hazard ratios (HRs) were adjusted for established CV risk factors applying Cox regression. RESULTS: In the Kaplan-Meier analysis (log-rank test: p < .001) and Cox regression (HR: 0.545, 95%-CI: 0.387-0.773; p = .001), the decreased occurrence of E. corrodens was shown to be an independent predictor for adverse CV events after 3 years of follow-up. CONCLUSIONS: The detection of E. corrodens was associated with a reduced risk of adverse CV events in patients with CV disease. The pathophysiological background underlying this association should be investigated in further studies.

Bromocriptine for the treatment of peripartum cardiomyopathy: a multicentre randomized study.

AIMS: An anti-angiogenic cleaved prolactin fragment is considered causal for peripartum cardiomyopathy (PPCM). Experimental and first clinical observations suggested beneficial effects of the prolactin release inhibitor bromocriptine in PPCM. METHODS AND RESULTS: In this multicentre trial, 63 PPCM patients with left ventricular ejection fraction (LVEF) ≤35% were randomly assigned to short-term (1W: bromocriptine, 2.5 mg, 7 days) or long-term bromocriptine treatment (8W: 5 mg for 2 weeks followed by 2.5 mg for 6 weeks) in addition to standard heart failure therapy. Primary end point was LVEF change (delta) from baseline to 6 months assessed by magnetic resonance imaging. Bromocriptine was well tolerated. Left ventricular ejection fraction increased from 28 ± 10% to 49 ± 12% with a delta-LVEF of + 21 ± 11% in the 1W-group, and from 27 ± 10% to 51 ± 10% with a delta-LVEF of + 24 ± 11% in the 8W-group (delta-LVEF: P = 0.381). Full-recovery (LVEF ≥ 50%) was present in 52% of the 1W- and in 68% of the 8W-group with no differences in secondary end points between both groups (hospitalizations for heart failure: 1W: 9.7% vs. 8W: 6.5%, P = 0.651). The risk within the 8W-group to fail full-recovery after 6 months tended to be lower. No patient in the study needed heart transplantation, LV assist device or died. CONCLUSION: Bromocriptine treatment was associated with high rate of full LV-recovery and low morbidity and mortality in PPCM patients compared with other PPCM cohorts not treated with bromocriptine. No significant differences were observed between 1W and 8W treatment suggesting that 1-week addition of bromocriptine to standard heart failure treatment is already beneficial with a trend for better full-recovery in the 8W group. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, study number: NCT00998556.

Time in therapeutic range and major adverse outcomes in atrial fibrillation patients undergoing percutaneous coronary intervention: The Atrial Fibrillation Undergoing Coronary Artery Stenting (AFCAS) registry.

BACKGROUND: Combination of oral anticoagulation (OAC) and antiplatelets is used in atrial fibrillation (AF) patients undergoing percutaneous coronary intervention and stent (PCI-S) procedure but is associated with increased bleeding when triple antithrombotic therapy (TAT) is used. Our aim was to analyze the impact of time in therapeutic range (TTR) on outcomes, in patients prescribed with TAT. METHODS: Ancillary analysis from the AFCAS registry in patients assigned to TAT. TTR was calculated with Rosendaal method. Outcomes were analyzed according to TTR tertiles (T1 [≤56.8%] vs. T2 [56.9-93.8%] vs. T3 [≥93.9%]). Major bleeding was the primary outcome. RESULTS: Of 963 patients enrolled, 470(48.8%) were prescribed with TAT at discharge and qualified for this analysis. Median [IQR] TTR was 80.0% [45.3-100%]. After 359 [341-370] days, major bleeding rates were progressively lower with increasing TTR tertiles (T1 vs. T2 vs. T3: 10.3% vs. 4.7% vs. 2.3%, P=.006). Kaplan-Meier analysis demonstrated a progressively lower risk for major bleeding across tertiles (P=.006). Patients in the highest TTR tertile had a non-significant lower risk for major adverse coronary and cerebrovascular events (MACCE) (log-rank: 4.905, P=.086). Cox regression analysis showed that T2 and T3 were inversely associated with major bleeding (hazard ratio [HR]:0.39, P=.050 and HR: 0.21, P=.005). Continuous TTR was inversely associated with major bleeding (HR: 0.98, P<.001). For MACCE, adjusted Cox analysis found a non-significant lower risk for T3 (HR: 0.64, P=.128). CONCLUSIONS: In AF patients undergoing PCI-S prescribed TAT, good quality anticoagulation control (as reflected by TTR) was closely related to bleeding outcomes during follow-up. Despite some suggestive trends for an inverse relationship between TTR and MACCE, no definitive conclusions can be drawn, and further large studies are needed.

The interleukin 6 c.-174 CC genotype is a predictor for new cardiovascular events in patients with coronary heart disease within three years follow-up.

The main aim of this study was to evaluate putative associations between the interleukin (IL)-6 c.-174G>C polymorphism (rs 1800795) and the cardiovascular outcome (combined endpoint: myocardial infarction, stroke/TIA, cardiac death, death according to stroke) among patients with coronary heart disease (CHD) within three years follow-up. Overall 942 in-patients with CHD were included. The drop-out rate was 4.9%. The IL-6 polymorphism was determined with PCR-SSP. Kaplan-Meier plots with Log Rank test and Cox regression were used as statistically procedures. The IL-6 CC genotype was associated with a higher incidence of the combined endpoint (25.0% versus 13.5%, p<0.001) and an increased Hazard Ratio (HR 2.165, 95% CI 1.516-3.092, p<0.001) adjusted for established cofactors for CHD. This result suggests that the IL-6 -174 polymorphism is a putative independent risk indicator for new cardiovascular events among patients with CHD.

C-reactive protein levels and genetic variants of CRP as prognostic markers for combined cardiovascular endpoint (cardiovascular death, death from stroke, myocardial infarction, and stroke/TIA).

BACKGROUND: The aim of this analysis was to evaluate the importance of C-reactive protein levels and genetic variants of CRP as prognostic markers for further cardiovascular (CV) events (3-year follow-up) in a cohort of in-patients with cardiovascular disease (CVD) patients. METHODS AND RESULTS: Patients with angiographic proven CVD (n=939) were prospectively included. The three-year CV outcome of the patients was evaluated considering the predefined, combined endpoint (CV death, death from stroke, myocardial infarction, and stroke/TIA). Polymorphisms rs1800947, rs1417938, rs1130864, rs3093077 were analysed. In Kaplan-Meier survival curve and Cox regression increased CRP levels of ⩾5mg/l (log-rank test: p=0.001, Cox regression: hazard ratio=1.77, 95% CI: 1.2-2.7) and the GG genotype of rs1800947 (log-rank test: p=0.01, Cox regression: hazard ratio=1.99, 95% CI: 1.1-3.6) were associated with the incidence of the combined endpoint. CONCLUSIONS: Both a CRP level ⩾5mg/l and SNP rs1800947 of the CRP gene were independent risk factors for further adverse CV events among patients with CVD within three years follow-up.

Men and women differ in their diurnal expression of monocyte peroxisome proliferator-activated receptor-α in the fed but not in the fasted state.

Peroxisome proliferator-activated receptor-α (PPARα) plays a pivotal role in regulating metabolic response to fasting and is an inhibitor of inflammatory pathways in immune cells. It represents a therapeutic target for treatment of several diseases, mainly hyperlipidemia. To shed light on PPARα expression changes in response to fasting, young healthy male and female volunteers were fed or fasted for 24 hours. Monocytes were analyzed every 2 hours to compile both profiles of mRNA and protein expression of PPARα and its interactive partner, the circadian pacemaker brain and muscle aryl hydrocarbon receptor nuclear translocator like-1 (BMAL1). We found that women change their diurnal expression profiles of PPARα and BMAL1 when switching from the fed to the fasted state, whereas men do not. Interestingly, the PPARα and BMAL1 profiles of men and women in the fed state are different, whereas the profiles in the fasted state are virtually identical. The finding of diametrically opposite responses of male and female PPARα expression in the fed state might have practical implication in human medicine as PPARα activators like fibrates are used for the therapy of chronic lymphocytic leukemia, microvascular complications in diabetes, and kidney diseases.

Periodontal conditions and incidence of new cardiovascular events among patients with coronary vascular disease.

AIM: We wanted to investigate whether periodontal conditions and/or oral care habits are associated with new cardiovascular events among patients with coronary vascular disease (CVD). MATERIALS AND METHODS: In this longitudinal cohort study, 1002 inpatients with CVD were included. They were examined regarding prevalence of severe periodontitis, bleeding upon probing (BOP), number of missing teeth and oral care habits. The combined endpoint was defined as myocardial infarction, stroke/transient ischaemic attack, cardiovascular death and death caused by stroke. Survival analyses were carried out after a 3-year follow-up period. Hazard ratios (HRs) were adjusted for known cardiac risk factors using Cox regression. RESULTS: Nine hundred and fifty-three patients completed the 3-year follow-up. The overall incidence of the combined endpoint was 16.4%. Significant HRs for BOP (HR = 2, 95% CI: 1.2-3.3), severe tooth loss (HR = 1.8, 95% CI: 1.3-2.5), brushing teeth more than once a day (HR = 0.6, 95% CI: 0.5-1.0) and use of floss/inter-dental brushes (HR = 0.5, 95% CI: 0.3-0.9) were evaluated only in univariate but not in multivariate survival analyses. Patients with severe periodontitis achieved the combined endpoint more often (18.9% versus 14.2%), but the result was not statistically significant after both univariate and multivariate survival analyses. CONCLUSIONS: Periodontal conditions and oral care habits are not independent indicators for further adverse events in patients with CVD.

Bare-metal vs. drug-eluting stents in patients with atrial fibrillation undergoing percutaneous coronary intervention.

BACKGROUND: We explored 12-month clinical outcomes of 929 patients with atrial fibrillation (AF) undergoing percutaneous coronary intervention (PCI) with bare-metal stents (BMS) vs. drug-eluting stents (DES) from the prospective multicenter AFCAS (Atrial Fibrillation undergoing Coronary Artery Stenting) registry. METHODS AND RESULTS: Endpoints included the first occurrence of major adverse cardiac and cerebrovascular events (MACCE), defined as a composite of all-cause death, myocardial infarction (MI), target vessel revascularization, definite/probable stent thrombosis (ST), transient ischemic attack or stroke. Bleeding events were defined according to the Bleeding Academic Research Consortium criteria. Altogether, 673 (72.4%) patients received BMS and 220 (23.7%) at least one DES. Patients treated with DES more often had diabetes and prior ischemic events, and a longer stent length (P<0.05 for all), whereas patients treated with BMS more often had heart failure and were more likely to present with acute ST-elevation MI (P<0.05 for both). At 12-month follow-up, rates and risks of MACCE and total bleeding events were comparable between the groups (22.0% with BMS vs. 19.5% with DES, P=0.51, hazard ratio (HR) 0.89, 95% confidence interval (CI) 0.63-1.25 for DES) and (19.5% vs. 15.0%, respectively, P=0.16, HR 0.75, 95% CI 0.51-1.09 for DES). Definite/probable ST was more frequent in the BMS group (1.9% vs. 0%, respectively, P=0.046). CONCLUSIONS: In real-world patients with AF undergoing PCI, DES use was associated with outcomes comparable to those with BMS without excess bleeding complications. More ST was seen in BMS-treated patients.

In vitro comparison of the novel, dual-acting FIIa/FXa-inhibitor EP217609C101, unfractionated heparin, enoxaparin, and fondaparinux in preventing cardiac catheter thrombosis.

Efficient and safe anticoagulation is crucial in patients requiring percutaneous coronary intervention (PCI) or extracorporeal circulation during cardiac surgery. Although new anticoagulant strategies have emerged for PCI as alternatives to the established treatment with heparins, the development of new anticoagulants with an improved efficacy/safety ratio is still necessary. Our study compared the efficacy of the novel, dual-acting, neutralizable FIIa/FXa-inhibitor EP217609C101 (EP) at 2, 1.2, 0.9, and 0.6 µg/ml to unfractionated heparin (UFH), enoxaparin, and fondaparinux in preventing cardiac catheter thrombosis under in vitro conditions. Blood drawn by venepunction from healthy male volunteers (n = 10) pretreated with 500 mg aspirin orally was treated with the anticoagulant to test and continuously circulated through a cardiac catheter for 60 min or until the catheter became blocked by thrombotic debris. Anticoagulant efficacy was assessed by thrombus weight, electron microscopic features of the developing thrombi, and laboratory parameters. Whereas UFH, enoxaparin, EP 2, and EP 1.2 µg/ml secured maximum circulation times, statistically significant premature catheter occlusions were observed for EP 0.9, EP 0.6 µg/ml, and fondaparinux. The UFH group and both high-dose concentrations of EP showed significantly lower thrombus weights than the low-dose concentrations of EP and fondaparinux, (p ≤ 0.05). On electron microscopic analysis of the thrombotic debris no differences were observed in erythrocyte deposition between UFH, enoxaparin, and all EP concentrations tested. A significant reduction in fibrin deposition was achieved by UFH and EP 2 µg/ml but no significant differences in platelet deposition were found, except for a significant reduction for EP 0.6 µg/ml. Our in vitro study showed that EP217609C101 is a promising new drug that is dose-dependently superior to classical (UFH, enoxaparin) and newer (fondaparinux) drugs in preventing heart catheter thrombosis.

Incremental value of high-sensitive troponin T in addition to the revised cardiac index for peri-operative risk stratification in non-cardiac surgery.

AIMS: We aimed to evaluate the incremental value of high-sensitive troponin T (hsTnT) for risk prediction prior to non-cardiac surgery in comparison with the established revised cardiac index. METHODS AND RESULTS: In this prospective, international multicentre observational study, 979 patients prior to non-cardiac surgery were enrolled. The endpoints were in-hospital mortality, the combination of death, acute myocardial infarction, cardiac arrest, cardio-pulmonary resuscitation, and acute decompensated heart failure. Twenty-five patients (2.6%) deceased and 36 (3.7%) of the patients experienced the combined endpoint. Cardiac markers were elevated in those patients who died when compared with survivors (hsTnT: 21 ng/L vs. 7 ng/L; P < 0.001; NT-proBNP: 576 pg/mL vs. 166 pg/mL; P < 0.001). Applying a cut-off for hsTnT of 14 ng/L and for NT-proBNP of 300 pg/mL, those patients with elevated hsTnT had a mortality of 6.9 vs. 1.2% (P < 0.001) and with elevated NT-proBNP 4.8 vs. 1.4% (P = 0.002). The highest AUC of the ROC curve was found for hsTnT as a predictor for mortality of 0.809. In a multivariate Cox regression analyses, hsTnT was the strongest independent predictor for the combined endpoint [HR 2.6 (95% CI: 1.3-5.3); P = 0.01]. CONCLUSION: High-sensitive troponin T provides strong prognostic information in patients undergoing non-cardiac surgery incremental to the widely accepted revised cardiac index.

[Cardiac rehabilitation after acute coronary syndrome]. / Kardiologische Rehabilitation nach akutem Koronarsyndrom.

Cardiac rehabilitation is a fundamental part of treatment after acute coronary syndrome and should be followed within the first 14 days of the acute inpatient stay. The prognostic value in terms of improving quality of life, reducing both re-hospitalizations and cardiovascular mortality has been shown in numerous studies in recent years. The multimodal, interdisciplinary cardiac rehabilitation aims to maintain and restore the patients' ability to cope with everyday life. The characteristic of cardiac rehabilitation is the combination of sports and physiotherapy, psychosocial care, nutritional therapy, medical diagnostics, and therapy adjustment as well as aftercare recommendations within the framework of a 3-4 week stay in specialized rehabilitation facilities. Participation in exercise-based, multidisciplinary cardiac rehabilitation after acute coronary syndrome reduces cardiovascular mortality and is recommended with Class I, Level A evidence.

The management of patients with atrial fibrillation undergoing percutaneous coronary intervention with stent implantation: in-hospital-data from the Atrial Fibrillation undergoing Coronary Artery Stenting study.

Current recommendations on the management of patients with atrial fibrillation (AF) undergoing percutaneous coronary intervention with stent (PCI-S) essentially derive from small, single-center, retrospective datasets. To obtain larger and better quality data, we carried out the prospective, multicenter Atrial Fibrillation undergoing Coronary Artery Stenting (AFCAS) study. Therefore, consecutive patients with history of or ongoing AF undergoing PCI-S were enrolled, and occurrence of adverse ischemic and bleeding events recorded during 12 months follow-up. In this article, we report the in-hospital observations. Out of the 963 patients, in the majority of cases (49.1%) AF was permanent. The associated risk of stroke, as defined by a CHADS2 -score ≥2, was in 70% of patients moderate to high. Upon enrollment in the registry, 69.3% of patients were on VKA therapy. Overall occurrence of in-hospital major adverse cardiac events was 4.5% (cardiovascular death 1.9%, urgent revascularization in 1.5%, and stroke/arterial thromboembolism in 0.6%). Bleeding complications occurred in 7.1% of patients, being severe in 2.5%. In a logistic regression analysis, no risk factor was independently associated with bleeding events, whereas Clopidogrel treatment decreased and female gender/treatment with gpIIb/IIIa-antagonists, respectively increased the risk for the combined ischemic endpoint. The majority of AF patients undergoing PCI-S are at high stroke risk, and therefore VKA treatment should not be withdrawn and combined anticoagulant and antiplatelet treatment is warranted. Current management appears largely in accordance with current recommendations, whereby accounting for the limited occurrence of in-hospital adverse ischemic and bleeding events.

Embolic events caused by aortic thrombi: an underestimated entity?

Stroke and other thromboembolic events are mainly caused by emboli from heart, aorta and other arteries. In this paper we describe a group of 5 middle-aged patients suffering from emboli caused by large thrombi in the aorta. Since the development of giant thrombi under high flow conditions in the aorta is a pathophysiological process which is not well understood, a model of flow distribution by numerically simulating the Navier-Stokes equation for an incompressible fluid was generated. This model simulated how such thrombi may develop in the aorta. We hypothesize that large thrombi issuing from the aortic vessel wall represent a underestimated entity in middleaged persons and are probably overlooked as the cause of stroke or other embolic events in some cases.