Interdisciplinary consensus on indications for transfemoral transcatheter aortic valve implantation (TF-TAVI) : Joint Consensus Document of the Arbeitsgemeinschaft Leitende Kardiologische Krankenhausärzte e.V. (ALKK) and cooperating Cardiac Surgery Departments.

Indications for TF-TAVI (transfemoral transcatheter aortic valve implantation) are rapidly changing according to increasing evidence from randomized controlled trials. Present trials document the non-inferiority or even superiority of TF-TAVI in intermediate-risk patients (STS-Score 4-8%) as well as in low-risk patients (STS-Score < 4%). However, risk scores exhibit limitations and, as a single criterion, are unable to establish an appropriate indication of TF-TAVI vs transapical TAVI vs SAVR (surgical aortic valve replacement). The ESC (European Society of Cardiology)/EACTS (European Association for Cardio-Thoracic Surgery) guidelines 2017 and the German DGK (Deutsche Gesellschaft für Kardiologie)/DGTHG (Deutsche Gesellschaft für Thorax-, Herz- und Gefäßchirurgie) commentary 2018 offer a framework for the selection of the best therapeutic method, but the individual decision is left to the discretion of the heart teams. An interdisciplinary TAVI consensus group of interventional cardiologists of the ALKK (Arbeitsgemeinschaft Leitende Kardiologische Krankenhausärzte e.V.) and cardiac surgeons has developed a detailed consensus on the indications for TF-TAVI to provide an up-to-date, evidence-based, comprehensive decision matrix for daily practice. The matrix of indication criteria includes age, risk scores, contraindications against SAVR (e.g., porcelain aorta), cardiovascular criteria pro TAVI, additional criteria pro TAVI (e.g., frailty, comorbidities, organ dysfunction), contraindications against TAVI (e.g., endocarditis) and cardiovascular criteria pro SAVR (e.g., bicuspid valve anatomy). This interdisciplinary consensus may provide orientation to heart teams for individual TAVI-indication decisions. Future adaptations according to evolving medical evidence are to be expected. Interdisciplinary consensus on indications for transfemoral transcatheter aortic valve implantation (TF-TAVI).

[Recommendations of the ESC guidelines regarding cardiovascular imaging]. / Empfehlungen der ESC-Leitlinien zur kardiovaskulären Bildgebung.

Cardiac imaging plays a key role in the diagnosis and risk stratification in the ESC guidelines for the management of patients with stable coronary artery disease. Demonstration of myocardial ischaemia guides the decision which further diagnostic and therapeutic strategy should be followed in these patients. One should, however, not forget that there are no randomised studies supporting this type of management. In patients with a low pretest probability coronary CT angiography is the optimal tool to exclude coronary artery stenoses rapidly and effectively. In the near future, however, better data is needed showing how much cardiac imaging is really necessary and how cost-effective it is in patients with stable coronary artery disease.

[Coronary microvascular dysfunction : Clinical aspects, diagnosis and therapy]. / Koronare mikrovaskuläre Dysfunktion : Klinik, Diagnose, Therapie.

Just as in epicardial coronary stenosis, coronary microvascular dysfunction (CMD) also leads to an imbalance of myocardial oxygen supply and demand. The dysfunction is located at the level of the coronary microcirculation with vessel diameters < 500 µm and structural as well as functional alterations have been described. The underlying mechanisms are diverse, frequently overlap and are still incompletely understood. Among others, conditions such as chronic inflammation, estrogen deficiency and a genetic familial predisposition have been reported. A common and often underdiagnosed clinical manifestation of CMD is found in patients who have symptoms of angina pectoris but no obstructive epicardial coronary artery disease or myocardial disease. The CMD can be diagnosed using non-invasive procedures, such as the combination of coronary computed tomography (CT) angiography and cardiac stress magnetic resonance imaging (MRI) or coronary CT and positron emission tomography (PET). In addition, invasive coronary vasomotor assessment is also suitable. Very little evidence is available regarding the effectiveness of pharmacological treatment of CMD. The current European Society of Cardiology (ESC) guidelines on the management of stable coronary artery disease from 2013 recommend using acetylsalicylic acid (ASS) and a statin as well as beta blockers and/or calcium channel blockers. Patients with CMD have an elevated risk for coronary events and death of approximately 1.7 % per year. Moreover, there is an increased morbidity with frequent presentations in practices and emergency admissions. Clinical research efforts should aim at a better characterization of the underlying mechanisms of CMD in order to develop targeted treatment approaches.

Corrigendum to: 2014 ESC Guidelines on the diagnosis and treatment of aortic diseases.

Corrigendum to: 2014 ESC Guidelines on the diagnosis and treatment of aortic diseases [Eur Heart Journal (2014) 35, 2873­2926,doi:10.1093/eurheartj/ehu281]. In Table 3, the radiation for MRI is "0" and not "-". The corrected table is shown below.

2015 Update on Acute Adverse Reactions to Gadolinium based Contrast Agents in Cardiovascular MR. Large Multi-National and Multi-Ethnical Population Experience With 37788 Patients From the EuroCMR Registry.

OBJECTIVES: Specifically we aim to demonstrate that the results of our earlier safety data hold true in this much larger multi-national and multi-ethnical population. BACKGROUND: We sought to re-evaluate the frequency, manifestations, and severity of acute adverse reactions associated with administration of several gadolinium- based contrast agents during routine CMR on a European level. METHODS: Multi-centre, multi-national, and multi-ethnical registry with consecutive enrolment of patients in 57 European centres. RESULTS: During the current observation 37,788 doses of Gadolinium based contrast agent were administered to 37,788 patients. The mean dose was 24.7 ml (range 5-80 ml), which is equivalent to 0.123 mmol/kg (range 0.01 - 0.3 mmol/kg). Forty-five acute adverse reactions due to contrast administration occurred (0.12%). Most reactions were classified as mild (43 of 45) according to the American College of Radiology definition. The most frequent complaints following contrast administration were rashes and hives (15 of 45), followed by nausea (10 of 45) and flushes (10 of 45). The event rate ranged from 0.05% (linear non-ionic agent gadodiamide) to 0.42% (linear ionic agent gadobenate dimeglumine). Interestingly, we also found different event rates between the three main indications for CMR ranging from 0.05% (risk stratification in suspected CAD) to 0.22% (viability in known CAD). CONCLUSIONS: The current data indicate that the results of the earlier safety data hold true in this much larger multi-national and multi-ethnical population. Thus, the "off-label" use of Gadolinium based contrast in cardiovascular MR should be regarded as safe concerning the frequency, manifestation and severity of acute events.

[Diagnostics and therapy of chronic stable coronary artery disease : new guidelines of the European Society of Cardiology]. / Diagnostik und Therapie der chronisch stabilen koronaren Herzkrankheit : Neue Empfehlungen der Europäischen Gesellschaft für Kardiologie.

The European Society of Cardiology (ESC) guidelines on the management of stable coronary artery disease published in 2013 give practical recommendations for diagnostics and therapy. The approach depends on the clinical picture and symptoms of the patient, the severity and extent of ischemia, the degree and location of coronary stenoses, additional cardiac findings and finally on non-cardiac comorbidities. The selection of suitable diagnostic tools is based on the tabulated pretest probability for the presence of coronary artery disease which plays an important and central role in the diagnostic algorithm. An invasive approach is recommended only in patients with severe angina, i.e. a Canadian Cardiovascular Society (CCS) angina grading scale of ≥ CCS3 or in patients who are at high risk for death or myocardial infarction based on the results of the test used for detection of ischemia. Detailed therapeutic recommendations are given for medicinal and interventional or surgical therapy. Medicinal therapy includes drugs both for relief of symptoms and prevention of cardiovascular events. Recommendations are also given for the use of new antianginal drugs. A PCI is only indicated in vessels causing ischemia which can be verified by using fractional flow reserve measurements. The indications for PCI now also include patients with a low SYNTAX score and multivessel disease or left main stenosis; however, the optimal strategy should be individually determined in heart team discussions.

[Dizziness and syncope : clinical case examples]. / Schwindel und Synkope : Klinische Fallbeispiele.

Syncope is defined as a transient, self-limiting loss of consciousness and postural tone due to transient global cerebral hypoperfusion. After syncope the following questions have to be answered: was it a syncopal episode, has the etiological diagnosis been determined, are there data suggestive of a high risk of cardiovascular events or death and what are the therapeutic options? Therefore, a standardized diagnostic work-up is necessary. This diagnostic work-up with differential diagnostic considerations is given for three clinical cases: a 52-year-old man experienced syncope while driving a car and on the morning of the same day syncope had previously occurred while in a standing position. The initial cardiological and neurological evaluation revealed no pathological findings but after implantation of a loop recorder a further syncope with a sinus arrest of 17 s occurred 1 year later. The patient received a single chamber pacemaker. The second case is a 79-year-old female with Parkinson's disease for many years and a primary autonomic dysfunction leading to dizziness and syncope due to pronounced blood pressure fluctuations with hypertensive and hypotensive phases. The last patient is a 22-year-old female with postural orthostatic tachycardia syndrome and recurrent syncope. The diagnostic evaluation and treatment proved to be difficult.

[Unstable angina pectoris--combination of an epicardial stenosis and a Prinzmetal spasm]. / Instabile Angina pectoris: Zusammenspiel von epikardialer Stenose und Prinzmetal-Spasmus.

HISTORY AND ADMISSION FINDINGS: A 61-year-old man presented with recurrent angina pectoris at rest for 3 days. The medical history revealed hypertension and an elevated cholesterol level as cardiovascular risk factors. INVESTIGATIONS: The physical examination revealed no pathological findings. ECG at admission showed no signs of ischemia, while high-sensitive Troponin T was slightly elevated. Echocardiography showed diastolic dysfunction and biatrial dilatation. TREATMENT AND COURSE: During another episode of angina at rest, ECG showed T-wave inversion in lead aVL. Therefore, coronary angiography was performed. At the beginning of the examination the patient complained of angina at rest and ECG showed ST-elevation in the inferior leads. Coronary angiography revealed a subtotal stenosis in the middle part of the RCA. After intracoronary nitroglycerin injection there was a high-grade stenosis in this region. An intracoronary acetycholin provocation test was performed which reproduced a focal spasm in the area of the RCA stenosis with simultaneous changes in the ECG and reproduction of the patient's unusual angina. After implantation of a bare metal stent a subsequent ACH-test did not elicit any further coronary spasm. Four weeks after the procedure the patient had no further complaints under medical treatment. CONCLUSION: This case illustrates a patient with a focal Prinzmetal-type spasm with ST-elevation on top of a high-grade stenosis of the right coronary artery as an explanation for the unstable angina. Coronary spasm of the Prinzmetal-type can occur in vessels with epicardial stenosis as well as in vessels without stenosis. In some cases focal coronary spasm can be prevented by the implantation of a stent.

[Cardiorenal syndrome]. / Kardiorenales Syndrom.

The cardiorenal syndrome describes the frequent clinical situation in which therapy of a patient with acute cardiac decompensation is limited by a decline of renal function. This is frequently associated with preexisting chronic renal insufficiency. It is important to be aware of this potentially fatal constellation and perform diuretic therapy slowly and carefully in order to avoid inadequate volume depletion. This may require surveillance in an intensive care unit. Ultrafiltration is an alternative to diuretic therapy which may permit greater fluid loss when beginning therapy and better control of volume reduction once heart failure symptoms improve. The individual treatment of patients with cardiorenal syndrome requires a close cooperation between cardiologists and nephrologists.

[Angina pectoris without coronary stenosis--current concepts]. / Angina pectoris ohne Koronarstenosen - aktuelle Konzepte.

This review aims at demonstrating current concepts for the occurrence of angina pectoris (AP) and myocardial ischemia in patients without significant epicardial stenoses based on typical clinical examples. For applying these concepts, it is of utmost importance to clinically distinguish patients with resting AP only from those with exercise-induced symptoms or both. Resting AP may not only be caused by plaque rupture and subsequent coronary thrombosis, but may also be due (especially when repeated attacks occur in the early morning hours) to coronary vasospasm (in the microvasculature as well as in epicardial coronary segments). Similarly, exercise-induced AP and/or a pathological exercise test result may not only be caused by severe coronary stenoses, but may also be due to a reduced coronary perfusion reserve secondary to microvascular dysfunction. Hence, a pathological non-invasive stress-test result should not be necessarily described as "false positive" in case of the absence of any significant stenosis. In principle, proatherogenic cardiovascular risk factors are not only associated with atherosclerotic coronary artery disease (CAD), but also with the occurrence of a coronary vasomotility disorder. Both disease entities are characterised by the occurrence of myocardial ischemia. So far, the exact pathomechanism of respective subforms of coronary vasomotility disorders has not yet been not elucidated in detail. Endothelial dysfunction, abnormalities of the smooth muscle cells in the media as well as genetic predisposition or specific immunological abnormalities are discussed as underlying reasons. Intracoronary provocative testing (such as the acetylcholine-test) may help to diagnose as well as to differentiate the different subforms of coronary vasomotility disorders.

[Clinical spectrum of tako-tsubo cardiomyopathy in Germany: results of the tako-tsubo registry of the Arbeitsgemeinschaft Leitende Kardiologische Krankenhausärzte (ALKK)]. / Klinische Versorgung von Patienten mit Tako-Tsubo-Kardiomyopathie: Ergebnisse des Tako-Tsubo-Registers der ALKK.

BACKGROUND: Tako-tsubo cardiomyopathy (TTC) was first described in 1990 in Japan. A TTC registry was initiated by the Arbeitsgemeinschaft Leitende Kardiologische Krankenhausärzte (ALKK) in order to evaluate the clinical spectrum and the management of patients with this syndrome in Germany. METHODS: Patients from 37 hospitals were included in the registry if they fulfilled the following criteria: 1. acute chest symptoms or syncope, 2. new ischemic ECG changes with ST-segment elevation ± T-wave inversion, 3. reversible left ventricular regional wall motion abnormality not corresponding to a single coronary artery territory, 4. absence of significant coronary artery stenoses. RESULTS: 296 of the 324 patients (age 68 ± 12) were women (91 %) and 28 men (9 %). Leading symptoms were angina pectoris (72 %), dyspnoea (16 %), syncope (3 %) or resuscitation/cardiogenic shock (2 %). An antecedent trigger was found in 77  %. Time from symptom onset to hospital admission was 7,6 ± 6,9 hours. An acute coronary syndrome (ACS) was clinically suspected in 87 %. The ECG showed ST-segment elevation in 85 %. Cardiac troponin was elevated in more than 90 % of patients. Left ventricular ejection fraction by angiography was reduced to 49 ± 14 %. Initial medical treatment corresponded to the working diagnosis of an ACS. Catecholamines or an intraaortic balloon pump were necessary in 5 % and 1 %, respectively. Seven patients (2.2 %) died in hospital. CONCLUSION: TTC afflicts mainly women and presents clinically as an ACS in 87 %. Hospital mortality is low with symptomatic therapy.

[Cardiac computed tomography and magnetic resonance imaging in patients with coronary artery disease]. / Diagnostik der koronaren Herzerkrankung mit Computer- und Magnetresonanztomographie.

Coronary angiography by computed tomography (CTCA) is most suitable for symptomatic patients with an intermediate likelihood to exclude a coronary stenosis as the cause of the symptoms. It would also be appropriate in a patient in whom an equivoval stress test result has led to uncertainty about the patient's further management. CTCA may occasionally be acceptable in a high risk symptomatic patient who refuses the necessary invasive coronary angiography if the results of CTCA are likely to alter patient management.The main indication for cardiac magnetic resonance imaging (CMR) is for pharmacologic stress testing. If such a test is indicated, dobutamine stress CMR is an alternative to stress echocardiography and adenosine perfusion CMR is the alternative to nuclear myocardial perfusion imaging but without radiation. Late gadolinium enhancement CMR is the current gold standard for the assessment of myocardial scars and hence is well suited to predict recovery of function in dysfunctional myocardial regions following revascularisation (viability testing).

[Cardiac amyloidosis--cardiovascular magnetic resonance imaging as a valuable diagnostic tool]. / Kardiale Amyloidose--Kardio-MRT als hilfreiches diagnostisches Werkzeug.

HISTORY: A 90-year-old man presented at the emergency room with symptoms of severe heart failure. A few weeks earlier he had been seen with the same symptoms at another hospital where the diagnosis of severe aortic valve stenosis had been made and aortic valve replacement was recommended. However, the patient did not consent to surgery and was discharged after medical treatment. INVESTIGATIONS: Echocardiography demonstrated global hypertrophy, pronounced at the ventricular septum. Interestingly the transaortic pressure gradient was only slightly elevated, revealing mild aortic stenosis. Thus, for work-up of discrepancies between the recent and previous (in the other hospital) exam results, cardiac magnetic resonance imaging (CMR) was performed. DIAGNOSIS: CMR planimetry confirmed that the aortic stenosis was only mild. However, contrast CMR revealed typical circular subendocardial late gadolinium enhancement in the entire left ventricle, which is typically seen in cardiac amyloidosis. This diagnosis was confirmed by endomyocardial biopsy revealing transthyretin-type amyloidosis. TREATMENT AND COURSE: Recompensation was achieved using diuretics and usual heart failure medication. Unfortunately, there is no causal treatment for transthyretin-type amyloidosis. However, the unnecessary aortic valve replacement surgery could be avoided. CONCLUSION: CMR is capable to precisely assess the aortic valve area even in cases with discrepant findings by other techniques. In addition, contrast CMR allows noninasive detection of myocardial abnormalities in living patients. Based on the pattern of contrast enhancement, differentiation between etiologies is possible.

[Cardiac imaging in suspected coronary artery disease]. / Kardiale Bildgebung bei Verdacht auf eine koronare Herzkrankheit.

Within the scope of this review, non-invasive imaging modalities applicable for further work-up of suspected coronary artery disease (CAD) are discussed with regard to methodology, diagnostic accuracy and prognostic value. All of these imaging modalities can be employed in patients with an intermediate pretest probability of disease, if ECG stress testing is either not reasonable, not possible due to physical limitations or if the result is inconclusive. Stress echocardiography is a cost-effective and an easily practicable method based on the indirect detection of myocardial ischemia by visually assessing provoked wall motion abnormalities. Therefore, its diagnostic value is mainly determined by individual expertise. In case of myocardial scintigraphy, reduced myocardial perfusion causes signal intensity differences in SPECT images following physical or pharmacological stress which are reversible at rest. Myocardial scintigraphy is characterised by a high negative predictive value at the expense of a lower specificity due to false positive results based on methodological limitations. Cardiovascular magnetic resonance imaging (CMR) offers a comprehensive cardiac study in a single procedure. Apart from detecting myocardial ischemia by dobutamine-stress-CMR or adenosine-perfusion-CMR, it enables the precise detection of even small areas of myocardial infarction on contrast-enhanced images. In spite of fascinating high-resolution coronary images, multi-detector computed tomography (MDCT) has hardly been included in current guidelines due to the unavoidable risks of radiation and contrast medium exposure and the current uncertainty in defining appropriate clinical indications. However, quantification of coronary calcium is easily performed and may be useful for prognostic assessment in patients with intermediate risk profile.

The Euro Heart Survey - Germany: diabetes mellitus remains unrecognized in patients with coronary artery disease.

AIM: Diabetes mellitus is associated with a poor prognosis due to a high rate of coronary artery disease. It was the aim of this survey to assess the prevalence of an impaired glucose tolerance and manifest diabetes mellitus in patients with coronary artery disease (CAD). METHODS: We analyzed data of all German centers participating in the Euro Heart Survey on diabetes and the heart, an European-wide multicenter prospective observational study. Participating centers were asked to recruit patients >18 years with a diagnosis of CAD. RESULTS: In Germany, 261 patients with a diagnosis of CAD were enrolled in five participating centers. Patients were divided into an acutely (22,4%; n = 57) or electively admitted (77,6%; n = 198) group. There were 34% (n = 89) of patients with already known diabetes. In 36% (n = 22 of 56) of the patients without previously known diabetes, an oral glucose tolerance test (OGTT) was performed (3%, n = 5 in the acute and 33%, n = 51 in the elective group). As a result, 39% (n = 22 of 56) of these patients had an impaired glucose tolerance (acute group: 0%, n = 0 of 5; elective group: 43%, n = 22 of 51) and in 13% (n = 7 of 56) diabetes mellitus was diagnosed (acute group: 40%, n = 2 of 5; elective group: 10%, n = 5 of 51). Furthermore, on admission 86% of women and 94% of men reported to exercise less than three times per week and thus less than recommended in current guidelines. CONCLUSION: More than one third of the patients with CAD who underwent an OGTT had an impaired glucose tolerance. Implementation of this simple, effective and inexpensive test into clinical routine of patients with CAD would help diagnose diabetes mellitus and thus grant these high risk patients access to an optimal medical, interventional and surgical therapy. Furthermore, patients ought to be encouraged to include exercise training into their daily routine.

[Therapy of chronic stable angina]. / Therapie der stabilen Angina pectoris.

Chronic stable angina is a common clinical problem limiting the quality of life. Patients with suspected stable angina require prompt cardiological investigation to ensure that the diagnosis is correct and that the prognosis is evaluated. An initial non-invasive strategy using an exercise test is most appropriate. All patients should be advised regarding life-style modifications to correct risk factors. In the absence of contraindications or intolerance acetylsalicylic acid and statins should be given. ACE-inhibitors are indicated in patients with left ventricular dysfunction, hypertension or diabetes and patients with other high-risk features. Beta blockers are used in all patients after myocardial infarction and those with left ventricular dysfunction. Anti-anginal therapy is based on the use of short-acting nitrates. Beta blockers, calcium antagonists and long-acting nitrates reduce the frequency and intensity of angina. In patients with high-risk features and those whose symptoms cannot be adequately controlled by medications coronary angiography should be considered. Both percutaneous coronary intervention and coronary artery bypass graft operation (CABG) are effective measures to control anginal symptoms. However, only CABG has been shown to improve prognosis in some high-risk patients.

Coronary vasospasm as the underlying cause for chest pain in patients with PVB19 myocarditis.

OBJECTIVE: To evaluate the incidence of coronary vasospasm as a possible pathophysiological mechanism causing chest pain symptoms in patients with clinically suspected myocarditis. DESIGN AND SETTING: Prospective study in a teaching hospital. PATIENTS: 85 patients who presented at hospital with atypical chest pain and demonstrated clinical signs suggestive of myocarditis. MAIN OUTCOME MEASURES: Incidence of coronary vasospasm demonstrated by intracoronary acetylcholine (ACh) testing. METHODS: The combined procedure of intracoronary ACh testing and endomyocardial biopsy (EMB) was performed after ruling out significant coronary artery disease (CAD). EMBs were analysed for myocardial inflammation by immunohistological methods and for virus genome persistence. RESULTS: Pathological biopsy results, including myocardial inflammation or detection of viral genomes, or both, were found in 55 (64.7%) patients while 30 (35.3%) patients showed neither cardiac inflammation nor viral genomes and were defined as the control group. Coronary vasospasm was demonstrated in 39/55 (70.9%) patients with pathological results compared with only 12/30 (40.0%) with normal biopsy results (p = 0.01). Patients with isolated PVB19 infection (n = 22) demonstrated a significantly higher incidence of coronary vasospasm than both those with isolated HHV6 infection (86.4% vs 46.7%; p = 0.025) and those with normal biopsy results (86.4% vs 40.0%; p<0.001). Univariate and multivariate logistic regression analysis showed that only PVB19 infection was independently correlated with coronary vasospasm (OR = 4.9, 95% CI 1.56 to 15.28, p = 0.006). CONCLUSIONS: Coronary vasospasm is one of the main reasons for atypical chest pain in patients with clinical signs of myocarditis and biopsy-proven PVB19 myocarditis in the absence of significant CAD.