Target organ damage and control of cardiovascular risk factors in hypertensive patients. Evidence from the multicenter ESTher registry.

AIMS: This study investigated the incidence of hypertensive target organ damage (TOD), control of cardiovascular risk factors, and the short-term prognosis in hypertensive patients under contemporary guideline-oriented therapy. PATIENTS AND METHODS: A total of 1,377 consecutive patients (mean age 58.2 ± 9.9 years, 82.2 % male) with arterial hypertension were included in the ESTher (Endorganschäden, Therapie und Verlauf - target organ damage, therapy, and course) registry at 15 rehabilitation clinics within the framework of the National Genome Research Network. Cardiovascular risk factors, medication, comorbidities, and glomerular filtration rate (GFR) were assessed. Left ventricular hypertrophy (LVH), left ventricular mass (LVM), left ventricular mass index (LVMI), and left ventricular ejection fraction (LVEF) were determined by two-dimensional echocardiography. The mean follow-up was 513 ± 159 days. Changes in continuous parameters were tested by the t test, changes in discrete characteristics are presented by means of transition tables and tested with the McNemar test. RESULTS: The mean LVEF was 59.3 ± 9.9 %, both mean LVM (238.6 ± 101.5 g) and LVMI (54.0 ± 23.6 g/m(2.7)) were increased while relative wall thickness (RWT, 0.46 ± 0.18) indicated the presence of concentric LVH. Of the patients, 10.2 % displayed renal dysfunction (estimated GFR < 60 ml/min/1.73 m(2)). The 1.5-year overall mortality was 1.2 %. Compared with discharge, at follow-up the proportion of patients with blood pressure (BP) values < 140/90 mmHg decreased from 68.7 % to 55.0 % (p < 0.001) and with low-density lipoprotein (LDL) values < 100 mg/dl from 62.6 % to 38.1 % (p < 0.001). At follow-up significantly more patients displayed a GFR value of < 60 ml/min/1.73 m(2) (10.2 % vs. 16.0 %, p < 0.001). CONCLUSION: A significant proportion of hypertensive rehabilitation participants displayed TOD including LVH and renal dysfunction. Even after stringent BP reduction, a considerable increase in nephropathy could be found after 18 months.

Comparable short-term prognosis in diabetic and non-diabetic patients with acute coronary syndrome after cardiac rehabilitation.

BACKGROUND: Patients with pathological glucometabolism are at increased risk of recurrent cardiovascular events after acute coronary syndrome (ACS). The goal of this study was to investigate the association of glucometabolism and the one-year outcome of cardiac rehabilitation patients. DESIGN: Prospective multicentre registry from four German rehabilitation clinics. METHODS: During 2005-2006, 1614 consecutive patients (85.9% male, mean age 55 ± 10.3 years) were included after the first ACS (mean 18.9 days) and classified into group 1 (apparent diabetes mellitus, n = 268), group 2 (no diabetes, impaired oral glucose tolerance [OGT], n = 185), and group 3 (normal fasting glucose and normal OGT, n = 1161). The mean follow-up was 13.4 months and the follow-up events were analysed by multivariate logistic regression models with backward elimination. RESULTS: The overall mortality was 1.3% (group 1: 1.2%; group 2: 1.8%; group 3: 1.5%; p(Trend) = NS). The target blood pressure values at discharge (<140/90 mmHg) were achieved by 88.7%, 89.1% and 90.8% of patients in groups 1, 2 and 3, respectively (p(Trend) = NS). The target value for LDL cholesterol (<100 mg/dl) was attained by 87.0%, 80.8% and 81.5% of the patients in groups 1, 2 and 3, respectively (p(Trend) = NS). There was a trend of a lower proportion of patients reaching the target values for HDL-C of 46.1%, 51.4% and 60.8% (p(Trend) < 0.001) and triglycerides of 65.1%, 79.9% and 74.6% (p(Trend) = 0.004) for groups 1, 2 and 3, respectively. The strongest multivariate predictors for overall mortality were patients experiencing a previous stroke (OR, 6.29 [95% CI: 1.06-37.19]; p = 0.042) and, with a trend, peripheral arterial disease (OR, 3.60 [95% CI: 0.95-13.68]; p = 0.061). In the multivariate analysis, the diabetic state had no association with poor outcomes (i.e. death or rehospitalization). CONCLUSION: The short-term prognosis for both diabetic and non-diabetic patients was good and was determined by end organ damage rather than by glucometabolic status. Diabetic patients received comparable (and not more aggressive) pharmacotherapy and therefore achieved target values for cardiovascular risk factors to a lesser extent than the non-diabetic and pre-diabetic patients.

[Determinants of health care expenses during cardiac rehabilitation]. / Versorgungsaufwand und Kosten während der kardiologischen Rehabilitation.

BACKGROUND AND OBJECTIVES: Diagnosis-related systems (ICD-10, OPS, PCCL) are used in acute medical care as part of the multidisciplinary classification of overall care and related costs. In contrast, such systems, reflecting therapeutic requirements and distinguishing between patients according to the level of effort and costs incurred, are still not available for use in clinical rehabilitation units. METHODS: 215 consecutive patients (aged 63.8 +/- 11.1 years; 68.2% males ) were included in a single-center prospective registry during inpatient cardiac rehabilitation (CR). The following data were included: clinical condition, diagnosis of diseases, length of acute hospitalization and various parameters of physical and psychological state (Karnofsky performance score, Hospital Anxiety and Depression Scale [HADS]). Efforts out of normal care by nurses. doctors and laboratories were measured in minutes and divided into quartiles. Logistic regression models were used to estimate the odds for predictive parameters for patients requiring care and efforts above the highest quartile. RESULTS: Mean acute in-hospital stay was 14.7 +/- 14.5 days, duration of CR 21.8 +/- 3.5 days. Mean duration of nursing efforts was 221 +/- 170 min, of medical staff efforts 5564 min, of physiotherapy 174 +/- 281 min. In the multivariate model five determinants were significantly associated with increased care provision during CR: duration of hospitalization, diabetes, arterial hypertension, low exercise capacity and anxiety as measured by HADS. Increased laboratory testing was predominantly the result of diabetes mellitus and an increased Karnofsky score. CONCLUSION: Prolonged acute hospitalization, anxiety and diabetes mellitus were associated with increased nursing/medical/phyisiotherapeutic care during CR. These factors should be taken into account in any cost classification system that needs to be developed for use in rehabilitation clinics so as to provide better transparency in cost assessment.

[Rehabilitation of patients with cardiac pacemakers and implanted cardioverter-defibrillators: recommendations for training, physiotherapeutic procedures and re-employment]. / Rehabilitation von Patienten mit Herzschrittmachern und Kardioverter-Defibrillatoren: Empfehlungen zu Training, Physiotherapie und beruflicher Wiedereingliederung.

Rehabilitation of patients with cardiac pacemakers (CP) or implantable cardioverter defibrillators (ICD) comprises secondary prevention of underlying cardiac disease, conditioning training activities and psychological education and includes furthermore the assessment of aggregate function, detection of any device malfunction as well as the return to work efforts. The extent to which the physical activities can be permitted is determined by both cardiopulmonary capacity and the primary arrhythmic indication. Under consideration of upper frequency limit, left ventricular dysfunction and the avoidance of mechanical exposure on device can and leads, an individually designed training programme is acceptable even on a high load level. Likewise, electrotherapeutic procedures due to musculoskeletal pain syndrome are not generally contraindicated, if differentiated limitations are respected. Beside the assessment of aggregate function and, if necessary, parameter optimization, psychologic intervention programs play an important role particularly in ICD-patients and can be utilized as an additive therapeutic module. Personalized recommendations for driving with an ICD are determined by the time interval since idex arrhythmia and the rhythmological risk profile as well as by the motor vehicle class. The return to work rate of CP and ICD patients is resumably influenced by the underlying cardiac disease and to a lesser extend by the implanted device. Except industrial jobs the risk of electromagnetic interference during the working process is low and can be objected by working place analysis including noise field measurement. Thus cardiac of CP and ICD patients should be used to a large extend for the recovery of individual physical and psychological integrity as well as for the organisation of reemployment.

Secondary prevention of diabetic patients with coronary artery disease in cardiac rehabilitation: risk factors, treatment and target level attainment.

INTRODUCTION: Diabetic patients who have suffered from an acute coronary syndrome (ACS) or have had coronary artery bypass graft (CABG) surgery are at very high risk of recurrent cardiovascular events. Their prognosis, however, can be improved if the target values for blood pressure (BP < 130/80 mmHg) or low density lipoprotein cholesterol [LDL-C < 2.6 mmol/L (100 mg/dl), optionally < 1.8 mmol/L (70 mg/dl)] are achieved. It is not known what proportion of diabetic patients receives such stringent secondary prevention measures and achieves target level attainment for BP, lipids and glucose in cardiac rehabilitation (CR). METHODS: During 2003 to 2005, 11 973 diabetic (29.7%) and 28 370 non-diabetic patients (70.3%), predominantly after ACS (74 and 80%), were included in a nationwide registry. At entry and at discharge, patient characteristics, pharmacotherapy and blood pressure, lipids and blood glucose were recorded. In a mixed model approach, temporal changes between centres and within centres, respectively, were analysed. RESULTS: At discharge, a lower proportion of diabetic patients achieved normalisation of BP (in 2005: <140/90 mmHg: 78.4 vs. 82.9% in non-diabetic patients, p < 0.001) or <130/80 mmHg (45.5 vs. 49.8%), respectively. LDL-C < 2.6 mmol/L was more frequently attained in diabetic patients (68.2 vs. 66.5%), as was LDL-C < 1.8 mmol/L (28.8 vs. 23.0%). Fasting blood glucose was not changed during the observation period, as at discharge almost a quarter of all diabetic patients exceeded the threshold value of 7.0 mmol/L (126 mg/dl). In 2005 at discharge, statin therapy was administered in 93% in both diabetics and non-diabetics, acetylic salicylic acid in 79% in diabetics vs. 80% in non-diabetic patients (clopidogrel: 41 vs. 45%). CONCLUSION: Generally there is room for improvement in the management of cardiac risk factors for both patients groups. In diabetic patients in CR at high risk for recurrent cardiac events, in recent years an improvement of the lipid profile has been observed. Hypertension and glycaemia are still not optimally addressed.

[Renal and cardiac functions as prognostic factors after revascularization for myocardial infarction]. / Nieren- und Herzfunktion als prognostische Faktoren nach Revaskularisation bei Myokardinfarkt.

BACKGROUND AND OBJECTIVE: In the last few decades optimal treatment of myocardial infarction has been achieved by thrombolytic and interventional reperfusion as well as subsequent secondary pharmacological prevention. It remains a subject of debate what factors influence prognosis after such measures. PATIENTS AND METHODS: 939 patients who had sustained acute myocardial infarction (75.1% males, aged 62.5 10.1 years) were followed prospectively after revascularization, using a multicenter registry (PreSCD) registry. Date and site of infarction, reperfusion measures, cardiovascular risk factors, hemoglobin and creatinine, QRS duration, ventricular arrhythmias recorded by Holter ECG monitoring were recorded, as well as biplane left ventricular ejection fraction (LVEF). Multivariate logistic Cox regression analysis was used to determine the effect of these various factors on overall mortality, resuscitation outcome, ventricular tachycardia, re-infarction, syncope and interventional or surgical revascularization. RESULTS: Complete data were collected on 926 patients (98.6%). During the follow-up period of 578 47 days there were 39 deaths (4.2%), 29 of them due to cardiac reasons, predominantly sudden cardiac death (58.6%). The occurrence of left bundle branch block was associated overall with a sevenfold increase in the of death (hazard ratio [95% confidence interval, (CI) 6.940 (2.912-16.539); p<0.0001), while an increase of serum creatinine by 1 mol/l raised the overall mortality by 0.7% (Hazard ratio (95% CI) 1.007 (1.03-1.012); p<0.001]. Improvement of LVEF by 1 % was associated with a 5% reduction in mortality risk (Hazard ratio [95% CI] 0.946 (0.918-0.975); p<0.0001]. Conventional cardiovascular risk factors, previous revascularization measures, site of infarction and pharmacological treatment failed to show any significant influence on end-points. CONCLUSION: In patients who had revascularization measures after a myocardial infarction the mortality rate was less than 5%. The risk of death was determined by LVEF, occurrence of left bundle branch block and renal failure.

Predictors of chronotropic incompetence in the pacemaker patient population.

AIMS: We prospectively evaluated results from cardiopulmonary exercise testing for chronotropic incompetence (CI) in a cohort of 292 pacemaker patients. In addition, we evaluated comorbidity and antiarrhythmic patient data as indicators of CI. METHODS AND RESULTS: On the basis of exercise stress testing and application of the definition of CI by Wilkoff, 51% of our cohort was categorized as having CI. Indications for pacemaker implant for this patient group were 42% atrioventricular block, 56% sinus node disease, and 59% atrial fibrillation. Maximum oxygen uptake (VO(2) max) and exercise duration were significantly reduced among CI pacemaker patients, whereas oxygen uptake at the anaerobic threshold remained unchanged. The following clinical characteristics were significant predictors of CI: existence of coronary artery disease (P = 0.038), presence of an acquired valvular heart disease (P = 0.037), and former cardiac surgery (P = 0.041). Age, gender, arterial hypertension, cardiomyopathy, congenital heart disease, left ventricular ejection fraction, and time period between stress-exercise examination and pacemaker implantation were not significant predictors of CI. Chronic antiarrhythmic therapy with digitalis (P = 0.013), beta blockers (P = 0.036), and amiodarone (P = 0.045) were significant predictors of CI. In contrast, medication with class I and IV antiarrhythmics had no significant correlation with CI. CONCLUSION: We found the following characteristics predictive of CI in this pacemaker patient population: VO(2) max, existence of coronary artery disease or acquired valvular heart disease, previous cardiac surgery, as well as medication with digitalis, beta blockers, and amiodarone.

Implementation of evidence-based therapy in patients with systolic heart failure from 1998-2000.

BACKGROUND: In recent years, the incidence of systolic heart failure has increased. Besides a complete revascularization, guideline-based medication represents the most effective therapeutic approach. AIM: Analysis of adherence of guideline-recommended and actual medication during inpatient cardiac rehabilitation as well as under subsequent outpatient conditions. METHODS: From 01/1998 to 12/ 2000, 1346 consecutive patients (64 +/- 10 years, 73% male, LVEF 36.3 +/- 8%, 88% ischemic, 6.7% valvular cardiomyopathy, 5.3% other causes, 11.8% atrial fibrillation) were included in a singlecenter prospective register. Medication was recorded at discharge and after the follow-up period of 731 +/- 215 days. Trends in prescription rates were analyzed based on nonparametric correlations (Spearman's-Rho). Changes in medication from in- to outpatient settings were analyzed using exact McNemar test. RESULTS: At discharge 75.3% (67.9%/68.9%/ 86.6% in 1998/1999/2000, p <0.001) of the patients were treated as recommended. This rate dropped to 68.3% at followup (p <0.0001). Mortality within the follow-up period was low (12.6%). CONCLUSION: It could be shown that from 1998 to 2000 inpatient guideline conformity was implementable adequately. Outpatient conformity was significantly lower. Although a high proportion of correctly prescribed CHF medication could be demonstrated, a further effort to improve guideline adherence in the management of heart failure patients is desirable.

Right atrial thrombus treated successfully with abciximab and heparin.

We report here a case of right atrial thrombus diagnosed by echocardiography in a 25-year-old female patient with Hodgkin's disease receiving chemotherapy and heparin. After 24 hours therapy with the glycoprotein IIb/IIIa receptor antagonist (abciximab) with concomitant heparin the complete dissolution of the thrombus could be demonstrated by transesophageal echocardiography. To our knowledge this case represents the first use of abciximab in right atrial thrombosis.

[Biatrial pacing as an effective therapy method of paroxysmal atrial fibrillation]. / Biatriales Pacing als effektive Therapiemethode des paroxysmalen Vorhofflimmerns.

For effective management of drug-refractory atrial fibrillation as the most common arrhythmia new methods are needed. In case of existing interatrial conduction disturbance the use of biatrial pacemaker with standard right atrial lead and additive coronary sinus lead for left atrial pacing shows an antiarryhthmic effect due to atrial resynchronisation. In order to demonstrate the antiarrhythmic effect of biatrial pacing, 74 pts. (26 f/48 m, mean age 63 +/- 9.4 y, follow-up 482 +/- 183 days) received a biatrial pacemaker (AAD-mode, AV-delay 0 msec, LOGOS, Fa. Biotronik) from 11/97 to 03/99. All patients had a prolongation of P-wave duration more than 100 msec (mean 122.3 +/- 23.1 msec). Preoperatively 9/74 (12%) pts. had monthly, 49/74 pts. (66%) had weekly, and 11/74 pts. (15%) had daily episodes of atrial fibrillation. Permanent atrial fibrillation > 6 month was seen in 5/74 pts. (7%, preoperative cardioversion). The intraoperative right atrial pacing threshold was 0.89 +/- 0.64 V (0.5 msec pulse width), the atrial signal amplitude 2.31 +/- 1.03 mV, the impedance signal 616 +/- 157 omega. Voltage recording in the coronary sinus showed a pacing threshold of 1.4 +/- 0.68 V (0.5 msec pulse width) and a potential of 3.47 +/- 1.44 mV. The impedance signal was 559 +/- 137 omega. The obtained P-wave duration was reduced for 33.9 +/- 20.1 msec. In 7/74 pts. (9.4%) we found a dislocation and in 4/74 pts. (5.4%) an excessive high pacing threshold of coronary sinus lead > 4 V/0.5 msec. All pts. with dislocated lead were reoperated. There were no perforations and thromboses of coronary sinus. The intervention led to a significant inhibition of atrial fibrillation in 11/74 pts. (14.9%) without and in 17/74 pts. (24.3%) with antiarrhythmic drugs. 17/74 pts. (24.3%) had a reduction of episodes without and 16/74 pts. (21.6%) with concomitant medication. The treatment did not have any influence on the prevalence of atrial fibrillation in 9/74 pts. (27%). In conclusion, the implantation of biatrial pacemaker leads to a significant reduction of atrial fibrillation episodes and has proven to be practicable and safe for clinical use.

Estimulaçäo com adaptaçäo de freqüência controlada pelo sistema nervoso autônomo - uma avaliaçäo clínica / ANS controlled rate-adaptive pacing: a clinical evaluation

Para o tratamento da incompetência cronotrópica, marcapassos com adaptaçäo em freqüência baseados em diferentes sinais de sensores têm sido desenvolvidos, visando restaurar o mecanismo fisiológico em malha fechada e utilizando informaçäo fornecida pelo sistema nervoso autônomo (SNA). A medida da impedância cardíaca unipolar permite a monitorizaçäo do estado de contraçäo do coraçäo, diretamente relacionado ao tônus simpático. Marcapassos uni ou bicamerais com sistemas responsivos controlados pelo SNA foram implantados em 262 pacientes em vários centros clínicos. Protocolos de exercícios clíncos, monitorizaçäo por Holter, testes de estresse psicológico e estudos adicionais visando uma variaçäo intencional do tônus simpático confirmaram a resposta fisiológica em freqüência para os vários tipos de mudanças hemodinâmicas.