Koronare Herzerkrankung Behnes, M.; Mashayekhi, K.; Borggrefe, M. ...
Herz,
04/2017, Letnik:
42, Številka:
2
Journal Article
Recenzirano
Zusammenfassung
Die koronare Herzkrankheit (KHK) stellt eine häufige strukturelle Ursache für einen Herzstillstand im höheren Alter dar, während hierfür beim jungen Erwachsenen eher Kardiomyopathien ...oder Ionenkanalerkrankungen ursächlich sind. Strukturelle Herzerkrankungen sind bei etwa der Hälfte der Patienten mit Herzstillstand vorbekannt. Die vorliegende Übersichtsarbeit stellt aktuelle interventionelle und operative Therapiemöglichkeiten nach einem Herzstillstand dar. Schwerpunkte liegen hierbei auf der Darstellung der Zusammenhänge zwischen epidemiologischen Daten zur Inzidenz von malignen Herzrhythmusstörungen als Ursache für einen Herzstillstand in Abhängigkeit des Vorhandenseins einer KHK. Zum anderen wird der mögliche Nutzen einer möglichst frühen koronaren Revaskularisation und einer umgehenden kompletten Revaskularisation gegenüber der alleinigen Therapie der sog. „culprit lesion“ aufgezeigt. Abschließend werden die Vorteile invasiver Therapiemaßnahmen, wie etwa des zielgerichteten Temperaturmanagements und mechanischer Herzunterstützungssysteme für Patienten nach erfolgreich überstandener kardiopulmonaler Reanimation beschrieben. Letztere umfassen die sog. intraaortale Gegenpulsation (IABP) und Möglichkeiten der extrakorporalen Herzunterstützung („extracorporeal life support“, ECSL) zur peripheren und zentralen Unterstützung der rechten und linken Herzkammer.
Coronary artery disease (CAD) represents a common structural cause for developing cardiac arrest in older patients, whereas in young adults cardiac arrest is more often caused by cardiomyopathies and ...cardiac channelopathies. A structural heart disease is known in almost 50% of patients prior to cardiac arrest. The present review outlines current interventional and operative therapeutic options for patients surviving cardiac arrest. The focus is on associations between epidemiological data on the incidence of malignant arrhythmias causing cardiac arrest depending on the presence or absence of CAD. Furthermore, the potential benefits of an early coronary revascularization as well as of a prompt complete coronary revascularization compared to the individual treatment of the so-called culprit lesion only are described. Finally, the advantages of invasive therapies for patients surviving cardiac arrest, such as targeted temperature management and mechanical cardiac assist devices, are elucidated. Cardiac assist devices comprise the use of the intra-aortic balloon pump (IABP) and devices for extracorporeal life support (ECLS) for peripheral and central support of the right and left heart chambers.
Routine determination of troponin levels is recommended for all patients with acute ischemic stroke. In 20-55% of these patients the troponin levels are elevated, which may be caused by ischemic as ...well as non-ischemic myocardial damage and particularly neurocardiogenic myocardial damage. In patients with acute ischemic stroke, the prevalence of previously unknown coronary heart disease is reported to be up to 27% and is prognostically relevant for these patients; however, relevant coronary stenoses are less frequently detected in stroke patients with troponin elevation compared to patients with non-ST elevation myocardial infarction. The risk of secondary intracerebral hemorrhage due to the necessity for dual platelet aggregation inhibition illustrates the challenging indication for invasive coronary diagnostics and revascularization. Therefore, a diagnostic work-up and interdisciplinary risk evaluation appropriate to the urgency are necessary in order to be able to determine a reasonable treatment approach with timing of the intervention, type and duration of blood thinning. In addition to conventional examination methods, multimodal cardiac imaging is increasingly used for this purpose. This review article aims to provide a pragmatic and clinically oriented approach to diagnostic and therapeutic procedures, taking into account the available evidence.
Impedance cardiography measurement of cardiac output gained wide interest due to its ease of use and non-invasiveness. However, validation studies of different algorithms yielded diverging results. ...Bioreactance (BR) as a recent adaption differs fundamentally as the flow signal is derived from phase shifts. Our aim was to assess the accuracy and reproducibility of BR, as compared to the non-invasive gold standard- cardiac magnetic resonance imaging (CMR). We prospectively included 32 stable patients. BR was performed twice in the supine position and averaged over 30 seconds. Mean bias was 0.2 +- 1.8 l/minute (1 +- 28%, percentage error 55%) with limits of agreement ranging from -3.4 to 3.7 l/minute. Reproducibility was acceptable with a mean bias of 0.1 +- 0.9 l/minute (1 +- 14%, 27%). Low cardiac output was significantly overestimated (-1.1 +- 1.5 l/minute), while high cardiac output was underestimated (1.5 +- 1.7 l/minute), (P=0.001), although reproducibility was unaffected. Bias and weight were moderately correlated in men (r = 0.50, P=0.02). No differences for accuracy were found in nine patients who had an arrhythmia (0.3 +- 1.4 versus 0.1 +- 2.0 l/minute, P=0.76), while clinically relevant differences were found in patients with mild aortic valve disease (1.9 +- 2.2 versus -0.3 +- 1.7 l/minute, P=0.02). Overall, BR showed insufficient agreement with CMR, overestimating low and underestimating high cardiac output states. Reproducibility was acceptable and not negatively affected by the circulatory condition. Consequently, absolute values acquired with BR should be interpreted with caution and must not be used interchangeably in clinical practice.
Zusammenfassung
Der plötzliche Herztod und die chronische Herzinsuffizienz gehören zu den führenden Todesursachen in Deutschland. Neben der Behebung kausaler Faktoren und einer leitliniengerechten ...medikamentösen Therapie hat die Therapie mit kardial implantierbaren elektronischen Devices (CIED) ihren unbestrittenen Stellenwert. Zur Vermeidung des plötzlichen Herztodes sind implantierbare Defibrillatoren etabliert. Subkutane Defibrillatoren haben den Vorteil, dass sie bei gleicher Sicherheit und Effektivität keine intrakardialen Elektroden haben. Bei Patienten mit breitem QRS-Komplex und reduzierter Pumpfunktion hat die kardiale Resynchronisationstherapie zur Senkung der Morbidität und Mortalität geführt. Für Patienten mit normalem QRS-Komplex wurde für die kardiale Kontraktilitätsmodulation eine verbesserte Belastungskapazität, Lebensqualität und Verbesserung linksventrikulärer Parameter nachgewiesen. Als Verfahren der autonomen Modulation bei Patienten mit reduzierter Herzkraft ist die Datenlage für die Barorezeptorstimulation am überzeugendsten.
Abstract
Aim
Takotsubo syndrome (TTS) patients have a higher mortality rate than the general population. Our study was conducted to determine the short- and long-term outcome of TTS patients ...associated with a significantly compromised mitral annular plane systolic excursion (MAPSE) on hospital admission.
Methods and results
Our institutional database constituted a collective of 53 patients diagnosed with TTS between 2003 and 2016. The patients were classified into two groups based on the MAPSE, with those presenting with an MAPSE <1 cm on admission categorized into one group (n = 20, 38%) and those presenting with MAPSE ≥1 cm (n = 33, 62%) categorized into another group. Preliminary results indicated that patients with an MAPSE < 1 cm had a greater risk of developing thromboembolic events. The long-term mortality was significantly higher in TTS patients with an MAPSE < 1 cm. In the multivariate Cox regression analysis, cardiogenic shock (hazard ratio 3.5; 95% confidence interval: 1.2–10.7; P = 0.02) and MAPSE < 1 cm (hazard ratio 5.1; 95% confidence interval: 1.3–19.2; P = 0.01) figured as independent predictors of the mortality.
Conclusion
Although the short-term mortality rates among TTS patients diagnosed with a reduced MAPSE on admission were as similar as without reduced MAPSE, the long-term mortality rates among TTS patients diagnosed with a reduced MAPSE on admission were significantly higher. There is an urgent need for randomized trials, which could help define uniform clinical management strategies for high-risk TTS patients.
Previous studies revealed that patients with Takotsubo cardiomyopathy (TTC) have a higher mortality rate than the general population. It is still unclear whether sex differences may influence ...long-term prognosis of TTC patients. The purpose of this study was to determine whether sex differences do influence the short- and long-term outcomes of TTC.
A total of 114 patients with TTC were admitted to the University Medical Centre Mannheim from January 2003 to September 2015 and entered into the TTC database of the University Medical Centre Mannheim, and retrospectively analyzed. Patients were diagnosed by the Mayo Clinic criteria. All-cause mortality over mean follow-up of 1,529±1,121 days was revealed. Significantly more male patients died within long-term follow-up compared to female TTC patients (log-rank test;
=0.01). Most males died of noncardiac causes. In multivariate Cox regression analysis, the male sex (
=0.02, hazard ratio HR 2.8, 95% CI 1.1-7.2), the ejection fraction ≤35% (
=0.01, HR 3.3, 95% CI 1.2-9.2) and glomerular filtration rate <60 mL/min (
<0.01, HR 3.1, 95% CI 1.4-7.0) figured out as independent predictors of the adverse outcome.
This study shows that males suffering from TTC reveal a higher long-term all-cause mortality rate than females over a 5 year follow-up period.
Background
Arterial stiffness (AS) has emerged as a strong predictor of cardiovascular (CV) diseases. Although increased AS has been described as a predictor of atrial fibrillation (AF), its role as ...a risk marker for AF recurrence has not yet been elucidated.
Methods
Patients with AF who underwent pulmonary vein isolation (PVI) were included in this study. Presence of AS was evaluated by measuring aortic distensibility (AD) of the descending aorta by transoesophageal echocardiography.
Results
In total, 151 patients (mean ± standard deviation (SD) age 71.9 ± 9.8 years) were enrolled and followed for a median duration of 21 months (interquartile range 15.0–31.0). During follow-up, AF recurred in 94 (62.3%) patients. AF recurrence was seen more frequently in patients with permanent AF (27% vs 46%,
p
= 0.03) and in those who had undergone prior PVI (9% vs 23%,
p
= 0.02). AD was significantly reduced in patients with AF recurrence (mean ± SD 2.6 ± 2.3 vs 1.5 ± 0.7 × 10
−3
mm Hg
−1
,
p
< 0.0001), as well as left atrial volume index (LAVI) (mean ± SD 29 ± 12 vs 44 ± 15 ml/m
2
,
p
< 0.0001). Multivariable analysis revealed LAVI (odds ratio (OR) 2.9, 95% confidence interval (CI) 1.2–3.4) and AS (OR 3.6, 95% CI 2.8–4.1) as independent risk factors of AF recurrence.
Conclusion
Increased AS and left atrial size were independent predictors of AF recurrence after PVI. AD as surrogate marker of AS seemed to reflect the overall CV risk. In addition, AD was significantly correlated with left atrial size, which suggests that increased AS leads to atrial remodelling and thus to AF recurrence.
Trial registration
German registry for clinical studies (DRKS), DRKS00019007.
Abstract For many emergency facilities, risk assessment of patients with diffuse chest pain still poses a major challenge. In their currently valid recommendations, the international cardiological ...societies have defined a standardized assessment of the prognostically relevant cardiac risk criteria. Here the classic sequence of basic cardiac diagnostics including case history (cardiac risk factors), physical examination (haemodynamic and respiratory vital parameters), ECG (ST segment analysis) and laboratory risk markers (troponin levels) is paramount. The focus is, on the one hand, on timely indication for percutaneous catheterization, especially in patients at high cardiac risk with or without ST-segment elevation in the ECG, and, on the other hand, on the possibility of safely discharging patients with intermediate or low cardiac risk after non-invasive exclusion of a coronary syndrome. For patients in the intermediate or low risk group, physical or pharmacological stress testing in combination with scintigraphy, echocardiography or magnetic resonance imaging is recommended in addition to basic diagnostics. Moreover, the importance of non-invasive coronary imaging, primarily cardiac CT angiography (CCTA), is increasing. Current data show that in intermediate or low risk patients this method is suitable to reliably rule out coronary heart disease. In addition, attention is paid to the major differential diagnoses of acute coronary syndrome, particularly pulmonary embolism and aortic dissection. Here the diagnostic method of choice is thoracic CT, possibly also in combination with CCTA aiming at a triple rule-out.
Takotsubo cardiomyopathy (TTC) is a relevant differential diagnosis in patients presenting with signs of an acute coronary syndrome. Although recent literature has highlighted some salient features ...of this disorder, there has been little information elucidating the differences in clinical features, electrocardiographic findings, echocardiographic data and TTC-related complications associated with the different variants of TTC.
Our institutional database constituted a collective of 114 patients diagnosed with TTC between 2003 and 2015 and these patients were subsequently divided into two groups based on the presence (n = 82, 72%) or absence (n = 32, 28%) of the apical form of TTC. The protocol for our proposed study was approved by the Ethics Committee of the University Medical Centre in Mannheim. It was noticed that the patients presenting with the apical form of TTC belonged to an older age group as compared to those presenting with the non-apical form (61.1 ± 8.9 years vs. 69.5 ± 11.2; P < 0.01). The QTc interval prolongation at index-event was observed to be quantifiably greater in the 'apical variant' patients group (484.8 ± 57 ms vs. 464 ± 34.1 ms; P = 0.06). With respect to cardiovascular risk factors, patients with arterial hypertension did have a higher predilection to present with the apical form (63.4% vs. 43.7%; P = 0.06), however, the impact of smoking was less pronounced in this patient group (24.4% vs. 50%, P = 0.01). Furthermore, our study highlighted a significant impact on ejection fraction (EF), with a compromised left ventricular function (36 ± 9% vs. 42.4 ± 9.7%, P < 0.01) and greater involvement of the right ventricle in the apical variant patients group (23% vs. 3%, P = 0.04). Patients with the apical form also showed a greater tendency to develop TTC-related complications such as cardiogenic shock and required longer monitoring and care in comparison.
The apical and non-apical variants of TTC are manifestations of the same syndrome. They differ significantly, however, in their clinical presentation, related complications and prognosis.
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