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.
Atrial fibrillation (AF) is the most common form of cardiac tachyarrhythmia. It is estimated that in the Rhein-Neckar region approximately 40,000-50,000 out of 2 million people are affected. Due ...to demographic changes in the near future there will be a significant increase in the prevalence of AF within the next decades. The ARENA project was initiated by the Foundation Institute for Cardiac Infarction Research (IHF) Ludwigshafen in cooperation with cardiological and neurological departments of neighboring hospitals, resident doctors and pharmacies to improve the awareness and care of patients with AF. The particular aim is the prevention of stroke as one of the most dreaded complications. The project focusses on the following three subtopics: interventions, medication, migration. The aim of the intervention project is to raise awareness of AF as a risk factor for stroke and to improve the diagnostic work-up and care for patients with diagnosed or unknown AF. The subproject medication focusses on the adherence of patients with AF to the prescribed antithrombotic medication. To evaluate differences concerning patients with and without a migration background the subproject migration was initiated.
The heart and brain are constantly interacting under normal physiological conditions. This interaction is under the control of the autonomic nervous system with parasympathetic and sympathetic nerve ...fibers including the participating brain structures. Pathological conditions, such as epilepsy and ischemic cerebral stroke influence heart function, especially the frequency and may result in severe arrhythmia. An asymmetric influence of the left and right brain hemispheres on the heart rate is still under debate. Conversely, the influence of the heart in cases of acute cardiac arrest on brain function is equally relevant and a common clinical problem after resuscitation. We review the damaging cascade of global cerebral hypoxia and the value of different diagnostic procedures as well as the ethical problem of the point in time of termination of consciousness and the instruments for estimating the prognosis.
Zusammenfassung
Eine Interaktion von Herz und Gehirn ist schon unter physiologischen Bedingungen und unter Einbindung sympathischer und parasympathischer Nervenbahnen und beteiligter Hirnstrukturen ...nachweisbar. Wir zeigen Einflüsse des erkrankten Gehirns auf das Herz am Beispiel epileptischer Syndrome oder des Schlaganfalls – mit bislang heterogenen Daten zur Lateralisation der den Herzrhythmus beeinflussender Hirnfunktionen. Im klinischen Alltag bedeutsamer ist der Einfluss des Herzens auf das Gehirn im Moment des Herzstillstands. Die pathophysiologischen Prozesse der dabei entstehenden globalen Hypoxie, die ethischen Fragen über den Zeitpunkt des erloschenen Bewusstseins und die Instrumente zur Prognoseabschätzung werden hier skizziert. All diese Informationen erlauben es im Sinne einer Gesamtschau, das Ausmaß der zerebralen Schädigung zu ermessen und eine prognostische Einschätzung zu geben.
Patients with non-valvular atrial fibrillation (AF) and a high risk for oral anticoagulation can be treated by percutaneous implantation of left atrial appendage occlusion devices (LAAC) to reduce ...the risk of cardio-embolic stroke. This study evaluates whether LAAC may influence lipid metabolism, which has never been investigated before. Patients with successful LAAC were included consecutively. Venous peripheral blood samples of patients were collected immediately before (T0, baseline) and 6 months after (T1, mid-term) LAAC. A targeted metabolomics approach based on electrospray ionization liquid chromatography-mass spectrometry (ESI-LC-MS/MS) and MS/MS measurements was performed. A total of 34 lipids revealed a significant change from baseline to mid-term follow-up after successful LAAC. Subgroup analysis revealed confounding influence by gender, age, diabetes mellitus type II, body mass index, left ventricular ejection fraction, creatinine and NT-proBNP. After multivariable adjustment within logistic regression models, these 34 lipids were still significantly altered after LAAC. Successful percutaneous LAAC may affect lipid metabolism and thereby may potentially affect pro-atherogenic and cardio-toxic effects.
Background: Left ventricular (LV) thrombus is a known complication of tako-tsubo cardiomyopathy (TC). However, current literature almost exclusively consists of isolated case reports. The aim of this ...study was to determine the incidence and clinical significance of LV thrombus formation in TC. Methods and Results: Over a 33-month period 52 patients with TC were assembled into a database at our institution. A retrospective database search was performed to identify patients with LV thrombus among these patients. LV thrombus, by echocardiography, was discovered in four patients(8%); 95% confidence interval 3–19%. Thrombus was present at the time of diagnosis in three patients. In one patient thrombus was absent initially and developed later. The LV apex was the site of thrombus formation in two patients, but the true apex was spared in the other two. All four patients had elevated serum levels of C-reactive protein (CRP). Two patients also had thrombocytosis. Treatment with low molecular weight heparin (LMWH) led to resolution of thrombus in all cases. Conclusions: Our findings suggest that LV thrombus is a noteworthy complication in TC. It can occur both at initial presentation or at anytime later during the disease course. Elevated CRP levels and thrombocytosis may indicate a higher risk of thrombus formation.
Zusammenfassung
Die Europäische Gesellschaft für Kardiologie (ESC) und die Europäische Vereinigung für Herz-Thorax-Chirurgie (EACTS) haben erstmals Ende August 2016 eine gemeinsame Leitlinie für die ...Behandlung von Vorhofflimmern herausgegeben. Diese Leitlinie ersetzt die überarbeitete Leitlinie aus dem Jahr 2012 und beinhaltet einige interessante neue Aspekte. Die Themen reichen von der Pathophysiologie über die Diagnostik, Therapie und Schlaganfallprävention bis hin zu speziellen klinischen Situationen wie Vorhofflimmern bei Kardiomyopathien, beim Sport oder in der Schwangerschaft. Frühzeitiges Screening, Patientenaufklärung, individualisierte Therapie und die Modifikation von Vorhofflimmern begünstigenden Faktoren nehmen einen besonderen Stellenwert ein. Es werden „AF heart teams“ empfohlen, denen Spezialisten unterschiedlicher Fachgebiete angehören sollen. In der Schlaganfallprävention unterstreicht die Leitlinie den Stellenwert der nicht Vitamin-K-abhängigen oralen Antikoagulanzien (NOAK) gegenüber herkömmlicher Antikoagulation mit Vitamin-K-Antagonisten. Bei symptomatischem, insbesondere paroxysmalem Vorhofflimmern betont die Leitlinie neben einer frequenzregulierenden Therapie die Bedeutung einer antiarrhythmischen Behandlung mittels Katheterablation und/oder medikamentöser antiarrhythmischer Therapie.
A previously healthy 52-year-old man presented to our department with remitting and relapsing fever for more than 6 weeks. During complex staged work-up, we revealed that he suffered from an ...Abiotrophia defectiva endocarditis of the mitral valve with mitral regurgitation and vegetation requiring mitral valve replacement. He recovered well postoperatively and is currently being followed at our Outpatient Cardiology Clinic.
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