Prim?r- und Sekund?rpr?vention des Schlaganfalls

Despite considerable advances in acute stroke therapy, stroke prevention remains the most promising approach for reducing the burden of stroke. A healthy lifestyle and the treatment of cardiometabolic risk factors are the cornerstones of both primary and secondary stroke prevention. Due to a proportionately higher risk of bleeding complications, platelet inhibitors are not recommended for primary stroke prevention. Platelet inhibitors are effective in the secondary prevention of stroke with acetyl salicylic acid (ASS) and clopidogrel showing the most consistent data. New oral anticoagulants are slightly more effective than coumarin and significantly reduce the risk of intracranial hemorrhage. They offer the opportunity to bring more patients with atrial fibrillation at risk for stroke into anticoagulation particularly those on ASS therapy. Surgery for patients with asymptomatic carotid artery stenosis should be viewed critically with respect to an only marginal benefit and improvement in medical therapies. Carotid endarterectomy remains the gold standard for patients with symptomatic carotid stenosis because of an increased procedural stroke risk with carotid stenting. Patients with symptomatic intracranial stenosis or cryptogenic stroke and a patent foramen ovale should receive only medical treatment.     

Prävention des Diabetes

The aims of diabetes prevention are reduction of visceral obesity at the physiological level, the implementation of prevention managers at the structural level and realization of measures for primary prevention of diabetes in the daily routine at the conceptual level. The IMAGE toolkit for diabetes prevention is one of the products of a European study group of the IMAGE project. It is based on IMAGE evidence-based guidelines and the IMAGE training curriculum for prevention managers. It includes practical examples and worksheets which substantially facilitate the implementation of a prevention program and can be directly transferred from the toolkit. After a European curriculum for prevention managers was developed within the framework of the IMAGE project, it could be implemented in Germany over the previous 2 years and intensively evaluated. Since the beginning of 2013 a German curriculum for the further training to prevention manager is available and can currently be appreciated in Dresden. Various healthcare insurances rely on this model and intend to increase the use of preventive measures by the linking of prevention and healthcare treatment. The check-up 35+ can be such a measure. This article reports on these and other elements of prevention.     

Pr?vention des Diabetes mellitus Typ?2

The practical implementation of effective prevention against type 2 diabetes represents a central challenge for the health care system in Germany. Evidence is excellent for the effectiveness and efficiency of diabetes prevention. Several heath-economic and health policy studies see successful diabetes prevention as the only possibility to sustainably ensure public health and health care financing. Evidence for diabetes prevention comes mainly from clinically controlled trials. The challenge lies is transferring the efforts made in the studies to concrete clinical practice, as well as in the adequate implementation of these measures in terms of both structure and content while achieving similar results. To this end, an understanding of both the pathophysiological processes of diabetes onset and the pathophysiological basics of preventive processes is essential. At the same time, regional and national structural aspects of health care and the health-economic reality are the general parameters for the implementation of novel prevention programmes. Efficient and effective prevention of type 2 diabetes is possible. The medical know-how and the basis for a network of the various protagonists in the prevention of type 2 diabetes and the metabolic syndrome are available in Germany. Comprehensive and successful prevention represents a realistic goal and the conditions in Germany, as well as within the European Union, are very favourable.     

Pathophysiologie und Pr?vention des Typ-2-Diabetes

Modern lifestyles that promote inactivity and obesity play an important role in the pathogenesis of type 2 diabetes mellitus (T2DM). In addition to physical activity and nutrition, there are many other factors which influence the development of obesity and T2DM. Whereas, for example, an attractive neighborhood, sufficient sleep, moderate consumption of coffee and alcohol, as well as a positive attitude might promote health, it seems that increased television viewing, impairment of circadian rhythms, fast eating and sweetened beverages appear to have a negative impact. Thus, physicians should turn their attention to the lifestyles of people at risk for T2DM or patients with newly diagnosed T2DM. This might offer the chance, not only by pharmacological methods, to change lifestyles and, consequently, improve metabolic control.     

Akutversorgung des isch?mischen Schlaganfalls

The management of acute ischemic stroke aims to verify the clinical diagnosis, to start general supportive care and to enable decision-making about specific forms of therapy. The risk-benefit ratio is time-dependent for many therapeutic options; therefore time delays are a disadvantage within the rescue chain. The trained and multidisciplinary team of the stroke unit forms the backbone of acute management. In addition, technical infrastructure influences therapeutic options and cerebral imaging is the cornerstone. The following four therapies are evidence-based: treatment on a stroke unit, thrombolysis, early administration of acetylsalicylic acid (ASS) and hemicraniectomy in patients younger than 60 years with a so-called malignant infarction. This article describes the necessary diagnostic steps and the general and specific therapeutic options that comprise acute management within the first 48?h.     

Pr?vention der Kontrastmittelnephropathie

In America and Europe contrast medium nephropathy, also called contrast-induced nephropathy (CIN) is responsible for 10% of all cases of renal failure acquired in hospital. The incidence of this disease is dependent on the fundamental definition of acute kidney injury, on the type and dose of the contrast medium, the type of procedure carried out and patient-specific risk factors. In up to 30% of cases CIN leads to permanent renal damage and is accompanied by increased morbidity and a higher incidence of long-lasting severe events. Even for patients with no previous renal problems it is associated with an increased mortality within the following 12 months. The exact definition of CIN is still problematic. In one study increases in creatinine could be found even without administration of contrast medium in hospital. For this reason it is necessary to include a control group in future studies to exclude this??background noise??. A large multicenter study on the administration of acetylcysteine must also be promoted. If possible renal function should be determined using, for example measurement of cystatin C and not with serum creatinine. At present there are no evidence-based guidelines for prevention of CIN. This article presents the various currently available procedures. An interesting approach recommended by some physicians especially for patients with hyperhydration and those in intensive care, is the administration of theophylline. However, there are limitations due to the side-effects and large randomized studies are also lacking.     

Pr?vention durch Bewegung

Regular physical activity is now recognized as an important and very effective step to prevent many diseases, especially those of the cardiovascular system. Many studies within the last 20?years have also shown that exercise capacity or fitness is an important prognostic factor in healthy subjects and patients with cardiovascular diseases for both mortality and morbidity. Physical fitness, which is mainly determined by regular physical activity or training, can be analyzed by maximal exercise testing using the treadmill or cycle ergometry. In addition, fitness is also based on genetic factors. There are some methodological criticisms concerning self-reported questionnaires of physical activity, MET (metabolic equivalent) calculations and exhaustion during maximal voluntary stress testing. However, the results of both approaches are valid and reliable for daily use. Accordingly, every physician regardless of his or her discipline should encourage all patients at every visit to follow a healthy lifestyle, including regular exercise and physical activity. This also applies to older patients, who especially benefit from exercise and physical activity.     

Prävention von Malignomen des Verdauungstrakts

Malignancies of the gastrointestinal tract are the most common causes of cancer-related deaths in Germany. They also induce significant morbidity. Despite both surgical and medical therapeutic improvements, advanced stages of these cancers can rarely be cured. Preventive and screening measures are suitable to decrease gastrointestinal cancer-related mortality. Weight reduction and cessation of smoking are effective in preventing esophageal, pancreatic and colorectal cancer. Treatment of infections like chronic viral hepatitis and helicobacter pylori gastritis is able to protect from hepatocellular and gastric cancer, respectively. Colonoscopy is one of the best established screening methods. It allows early detection of colorectal neoplasia. Preneoplastic adenomas can be endoscopically removed during the same session. We here review simple prevention strategies and effective screening methods in gastrointestinal cancers of relevance in daily practice.     

Prävention von Erkrankungen des Respirationstrakts

There are multiple possibilities for pulmonary or bronchial damage and their number exceeds that for the other organ systems dealt with in this issue. This multiplicity of diseases which are at least in part attributable to exogenous damage gives rise to manifold approaches to prevention. This overview does not claim to be complete. It is however intended to clarify the possibilities that exist for the prevention of pulmonary diseases. In addition, it intends to show that effective primary and occasionally secondary and tertiary prevention is inadequately utilized in pulmonology or not even used at all. Against the background that individual preventive measures in pulmonology are considerably more successful than curative measures, also from a health economics point of view, various options for successful prevention are described. The great need for studies on the effectiveness of preventive strategies is also addressed.     

Prähospitalversorgung und Akuttherapie des ischämischen Schlaganfalls

An acute ischemic stroke (AIS) is always a life threatening medical emergency. The possibility and success of applying an effective acute therapy depends mainly on a fast decision-making process within the pre-clinical phase of patient care. Systemic thrombolysis using recombinant tissue plasminogen activator (rtPA) is an effective treatment for AIS, but is restricted to the first 3 h after symptom onset and is most effective the earlier the treatment is applied. Thus, avoiding delays until treatment is the main challenge in the acute care of stroke patients. Time to treatment consists of two distinct segments, each having its own special problems and challenges: the pre-hospital phase and the early in-hospital treatment. However, for optimized stroke care, both parts need to be closely coordinated. In this article, specifics and problems of pre- and in-hospital care of acute stroke patients are discussed.     

Primär- und Sekundärprävention des Schlaganfalls bei Diabetes

Stroke is one of the most important causes of permanent disability and death in adults worldwide. In addition to hypertension, smoking, lack of physical activity and cardiac diseases, diabetes mellitus is an independent and modifiable risk factor for ischemic stroke. To date no unambiguous evidence exists for a reduction of the incidence of stroke by normalizing and lowering of long-term glucose levels with or without drugs. Nevertheless, normalization of blood glucose is an important goal in daily clinical practice. This also applies to the acute phase after stroke. Excessive lowering of short-term and long-term glucose levels is not recommended due to the increased risk of adverse events (hypoglycemia) which outweighs possible benefits. The focus in the prevention of stroke in patients with diabetes consists of guideline-conform treatment of modifiable vascular risk factors, such as hypertension, hyperlipoproteinemia, obesity and smoking.     

Pr?vention der vaskul?ren Demenz

During recent years, increasing knowledge has been obtained from clinical studies about the impact that vascular factors have on cognitive function and dementia. Due to demographic reasons and still insufficient control of all vascular risk factors, dementia and associated problems are of increasing importance and will have impact on economical and social development in most countries. The incidence of cognitive impairment and dementia will increase exponentially. As long as no causal therapy for dementia exists, diagnosis and control of risk factors for dementia will need much more attention. Hypertension is not only the most important risk factor for stroke that often leads to dementia but also for silent brain infarcts, which are also associated with onset of dementia. Uncontrolled hypertension is associated with cognitive impairment and sufficient control of hypertension in middle-aged patients can reduce the risk of dementia in older ages. Nevertheless, treatment of all other risk factors (e.g., diabetes mellitus, hyperlipidemia, atrial fibrillation) is important to reduce the onset of not only vascular but also Alzheimer dementia.     

Pathophysiologie und Prävention des Typ-2-Diabetes

Die Diabetologie - In den letzten beiden Jahren wurden neue Erkenntnisse zur Pathophysiologie und Prävention des Typ-2-Diabetes im Rahmen des Diabetes Updates präsentiert, die in...     

Pr?vention von Vorhofarrhythmien durch Stimulation

Hintergrund: Vorhofflimmern ist die häufigste Herzrhythmusstörung. Es beeinträchtigt die Lebensqualität oft erheblich und ist wegen seiner thrombembolischen Komplikationen für einen großen Teil der Morbidität und Mortalität sowie die Behandlungskosten der betroffenen Patienten verantwortlich. Prävention: Während chronisches Vorhofflimmern vorwiegend die Kontrolle der Herzfrequenz und eine ausreichende Antikoagulation erfordert, gilt es bei (noch) intermittierendem Vorhofflimmern, das Fortschreiten in chronisches Vorhofflimmern zu verhindern oder zumindest zu verzögern. Da Vorhofflimmern infolge negativer Remodeling-Prozesse die Neigung hat, sich selbst zu perpetuieren, dürften alle Maßnahmen, die die Anzahl und die jeweilige Dauer von Vorhofflimmerepisoden ("atriale Arrhythmielast") reduzieren, grundsätzlich geeignet sein, dieses Ziel zu erreichen. Bisher wurden zur Rhythmusstabilisierung und Rezidivprophylaxe vor allem medikamentöse Maßnahmen eingesetzt und in unterschiedlichem Maße proarrhythmische Wirkungen in Kauf genommen. Inzwischen vorliegende, allerdings noch nicht beweisende Daten lassen es sinnvoll erscheinen, Schrittmachersysteme mit präventiven Stimulationsalgorithmen zur Reduktion der atrialen Arrhythmielast einzusetzen. Neben konsequenter Überstimulation der Sinusknotenfrequenz wurden weitere Algorithmen entwickelt, mit denen es grundsätzlich möglich ist, dem größten Teil der Auslösemechanismen von Vorhofflimmern entgegen zu wirken. Darüber hinaus konnte neuerdings gezeigt werden, das ebenfalls in Schrittmacher integrierte Algorithmen zur antitachykarden Stimulation (ATP = antitachykardes Pacing), die ohne Latenz direkt nach der Wahrnehmung einer Vorhoftachyarrhythmie einsetzen, in der Lage sind, etwa zwei Drittel der Vorhoftachyarrhythmien aktiv zu terminieren. Laufende Studien: Gegenstand aktueller klinischer Studien ist es außerdem, den optimalen Implantationsort der üblicherweise einen oder aber auch mehrerer Vorhofelektroden herauszufinden. Neben den klassischen Implantationsorten (Vorhofohr, freie laterale Wand) werden die Stimulation des interatrialen Septums und des Koch'schen Dreiecks sowie multifokale Stimulationskonfigurationen (bifokale rechtsatriale und biatriale Stimulation) in Kombination mit präventiven Stimulationsalgorithmen untersucht. Die meisten dieser prospektiven Studien werden mit schrittmacherpflichtigen Patienten durchgeführt. Ihre Ergebnisse müssen abgewartet werden, bevor der klinische Stellenwert der Elektrostimulation bei intermittierenden Vorhoftachyarrhythmien abschließend beurteilt werden kann. Background: Atrial fibrillation is the most frequent arrhythmia. It can impair quality of life considerably. Due to thromboembolic complications it contributes to the patients' morbidity and mortality and to the costs for their medical treatment. Prevention: In chronic atrial fibrillation there is a need for adequate anticoagulation and heart rate control. In paroxysmal and intermittent atrial fibrillation it should be sought to prevent its progression to chronic atrial fibrillation. Since atrial fibrillation initiates negative processes of remodeling within the atrial myocardium, it has the tendency to perpetuate itself. From a theoretical point of view, it can be expected that all means which prevent episodes of atrial fibrillation or which terminate it immediately after its onset, are able to prevent or at least to delay the progression to chronic atrial fibrillation. Pharmacologic treatment is usually used to prevent recurrences of atrial fibrillation. Based on the actual data it can also be expected that pacemakers with special preventive pacing algorithms are able to reduce the atrial arrhythmic burden. Besides consequent overdrive pacing, more sophisticated algorithms like "suppression of premature atrial contractions", "post exercise response", "automatic rest rate" or "post mode-switch pacing" have been developed. They can be applied either alone or in combination with special lead positions (inter-atrial septal pacing or pacing of the triangle of Koch) or special stimulation configurations like dual site right atrial pacing or biatrial pacing. These pacing strategies cover the most relevant onset mechanisms of atrial fibrillation. Furthermore, there are algorithms to treat atrial tachyarrhythmias actively by antitachycardia pacing (ATP). First clinical results have shown that about 2/3 of the diagnosed atrial tachyarrhythmias could be terminated by these means immediately after their onset. Ongoing Trials: This article gives an overview over the principles of pacing in the management of atrial arrhythmias and ongoing clinical trials in this field. Before a definite judgement on the clinical relevance of these new preventive and therapeutic pacing strategies can be given, the results of these ongoing controlled clinical studies have to be analyzed.