Aktueller Stand der primären Katheterablation von Vorhofflimmern*

Curative catheter ablation of atrial fibrillation has made some important advances during the last years toward a reproducible and effective procedure. Besides the role of the trigger to induce atrial fibrillation episodes by rapid burst from within the pulmonary veins (PVs), invasive electrophysiological studies could also demonstrate the importance of the close-by surrounding atrial myocardium to sustain atrial fibrillation. Meanwhile, new energies sources such as laser, ultrasound and cryothermia are used, next to the established ablation technology of radiofrequency current ablation, to apply lesions mostly around the PV ostia. With the magnetic navigation system, a new technology has entered the arena of catheter ablation of complex arrhythmia. By combining both three-dimensional mapping system and three-dimensional imaging ability, the system allows complete remote-controlled mapping (and ablation) of atrial fibrillation.     

Aktueller Stand der Therapieansätze bei Spondylarthropathien

Anti-TNF therapy seems to be highly effective in AS. Based on the available results, this treatment seems to be at least as effective as in RA. Furthermore, because no other treatments are available for AS--in contrast to RA or psoriatic arthritis--infliximab might even become a first-line immuno-suppressive treatment in patients with severe, active AS. A dosage of 5 mg/kg seems to be required and intervals between 6-12 weeks seem to be necessary depending on the disease activity. It remains to be shown what the long-term effects are, whether the patients benefit from long-term therapy and whether radiological progression and ankylosis can be stopped. Allergy, lupus-like diseases and tuberculosis are rare side effects which need to be addressed. At first glance, the possible benefits of anti-TNF therapy seem to outweigh these shortcomings.     

Strahlenschutzaspekte in der kardiovaskulären Brachytherapie

In the scope of cardiovascular brachytherapy beta- as well as gamma-ray emitting radionuclides are used. The handling of radioactive sources is within the range of the radiation protection regulations (Strahlenschutzverordnung [StrlSch V]). According to EU guidelines an amendment of the StrlSch V is required by May 2000. The connected reduction of dose limits now should already be taken into consideration when planning irradiation facilities, likewise in cardiovascular brachytherapy. Temporary regulations for equipment that was already in operation before May 2000 are not planned in the new StrlSch V.     

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.     

Bedeutung von Adipositas und Bewegungsmangel in der kardiovaskulären Primärprävention

The important role of obesity and inactivity in the pathogenesis of cardiovascular diseases is generally accepted. In Germany, 75% of men and 59% of women at the age of 25-69 years are overweight or obese. The prevalence of inactivity in Germany is 30% for all age groups, and only 13% of the population achieves a level of physical activity known to have cardioprotective effects. Overweight and inactivity have shown to be associated with several cardiovascular risk factors such as hypertension, diabetes mellitus type 2 and dyslipoproteinemia. It has been demonstrated that obesity (body mass index > 30 kg/m2) considerably increases the risk for cardiovascular diseases (by up to 50%). Comparable findings have been observed in a meta-analysis when the effects of inactivity on cardiovascular morbidity or mortality have been investigated. Compared to regular physical activity, inactivity increased the relative risk for myocardial infarction or death by 60% and 90%, respectively. Therapeutic lifestyle changes (TLC) by increased physical activity and dietary intervention have shown to reduce cardiovascular risk factors and the incidence and prevalence of cardiovascular disease. Therefore, TLC should be the primary intervention in inactive overweight or obese subjects. This recommendation is specifically important for patients with the metabolic syndrome.     

Zwischen Skylla und Charybdis – Blutung und Thromboembolie in der kardiovaskulären Medizin

Ohne Zusammenfassung     

Wege aus der Versorgungskrise in der kardiovaskulären Prävention

The financial balance of the health care system has changed dramatically due to a longer life expectancy and improved treatment options in elderly patients. More than 80% of cardiovascular events are lifestyle related and potentially preventable. Lifestyle modification is therefore the causal approach to decrease cardiovascular events. Improvement of nutrition and activity habits and prevention of cigarette smoking should start in the kindergarten, school and later at the workplace. A co-operation between medical societies and government institutions is necessary to achieve a population wide modification of lifestyle habits to lower the incidence of cardiovascular events in the population. Individual risk stratification is the basis for pharmacological prevention of cardiovascular events. The concept of the polypill has to be tested in controlled randomised studies.     

Genderaspekte bei kardiovaskulären Krankheiten

Cardiovascular diseases are the main cause of death in women and men worldwide, and, especially as far as coronary heart disorders are concerned, this is true of an increasing number of older and elderly persons. For decades, Gender Medicine research has shown gender differences in cardiology to the detriment of women, for example it takes longer for them to receive and they are less likely to have access to high-tech medicine, such as the ICU, heart catheters, bypass surgery, and they have a poorer outcome. Meanwhile, numerous scientific studies and awareness campaigns have been conducted. However, the more recent publications still show the same trends, albeit at a decreasing rate. Thanks to the emphasis placed on prevention and, thus, also the attention called to the leading heart risk factors such as smoking, high blood pressure, blood lipids, diabetes mellitus and overweight, namely for women and men, heart death is no longer exclusively male. In order to promote equal opportunity, Gender Medicine must be further implemented in medical training and post-graduate training, and—above all—the scientific findings concerning Gender Medicine must be incorporated into the guidelines of our professional societies.     

Fahreignung bei kardiovaskulären Erkrankungen

The general rules governing participation in road traffic in Germany are defined in the driver’s license law. Attending physicians are obligated to determine if a patient lacks the ability to drive from the perspective of their medical specialty. This assessment must be documented. In addition to the legal requirements laid down in the driver’s license law, the driving ability of patients with cardiovascular diseases is covered in the guideline on expert opinions appraising driving capability as specified by the Advisory Board for Traffic Medicine. Since the driver’s license law only addresses a few cardiovascular disorders and the guideline on expert opinions no longer reflects the current standard of medical knowledge, a position paper on fitness to drive and cardiovascular diseases was formulated on behalf of the German Cardiac Society. Taking the current level of knowledge into consideration, this position paper describes the conditions when cardiac arrhythmias, syncopes, coronary heart disease, cardiac insufficiency, and arterial hypertension represent grounds for establishing temporary or permanent inability to drive.     

Abschätzung des kardiovaskulären Risikos

The SCORE classification is recommended by the European Society of Cardiology to calculate the mortality risk over a period of 10 years in asymptomatic adults. It takes into account the risk factors of age, gender, systolic blood pressure, cholesterol and smoking, however, the determined risk is not always sufficiently precise and its prognostic performance is improved by considering renal variables. In this context the estimated glomerular filtration rate and urinary albumin excretion are of particular importance. For both parameters an incremental increase in risk regardless of the actual SCORE classification was shown and above a risk of 1% leads to an assignment of the patient to the next level of risk in the SCORE.     

Stand und gegenwärtige Strategien der HIV-Vakzineentwicklung

Despite intensive research efforts a vaccine against HIV has not yet been developed twenty years even after the onset of the HIV-epidemic. The problems in the development of an HIV-vaccine as well as former and current strategies to overcome these problems are presented here. The current status of human studies of different candidate vaccines is outlined.     

Das Kolonkarzinom Aktueller Stand von Früherkennung und endoskopischer Prävention

Zum Thema Das Kolonkarzinom stellt in Deutschland nach dem Bronchialkarzinom die zweith?ufigste Todesursache aller Krebserkrankungen dar. Die Karzinogenese dieses Malignoms verl?uft in aller Regel über einen Zeitraum von 10–15 Jahren. Auf der Grundlage von Adenomen kommt es nach dieser Zeitspanne zu einer malignen Transformation. Die Prognose der Patienten h?ngt entscheidend vom Tumorstadium bei Diagnose ab. Ein breites Screening der asymptomatischen Bev?lkerung ist umso wichtiger, da eigentliche Frühwarnzeichen fehlen und es nur durch Stuhlbluttestung und endoskopische Ma?nahmen m?glich ist, den Krebs und seine Vorboten frühzeitig zu erkennen oder durch Polypektomie zu verhindern. Der vorliegende Beitrag gibt daher einen überblick über die Eignung der verschiedenen Screening-Methoden zur Pr?vention des Kolonkarzinoms.     

Die sogenannten funktionellen Krankheiten des kardiovaskulären Systems als Syndrome der neurokardiovaskulären Inadaptation betrachtet

Ohne ZusammenfassungHerrn Prof. Dr.B. Kisch zum 70. Geburtstage gewidmet.Professor für Kardiologie in der Escuela Nacional de Medicina del Trabajo. Chef der Kardiologie-Abteilung in dem Ambulatorio Matias Montero des (S.O.E.) und des Instituto Nacional de Medicina del Trabajo in Madrid.     

Orale Thrombozytenhemmung in der primären und sekundären Prävention

Cardiovascular disease is the leading cause of death in western societies, with further increasing incidence. Therefore both, primary and secondary prevention play a pivotal role. Medicamentous prevention schemes include the antithrombotic drugs acetylsalicylic acid (ASS) and clopidogrel. A number of studies tested the efficacy and safety of ASS for primary prevention. A meta-analysis of these primary prevention trials could demonstrate a decrease of cardiovascular events only for patients being at high cardiovascular risk. However, since ASS does not influence the mortality but is significantly increasing the risk for bleeding, careful risk stratification is indispensable prior to preventive chronic administration of the drug. Therapy with ASS in the secondary prevention is commonly accepted and clearly evidence-based given that a meta-analysis of 145 trials could demonstrate a significant decrease in mortality. A daily dose of 100 mg has been shown to achieve sufficient antithrombotic effects with an acceptable rate of side effects. Clopidogrel is currently not used for primary prevention, since evidence is lacking and the costs are high. For secondary prevention after acute coronary syndromes, a decrease of cardiovascular events could be demonstrated for clopidogrel. This benefit was especially pronounced after percutaneous coronary interventions. However, clopidogrel could not decrease the mortality. Therefore, long-term treatment with clopidogrel in the secondary prevention should be based on a critical appraisal of risk and benefit on the one hand and socioeconomic aspects on the other hand.