ICD-Therapie zur Sekundärprävention

Patients who survive out-of-hospital cardiac arrest or symptomatic ventricular tachyarrhythmias are at considerable risk of recurrence of these events and ultimately death. The implantation of an implantable cardioverter defibrillator (ICD) in patients with previous sustained ventricular tachyarrhythmias (VT) is considered secondary prevention of sudden cardiac death. The purpose of this review is to summarize the most important trials on secondary prevention with an ICD. The results from a meta-analysis showed a relative-risk reduction of 28% in overall mortality. Compared with amiodarone, an ICD provided maximal benefit for those patients with an ejection fraction between 20% and 35%. The results of the ICD trial demonstrate that there is clear evidence for the effectiveness of an ICD in patients with unstable VT; however, for patients with stable VT the results are less clear. Data on older patients are scant, and whether the survival benefit observed in the middle aged and younger-old also extend to older elderly patients with a more limited life span is less clear. Therefore, as the population becomes older, it is important to evaluate the safety, effectiveness, and the cost effectiveness of ICD implantation in this population. Guidelines are important and helpful to guide clinical decisions, but the indication for an ICD still remains an individual decision after evaluation of the risks and benefits for the individual patient. However, the patient needs to be involved, which emphasizes the importance of dialogue between the patient and physician.     

Sekundärprävention nach Myokardinfarkt

A significant reduction in cardiovascular mortality has been achieved during the last decade. New techniques and materials for early coronary intervention have contributed significantly to reduce early mortality after myocardial infarction. Secondary prevention determines further progress; it combines evidence-based medical treatment as well as lifestyle modifications. ACE inhibitors, angiotensin receptor blockers, and beta-blocker positively affect elevated blood pressure, left ventricular remodeling, and electrical stability. Statins decrease LDL and increase HDL cholesterol. Acetylsalicylic acid and clopidogrel are indicated for antiplatelet therapy. Lifestyle modifications unite a diet rich in polyunsaturated fatty acids, moderate physical activity, weight reduction, and smoking cessation.     

ICD-Therapie zur Primärprävention

There is high mortality during the first few weeks after an acute myocardial infarction. However, according to the guidelines, the prophylactic implantation of an ICD, given the corresponding risk constellation, is recommended not earlier than 1 month after acute myocardial infarction. This article analyzes available data and highlights that the recently published IRIS study supports current clinical practise.     

Aktuelle Therapie und Sekundärprävention der Lungenembolie

Currently strategies for risk stratification and risk-adjusted diagnostics and management algorithms of patients with pulmonary embolism are undergoing considerable progress and transition. For the new European guidelines expected in 2014, extensive changes are expected in the areas of (1) thrombolysis of normotensive patients with intermediate risk, (2) interventional ultrasound-enhanced low-dose catheter-derived (pharmacomechanical) local thrombolysis, (3) novel oral anticoagulants for therapy and (extended) secondary prophylaxis, (4) possible indications of low-dose aspirin for extended secondary prophylaxis and (5) home treatment of patients with low risk pulmonary embolism. This article summarizes the current guidelines for therapy and secondary prophylaxis of pulmonary embolism and novel clinical studies and the possible implications for therapy and secondary prophylaxis of pulmonary embolism.     

Aktuelle Therapie und Sekundärprävention der Lungenembolie

Currently strategies for risk stratification and risk-adjusted diagnostics and management algorithms of patients with pulmonary embolism are undergoing considerable progress and transition. For the new European guidelines expected in 2014, extensive changes are expected in the areas of (1) thrombolysis of normotensive patients with intermediate risk, (2) interventional ultrasound-enhanced low-dose catheter-derived (pharmacomechanical) local thrombolysis, (3) novel oral anticoagulants for therapy and (extended) secondary prophylaxis, (4) possible indications of low-dose aspirin for extended secondary prophylaxis and (5) home treatment of patients with low risk pulmonary embolism. This article summarizes the current guidelines for therapy and secondary prophylaxis of pulmonary embolism and novel clinical studies and the possible implications for therapy and secondary prophylaxis of pulmonary embolism.     

Sekundärprävention nach Herzinfarkt Therapeutische Effizienz – Kosten-Nutzen-Relation

Zum Thema Verschiedene gro?e randomisierte Studien haben den Nachweis für die Effektivit?t der verschiedenen therapeutischen Ma?nahmen bei der Postinfarkttherapie erbracht (s. auch den Beitrag von Darius u. Meyer in diesem Heft). In Zeiten zunehmenden Kostendrucks sind jedoch auch die ?konomischen Folgen einer generellen Anwendung dieser Ma?nahmen zur Sekund?rpr?vention zu beachten. Dieser Beitrag beschreibt neben der nachgewiesenen therapeutischen Effizienz auch kurz die Methoden zur Bestimmung von Kosten-Nutzen-Relationen. Zus?tzlich werden die einzelnen Substanzen, die in der medikament?sen Sekund?rprophylaxe nach Myokardinfarkt eingesetzt werden, hinsichtlich ihrer Kosteneffizienz untersucht.     

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.     

Atorvastatin zur Primärprävention kardiovaskulärer Ereignisse

Ohne Zusammenfassung     

ICD-Therapie zur Primärprävention des plötzlichen Herztods

ICD therapy represents a major advance in the treatment of patients with severely impaired left ventricular function after myocardial infarction. While an ICD implantation also remains a valuable option late (>5 years) after myocardial infarction, patients early after this event are at a competitive risk of arrhythmogenic and nonarrhythmogenic cardiac death. Prevention of sudden cardiac death in patients early after myocardial infarction, therefore, just converts the mode of death in a significant number of patients from sudden to nonsudden cardiac death (conversion theory). In patients with a left ventricular ejection fraction (LVEF) of ≤30% after myocardial infarction, implantation of the ICD should, therefore, be postponed to at least 30–40 days after the event. It is, however, not clear how the risk of sudden cardiac death should be approached during this post infarction phase. Similarly, it is not clear if patients with a reduced LVEF post infarction and additional specific risks (nonsustained ventricular tachycardia, atrial fibrillation, bundle branch block, etc.) beyond this single criterion may also benefit from ICD implantation and which risk factors may be relevant. In any case, ICD therapy should avoid right ventricular pacing and shock discharges whenever possible.     

Primärprävention von Herz-Kreislauf-Erkrankungen

Preventive medicine has not been adequately established in our health care system. Despite growing in-sight into the causes underlying arteriosclerotic cardiovascular disease, half of the population dies and even more suffer from it. Generally the correction of risk factors is regarded as causal therapy. Modification of the lipid and carbohydrate metabolism or the blood pressure are certainly effective, however, intervention trials have also demonstrated the limitations. Mostly an unhealthy lifestyle underlies these risk factors so that correction of the lifestyle is the causal therapy in the true sense. That is the principle basis for primary prevention, while pharmacotherapy can only be an adjunct. Inadequate nutrition, physical inactivity and smoking are considered the true major risk factors in our society. Changes in nutrition in favor of plant products, some physical activity and refraining from smoking can serve an effective contribution to health. In the future not only medical, but also economic requirements will increasingly force us to establish prevention on the basis of lifestyle changes as a mainstay of medicine.     

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.     

Primärprävention beim Diabetes mellitus Typ 2

The increasing incidence of type 2 diabetes constitutes a considerable individual and socio-economic risk, therefore preventive concepts are urgently needed. Three prospective studies show that a “life-style-intervention” as well as drugs can prevent the development of diabetes as well as cardiovascular complications:The Diabetes Prevention Study (DPS) evaluated the influence of a “life-style-intervention”. The Diabetes Prevention Program (DPP) additionally examined the effect of metformin. In the Stop-NIDDM-Study acarbose was used for diabetes prevention and cardiovascular endpoints were also evaluated. The incidence of type 2 diabetes can be significantly reduced by a “life-style-intervention” and also by the administration of metformin or acarbose. With acarbose cardiovascular events are reduced significantly and comparably to a therapy with statins in primary prevention.