Aortenklappenstenose bei erhöhtem Risiko

Aortic valve stenosis is the most prevalent, clinically significant valvular disorder in adult patients. Surgical valve replacement is the standard therapy for patients with symptomatic and severe aortic stenosis; however, many patients are suboptimal candidates for surgery due to age and co-morbidities. The development of transcatheter aortic valve implantation (TAVI) has broadened the therapeutic options, especially in high-risk patients. The first randomized study comparing surgical valve replacement with TAVI in operable high-risk patients show similar mortality and reduction in symptoms after a 2-year follow-up. These data support the use of this technique in high-risk patients with severe aortic stenosis.     

Starke Blutdrucksenkung durch hochdosierte Kombinationstherapie von 160 mg Valsartan und 25 mg HCT in der alltäglichen Behandlungspraxis bei Patienten mit erhöhtem kardiovaskulären Risiko

BACKGROUND AND PURPOSE: Hypertension is one of the most common cardiovascular risk factors. Thus, achievement and maintenance of a sufficient reduction of blood pressure markedly contribute to successful risk prevention. Therefore, the primary objective of this observational postmarketing study MACHT II was to examine the efficacy and the tolerability of the combined therapy with 160 mg valsartan plus 25 mg hydrochlorothiazide (HCT) in a large population of patients with a well-defined individual risk profile and treatment status at baseline. PATIENTS AND METHODS: This multicenter, open singlearm trial involved 17,591 patients, either without or with insufficient prior antihypertensive medication. RESULTS: The mean absolute blood pressure improvement obtained for the total population was -26.8 mmHg systolic and -13.5 mmHg diastolic. The maximum absolute improvement in blood pressure was observed in patients with severe hypertension: on average, the systolic blood pressure decreased by 41.7 mmHg and the diastolic blood pressure by 20.5 mmHg compared to baseline. The results demonstrated an effective blood pressure reduction in every subgroup analyzed: mean values of systolic and diastolic blood pressure decreased to high normal values. More than two thirds of the patients achieved normalization of the diastolic blood pressure. Normalization of diastolic blood pressure was observed in 65.2% of the patients with previous antihypertensive medication and in 74.3% of those without previous antihypertensive medication. The overall incidence of adverse drug reactions was 0.6%. CONCLUSION: The combined antihypertensive therapy with 160 mg valsartan plus 25 mg HCT shows a high degree of efficacy and a very favorable safety profile.     

Schwere Progression einer koronaren Herzkrankheit bei einem Patienten mit erhöhtem Lipoprotein-(a)-Spiegel trotz optimaler LDL-C-Senkung

The patient introduced in the case history had a myocardial infarction in 2001 and a coronary two-vessel disease (extensive subtotal proximal stenosis of the left anterior descending [LAD] and proximal subtotal stenosis of the right coronary artery) which was diagnosed via coronary angiography at the age of 39 years. Besides smoking and obesity an important coronary risk factor was hyperlipoproteinemia with an especially massive increase in lipoprotein (a) level.The lipoprotein (a) level in January 2002 was massively elevated with 273.7 mg/dl (2 737 mg/l; Table 1). Despite invasive therapy with percutaneous transluminal coronary angioplasty (PTCA) and stent implantation in LAD and immediate therapy with atorvastatin, a restenosis in LAD was detected in April 2002 (Figure 1). Re-PTCA and intracoronary brachytherapy were performed (Figure 2). After presentation of unstable angina pectoris symptoms in November 2003, again a new in-stent restenosis in LAD could be detected via coronary angiography (Figure 3a), so that a single-bypass operation became necessary (Figure 3b).Since December 2001, an intensified treatment in a specialized polyclinic for lipid metabolism has been carried out, in which LDL-C values of 104 mg/dl (2.7 mmol/l) were targeted under aggressive lipid-lowering therapy with atorvastatin 80 mg/d and ezetimibe 10 mg/d (Table 1). Since 1998, the patient has quitted smoking. Blood pressure values are now in the therapeutic range, but the obesity could not be overcome.A distinctly elevated lipoprotein (a) level is an important risk factor for an early-onset and badly progressive arteriosclerosis. Thus, once in lifetime in the scope of risk factor management one should measure the lipoprotein (a) level. In case of elevated values the crucial treatment options include a very good management of all other risk factors, whereas an LDL-C level < 100 mg/dl (< 2.6 mmol/l), optionally < 70 mg/dl (< 1.8 mmol/l), is of vital importance. Nicotinic acid derivatives lower lipoprotein (a) levels by about 20-30%. All other risk factors, e.g., diabetes or hypertension, should be strictly managed as well. Cardiologic and angiologic examinations have to be an integral part of the treatment of these patients.     

Prävention und Behandlung von Herzrhythmusstörungen bei Patienten mit angeborenen Herzfehlern

Catheter ablation procedures have become established over the years due to their effectiveness and low invasiveness and have changed the indications for surgical treatment. The main field of activity of cardiac surgery remains the treatment of patients with congenital heart defects which show arrhythmia and necessitate surgical treatment. The combination of surgical ablative measures with a good view of the site using modern ablation instruments, atrial reduction by tissue resection and correction of the defect with the resulting volume relief, bring the best conditions for a curative treatment of arrhythmia. The same applies to the treatment of ventricular tachycardia resulting from old scars and residual defects. Special attention should be given to patients who received a Fontan conversion. This operation is a unique opportunity to relieve volume which in turn reduces the atrial size and at the same time to take ablative measures to restore sinus rhythm. The results are promising with low mortality and morbidity, high efficiency and finally a clear improvement of the functional status of patients. In appropriate cases minimally invasive surgical procedures can help where pharmacological and catheter ablation therapies remain ineffective.     

30-j?hriger Mann mit Fieber, Gewichtsverlust und leicht erh?htem Kreatinin

A 30-year-old man presented with recurrent febrile episodes and B symptoms. Laboratory analyses were remarkable for elevated creatinine and CRP levels, increased erythrocyte sedimentation rate, glycosuria, and proteinuria. Sonography showed an indistinct parenchyma-renal pelvis border and slightly increased echogenicity at the edge of the parenchyma. Kidney biopsy revealed tubulointerstitial nephritis. Uveitis developed later and TINU syndrome was diagnosed. In younger patients who present with a clinical picture of inflammatory systemic disease with reduced kidney function, TINU syndrome should be considered in the differential diagnosis. Determining factors for the diagnosis of TINU syndrome are slight proteinuria with tubular pattern, elevated β_2-microglobulin excretion, and lack of glomerular hematuria. Ocular changes can develop with considerable delay subsequent to the appearance of general symptoms. Differential diagnoses include sarcoidosis, vasculitides, Sjögren’s syndrome, rheumatoid arthritis, Wegener’s granulomatosis, tuberculosis, and Behçet’s syndrome.     

Bedeutung der stummen Myokardischämie für die Identifikation und optimale Therapie von Patienten mit latenter koronarer Herzkrankheit

Although percutaneous transluminal coronary angioplasty (PTCA) improves the symptomatic status and exercise capacity of patients with coronary artery disease and stale or unstable angina pectoris, a beneficial effect on long-term prognosis has not been convincingly demonstrated so far. In totally asymptomatic patients with coronary artery disease, however, decision to undertake PTCA is greatly influenced by prognostic considerations. Usually, detection of silent myocardial ischemia in non-invasive examinations (exercise stress testing, ambulatory electrocardiographic monitoring) precedes the angiographic diagnosis of coronary artery disease in these patients.     

Quantitative Cholinbestimmungen im Serum von Carcinompatienten mit erhöhter Phosphataseaktivität

Zusammenfassung Im Serum von Carcinompatienten wiesen wir in allen Fällen mit erhöhter Phosphataseaktivität eine Substanz nach, die sich bei der von uns angewandten Methode wie Cholin verhält, im Gegensatz zu Cholin jedoch durch Kochen mit n-HCl zerstört wird. Sie läßt sich auch in Seren, die längere Zeit gestanden haben, nicht mehr nachweisen, ebensowenig wie in Seren von Carcinomkranken mit normaler Serumphosphataseaktivität. Die Substanz steht in keinem unmittelbaren Zusammenhang zum Cholinstoffwechsel. Versuche, sie zu identifizieren, waren bisher erfolglos.     

Umgang mit ICD-Patienten an ihrem Lebensende: Einstellungen, Wissen und Verhalten von ?rzten und Patienten

Background

The implantable cardioverter-defibrillator (ICD) is highly effective in the therapy of malign heart rhythm abnormalities. However, the ethical dilemma of harming a dying patient has received little attention. We studied the current state of knowledge and behavior of physicians and the subjective needs of ICD patients with respect to end-of-life issues.

Methods

A literature search of articles published between 8/2010 and 3/2011 in PubMed resulted in the identification of 32 reports, of which 25 met selection criteria.

Results

Practically no clinical institution (96% in Europe) offers routine counseling of ICD patients on end-of-life issues. In only about 25% of cases do doctors initiate a discussion on this issue with the ICD patient, of which the majority takes place during the final hours of the patient??s life. Knowledge of legal aspects of ICD deactivation is insufficient in about 50% of physicians. Many physicians underestimate the impact of ICD shocks and often have unrealistic expectations about the patient??s knowledge on technical aspects of the ICD device. The majority of patients are reluctant to address this topic and prefer to rely on the decision of their attending physician.

Conclusion

Despite insufficient empirical data, findings point to a low willingness of ICD patients to confront the end-of-life issue and prefer decisions to be made by their physician. Substantial knowledge gaps of physicians may cause barriers in considering the option of deactivating the ICD.     

42-jähriger Landwirt mit unklarer Leukozytose und erhöhten Transaminasen

We report about a 42-year-old farmer with leucocytosis, elevation of transaminases and liver cirrhosis as an underlying condition. The diagnosis of Q fever hepatitis was made through liver biopsy and serology. Under therapy with doxycycline, transaminases initially increased again; after switching to ciprofloxacin, the patient could be discharged 3 weeks after admission. Q fever is caused by Coxiella burnetii. The most frequent acute manifestation is a self-limiting flu-like illness. Chronic Q fever mostly presents as endocarditis. The diagnosis is made through histology ("doughnut" granulomas), PCR, serology (acute: anti-phase II antibodies, chronic: anti-phase I antibodies) and culture. Standard therapy is doxycycline.