Management und Therapie des Vorhofflimmerns beim geriatrischen Patienten

Among geriatric patients, atrial fibrillation is the most common cardiac arrhythmia. In patients over 80?years of age, the prevalence rises to approximately 10%. Atrial fibrillation is associated with serious health implications, including a 2-fold increase in mortality risk and a 5-fold increase in stroke risk. In contrast to these facts, the current guidelines on the management of atrial fibrillation of the European Society of Cardiology (ESC) contain only a short paragraph on these patients. Many relevant clinical aspects go without any comment. Thus, the purpose of our paper is to discuss those special needs of geriatric patients and their physicians which are not mentioned in the guidelines of the ESC. In our review, we discuss rhythm versus rate control, oral anticoagulation, outcome, prevention, falls, adherence, polypharmacy, dementia, nursing home patients, frailty, and geriatric assessment in consideration of geriatric patients. An extended search of the literature on Pubmed served as the basis for this review. Individual aspects of each geriatric patient should be considered when managing these complex patients; however, the complexity of each case must not lead to an individualized therapy that is not in accordance with current guidelines and the literature. A large number of papers which help us to answer most of the clinical questions regarding the management of trial fibrillation in geriatric patients have already been published.     

Three-question dementia screening

Background

To date, short dementia screenings are often limited by poor specificity or still take too much time with respect to the restricted resources of primary care physicians and the increasing number of dementia disorders. As a new instrument, the three-question dementia screening (SDTP, Salzburg Dementia Test Prediction) should be compared with the eight-item screening of Chen et al. and the CERAD battery (Consortium to Establish a Registry for Alzheimer’s Disease), focusing on specificity and economy of time.

Materials and methods

We tested 404 patients (243 women). The mean age of the subjects was 80.1 years (SD =?6.8) for men and 83.2 years (SD?=?6.0) for women. The mean Mini-Mental State Examination (MMSE) score was 21.9 (SD?=??5.8) for men and 21.1 (SD?=??6.3) for women. Artificial neural networks (ANNs) were used to find a mathematical model that allows the total MMSE to be predicted with only three questions of the MMSE. This is achieved by multiplying the outcome of the three best predictor questions with a weighting coefficient, which was delineated by using ANNs.

Results

The Salzburg Dementia Test Prediction (SDTP) had a sensitivity of 94?% (95?% CI: 87–97?%) for screening of possible dementia, when the MMSE (MMSE MMSE was used and 70?% if the whole test battery (CERAD) was used, which is as sensitive as and more specific than the eight-item screening.

Conclusion

The SDTP is a time-saving instrument for screening of dementia, which is as sensitive as and more specific than the eight-item screening of Chen et al. and provides a prediction of the MMSE with high accuracy.     

Gender-specific effect of metabolic syndrome on rate adjusted QT interval in middle-aged participants of an atherosclerosis prevention program

INTRODUCTION: The metabolic syndrome is a matter of immense public concern for atherosclerosis prevention. Key features are visceral obesity, dyslipidemia, hyperglycemia in the non-diabetic range, and arterial hypertension. Subclinical atherosclerosis is the clinical consequence of metabolic syndrome, which may influence the QT interval. The aim was to investigate the rate corrected QT interval in subjects with metabolic syndrome in comparison to those without cardiometabolic risk factor clusters, and to explore gender differences in cardiac repolarization between the two groups. PATIENTS, MATERIALS AND METHODS: Heart rate and QT interval were automatically measured from surface ECG in 1086 participants (767 men, 319 women) from the Salzburg-Atherosclerosis-Prevention-program-in-subjects-at-High-Individual-Risk (SAPHIR). To omit the QT adjustment bias inherent in Bazett's formula we used a QT adjustment method with linear scaling as described by Rautaharju. RESULTS: The prevalence of metabolic syndrome was 13.8% among males and 10% among females. Mean rate adjusted QT (QTa) intervals were longer in women than in men. Presence of metabolic syndrome, however, was associated with significantly prolonged QTa only in men but not in women. Adjustment for relevant confounders reduced the difference of mean QTa in men from 9.24 to 5.83 ms (95% CI 0.9-10.8), but this difference was still statistically significant (p = 0.021). The effect of metabolic syndrome on QTa was only partly mediated by hypertension and insulin resistance. In females, however, no relevant differences were detected for QTa interval between subjects categorized by presence or absence of metabolic syndrome. CONCLUSIONS: The findings indicate a significant association between metabolic syndrome and rate-invariant QT in middle-aged men after adjustment for other risk factors. QT measurement may provide additive diagnostic and prognostic information in populations undergoing cardiovascular risk screening. However, the effect of metabolic and hormonal factors on ventricular repolarization seems to differ between the sexes.     

Lack of association of the Glu298Asp polymorphism of endothelial nitric oxide synthase with manifest coronary artery disease,carotid atherosclerosis and forearm vascular reactivity in two Austrian populations

OBJECTIVE: Conflicting data exists about the possible contribution of the homozygous Asp/Asp genotype of the Glu298Asp polymorphism of endothelial nitric oxide synthase to human atherosclerotic vascular disease. We investigated the polymorphism in two independent study populations: a case-control study including patients with angiographically verified coronary artery disease (CAD) on the one hand and a cross-sectional epidemiological study on the other hand. METHODS: The Glu298Asp polymorphism was determined by PCR-RFLP as established. In the case-control study (240 patients and 248 controls) a possible association between the polymorphism and CAD, and age of onset of CAD and myocardial infarction was investigated. In the cross-sectional epidemiological study (932 subjects) intima-media thickness (IMT) of the carotid artery as well as morphological plaque burden and forearm vascular reactivity (peak postischemic reactive hyperaemia, determined by venous occlusion plethysmography) were measured. RESULTS: In the case-control study genotype distribution (Glu/Glu; Glu/Asp; Asp/Asp) was not different between the CAD patients (43/46/11%) and the controls (49/41/10%, P = NS). No association of the polymorphism with age of onset of CAD or myocardial infarction was found. In the epidemiological study no influence of the genetic variant on IMT was observed after correction for classical determinants of IMT (average IMT: Asp/ Asp: 0.077 +/- 0.011 mm; Glu/Glu and Glu/Asp: 0.080 +/- 0.012 mm, P = NS). Forearm vascular reactivity was also not different between homozygous Asp/Asp subjects and Glu/Glu and Glu/Asp subjects (peak-reactive hyperaemia 20.1 +/- 7.3 mL min-1 100 mL-1 vs. 20.0 +/- 6.5 mL min-1 100 mL-1, P = NS). CONCLUSIONS: Our results suggest that there is no association of the Glu298Asp polymorphism with coronary or carotid atherosclerosis or forearm vascular reactivity in these populations recruited in a country with a rather high risk for atherosclerosis. We suggest additional investigations to be performed in populations at different risk for coronary events to further elucidate the possible contribution of this polymorphism to vascular disease.     

MMP-9 haplotypes and carotid artery atherosclerosis: an association study introducing a novel multicolour multiplex RealTime PCR protocol

Background Among other matrix metalloproteinases (MMPs), gelatinase B (MMP‐9) is discussed to be associated with the pathogenesis of vascular diseases. Two single nucleotide polymorphisms (SNPs) of the MMP‐9 gene, C‐1562T in the promoter region and a G/A transition in exon 6 (R + 279Q), have been addressed in previous association studies which, however, produced conflicting results. Material and methods A novel multiplex RealTime PCR protocol for the fast and simultaneous detection of both polymorphisms is presented, which was used for genotyping 1737 participants of a prospective study investigating genetic factors influencing the progression of atherosclerosis. Results Haplotype analysis revealed –1562C/+279Q as the major haplotype in this population. Allelic distribution of the C‐1562T polymorphism was consistent with data published for similar cohorts; however, we found that R + 279Q allelic distribution appears to vary significantly among Caucasian populations. Considering clinical data available from 1487 participants, we found significant associations between the presence of atherosclerotic plaque and the CA‐haplotype in men (P = 0·028, phi = 0·08), and between the AG variant of exon 6 and common carotid artery intima‐media thickness (CIMT) in women (P = 0·004, Eta² = 0·019). Conclusions In summary, our results demonstrate associations of MMP‐9 genotypes with different stages of carotid atherosclerosis.