Showing papers in "Clinical Research in Cardiology in 2007"

Isolated noncompaction of the left ventricular myocardium -- a review of the literature two decades after the initial case description.

Abstract: Isolated noncompaction of the left ventricular myocardium (INVM), first described in 1984, is an unclassified cardiomyopathy and is assumed to occur as an arrest of the compaction process during the normal development of the heart. Between weeks 5 to 8 of human fetal development, the ventricular myocardium undergoes gradual compaction with transformation of the relatively large intertrabecular spaces into capillaries while the residual spaces within the trabecular meshwork gradually flatten or disappear. In the case of INVM, the spaces within the intertrabecular meshwork persist while no other cardiac abnormalities exist. Although there is substantial evidence supporting the developmental hypothesis, other pathogenetic processes responsible for INVM have been discussed. It can be assumed that INVM will be better understood in the future as the molecular genetic basis of cardiomyopathies will be further unravelled. Echocardiography has been shown to be the method of choice in diagnosis of INVM. The diagnostic criteria can be summarized as: 1) appearance of at least four prominent trabeculations and deep intertrabecular recesses; 2) appearance of blood flow from the ventricular cavity into the intertrabecular recesses as visualized by color Doppler imaging; 3) the segments of noncompacted myocardium mainly involve the apex and the inferior mid and lateral mid of the left ventricular wall and typically show a two-layered structure with an endsystolic ratio greater than two between the noncompacted subendocardial layer and the compacted subepicardial layer; 4) absence of coexisting cardiac abnormalities. Magnetic resonance imaging using modern gradient echo sequences has also been shown to diagnose INVM accurately. The clinical presentation of INVM is characterized by a high prevalence of heart failure, thromboembolic events and arrhythmias including ventricular tachycardia and atrial fibrillation. The establishment of a registry, which was initiated by the "Arbeitsgemeinschaft Leitende Kardiologische Krankenhausarzte (ALKK)" recently, may provide further clues for diagnosis, risk stratification, and management of this disease.

Percutaneous coronary interventions in Europe: prevalence, numerical estimates, and projections based on data up to 2004.

Abstract: A registry mandated by the European Society of Cardiology collects data on trends in interventional cardiology within Europe. Special interest focuses on relative increases and ratios in new techniques and their distributions across Europe. We report the data through 2004 and give an overview of the development of coronary interventions since the first data collection in 1992. Questionnaires were distributed yearly to delegates of all national societies of cardiology represented in the European Society of Cardiology. The goal was to collect the case numbers of all local institutions and operators. The overall numbers of coronary angiographies increased from 1992 to 2004 from 684 000 to 2 238 000 (from 1250 to 3930 per million inhabitants). The respective numbers for percutaneous coronary interventions (PCIs) and coronary stenting procedures increased from 184 000 to 885 000 (from 335 to 1550) and from 3000 to 770 000 (from 5 to 1350), respectively. Germany was the most active country with 712 000 angiographies (8600), 249 000 angioplasties (3000), and 200 000 stenting procedures (2400) in 2004. The indication has shifted towards acute coronary syndromes, as demonstrated by rising rates of interventions for acute myocardial infarction over the last decade. The procedures are more readily performed and perceived safer, as shown by increasing rate of "ad hoc" PCIs and decreasing need for emergency coronary artery bypass grafting (CABG). In 2004, the use of drug-eluting stents continued to rise. However, an enormous variability is reported with the highest rate in Switzerland (70%). If the rate of progression remains constant until 2010 the projected number of coronary angiographies will be over three million, and the number of PCIs about 1.5 million with a stenting rate of almost 100%. Interventional cardiology in Europe is ever expanding. New coronary revascularization procedures, alternative or complementary to balloon angioplasty, have come and gone. Only stenting has stood the test of time and matured to the default technique. Facilitated access to PCI, more complete and earlier detection of coronary artery disease promise continued growth of the procedure despite the uncontested success of prevention.

Genetics and heritability of coronary artery disease and myocardial infarction

Abstract: A positive family history is frequently reported by patients with coronary artery disease (CAD) or myocardial infarction. For risk stratification, it is crucial to distinguish between accidental reoccurrence of sporadic cases and cases with a true heritable component of the conditions. A familial predisposition is assumed when a myocardial infarction is diagnosed by a male first degree relative before the 55th year of life or a female first degree relative before the 65th year of life. The current manuscript reviews major studies from which a familial risk of CAD or myocardial infarction can be inferred. Moreover, a brief overview summarizes the current results of molecular genetic research on chromosomal loci and genes relevant for CAD and myocardial infarction.

Transplantation of autologous mononuclear bone marrow stem cells in patients with peripheral arterial disease (The TAM-PAD study)

Abstract: For patients with severe, chronic limb ischemia in many cases interventional or surgical treatment is not possible anymore. In the past, both intramuscular and intraarterial transplantation of autologous BMCs had been proved therapeutically beneficial. The TAMPAD study is the first one to analyze combined intraarterial and intramuscular BMC transplantation in its acute and long-term effects. 13 patients with chronically ischemic limbs due to peripheral arterial disease (Fontaine stage IIb) were recruited and underwent follow-up examinations after 2 and 13 months. Mononuclear cells from bone marrow were injected intramuscular and intraarterial into the ischemic limb. In contrast to the control group, after 2 months the pain-free walking distance of the transplanted patients significantly increased (from 147 ± 90 to 500 ± 614 m, p = 0.001). Furthermore the ankle-brachial index was significantly improved (at rest from 0.66±0.18 to 0.80±0.15, p=0.003, after stress from 0.64 ± 0.19 to 0.76 ± 0.16, p = 0.006). Similar improvement was documented in capillary-venous oxygen-saturation (thigh from 59 ± 9 to 66 ± 5, p = 0.005, lower leg from 56 ± 14 to 63 ± 5, p = 0.021) and venous occlusion plethysmography (rest from 2.1 ± 0.7 to 2.5 ± 0.7, p = 0.009, mean reactive hyperemia from 5.3 ± 1.8 to 7.2 ± 1.8, p = 0.003, and peak flow from 7.2 ± 3.2 to 10.8 ± 2.8, p = 0.002). After 13 months these positive effects persisted at their improved level. No side effects or complications were monitored. Combined intraarterial and intramuscular transplantation of autologous mononuclear bone marrow stem cells is a clinically feasible and minimally invasive therapeutic option for patients with severe chronic peripheral occlusive arterial disease.

Low-grade albuminuria and cardiovascular risk : what is the evidence?

Abstract: Microalbuminuria (MA), conventionally defined as a urinary albumin excretion (UAE) of 30–300 mg/day, is recognised as a marker of endothelial dysfunction. Furthermore, it represents an established risk factor for cardiovascular morbidity and mortality and for end-stage renal disease in individuals with an adverse cardiovascular risk profile. It is common in the general population, particularly in patients with diabetes mellitus or arterial hypertension. There is growing evidence from prospective observational trials that UAE levels well below the current MA threshold (“lowgrade MA”) are also associated with an increased risk of incident cardiovascular disease and allcause mortality. Even in apparently healthy individuals (without diabetes or hypertension), such an association has been shown. As albuminuria screening assays that are reliable even in the lower ranges are commercially available, there may be an important clinical role for MA in disease screening, comparable to the role of blood pressure and lipid screening. MA is modifiable, and the inhibition of the renin-angiotensin system by ACE inhibitors and AT1 receptor antagonists has been shown to result in a lower incidence of cardiovascular events.

A randomized controlled trial comparing hydration therapy to additional hemodialysis or N-acetylcysteine for the prevention of contrast medium-induced nephropathy: the Dialysis-versus-Diuresis (DVD) Trial.

Abstract: Contrast mediuminduced nephropathy (CIN) is a serious complication with increasing frequency and an unfavorable prognosis. Previous analyses of surrogate parameters have suggested beneficial effects of hemodialysis that are assessed in this randomized clinical trial.

Noise perception, heart rate and blood pressure in relation to aircraft noise in the vicinity of the Frankfurt airport

Abstract: The aim of this study was to evaluate subjective noise perception and objective parameters of circulation in the vicinity of the Frankfurt airport. Two areas were selected in which aircraft noise was the predominant source of noise (and was) created by planes induced by take off but not during landing. Data of residents living in the two areas were observed over a period of twelve weeks, one area being exposed to air traffic noise for three quarters of the given time, the other for one quarter of the time. Fifty three volunteers (age 50–52 ± 15 y) monitored their blood pressure and heart rate over a period of three months by using an automatic device with digitized readings. They also protocolled their own subjective perception of noise and sleep quality. Thirty one probands were living West of the airport (West group) and were exposed to a nocturnal equivalent continuous air traffic noise level of Leq(3) = 50 dB(A) outside, during flight direction 25 to the West. Twenty two probands were living East of the airport (East group) and were exposed to Leq(3) = 50 dB (A) during flight direction 07 to the East. During the opposite flight directions air craft noise corresponded to Leq(3) = 40 dB(A) in both areas. Frankfurt airport operates direction 25 for about 75% of the time on average and direction 07 for 25% of the time. The average blood pressure was significantly higher in the West group with higher noise exposure. Morning systolic blood pressure was 10 mmHg and diastolic pressure 8 mmHg higher in the West group. Throughout the observation period, the East group showed a parallel between daily changes in noise and subjective noise perception. In the West group such a parallel did not appear. This reaction was considered to be the consequence of the high noise exposure of the West group. It is concluded that a population exposed to a nocturnal equivalent continuous air traffic noise level of Leq(3) = 50 dB(A) for three quarters of a given time has a higher average blood pressure compared to a population exposed to the same equal energy noise level for only one quarter of the time. Within the East group a parallel between noise exposure and noise perception was observed, while in the West group this parallel did not appear. The difference is considered to be the consequence of higher noise stress levels in the West group. The data are in accordance with recent epidemiological studies and indicate that a nocturnal aircraft noise of Leq(3) = 50 dB(A) can have negative effects on subjective noise perception and on objective parameters of circulation.

Novel insights into an old controversy: is coronary artery ectasia a variant of coronary atherosclerosis?

Abstract: Coronary artery ectasia (CAE) is defined as a localized or diffuse non-obstructive lesion of the epicardial coronary arteries with a luminal dilation exceeding 1.5-fold the diameter of the normal adjacent arterial segment. The incidence of CAE has been reported to range between 2% and 4%, which might be an overestimation of the true frequency. The coincidence of CAE with other systemic vascular dilatations has suggested that the mechanism underlying CAE is not only localized to coronary arteries, but also to other vascular compartments such as aorta or peripheral veins. Although the pathophysiology of CAE remains largely unknown, it was supposed to represent a variant of coronary atherosclerosis. This review focuses on this controversy of whether CAE and coronary artery disease (CAD) are two manifestations of the same underlying process. There are clear differences between CAD and CAE with respect to cardiovascular risk factors such as diabetes mellitus, and pathogenic steps in disease progress such as inflammation or extracellular matrix remodeling. As this review will underscore, the current knowledge of the field is insufficient to finally clarify the causative interrelation between CAE and CAD. The clinical course and treatment of CAE mainly depends on its coexistence with CAD. When coexisting with CAD, the prognosis and treatment of CAE are the same as for CAD alone. In isolated CAE, prognosis is better and anti-platelet drugs are the mainstay of treatment. Surgical treatment can be considered in selected patients. For clarifying the mechanism underlying CAE, additional clinical, histopathological and pathophysiological investigations are required. In fact, every patient with CAE should be evaluated systematically for pathological changes in other vascular territories, both in the arterial system as well as in the venous system, which might occur in the disease process.

The role of heart rate in the development of cardiovascular disease.

Abstract: Heart rate is an independent risk factor for patients with cardiovascular disease, in particular with arterial hypertension, myocardial infarction, coronary artery disease and heart failure. This relation is supported by a large number of animal studies as well as clinical trials which are summarized in this article. These studies demonstrated detrimental effects of increased heart rate on the function and structure of the cardiovascular system. Heart rate can be easily detected during physical examination of the patient and therefore allows a simple conclusion on prognosis and efficiency of therapy.

Stereolithographic Reproduction of Complex Cardiac Morphology Based on High Spatial Resolution Imaging

Abstract: Precise knowledge of cardiac anatomy is mandatory for diagnosis and treatment of congenital heart disease. Modern imaging techniques allow high resolution three-dimensional (3D) imaging of the heart and great vessels. In this study stereolithography was evaluated for 3D reconstructions of multidetector computed tomography (MDCT) and magnetic resonance imaging (MRI) data. A plastinated heart specimen was scanned with MDCT and after segmentation a stereolithographic (STL) model was produced with laser sinter technique. After scanning the STL model with MDCT these data were compared with those of the original specimen after rigid registration using the iterative closest points algorithm (ICP). The two surfaces of the original specimen and STL model were matched and the symmetric mean distance was calculated. Additionally, the heart and great vessels of patients (age range 41 days–21 years) with congenital heart anomalies were imaged with MDCT (n = 2) or free breathing steady, state free-precession MRI (n = 3). STL models were produced from these datasets and the cardiac segments were analyzed by two independent observers. All cardiac structures of the heart specimen were reconstructed as a STL model within sub-millimeter resolution (mean surface distance 0.27 ± 0.76 mm). Cardiac segments of the STL patient models were correctly analyzed by two independent observers compared to the original 3D datasets, echocardiography (n = 5), x-ray angiography (n = 5), and surgery (n = 4). High resolution MDCT or MRI 3D datasets can be accurately reconstructed using laser sinter technique. Teaching, research and preoperative planning may be facilitated in the future using this technique.

Long-term follow-up after percutaneous septal ablation in hypertrophic obstructive cardiomyopathy

Abstract: The aim of this study was to evaluate the longterm follow-up results of percutaneous transluminal septal myocardial ablation (PTSMA) in a large patient cohort. PTSMA by alcohol injection into septal branches has shown good acute and short-term results in symptomatic patients with hypertrophic obstructive cardiomyopathy. A total of 100 consecutive symptomatic (NYHA class 2.8 ± 0.6) patients underwent PTSMA. All patients had clinical and non-invasive follow-up at 3 months, 1 year, and annually up to 8 years. One patient died at day 2 after intervention due to fulminant pulmonary embolism following deep venous thrombosis, and eight patients required a permanent DDD-pacemaker due to post-interventional complete heart block. Acute reduction of the left ventricular outflow tract gradient was achieved from 76 ± 37 to 19 ± 21 mmHg at rest, from 104 ± 34 to 43 ± 31 mmHg during Valsalva maneuver, and from 146 ± 45 to 59 ± 42 mmHg post extrasystole (p < 0.0001, each). During follow-up (mean follow-up time: 58 ± 14 months), three additional patients died (sudden death at 48 months, non-cardiac death at 49 months and stroke-related death at 60 months after the index procedure). All living patients showed clinical improvement to NYHA-class 1.4 ± 0.6 (after 3 months, n = 99), 1.5 ± 0.6 (after 1 year, n = 99), and 1.6 ± 0.7 at final follow-up (n = 96; p < 0.0001, each). Non-invasive follow-up studies documented ongoing outflow tract gradient reduction, decrease of septal and left ventricular posterior wall thickness, and improvement of exercise capacity. PTSMA is an effective treatment for symptomatic patients with hypertrophic obstructive cardiomyopathy. Follow-up showed ongoing hemodynamic and clinical improvement without increased mortality and morbidity.

One-year follow-up of percutaneous septal ablation for symptomatic hypertrophic obstructive cardiomyopathy in 312 patients: predictors of hemodynamic and clinical response.

Abstract: The aim of this study was to analyze hemodynamic and clinical outcome in a cohort of 312 patients who were followed up over a period of 12 months after alcohol septal ablation (PTSMA) for symptomatic hypertrophic obstructive cardiomyopathy (HOCM). PTSMA was intended in 337 patients with HOCM (mean age: 54±15 years), with 312 procedures completed by injection of 2.8±1.2 ml of alcohol. In 25 patients (8%) the intervention was aborted, mostly because of contrast echocardiographic findings. In the 312 patients who received alcohol, permanent pacing was necessary in 22 cases (7%); and in-hospital mortality was 1.3% (four patients). During follow-up, contact to six patients (2%) was lost, and three additional patients (1%) died. The 299 patients who either underwent non-invasive reassessment in our institution or transmitted followup data from their local physician formed the study population. Improvement in symptoms was reported by 272 patients (91%). Mean NYHA functional class was reduced from 2.9±0.4 to 1.5±0.7 (p<0.0001) along with a gradient reduction (echo-Doppler) from 59±32 to 8±15 mmHg at rest, and from 120±42 to 28±32 mmHg with provocation (p<0.0001 each). Exercise capacity improved from 94±51 to 119±40 watts (p=0.001), and peak oxygen consumption from 18±4 to 21±6 ml/ kg/min (p=0.01). Younger age and higher outflow gradients at baseline and immediately after intervention were associated with a less favorable hemodynamic outcome. The degree of limitation of exercise capacity at baseline was the only predictor of symptomatic improvement. Catheter-based septal ablation is an effective non-surgical technique for reducing symptoms and outflow gradients in HOCM. In contrast to a previous study, in this cohort of 312 patients there was no association between post-interventional enzyme release and hemodynamic success. Younger patients with high baseline gradients, however, tended to have a less favorable hemodynamic outcome with higher residual gradients.

Transcatheter closure of secundum atrial septal defects in adults with the Amplatzer septal occluder: Intermediate and long-term results

Abstract: Aims Transcatheter closure of secundum atrial septal defects (ASD) with the Amplatzer septal occluder (ASO) has become a standard procedure in most pediatric and adult patients. However, data addressing success rates and outcome in adults is limited. We sought to define the safety profile of the ASO in the community setting and identify the percentage of adults with ASD amenable to percutaneous closure with the ASO.

Cardiospecificity of the 3rd generation cardiac troponin T assay during and after a 216 km ultra-endurance marathon run in Death Valley

Abstract: Background The reasons for the appearance of cardiacspecific troponin (cTnT) after strenuous exercise are unclear. The aim of the present study was to evaluate the cardiospecificity of the 3rd generation cardiac cTnT assay during and after an ultra-endurance race of 216 km at extreme environmental conditions in Death Valley.

Pulmonary hypertension: current diagnosis and treatment

Abstract: Pulmonary hypertension (PH) is a devastating disease that - if untreated - is characterized by a poor prognosis. According to the current classification (Venice, 2003), pulmonary arterial hypertension (PAH) is distinguished from other forms of PH. Recent advances in drug therapy have led to a dramatic improvement of medical care particularly in patients with PAH. Hence, early establishment of the diagnosis appears increasingly important. This review article gives an overview on the definition, classification, pathophysiology, and clinical presentation of various forms of PH. Furthermore, it summarizes the recommended diagnostic work-up and the current treatment options particularly in PAH, with special emphasis on prostanoids, endothelin receptor antagonists (ERAs), and phosphopdiesterase type 5 (PDE5) inhibitors such as sildenafil. Finally, novel developments are being discussed which currently represent an exciting field of research.

Comparison of the slow-release polymerbased paclitaxel-eluting Taxus-Express stent with the bare-metal Express stent for saphenous vein graft interventions

Abstract: The paclitaxel-eluting Taxus-Express stent is superior regarding angiographic and clinical outcome compared with its bare-metal platform for lesions in native coronary arteries. We studied the potential impact of the Taxus-Express stent in comparison with its bare-metal counterpart for treatment of lesions in saphenous vein grafts (SVGs). Furthermore, a metaanalysis was performed regarding use of drug-eluting (DES) vs bare-metal stents (BMS) in SVG lesions. We analyzed 13 consecutive patients who underwent percutaneous revascularization in SVG lesions using the slowrelease, paclitaxel-eluting Taxus- Express stent. These lesions were balanced with 26 patients with SVG lesions treated with the baremetal Express stent (BMS) in the preceding period. Angiographic follow-up was performed after 6 months, clinical follow-up after 6 and 12 months. There were no statistically significant differences regarding clinical, procedural and angiographic parameters pre and post intervention. Binary restenoses occurred significantly less in the Taxus group compared with the BMS group (0% vs 34.6%; p=0.016). This translated into a significantly lower occurrence of major adverse cardiac events (death, Q-wave myocardial infarction, repeat target vessel revascularization) in the Taxus group compared with the BMS group at the 6-month (0% vs 26.9%, p=0.039) and 12-month follow-up (7.7% vs 38.5%, p=0.045). Multivariate predictors for freedom of binary restenosis were the reference diameter pre intervention and treatment with Taxus stents. Metaanalysis including 280 DES and 256 BMS patients revealed an odds ratio of 0.34 (95% confidence interval 0.21–0.54) for MACE and 0.26 (95% confidence interval 0.16–0.44) for target vessel revascularizations, both favoring DES. We conclude that the use of the slow-release Taxus-Express stent has the potential to be superior regarding angiographic and clinical outcome compared with its bare-metal counterpart for treatment of SVG lesions within a 12-month follow-up. A large, randomized trial including a long follow-up period is now required to prove the results of the metaanalysis.

Autoimmunological features in inflammatory cardiomyopathy

Abstract: During recent years, increasing evidence has been obtianed that cellular as well as humoral autoimmunity is involved in the pathogenesis of dilated cardiomyopathy (DCM). The immune system is generally activated by viral infections with the objective of virus elimination from the myocardium. However, a relevant number of patients demonstrate viral persistence and/or chronic inflammation in the myocardium. This chronic myocardial inflammation, defined by chronic inflammation, is termed “inflammatory cardiomyopathy” according to the WHO classification of cardiomyopathies. Chronic inflammation is frequently followed by the development of autoimmunity. A breakdown in the control mechanisms protecting against autoimmune reactions by both presentation of normally not accessible self-antigens and bystander- activation, induced by the pathogen, leads to the formation of autoreactive antibodies and T cells. The auto-reactive antibodies interact directly with heart tissue resulting in altered signal transduction or complement activation, whereas the T cell-mediated mechanisms include direct attack by cytotoxic T cells or indirect effects of cytotoxic cytokines released by stimulated T cells or macrophages.

Pathology, natural history and treatment of abdominal aortic aneurysms

Abstract: With increasing age of the population and improvement of diagnostic tools, the incidence of abdominal aortic aneurysms (AAA) has been rising steadily. Despite an improvement in operative and interventional treatment options, AAA is the cause of death in 1-3% of men over 65 years of age in industrial countries, mostly due to rupture [1]. Therefore, routine screening for AAA by ultrasonography has been postulated in the past: a 60 year old man with an abdominal aortic diameter of less than 3 cm has a life-time risk of developing AAA close to zero. However, routine screening has not been found to be cost effective. Despite of the results of two well-designed studies, the limits of AAA qualifying the patient for surgery or intervention in contrast to conservative treatment is still a matter of debate. The present review article summarizes the current knowledge of the pathology, incidence, risks, natural course as well as symptoms and current treatment strategies of AAA on the basis of the recent literature.

Lipoprotein-associated phospholipase A2 for early risk stratification in patients with suspected acute coronary syndrome: a multi-marker approach: the North Wuerttemberg and Berlin Infarction Study-II (NOBIS-II).

Abstract: Numerous markers have been identified as useful predictors of major adverse cardiac events (MACE) in patients with suspected acute coronary syndrome (ACS). However, only little is known about the relative benefit of the single markers in risk stratification and the best combination for optimising prognostic power. The aim of the present study was to define the role of the emerging cardiovascular risk marker lipoprotein-associated phospholipase A2 (Lp-PLA2) in a multi-marker approach in combination with troponin I (TnI), NT-proBNP, high sensitivity (hs)CRP, and D-dimer in patients with ACS. A total of 429 consecutive patients (age 60.5±14.1 years, 60.6% male) who were admitted to the emergency room with suspected ACS were analysed in the study. Biochemical markers were measured by immunoassay techniques. All patients underwent point-of-care TnI testing and early coronary angiography if appropriate, in accordance with the current guidelines. Classification and regression trees (CART) and logistic regression techniques were employed to determine the relative predictive power of markers for the primary end-point defined as any of the following events within 42 days after admission: death, non-fatal myocardial infarction, unstable AP requiring admission, admission for decompensated heart failure or shock, percutaneous coronary intervention, coronary artery bypass grafting, life threatening arrhythmias or resuscitation. The incidence of the primary end-point was 13.1%, suggesting a mild to moderate risk population. The best overall risk stratification was obtained using NT-proBNP at a cut-off of 5000 pg/mL (incidence of 40% versus 10.3%, relative risk (RR) 3.9 (95% CI 2.4–6.3)). In the remaining lower risk group with an incidence of 10.3%, further separation was performed using TnI (cut-off 0.14 µg/L; RR= 3.1 (95% CI 1.7–5.5) 23.2% versus 7.5%) and again NT-proBNP (at a cut-off of 140 ng/L) in patients with negative TnI (RR=3.2 (95% CI 1.3–7.9), 11.7% versus 3.6%). A final significant stratification in patients with moderately elevated NT-proBNP levels was achieved using Lp-PLA2 at a cut-off of 210 µg/L) (17.9% versus 6.9%; RR=2.6 (95% CI 1.1–6.6)). None of the clinical or ECG variables of the TIMI (Thrombolysis In Myocardial Infarction) risk score provided comparable clinically relevant information for risk stratification. In the setting of stateof- the-art coronary care for patients with suspected ACS in the emergency room, NT-proBNP, troponin I, and Lp-PLA2 are effective independent markers for risk stratification that proved to be superior to the TIMI risk score. Lp-PLA2 turned out to be a more effective risk marker than hsCRP in these patients.

Clinical Trial Updates and Hotline Sessions presented at the European Society of Cardiology Congress 2007

Abstract: This article provides information and commentaries on trials which were presented at the Hotline and Clinical Trial Update Sessions at the European Society of Cardiology Congress 2007 in Vienna. The key presentations were performed by leading experts in the field with relevant positions in the trials or registries. It is important to note that unpublished reports should be considered as preliminary data, as the analysis may change in the final publications. The comprehensive summaries have been generated from the oral presentation and the webcasts of the European Society of Cardiology and should provide the readers with the most comprehensive information of relevant publications.

Leitlinien zur Katheterablation

Abstract: Herausgegeben vom Vorstand der Deutschen Gesellschaftfur Kardiologie – Herz- und Kreislaufforschung eVBearbeitet im Auftrag der Kommission fur Klinische KardiologieM Borggrefe, M Bohm, J Brachmann, H-R Figulla, G Hasenfus,A Osterspey, K Rybak, U Sechtem, S Silberauserdem HM HoffmeisterOnline publiziert: 26 Oktober 2007Prof Dr med Karl-Heinz Kuck (

Pulmonary and caval blood flow patterns in patients with intracardiac and extracardiac Fontan: a magnetic resonance study.

Abstract: We compared in vivo blood flow and pulsatility after different types of Fontan operation using magnetic resonance imaging. A total of 37 consecutive patients (mean age 19±7.9 years, 7.3±3.2 years after Fontan operation), 7 with atriopulmonary anastomosis (APC), 18 with intra-atrial lateral tunnel (LTFO) and 12 with extracardiac Fontan (ECFO) were studied using magnetic resonance phase-contrast velocity mapping. Blood flow (volume flow) in the superior vena cava (SVC), inferior vena cava (IVC) and both pulmonary arteries were measured and a pulsatility index was calculated for each vessel. For all modifications, the blood flow distribution between the SVC and IVC was normal (1 : 2). Patients with APC had a normal pulsatility, a dilated right atrium, partial backward flow in the IVC and physiological blood flow distribution between the pulmonary arteries. LTFO and ECFO patients had no retrograde flow in the IVC, equal blood flow distribution between the pulmonary arteries and very low or absent pulsatility. MRI allows hemodynamic quantification and characterization of various types of Fontan modifications and may be a valuable tool to predict Fontan failure. Despite showing normal pulsatility, patients with APC have right atrial dilatation and partial backward flow in the IVC, demonstrating suboptimal Fontan circulation. LTFO and ECFO both produce unidirectional antegrade flow in the IVC but pulsatility is very low or absent, which may promote poor pulmonary artery growth and increase of pulmonary vascular resistance contributing to late Fontan failure.

Is late stent thrombosis in drug-eluting stents a real clinical issue? A single-center experience and review of the literature.

Abstract: Background Randomized studies have not found an increased rate of late stent thrombosis (LAST) in drug-eluting stents (DES) compared with bare metal stents (BMS) but those studies were statistically not powered to show such a difference. At the same time there is an increasing number of reports of LAST in DES patients in the current literature.

Glycoprotein IIb/IIIa inhibitor-induced thrombocytopenia: diagnosis and treatment.

Abstract: Thrombocyte glycoprotein IIb/IIIa inhibitors prevent fibrinogen binding and thereby thrombocyte aggregation. The inhibition of thrombocyte activation at the damaged coronary plaque is the target of the new therapeutic strategies in treating acute coronary syndrome. This reduces the ischemic complications associated with the non-STelevation myocardial infarction (NSTEMI) and percutaneous coronary intervention (PCI).

Hormonal status modulates circulating endothelial progenitor cells

Abstract: Objective Endothelial progenitor cells (EPCs) may have an important role in vascular homeostasis and repair.

Differential increase of CD34, KDR/CD34, CD133/CD34 and CD117/CD34 positive cells in peripheral blood of patients with acute myocardial infarction.

Abstract: Circulating progenitor cells (CPC) may contribute to cardiac regeneration and neovascularization after acute myocardial infarction (AMI). For potential therapeutic use, understanding the endogenous mechanisms after ischemia is inevitable. We investigated the absolute number, but also the subset composition of CD34+ CPC after AMI. CD34+, KDR+/ CD34+, CD133+/CD34+ and CD117+/CD34+ CPC were analyzed by FACS in peripheral blood of 10 patients with acute MI (59±5 yrs, m/f=8/2) at day of AMI (day 0) and days 1–5. For comparison patients with stable coronary artery disease (CAD, n=12, 66±2 yrs, m/f=10/2) and young healthy volunteers (n=7, 26±2 yrs, m/f=3/4) were studied. CD34 and KDR/CD34, CD133/CD34, CD117/CD34 were increased day 3 and 4 after AMI. KDR+ fraction within CD34+ population remained unchanged (58.3±7.8% vs 55.3±10.6%), whereas CD133+ (64.9±3.1% vs 43.5±5.9%, P=0.006) and CD117+ fractions (71.7±5.6% vs 50.1±5.5%, P=0.02) were elevated. In CAD, all CPC and fractions were similar as AMI day 0. Healthy volunteers had more CD34+ than CAD and AMI day 0. Double positive CPC were also higher, but fractions were unchanged vs CAD with more KDR/CD34 in trend (72.8±10.6% vs 50.5±5.6%, P=0.058). After AMI both absolute numbers of CD34+ and their subset composition change, suggesting selective mobilization of CPC. Increased CPC after AMI never reach numbers of young healthy volunteers.

Effect of stress-induced reversible ischemia on serum concentrations of ischemia-modified albumin, natriuretic peptides and placental growth factor

Abstract: Objective There is controversy whether new biomarkers are able to identify myocardial ischemia in the absence of myonecrosis.

Long-term results of a three-week intensive cardiac out-patient rehabilitation program in motivated patients with low social status

Abstract: The short-term benefits of cardiac rehabilitation (CR) are well established. In contrast, well-documented long-term results are rare. The objective of this longitudinal multi-centre observational study was to examine the effects of intensive out-patient CR in a larger patient cohort, especially for patients with low social status. We present the final results 24 months after CR. The study group of 327 patients (288 men, 39 women, aged 56.0±10.8 years, coronary artery disease in 295, other cardiac diseases in 32) participated in a 3- week CR programme followed by clinical re-evaluations 6 (III), 12 (IV) an 24 (V) months later. The improvement in mean maximal performance of 100.5±31.4 to 123.1±36.2 W (p<0.01) achieved during CR was further improved to 128.7±40.9 W (p < 0,01) after 24 months. Of the patients, 61.2% reported regular physical activity during the 24 months of the study. The lipid management achieved by CR was maintained over 24 month. At I 65%, at II 84.4% and at V 82.4% of the patients with coronary artery disease (CAD) were undergoing lipid lowering therapy. BMI increased from 26.8±3.0 to 27.6±3.6 kg/m2 (p < 0.01) during follow-up. Of the patients, 23.2% were active smokers at V. Cardiovascular diagnosis remained unaltered in 74.3% of patients. The obtained results are interesting with respect to the social status of the patients since 68% were general laborers. The results confirm the long-term effectiveness of an intensive 3-week out-patient CR programme. Most of the benefits achieved by CR appear to be sustainable in this population for at least 2 years.

Hotline update of clinical trials and registries presented at the German Cardiac Society Meeting 2007: 2L-Registry, Kardio-Pro, EVER, AFFECT, VTACH, ARTS II, OPTAMI, PEPCAD I, PEPCAD II, GERSHWIN, SPICE, FIX-CHF and CREDIT.

Abstract: This article summarizes the results of a number of new clinical trials, registries and metaanalyses in the field of cardiovascular medicine. Key presentations made at the 73rd annual meeting of the German Cardiac Society, held in Mannheim, Germany, in April 2007 are reported. The data were presented by leading experts in the field with relevant positions in the trials, registries or metaanalyses. These comprehensive summaries should provide the readers with the most recent data on diagnostic and therapeutic developments in cardiovascular medicine.

Continuous intravenous iloprost to revert treatment failure of first-line inhaled iloprost therapy in patients with idiopathic pulmonary arterial hypertension

Abstract: To describe the clinical and haemodynamic effects during the first 6 months of continuous intravenous iloprost treatment in patients with idiopathic pulmonary arterial hypertension (IPAH) and relevant disease progression despite continued mono therapy with aerosolized iloprost. Twenty-four IPAH patients with clinical decompensation to NYHA class IV despite therapy with aerosolized iloprost and optimized conservative treatment were assessed clinically, haemodynamically and by cardiopulmonary exercise testing for at least 6 months. Upon switching from inhaled to intravenous iloprost all patients improved clinically (NYHA III) while pulmonary vascular resistance (PVR) and right atrial pressure decreased from 2386 ± 243 to 1381 ± 124 dyne ·s ·cm−5 and 12 ± 1 to 8.5 ± 1 mmHg, respectively (both p < 0.05). Despite this acute improvement haemodynamic (PVR increased from 1462±223 to 1978 ± 327 dyne ·s ·cm−5) and clinical (4 deaths, 4 transplantations) deterioration occurred with continued intravenous treatment during the following 6 months. In the group of patients described in this report the clinical and haemodynamic deterioration occurring while on mono therapy with inhaled iloprost could be stopped by switching to continuous application of intravenous iloprost. However, with continued intravenous therapy only a subgroup of patients could clinically be stabilized and transplanted successfully.