Efficient and safe glycaemic control with basal-bolus insulin therapy during fasting periods in hospitalized patients with type 2 diabetes using decision support technology: A post hoc analysis

AIM

To evaluate the efficacy and safety of basal-bolus insulin therapy in managing glycaemia during fasting periods in hospitalized patients with type 2 diabetes.

MATERIALS AND METHODS

We performed a post hoc analysis of two prospective, uncontrolled interventional trials that applied electronic decision support system-guided basal-bolus (meal-related and correction) insulin therapy. We searched for fasting periods (invasive or diagnostic procedures, medical condition) during inpatient stays. In a mixed model analysis, patients' glucose levels and insulin doses on days with regular food intake were compared with days with fasting periods.

RESULTS

Out of 249 patients, 115 patients (33.9% female, age 68.3 ± 10.3 years, diabetes duration 15.1 ± 10.9 years, body mass index 30.1 ± 5.4 kg/m² , HbA1c 69 ± 20 mmol/mol) had 194 days with fasting periods. Mean daily blood glucose (BG) was lower (modelled difference [ModDiff]: -0.5 ± 0.2 mmol/L, P = .006), and the proportion of glucose values within the target range (3.9-10.0 mmol/L) increased on days with fasting periods compared with days with regular food intake (ModDiff: +0.06 ± 0.02, P = .005). Glycaemic control on fasting days was driven by a reduction in daily bolus insulin doses (ModDiff: -11.0 ± 0.9 IU, P < .001), while basal insulin was similar (ModDiff: -1.1 ± 0.6 IU, P = .082) compared with non-fasting days. Regarding hypoglycaemic events (BG < 3.9 mmol/L), there was no difference between fasting and non-fasting days (χ² 0.9% vs. 1.7%, P = .174).

CONCLUSIONS

When using well-titrated basal-bolus insulin therapy in hospitalized patients with type 2 diabetes, the basal insulin dose does not require adjustment during fasting periods to achieve safe glycaemic control, provided meal-related bolus insulin is omitted and correction bolus insulin is tailored to glucose levels.

Safe and Sufficient Glycemic Control by Using a Digital Clinical Decision Support System for Patients With Type 2 Diabetes in a Routine Setting on General Hospital Wards

The aim was to investigate the applicability of a clinical decision support system in a real-world inpatient setting for patients with type 2 diabetes on general hospital wards.A total of 150 patients with type 2 diabetes requiring subcutaneous insulin therapy were treated with basal-bolus insulin therapy guided by a decision support system (GlucoTab) providing automated workflow tasks and suggestions for insulin dosing to health care professionals.By using the system, a mean daily blood glucose (BG) of 159 ± 32 mg/dL was achieved. 68.8% of measurements were in the target range (70 to <180 mg/dL). The percentage of BG values <40, <70, and ≥300 mg/dL was 0.02%, 2.2%, and 2.3%, respectively. Health care professionals' adherence to suggested insulin doses and workflow tasks was high (>93% and 91%, respectively).The decision support system facilitates safe and efficacious inpatient diabetes care by standardizing treatment workflow and providing decision support for basal-bolus insulin dosing.

Standardized Glycemic Management with a Computerized Workflow and Decision Support System for Hospitalized Patients with Type 2 Diabetes on Different Wards

BACKGROUND

This study investigated the efficacy, safety, and usability of standardized glycemic management by a computerized decision support system for non-critically ill hospitalized patients with type 2 diabetes on four different wards.

MATERIALS AND METHODS

In this open, noncontrolled intervention study, glycemic management of 99 patients with type 2 diabetes (62% acute admissions; 41 females; age, 67±11 years; hemoglobin A1c, 65±21 mmol/mol; body mass index, 30.4±6.5 kg/m(2)) on clinical wards (Cardiology, Endocrinology, Nephrology, Plastic Surgery) of a tertiary-care hospital was guided by GlucoTab(®) (Joanneum Research GmbH [Graz, Austria] and Medical University of Graz [Graz, Austria]), a mobile decision support system providing automated workflow support and suggestions for insulin dosing to nurses and physicians.

RESULTS

Adherence to insulin dosing suggestions was high (96.5% bolus, 96.7% basal). The primary outcome measure, percentage of blood glucose (BG) measurements in the range of 70-140 mg/dL, occurred in 50.2±22.2% of all measurements. The overall mean BG level was 154±35 mg/dL. BG measurements in the ranges of 60-70 mg/dL, 40-60 mg/dL, and <40 mg/dL occurred in 1.4%, 0.5%, and 0.0% of all measurements, respectively. A regression analysis showed that acute admission to the Cardiology Ward (+30 mg/dL) and preexisting home insulin therapy (+26 mg/dL) had the strongest impact on mean BG. Acute admission to other wards had minor effects (+4 mg/dL). Ninety-one percent of the healthcare professionals felt confident with GlucoTab, and 89% believed in its practicality and 80% in its ability to prevent medication errors.

CONCLUSIONS

An efficacious, safe, and user-accepted implementation of GlucoTab was demonstrated. However, for optimized personalized patient care, further algorithm modifications are required.

Efficacy, usability and sequence of operations of a workflow-integrated algorithm for basal-bolus insulin therapy in hospitalized type 2 diabetes patients

AIMS

To evaluate glycaemic control and usability of a workflow-integrated algorithm for basal-bolus insulin therapy in a proof-of-concept study to develop a decision support system in hospitalized patients with type 2 diabetes.

METHODS

In this ward-controlled study, 74 type 2 diabetes patients (24 female, age 68 ± 11 years, HbA1c 8.7 ± 2.4% and body mass index 30 ± 7) were assigned to either algorithm-based treatment with a basal-bolus insulin therapy or to standard glycaemic management. Algorithm performance was assessed by continuous glucose monitoring and staff's adherence to algorithm-calculated insulin dose.

RESULTS

Average blood glucose levels (mmol/l) in the algorithm group were significantly reduced from 11.3 ± 3.6 (baseline) to 8.2 ± 1.8 (last 24 h) over a period of 7.5 ± 4.6 days (p < 0.001). The algorithm group had a significantly higher percentage of glucose levels in the ranges from 5.6 to 7.8 mmol/l (target range) and 3.9 to 10.0 mmol/l compared with the standard group (33 vs. 23% and 73 vs. 53%, both p < 0.001). Physicians' adherence to the algorithm-calculated total daily insulin dose was 95% and nurses' adherence to inject the algorithm-calculated basal and bolus insulin doses was high (98 and 93%, respectively). In the algorithm group, significantly more glucose values <3.9 mmol/l were detected in the afternoon relative to other times (p < 0.05), a finding mainly related to pronounced morning glucose excursions and requirements for corrective bolus insulin at lunch.

CONCLUSIONS

The workflow-integrated algorithm for basal-bolus therapy was effective in establishing glycaemic control and was well accepted by medical staff. Our findings support the implementation of the algorithm in an electronic decision support system.

Near Field Communication-based telemonitoring with integrated ECG recordings

OBJECTIVES

Telemonitoring of vital signs is an established option in treatment of patients with chronic heart failure (CHF). In order to allow for early detection of atrial fibrillation (AF) which is highly prevalent in the CHF population telemonitoring programs should include electrocardiogram (ECG) signals. It was therefore the aim to extend our current home monitoring system based on mobile phones and Near Field Communication technology (NFC) to enable patients acquiring their ECG signals autonomously in an easy-to-use way.

METHODS

We prototypically developed a sensing device for the concurrent acquisition of blood pressure and ECG signals. The design of the device equipped with NFC technology and Bluetooth allowed for intuitive interaction with a mobile phone based patient terminal. This ECG monitoring system was evaluated in the course of a clinical pilot trial to assess the system's technical feasibility, usability and patient's adherence to twice daily usage.

RESULTS

21 patients (4f, 54 ± 14 years) suffering from CHF were included in the study and were asked to transmit two ECG recordings per day via the telemonitoring system autonomously over a monitoring period of seven days. One patient dropped out from the study. 211 data sets were transmitted over a cumulative monitoring period of 140 days (overall adherence rate 82.2%). 55% and 8% of the transmitted ECG signals were sufficient for ventricular and atrial rhythm assessment, respectively.

CONCLUSIONS

Although ECG signal quality has to be improved for better AF detection the developed communication design of joining Bluetooth and NFC technology in our telemonitoring system allows for ambulatory ECG acquisition with high adherence rates and system usability in heart failure patients.

[Heart rate and functional impairment are predictors of outcome in heart failure patients in the real world. Data from the Austrian Heart Failure registry]

PURPOSE

Elevated heart rate (70 beats per minute-bpm or more) is a predictor of impaired prognosis in patients with ischemic heart failure. The Austrian Working Group on Heart Failure has established a registry in May 2006 for all patients referred to dedicated heart failure clinics with a planned follow-up after 12 ± 3 months. Here we report an analysis of the prognostic impact of elevated heart rate at referral in a well-defined cohort of heart failure patients.

METHODS

Between May 2006 and October 2009 1904 patients have been documented in the Austrian Heart Failure Registry. One thousand threehundred and sixty three patients (72%) had sinus rhythm at referral. Kaplan-Meier and Cox proportional hazards regression analyses were used to compare overall and cardiovascular mortality between high (70 bpm or more) and low heart-rate groups. Patients who were lost-to-follow-up (n = 166) were censored at the time of last contact.

RESULTS

At baseline in 793 patients (58%) heart rate has been elevated (70 bpm or more) while in 562 patients it has been below 70 bpm, in 8 patients no baseline heart rate has been recorded. Groups were equally balanced regarding age, gender and cardiovascular risk factors with the exception of smokers (more active smokers in the high heart-rate group: 23 vs 14%; p = 0.001) and valvular cause of heart failure (more frequent in the high heart-rate group: 3% vs 1%; p = 0.012). Patients in the high heart-rate group had significantly higher median NT-pro-BNP (1470 pg/ml, IQR 499-4188 pg/ml) compared to patients in the low heart-rate group (784 pg/ml, IQR 314-2162 pg/ml; p < 0.001). NYHA functional classes III and IV have been more frequent in the high heart-rate group than in the low heart-rate group (32% and 22%, respectively; p < 0.001) while reduced left ventricular ejection fraction (39% or less) has been more frequent in the high heart-rate group than in the low heart-rate group (71% and 61%, respectively; p < 0.001). In the high heart-rate group treatment with beta-blockers has been less frequent than in the low heart rate group (76% and 86%, respectively; p < 0.01) while dosage of beta-blocker therapy has been comparable in both groups. Of the 75 patients who died within 3.5 years 38 deaths had a cardiovascular cause. Cox proportional hazards analysis revealed that high NYHA functional class (III and IV) and elevated heart rate (70 bpm or more) were the best predictors of overall mortality while cardiovascular mortality could best be predicted by NYHA functional classes III and IV.

CONCLUSION

Higher NYHA-functional classes and elevated heart rate are predictors of adverse outcome in chronic heart failure patients.

Effect of home-based telemonitoring using mobile phone technology on the outcome of heart failure patients after an episode of acute decompensation: randomized controlled trial

BACKGROUND

Telemonitoring of patients with chronic heart failure (CHF) is an emerging concept to detect early warning signs of impending acute decompensation in order to prevent hospitalization.

OBJECTIVE

The goal of the MOBIle TELemonitoring in Heart Failure Patients Study (MOBITEL) was to evaluate the impact of home-based telemonitoring using Internet and mobile phone technology on the outcome of heart failure patients after an episode of acute decompensation.

METHODS

Patients were randomly allocated to pharmacological treatment (control group) or to pharmacological treatment with telemedical surveillance for 6 months (tele group). Patients randomized into the tele group were equipped with mobile phone-based patient terminals for data acquisition and data transmission to the monitoring center. Study physicians had continuous access to the data via a secure Web portal. If transmitted values went outside individually adjustable borders, study physicians were sent an email alert. Primary endpoint was hospitalization for worsening CHF or death from cardiovascular cause.

RESULTS

The study was stopped after randomization of 120 patients (85 male, 35 female); median age was 66 years (IQR 62-72). The control group comprised 54 patients (39 male, 15 female) with a median age of 67 years (IQR 61-72), and the tele group included 54 patients (40 male, 14 female) with a median age of 65 years (IQR 62-72). There was no significant difference between groups with regard to baseline characteristics. Twelve tele group patients were unable to begin data transmission due to the inability of these patients to properly operate the mobile phone ("never beginners"). Four patients did not finish the study due to personal reasons. Intention-to-treat analysis at study end indicated that 18 control group patients (33%) reached the primary endpoint (1 death, 17 hospitalizations), compared with 11 tele group patients (17%, 0 deaths, 11 hospitalizations; relative risk reduction 50%, 95% CI 3-74%, P = .06). Per-protocol analysis revealed that 15% of tele group patients (0 deaths, 8 hospitalizations) reached the primary endpoint (relative risk reduction 54%, 95% CI 7-79%, P= .04). NYHA class improved by one class in tele group patients only (P< .001). Tele group patients who were hospitalized for worsening heart failure during the study had a significantly shorter length of stay (median 6.5 days, IQR 5.5-8.3) compared with control group patients (median 10.0 days, IQR 7.0-13.0; P= .04). The event rate of never beginners was not higher than the event rate of control group patients.

CONCLUSIONS

Telemonitoring using mobile phones as patient terminals has the potential to reduce frequency and duration of heart failure hospitalizations. Providing elderly patients with an adequate user interface for daily data acquisition remains a challenging component of such a concept.

Early and sustained effects of cardiac resynchronization therapy on N-terminal pro-B-type natriuretic peptide in patients with moderate to severe heart failure and cardiac dyssynchrony

AIMS

The Cardiac Resynchronization-Heart Failure (CARE-HF) study demonstrated that cardiac resynchronization therapy (CRT) could reduce morbidity and mortality and improve cardiac function in patients with moderate or severe heart failure secondary to left ventricular systolic dysfunction and markers of cardiac dyssynchrony. The purpose of this analysis was to investigate the effect of CRT on plasma concentrations of N-terminal pro-brain natriuretic peptide (NT-pro-BNP), a powerful marker of cardiac dysfunction and prognosis.

METHODS AND RESULTS

Blood samples were collected routinely at baseline and 3 and 18 months. Plasma was separated by cool centrifugation and stored at -70 degrees C until transported to a central laboratory for analysis of NT-pro-BNP using a standard commercial assay. Cardiac function was assessed echocardiographically. At baseline, median plasma concentration of NT-pro-BNP was similar in patients assigned to CRT or medical therapy [1920 pg/mL (inter-quartile range (IQR) 744-4288) and 1809 pg/mL (IQR 719-3949), respectively]. The differences in medians between the CRT and medical therapy groups were highly significant at both 3 months (537 pg/mL; P < 0.0001) and 18 months of follow-up (567 pg/mL; P < 0.0001). These differences could not be accounted for by changes in pharmacological therapy or renal function but were associated with improvement in ventricular volumes and function.

CONCLUSION

CRT exerts an early and sustained reduction in NT-pro-BNP. This appears to reflect improvements in ventricular function. NT-pro-BNP may be a simple method for monitoring the effects of CRT.

Mobile phone-based surveillance of cardiac patients at home

We tested the reliability, acceptability and feasibility of a home-monitoring system for cardiac patients. Each participant was equipped with a mobile phone, an automatic blood pressure device and a digital weight scale. In total, 20 patients (14 patients with chronic heart failure, six patients with hypertension; mean age 50 years, standard deviation [SD] 14) were monitored for 90 days each. They were asked to measure their blood pressure, pulse and body weight every day, and to transfer the data together with the dosage of medication to the telemonitoring server using wireless Internet technology in the mobile phone. The physician in charge received email alerts when reported data fell outside pre-defined limits. The patients' compliance with the system was high. During a cumulative monitoring period of 1,735 days, there were 2,040 data transfer sessions, a mean of 102 per patient (SD 43). The mean percentage of successful data transfers was 83% (SD 22). The stability of the telemonitoring system was 98%, meaning that patient data transfer was almost always possible. The accessibility of the secure web server for physicians was above 99%. The web-based home-monitoring system was reliable and easy to handle for both patients and health care professionals. It may be a useful tool for patients with heart failure as well as hypertensive patients.

Continuous haemodynamic monitoring during exercise in patients with pulmonary hypertension

BACKGROUND

Right heart haemodynamic parameters can be recorded continuously with the help of an implanted haemodynamic monitor. Aim of the study was to assess the haemodynamic response with and without inhalation of iloprost during cardiopulmonary exercise testing (CPET) in patients with pulmonary hypertension.

MATERIALS AND METHODS

Five female patients with documented pulmonary hypertension (mean +/- S.D. age 47 +/- 16 years, 4 arterial, 1 venous) previously implanted with a haemodynamic monitor underwent an incremental exercise test on 2 separate days. The tests were performed before and immediately after inhalation of a single dose of iloprost (17 microg). Parameters recorded by the device were right ventricular (RV)-afterload (RV systolic pressure, RVSP), RV-preload (RV diastolic pressure, RVDP), estimated pulmonary artery diastolic pressure (ePAD), heart rate (HR) and maximum positive rate of RV pressure development (RVdP/dt) (reflecting the dynamic and inotropic state of the RV).

RESULTS

After inhalation of iloprost, RV systolic pressure was always reduced at rest. It was followed by an increase with higher workloads without any difference at VO(2peak). The time course of RV systolic pressure was not linear with a flattening at higher workload during the test. This behaviour was found irrespective of iloprost treatment. The remaining determinants of RV performance showed no relevant differences and a linear behaviour during the exercise test.

CONCLUSIONS

Inhalation of aerosolised iloprost resulted in a reduction in right ventricular pressure at rest but not at maximal workload. The implantable haemodynamic monitor (IHM) may be useful for the evaluation of RV haemodynamics during exercise and in assessing treatment efficacy.

Hemodynamic Observations in Two Pulmonary Hypertensive Patients Changing Treatment From Inhaled Iloprost to the Oral Endothelin-Antagonist Bosentan

Two female patients with pulmonary arterial hypertension and a permanently implanted hemodynamic monitor changed treatment from inhaled iloprost to oral bosentan. The hemodynamic changes were seen very early after the first dose of bosentan and there was no need to re-establish inhaled iloprost.

Clinical Applications of Cardiovascular Magnetic Resonance

The clinical role of magnetic resonance in diseases of the heart and great vessels is rapidly evolving. Cardiovascular magnetic resonance (CMR) has become an established non-invasive imaging modality for the assessment of various cardiac disorders, such as congenital heart disease, cardiac masses, cardiomyopathies, aortic and pericardial diseases. Moreover, due to its accuracy and reproducibility, CMR is currently considered the gold standard for quantification of ventricular volumes, function, and mass. Thus, this technique is ideally suited to assess the efficacy of therapeutic interventions on ventricular hypertrophy and remodelling, which may allow a reduction in sample size to show clinically relevant effects. Comprehensive functional assessment is possible by CMR due to its capability to measure flow velocity and flow volume, which is a basic requirement to quantify lesion severity in valvular heart disease. Within the past years, major technical advances have considerably improved acquisition speed and image quality making CMR a useful tool for the evaluation of patients with ischaemic heart disease. Although the clinical robustness of coronary magnetic resonance angiography still needs improvement, CMR currently provides valuable information to detect reversible ischemia, myocardial infarction, and residual viability. In this review we will present in detail the well-established indications of CMR accompanied by an outlook on new applications that are likely to enter the clinical arena in the near future.

Austrian survey of treating heart failure-AUSTRIA

BACKGROUND

Treatment of chronic heart failure is based on the results of large clinical trials, which form the basis of treatment guidelines, such as those from the European Society of Cardiology (ESC). The aim of this study was to record treatment-modalities and the implementation of guidelines of chronic heart failure in clinical practice in Austria.

METHODS

Overall 96 general physicians, specialists for internal medicine in private practice or in hospital outpatient departments participated in the survey. Physicians were asked to prospectively document 30 consecutive patients with chronic heart failure.

RESULTS

1880 patients were documented. The majority of patients were treated by general physicians (57%). Coronary artery disease was the most frequent aetiology for heart failure (47%). The most frequently used drugs were blockers of the renin-angiotensin-system (RAS-blocker including ACE-inhibitors and angiotensin-receptor-blockers, 78%), diuretics (76%) and beta-blockers (49%). Other drugs like digitalis and spironolactone were used infrequently. Average doses of ACE-inhibitors were approximately 90% of those recommended by the ESC, average doses of beta-blockers were approximately 50% of those recommended. Treatment among the three classes of physicians differed with respect to RAS-blockers and beta-blockers, which were used infrequently by general practitioners. Both groups of drugs were given more frequently to younger patients (<70 years) while digitalis was given more often to elderly patients.

CONCLUSIONS

Results from this survey suggest that Austrian physicians treating patients with heart failure use the appropriate drugs in dosages that are suggested by recently published guidelines (ACE-inhibitors and beta-blockers). However, dosages of spironolactone clearly differed from current recommendations.

Influence of beta-blocker use on percentage of target heart rate exercise prescription

BACKGROUND

Exercise is recommended for cardiac patients irrespective of beta-blockers. Percentages of maximal heart rate (%HRmax) and heart rate reserve (%HRR) are widely used to determine training intensities. The purpose of this study was to investigate the influence of chronic cardioselective beta blockade on the %HRmax and %HRR model.

METHODS

Ten healthy male subjects randomly received oral placebo or beta-blocker bisoprolol (5 mg/day) for 2 weeks using a double-blind, crossover design. In the second week, the subjects performed a cardiopulmonary exercise test until exhaustion to determine the aerobic (AeT) and anaerobic (AnT) threshold.

RESULTS

No significant differences were found for absolute and relative values of oxygen consumption, power output and ratings of perceived exertion at AeT, AnT and maximum workload. Mean HR was significantly (P<0.05) lower at rest (-15 +/- 5 bpm), AeT (-19 +/- 8 bpm), AnT (-22 +/- 10 bpm) and maximal workload (-19 +/- 11 bpm) with bisoprolol compared to placebo. Percentage of maximal heart rate (%HRmax) was significantly (P<0.05) reduced at rest (43 versus 39%), AeT (64 versus 60%) and AnT (86 versus 82%), a trend for a reduction was found for %HRR at AnT (75 versus 71%, P=0.07).

CONCLUSIONS

Exercise prescription using %HRmax or %HRR methods are of limited accuracy for patients taking beta-blockers. Although %HRmax and %HRR are easy to determine and therefore attractive, we suggest that the most precise exercise prescription would depend on AeT and AnT. Percentages of maximal oxygen consumption or maximal workload or ratings of perceived exertion may be suggested as a substitute. Alternatively, upper limits for %HRmax and %HRR should be lower for patients taking beta-blockers.

Continuous hemodynamic monitoring in pulmonary hypertensive patients treated with inhaled iloprost

BACKGROUND

Aerosolized iloprost is used as an alternative to IV prostacyclin in patients with pulmonary hypertension. The desired outcome of this treatment is a reduction of pulmonary pressure, which can be measured by right-heart catheterization or Doppler echocardiography. However, both techniques provide only snapshots of the hemodynamic state.

PATIENTS AND METHODS

The aim of our study was to test the usability of an implantable hemodynamic monitor (IHM) [the Chronicle, model 9520; Medtronic Inc; Minneapolis, MN] in patients with pulmonary hypertension. For this purpose, the device was implanted into five patients (mean [+/- SEM] age, 45 +/- 16 years; all women) with pulmonary hypertension who had received long-term treatment with aerosolized iloprost (100 micro g/d). Repeated short-term tests including two standard inhalations of iloprost as well as repeated long-term tests lasting 20 to 26 h, including nighttime, without inhalation were performed on an outpatient basis.

RESULTS

The device provided information that was reproducible and individual for each patient during the entire study period. During short-term tests, pulmonary artery pressure was reduced from a mean (of all patients) of 68 +/- 13 to 49 +/- 11 mm Hg, with a mean total effective treatment time of 49 +/- 8 min. Thereafter, pulmonary pressure returned to preinhalation levels before the next inhalation. Long-term tests showed similar results. During a total recorded time of 15,876 min, the vasodilator effect lasted 2,140 min, corresponding to 13% of the whole time span.

CONCLUSION

Our study provided new insights into the short-term and long-term effects of treatment with inhaled iloprost in patients with pulmonary hypertension. While there were no signs of tachyphylaxis, the improvement of central hemodynamics was much shorter than expected. Continuous hemodynamic monitoring with the IHM demonstrated the need to improve the treatment modalities of aerosolized iloprost in patients with pulmonary hypertension.

Human paraoxonase 1 gene polymorphisms and the risk of coronary heart disease: a community-based study

Published data on the association between paraoxonase1 (PON1) polymorphisms and coronary heart disease (CHD) have yielded controversial results. The objective of this study was to determine the possible relationship between the two human PON1 amino acid variants, the Leu55Met and the Gln192Arg polymorphism, and the risk of CHD in a community-dwelling cohort of European ancestry. PON1 genotypes of 152 women and 151 men out of 1,998 randomly selected individuals aged 44-75 years were determined by polymerase chain reaction-based restriction enzyme digestion. Study participants underwent cardiological examination including a structured clinical interview, resting ECG, exercise testing and echocardiography. The diagnosis of CHD was based on history and/or appropriate findings during cardiac examination. Evidence for CHD was found in 43 (14.2%) study participants. The Leu/Leu (LL), Leu/Met (LM) and Met/Met (MM) genotypes at position 55 were noted in 131 (43.2%), 128 (42.2%) and 44 (14.5%) subjects; the Gln/Gln (QQ), Gln/Arg (QR) and Arg/Arg (RR) genotypes at codon 192 occurred in 167 (55.1%), 118 (38.9%) and 18 (5.9%) individuals, respectively. Homozygosity for the 55L-allele was significantly associated with CHD (p = 0.02), while the Gln192Arg polymorphism had no effect (p = 0.16). Logistic regression analysis demonstrated age (odds ratio 1.06/year), smoking (odds ratio 2.86), HDL cholesterol (odds ratio 0.94/mg/dl) and the paraoxonase LL genotype (odds ratio 2.25) to be significant predictors of CHD. These data suggest that the paraoxonase LL genotype at position 55 may present a risk factor for CHD.

Effect of beta(1)-selective adrenergic blockade on maximal blood lactate steady state in healthy men

The aim of this study was to compare the effect of taking bisoprolol (B), a highly beta(1)-selective adrenoceptor antagonist to that of a placebo (P) on maximal lactate steady state (MLSS), which reflects the transition from oxidative to partially anaerobic metabolism. Ten healthy male subjects [mean (SD) age 23 (3) years, height 181 (6) cm, body mass 76 (6) kg] randomly received oral P or B (5 mg x day(-1)) for 2 weeks using a double-blind crossover design. In the 2nd week, the subjects performed an incremental cycle ergometer test until exhaustion to determine the second blood lactate turn point (LTP(2)). At regular intervals of 24-48 h, the subjects performed 2-3 steady-state tests to determine the MLSS. During the incremental exercise, heart rate (HR) was significantly lower at rest (15 beats x min(-1)), at LTP(2) (23 beats x min(-1)) and at maximal power output (19 beats x min(-1)) when taking B compared to P. Oxygen pulse was significantly higher taking B and no significant differences were observed for any of the respiratory gas exchange measurements (RGEM) (oxygen consumption, carbon dioxide production, minute ventilation, respiratory exchange ratio), exercise intensity or blood lactate concentration (LA) at baseline, at LTP(2) and at maximal power output. During exercise at constant intensity, significant differences between B and P were found for HR [148 (12) compared to 176 (11) beats x min(-1)] and oxygen pulse [21.8 (1.9) compared to 19.2 (1.6) ml] at MLSS. No difference was found for exercise intensity [216 (18) compared to 218 (18) W], for RGEM, LA [5.3 (1.1) compared to 4.8 (1.5) mmol x l(-1)] and ratings of perceived exertion [18.1 (1.6) compared to 17.4 (1.7)] for B and P at MLSS. In both, the power output at LTP(2) was slightly higher than power output at MLSS (within an intensity step). Commonly measured cardiorespiratory and subjective variables determined during treatment with 5 mg bisoprolol can be used for testing cardiorespiratory fitness and for prescription of training intensity.

Differing beta-blocking effects of carvedilol and metoprolol

BACKGROUND

Metoprolol is a beta(1)-selective beta-adrenergic antagonist while carvedilol is a non-selective beta-blocker with additional blockades of alpha(1)-adrenoceptors. Administration of metoprolol has been shown to cause up-regulation of beta-adrenoceptor density and to decrease nocturnal melatonin release, whereas carvedilol lacks these typical effects of beta-blocking drugs.

AIMS

To compare beta-blocking effects of metoprolol and carvedilol when applied orally in healthy subjects.

METHODS

We investigated the effects of single oral doses of clinically recommended amounts of metoprolol (50, 100 and 200 mg) and carvedilol (25, 50 and 100 mg) to those of a placebo in a randomised, double-blind, cross-over study in 12 healthy male volunteers. Two hours after oral administration of the drugs heart rate and blood pressure were measured at rest, after 10 min of exercise, and after 15 min of recovery.

RESULTS

Metoprolol tended to decrease heart rate during exercise (-21%, -25% and -24%) to a greater extent than carvedilol (-16%, -16% and -18%). At rest, increasing doses of metoprolol caused decreasing heart rates (62, 60 and 58 beats/min) whereas increasing doses of carvedilol caused increasing heart rates (62, 66 and 69 beats/min), 50 and 100 mg carvedilol failed to differ significantly from the placebo (71 beats/min).

CONCLUSIONS

We conclude that clinically recommended doses of carvedilol cause a clinically relevant beta-blockade in humans predominantly during exercise where it appears to be slightly (although not significantly) less effective than metoprolol. On the other hand, the effects of carvedilol on heart rate at rest appear rather weak, particularly in subjects with a low sympathetic tone. This might be caused by a reflex increase on sympathetic drive secondary to peripheral vasodilation resulting from the alpha-blocking effects of the drug. These results might be helpful in explaining why carvedilol, in contrast to metoprolol, may fail to cause up-regulation of beta-adrenoceptor density and does not decrease nocturnal melatonin release. This, in turn, may be a reason for the weak side-effects of carvedilol resulting from the beta-blockade. In addition, our data might be of interest in the interpretation of the forthcoming results of the COMET trial, although it has to be emphasised that they were derived from healthy subjects and, therefore, cannot be directly extrapolated to patients with heart failure.

[Angiotensin I receptor blockers for heart failure]

Angiotensin conversion enzyme inhibitors (ACE-inhibitors) have long been the only possibility to influence the renin angiotensin system (RAS) and its often fatal influences in heart failure. In the last few years specific blockers of the angiotensin 1 receptor (AT I blockers) offered a new possibility for this therapeutic target. In contrast to ACE inhibitors AT I blockers are relatively new and, therefore, few data on heart failure are available. The first head-to-head studies that compared AT I blockers and ACE-inhibitors and their effect on mortality did not show a reduced mortality in the AT I blocker groups. Based on the available data AT I blockers should be used in heart failure patients who are intolerant of ACE-inhibitors.

Change in left atrial and ventricular dimensions during and immediately after exercise

PURPOSE

The aim of this study was to evaluate differences in the left atrial (LAD), total ventricular end-diastolic (TEDD), end-systolic diameters (TESD), and left ventricular shortening fraction (SF) compared with heart rate (HR) and systolic blood pressure (SBP) during exercise and recovery.

METHODS

Healthy young male (N = 15) and female (N = 16) subjects performed an incremental cycle ergometer test in upright position, and three phases of energy supply were defined by means of blood lactate concentration (LA) and respiratory gas exchange variables (I: aerobic; II: aerobic-anaerobic transition; III: anaerobic). Subjects were required to rest their arms on a steering bar and to lean their upper body forward; two dimensional (2-D) echocardiograms were obtained over the left parasternal area at rest (R), at the end of each phase, immediately within 15 s post, and 6 min after exercise (6 min). By using VINGMED's "Anatomical M-Mode," it was possible to extract M-Mode Sweeps from stored 2-D-Loops and perform the M-Mode measurement.

RESULTS

In contrast to the significant decrease in TEDD and TESD from III to 15 s up to resting values and the significant increase in SF from III to 15 s, the moderate decrease in HR immediately post exercise (15 s) was not significant. The SBP showed a significantly decrease from III to 15 s; in contrast to TEDD, TESD, and SF, the values at 15 s were comparable with the values at II. For LAD, significant increase during exercise and a decrease during recovery were observed. Sex-specific differences of changes in measured variables could not be found.

CONCLUSION

We concluded that post exercise measurement of left ventricular and atrial dimensions or SF were not valid to describe heart function at maximal exercise although immediately post exercise HR was near maximal level.

Comparison of wrist blood pressure measurement with conventional sphygmomanometry at a cardiology outpatient clinic

OBJECTIVE

Oscillometric measurement of blood pressure at the wrist is becoming a widely used method for detection of hypertension and its control by treatment. The objective of the present study was to evaluate accuracy and suitability of wrist measurement in a clinical routine setting.

PATIENTS AND METHODS

A series of 333 consecutive patients admitted to our cardiology outpatient clinic were included. Blood pressure was measured at both upper arms according to World Health Organization-International Society of Hypertension guidelines. Oscillometric measurement was performed at the contralateral wrist simultaneously. Blood pressure readings were taken by an oscillometric device applied at the wrist ('Klock'; Industrielle Entwicklung Medizintechnik, Stolberg, Germany) and a conventional mercury sphygmomanometer applied at the upper arm.

RESULTS

Seventy-eight patients were excluded due to differences in blood pressure > 5 mmHg between both upper arms or due to 'error' messages of the wrist device. The data of the remaining 255 patients (149 males; mean age, 65 +/- 13 years; range, 18-95 years) are presented. Mean conventional blood pressure was significantly lower compared with the wrist device (137 +/- 20/80 +/- 11 mmHg versus 153 +/- 28/87 +/- 18 mmHg; P < 0.001 and P < 0.001). The mean difference was 16 +/- 25/6 +/- 17 mmHg. In clinical terms, differences in blood pressure exceeding +/-20/+/-10 mmHg reflecting classification of hypertension are considered important. Measurements of 101 (40%) patients were within these limits. Systolic readings of 110 (43%) and diastolic readings of 117 patients (46%) were beyond this scope.

CONCLUSION

Due to low reliability of wrist blood pressure measurement, it cannot compete with the upper arm standard procedure. If ever, it should only be used if test readings in an individual comparing wrist and upper arm measurement show differences within a range of +/-20/+/-10 mmHg.

N-terminal proatrial natriuretic peptide correlates with systolic dysfunction and left ventricular filling pattern in patients with idiopathic dilated cardiomyopathy

OBJECTIVE

To investigate the diastolic Doppler filling pattern in patients with idiopathic dilated cardiomyopathy and its relation to N-terminal pro-atrial natriuretic peptide (NT-pro-ANP).

METHODS

32 patients (26 male, six female) with idiopathic dilated cardiomyopathy were investigated. All were in sinus rhythm. Conventional M mode echocardiography and Doppler echocardiography was done in each patient. Pulsed wave Doppler inflow signals were obtained and the following variables were measured: maximum E wave, maximum A wave, E/A ratio, E wave deceleration time, A wave deceleration time. NT-pro-ANP was measured using radioimmunoassay.

RESULTS

Mean (SD) left ventricular ejection fraction was 34 (7)% and mean left ventricular end diastolic diameter on M mode echocardiography was 69 (7) mm. Left ventricular filling indices were as follows: maximum E wave velocity, 0.86 (0.22) m/s; maximum A wave velocity, 0.71 (0.24) m/s; E/A ratio, 1.41 (0.65). Mean E wave deceleration time was 140 (50) ms; mean A wave deceleration time was 100 (20) ms. In a stepwise forward regression model, NT-pro-ANP correlated significantly with left atrial diameter (r = 0.603; p < 0. 001), left ventricular ejection fraction (r = -0.758; p < 0.001), and Doppler derived E/A ratio (r = 0.740; p < 0.001).

CONCLUSIONS

In patients with idiopathic dilated cardiomyopathy there is a relation between NT-pro-ANP and both systolic and diastolic variables. In a multivariate model NT-pro-ANP correlated with left atrial diameter, left ventricular ejection fraction, and Doppler derived E/A ratio on transmitral inflow.

Natriuretic peptides in patients with diastolic dysfunction due to idiopathic dilated cardiomyopathy

AIMS

The degree of systolic dysfunction does not always correlate with functional impairment in patients with congestive heart failure. In contrast, diastolic dysfunction correlates well with functional impairment. In heart failure, both elevation of N-terminal proatrial natriuretic peptide and B-type natriuretic peptide are markers of a poor prognosis.

METHODS

We investigated 32 patients (26 male, 6 female; mean age 55+/-2 years) with dilated cardiomyopathy and sinus rhythm. M-mode echocardiography and 2D-echocardiography were carried out in each patient. Pulsed-wave Doppler inflow signals were obtained and the following parameters were measured: maximal E wave and maximal A wave velocity, E/A ratio, E wave deceleration time, A wave deceleration time. Immediately after echocardiography blood samples were collected from patients in the supine position. N-terminal proANP and brain natriuretic peptide were measured using a radioimmuno assay.

RESULTS

The left ventricular ejection fraction was 34+/-1%, the left ventricular end-diastolic diameter on M-mode echocardiography was 68+/-1 mm, while left atrial diameter was 45+/-1 mm. Univariate analysis revealed a significant correlation between both left atrial diameter and ejection fraction and N-terminal proANP and brain natriuretic peptide. All transmitral Doppler parameters showed a significant correlation with N-terminal proANP and brain natriuretic peptide. On forward stepwise regression analysis, left atrial diameter and ejection fraction were able to predict both N-terminal proANP and brain natriuretic peptide. However, of the diastolic parameters only the E/A ratio remained significant. Mildly symptomatic patients differed significantly from severely symptomatic patients in all Doppler parameters. Mildly symptomatic patients had significantly lower levels of N-terminal proANP (0.571+/-0.079 vs 2.282+/-0.340 nmol. l(-1);P<0.001) and brain natriuretic peptide (51+/-14.8 vs 474.2+/- 86.8 pg. ml(-1);P<0. 001).

CONCLUSION

There is a close relationship between natriuretic peptides and diastolic Doppler parameters of left ventricular filling in patients with dilated cardiomyopathy. There is also a significant difference between patients with mild and severe functional impairment regarding both natriuretic peptides and transmitral Doppler parameters.

[Results of efficacy study with diclofenac/orphenadrine infusions in patients with musculoskeletal diseases and functional disorders]

During a post-marketing surveillance study, 641 patients (age range 18 to 86 years) with painful rheumatic diseases, mostly of vertebral etiology, were given ready-for-use infusions containing a combination of the non-steroid antiphlogistic agent diclofenac (75 mg) and the muscle relaxing agent orphenadrine (30 mg) parenterally for 7 days. The goal of the study was to investigate efficacy, tolerability, and acceptance of this intravenous therapy in wide use in physicians' practices. At the end of treatment, the global evaluation resulted in a score of 1.6 on a scale of 1 (very good) to 4 (insufficient). The tolerability score was 1.3 and the acceptability score was 1.5. Only 20 patients (3.1%) had adverse effects, most of which were of gastrointestinal nature. The medication proved appropriate for use in the treatment of painful spine syndromes, inflammatory osteoarthritis, painful osteoporosis, post-operative conditions, and extra-articular rheumatism and could represent a first step towards multi-factorial therapeutic management of these diseases.

Pericardiocentesis Guided by Contrast Echocardiography

Although pericardiocentesis is a relatively safe procedure, there are some hazards, particularly when hemorrhagic fluid is aspirated. Having the opportunity to outline the space from which the fluid is withdrawn is of particular interest in this situation. A current technique of echocardiography with contrast enhancement involves injection of a few milliliters of agitated saline solution or reinjection of blood-stained fluid. Performing this procedure, we repeatedly observed a weak and inhomogeneous echo contrast; therefore, we evaluated the applicability of the ultrasound contrast medium SH U 454 (Echovist Schering, Berlin, Germany) for contrast enhancement in hemorrhagic pericardiocentesis. In all patients, pericardiocentesis was performed in a supine position by a subxiphoid approach. A Teflon catheter/needle unit attached to a syringe containing a few milliliters of contrast medium was introduced in the usual way. On the return of hemorrhagic fluid, 1-2 ml of Echovist was injected to provide contrast from the space from which it had been aspirated. We observed excellent contrast clearly outlining the pericardial space through the injection of 1-2 ml of contrast medium. No adverse or side effects were seen resulting from Echovist injection to the pericardial sac. In conclusion, contrast echocardiography appears to be a useful tool to secure the correct position of the needle during pericardiocentesis of hemorrhagic or loculated effusions. It is suggested that injection of Echovist should be considered whenever the contrast obtained by the conventional technique is poor and inconclusive.

[Drug therapy of chronic heart failure]

Prevention of disease leading to cardiac dysfunction, improvement of quality of life and reduction of mortality are the primary objectives in the treatment of chronic heart failure. The therapeutic possibilities are various, including general advices, pharmacological therapy and surgical interventions. Standard medical treatment of systolic cardiac dysfunction contains ACE inhibitors, diuretics and cardiac glycosides. Beta-blocking agents, oral anticoagulation and antiarhythmic drugs can be used in addition. A therapeutic management of chronic heart failure tailored to the individual patient has nowadays become available due to multiple treatment options.

[Diagnosis of heart failure]

Heart failure is a clinical syndrome caused by various etiologic factors. The physician should undertake every effort to identify potentially reversible causes that lead to heart failure. Therefore one should go through various non-invasive as well as invasive diagnostic procedures. The diagnostic tests can be helpful in identifying patients with a poor prognosis.

Parasympathetic receptor blockade and the heart rate performance curve

Parasympathetic receptor blockade and the heart rate performance curve. Med. Sci Sports Sci., Vol. 30. No. 2, pp. 229-233, 1998. The aim of the present study was to investigate the influence of parasympathetic receptor blockade on the heart rate performance curve (HRPC). Twenty healthy male subjects performed a first cycle ergometer test (F), showing a HRPC deflection of varying degree and direction. Subjects then in random order performed two additional cycle ergometer tests, one with atropine (A) and the other with placebo (P). Two lactate turn points (LTP1, and LTP2) were determined by means of linear regression turn point analysis. The degree and direction of the deflection of the HRPC was calculated mathematically as factor kHR (kHR>0 = downsloping of HPRC; kHR<0 = upsloping of HRPC). In comparison with that in F and P, HR in A was significantly higher at rest, LTP1, LTP2, and during recovery, but not at Power(max). An upsloping deflection of the HRPC was seen in only five cases in F and P, whereas in A 10 cases were observed (P < 0.05). In A, kHR was significantly lower than in F and P. A significant correlation for kHR was found among F, P, and A. Independent from parasympathetic receptor blockade and the HR at Power(max), the HR at LTP2 was lower in cases with negative kHR (upsloping). In A as well as in P a significant correlation was observed between kHR and HR at LTP2. The individual time course of HRPC is reproducible and may be independent of parasympathetic activity.

Bradydysrhythmia-related presyncope secondary to pheochromocytoma

Pheochromocytoma endures as a life-threatening disorder. In the absence of systemic hypertension, diagnosis may be difficult. We present a 46-year-old normotensive male with a history of presyncope. One of these episodes could be documented, and revealed symptomatic bradycardia suspicious of sinus node arrest. Due to hints of an elevated sympathetic tone (Schellong test, circadian blood pressure pattern without diurnal rhythm) 24-h urinary catecholamine concentrations were measured and found increased. MIBG-scintigraphy and abdominal-computed tomography indicated the location of the pheochromocytoma. After removal of the tumour, no further episodes of presyncopes or bradydysrhythmias were observed.

Increased neopterin in patients with chronic and acute coronary syndromes

OBJECTIVES

The aim of our study was to determine neopterin levels in patients with chronic and acute coronary syndromes.

BACKGROUND

In chronic and acute coronary syndromes the release of different cytokines activates cellular defense. Infiltration of neutrophils and monocytes/macrophages is detected in the vessel wall as well as in the myocardium. Neopterin, which is a by-product of the guanosine triphosphate-biopterin pathway, is a marker for those activated macrophages.

METHODS

We studied 123 subjects: 1) 21 consecutive patients (17 men, 4 women; mean age +/- SD 66 +/- 15 years, range 31 to 87) with acute myocardial infarction (AMI); 2) 62 consecutive patients (50 men, 12 women; mean age 61 +/- 8 years, range 43 to 81) with signs and symptoms of clinically stable coronary artery disease (CAD); and 3) 40 healthy blood donors (28 men, 12 women; mean age 35 +/- 13 years). Neopterin levels were determined with a commercially available enzyme-linked immunosorbent assay method.

RESULTS

In patients with AMI before thrombolytic therapy, neopterin levels were significantly higher than levels in patients with CAD and control subjects (13.7 vs. 8.6 and vs. 6.8 nmol/liter, p < 0.0001). Values also differed significantly between patients with CAD and control subjects (p < 0.0001). Neopterin levels in patients with AMI were measured seven times during a 72-h period. Within-group comparison showed significant differences over this period (p < 0.00001). The lowest value (11.4 nmol/liter) was observed after 4 h and differed significantly from the initial value and values after 24 and 72 h (p < 0.05). After 72 h, neopterin increased to 14.9 nmol/liter, a value significantly different from all values other than the initial one. There was no correlation between neopterin and creatine kinase (CK); CK, MB isoenzyme; or lactate dehydrogenase as markers for the extent of the myocardial infarction during the observation period.

CONCLUSIONS

Our data support the hypothesis of an activation of monocytes and macrophages in patients with an acute or chronic coronary syndrome. Neopterin as a marker for macrophage activation is significantly increased in patients with chronic CAD and more pronounced in patients with AMI shortly after the onset of symptoms.

Left ventricular function in response to the transition from aerobic to anaerobic metabolism

The purpose of this investigation was to study myocardial function at rest, during three phases of energy supply, and during recovery. Radionuclide angiography was performed during the aerobic phase (phase I, rest-first lactate increase), the aerobic-anaerobic transition phase (phase II, first lactate increase-second lactate increase), the anaerobic phase (phase III, second lactate increase-maximal work performance (Pmax)), and during recovery. Thirty-eight male patients (59 +/- 7 d after myocardial infarction) were compared with 19 healthy control subjects and 21 sport students of comparable age. Left ventricular ejection fraction (LVEF) increased from rest to phase I and from phase I to phase II in sports students and control subjects. During phase III, LVEF did not change significantly in sports students, but it decreased significantly in control subjects. This is in contrast to the patients, who showed an increase of LVEF from resting values (47 +/- 3%) to phase I (50 +/- 1%), no change during phase II (51 +/- 2%), and a decrease to resting values (45 +/- 2) during phase III. All subjects showed an increase in stroke volume (SV) during phase I and II, reaching a maximum at phase II. This was evidenced by an improvement of the systolic function with a constant left ventricular end-diastolic volume (EDV) in control subjects and sports students. In contrast, an improved SV in patients was achieved through an increase in EDV and a less distinct increase in the left ventricular end-systolic volume (ESV). Maximal LVEF values were measured during the first 90 s of recovery in all subjects. Values during recovery are not representative of load dependent myocardial function. This increase in LVEF does not cause an increase in cardiac output but is a consequence of changes in the EDV and ESV, which decrease again immediately after the end of exercise performance.

[The extent of diastolic dysfunction and its correlation with subjective impairment of physical capacity in dilated cardiomyopathy]

OBJECTIVE

To find out whether in patients with dilated cardiomyopathy (DCM) there is a correlation between subjective reduction in physical capacity and the transmitral Doppler profile as a measure of left ventricular (LV) filling.

PATIENTS AND METHODS

30 consecutive patients (24 men, six women; average age 55 +/- 2 years) with chronic primary DCM were examined by Doppler echocardiography to determine possible differences in LV filling pattern, in correlation with subjective impairment of physical capacity graded according to the New York Heart Association (NYHA) classification.

RESULTS

Mean LV ejection fraction was 34 +/- 1%. All patients were in sinus rhythm. Eight patients, in NYHA class I had nearly normal LV filling (E wave 79 m/s, A wave 0.76 m/s); 11 patients in class II had impaired relaxation (E wave 0.77 m/s. A wave 0.82 m/s) and 11 in class III/V had a restricted filling pattern (E wave 0.98 m/s. A wave 0.57 m/s). There was a significant difference between class II and class III/IV patients with regard to E wave deceleration time (0.15 and 0.11 s, respectively; P < 0.05), as well as between class I and class III/IV patients (0.18 and 0.11 s, respectively; P < 0.05). The A wave deceleration time was clearly shorter in class III/IV than class II (0.08 s and 0.11 s; P < 0.05) and class I patients (0.08 s and 0.10 s; P < 0.05).

CONCLUSIONS

The extent of LV diastolic dysfunction correlated with subjective physical capacity. The more the LV filling pattern had changed from normal towards restricted, the greater the patient's symptoms.

Subclinical thyroid disorders in patients with dilated cardiomyopathy

Severe thyrotoxicosis can cause irreversible congestive heart failure. To investigate the coincidence of subclinical thyroid disorders and idiopathic dilated cardiomyopathy (IDC) we investigated these patients with respect to their morphological and functional thyroid status. Thyroid sonography as well as thyroid hormone levels were measured in all patients.

RESULTS

Sixty-one patients (50 male, 11 female) with chronic stable IDC were included. Two out of 61 patients showed completely normal thyroid morphology and function. The other 59 patients showed either morphological or functional abnormalities or both. Of the 53 patients with morphological abnormalities 23 patients (all male) showed diffuse goiter as opposed to 29 nodular enlarged organs (24 male, 5 female). No clinically significant hypothyroidism or thyrotoxicosis was seen. A good correlation was found between the duration of IDC and thyroid volume (r = 0.44; p < 0.001). Two patients died during the study period, 1 from sudden death and 1 from progressive heart failure.

CONCLUSION

Subclinical thyroid disorders are frequently seen in patients with long-standing IDC when they live in an area of chronic iodine deficiency. This can be explained by chronic salt restriction as basic treatment for congestive heart failure. Therefore we conclude that examination of the thyroid gland should be done routinely in patients with IDC, especially when restriction of salt intake is recommended by the treating physician.

Syncope in dilated cardiomyopathy is a predictor of sudden cardiac death

Fifty percent of patients with dilated cardiomyopathy die within 5 years of diagnosis. Syncope is known to be a predictor of poor outcome in patients with advanced heart failure. To assess the risk of patients with dilated cardiomyopathy with a history of syncope during standard medical treatment we compared this group to similar patients without syncope. Twenty-three patients with angiographically proven dilated cardiomyopathy and syncope were followed prospectively and compared to 201 patients without history of syncope. All patients showed a left-ventricular ejection fraction of less than 45%. Both groups did not differ in left-ventricular ejection fraction at baseline (30 +/- 7% in the syncope group, 30 +/- 8% in the no syncope group). Mean follow-up was 2.6 years in the syncope group and 2.4 years in the no syncope group. At baseline, syncope patients used more often amiodarone (p < 0.04), while there was no statistically significant difference between the two groups regarding the intake of digitalis, diuretics and angiotensin-converting enzyme inhibitors. Twenty-six percent of patients in the syncope group and 20% in the no syncope group died during follow-up (non significant). The striking difference, however, was the type of death: 5 out of 6 patients in the syncope group died suddenly compared to 13 of 41 patients in the no syncope group (p < 0.025). Patients with dilated cardiomyopathy and a history of syncope are at high risk of sudden death.

[Coronary aneurysm in a 69-year-old patient. Transthoracic echocardiography]

This case report is on a 69-year old male patient treated with cephalosporins because of suspected myocarditis due to borreliosis. Using transthoracic echocardiography a big aneurysm of the proximal part of the left coronary artery was detected. Coronary angiography revealed an aneurysm 1.2 cm in diameter at the origin of the left anterior descending branch and confirmed the initial diagnosis. In addition, coronary three-vessel disease with reduced left ventricular function was found. Coronaritis due to Lyme borreliosis could not be ruled out with certainty. The patient was relatively asymptomatic, and hence conservative therapy was recommended. The case described here serves as a basis for a discussion on the aetiology, clinical manifestation, diagnosis and therapeutic management of coronary aneurysms.

[Thrombosis of a prosthetic mitral valve in the anticardiolipin syndrome]

A 40-year-old woman in whom the mitral valve had to be replaced with a prosthetic one (St. Jude's) had to be reoperated 8 months later because of endocarditis on the second prosthetic valve (Carbo-Medics). Four months later her general condition deteriorated progressively with cough and dyspnoea, requiring hospitalization. Auscultation revealed moist rales over both lung bases; heart sounds were distant but otherwise normal. The "international normalized ratio" was 2.5, while erythrocyte sedimentation rate, white cell count and C-reactive protein were normal. Transthoracic echocardiography demonstrated a hardly moving mitral valve prosthesis with an opening area of 0.8 cm. Subsequently this decreased further and measurement of the anticardiolipin antibody titre revealed an IgG fraction of 37.9 U/ml (normal up to 12 U/ml). Within 48 hours thrombolysis with streptokinase had increased the valve's opening area to 1.8 cm. The patient made an uneventful recovery under strict anticoagulation. This case illustrates that the anticardiolipin syndrome can be a cause of an otherwise unclear genesis.

Transient reduction of autoantibodies against oxidized LDL in patients with acute myocardial infarction

Fifteen consecutive patients (mean age 66 +/- 14, range 31-82) with an acute myocardial infarction (MI) suitable for thrombolytic therapy were included in this study. Autoantibodies against oxidized low-density lipoprotein (LDL) were determined by enzyme-linked immunosorbent assay (ELISA). Patients (n = 10) with marked elevation of the MB isoenzyme of creatinine kinase (CK-MB)-mass had significant decreases of oLDL-Ab during the acute phase, with a minimum after 8 h following the onset of thrombolytic therapy (within-group significance: p < .001; between groups: p = .01). Patients (n = 5) with CK-MB-mass values less than 70 ng/ml did not show this phenomenon. Furthermore, significant correlations existed between CK-MB-mass and oLDL-Ab after 6 and 8 h (n = 15; r = .72; p = .003) and the time of the highest CK-MB-mass values (after 12 h) and the time of the maximal decrease of oLDL-Ab (after 8 h) (r = .74; p = .003). Our observations provide further evidence for the release of free radicals and for increased lipid peroxidation during reperfusion after prolonged ischemia. The decrease of oLDL-Ab appears to be a marker for the severity of MI.