[Atlantoaxial malformation as a rare cause of dysphagia and snoring]. / Eine atlantoaxiale Fehlbildung als seltene Ursache für Dysphagie und Rhonchopathie.

Abnormalities of the atlantoaxial spine are very rare variants. Bony outgrowths, osteophytes, clefts and aplasia may be misinterpreted as degenerative diseases. One patient presented with intermittent dysphagia and snoring and CT and MRI scans of the cervical spine showed an accessory bone located anterior to the atlas and axis. Atlantoaxial anomalies are often incidental findings without clinical symptoms. Such changes are rarely the cause of intermittent dysphagia and snoring.

Patients' profiles in end stage coronary artery disease. Indications for treatment with transmyocardial laser revascularisation.

There is a subgroup of patients with coronary artery disease who are refractory to the therapeutical methods so far applied. We report on 128 patients who fulfill this definition and have therefore undergone pure transmyocardial laser revascularisation (TMLR) or transmyocardial laser revascularisation in combination with coronary bypass surgery at our institution. The patients can be characterized by a long history of coronary artery disease with multiple revascularizing procedures, e.g. bypass surgery or percutaneous transluminal coronary angioplasty (PTCA), pronounced symptoms of coronary artery disease and chronic heart failure in the presence of markedly reduced left ventricular ejection fractions and intense antiischemic medical therapy. The patients were 62.2 +/- 9.8 (SD) years of age, in 89.9% of them at least one bypass operation and in 44.5% up to more than three percutaneous transluminal coronary angioplasties (PTCAs) had been performed prior to TMLR. There was a history of myocardial infarction in 90.7% of patients and 89.8% were in the Canadian Cardiovascular Society (CCS) classes III or IV and 94.5% of them were in the NYHA classes III or IV. The left ventricular ejection fraction was 49.5 +/- 16.4% and all of the patients were under intense antiischemic medical treatment which included nitrates or molsidomine in 96.9%, beta blockers in 53.1%, angiotensin converting enzyme inhibitors (ACE inhibitors) in 44.5%, digitalis in 22.7% and diuretics in 52.3% of patients. The preoperative data on myocardial viability, inducible ischemia and coronary morphology provided important clinical information for the decision, which revascularizing method would be the most appropriate for each vessel or myocardial region. This had to be weighed against the patient's operative risk, which is predominantly determined by the left ventricular ejection fraction, the arteriosclerotic involvement of the remaining vascular system and concomitant diseases, particularly of pulmonary origin.

[Transmyocardial laser revascularization and rehabilitation]. / Transmyokardiale Laserrevaskularisation und Rehabilitation.

Transmyocardial laser revascularization (TMLR) is a new technique for patients with CAD or heart attack to revascularize ischemic areas of the myocardium in which the localisation or the condition of the vessels does not allow bypass grafting. This study shows the results in observation of patients before and during the first 3 months after TMLR. Of 110 patients operated on from 1994 to 1996, 86 were evaluated for well being (quality of life), using NYHA- and CCS-classification, stress test and nitril-scintigraphy at rest and under stress conditions. 51 patients, of whom 11 were females, underwent TMLR combined with coronary artery bypass graft (CABG). 35 male patients were treated singularly with TMLR. The average age in both groups was 59 years (+/- 23). All patients were subject to phase I rehabilitation in specialised institutions after being mobilised in the operating hospital. The evaluations took place on the day of admission to the hospital prior to surgery, within 10 days after surgery and 3 months following. The average stay in the rehabilitation-institution was between 4 and 6 weeks. Our findings demonstrate that both groups profited from the procedures, while the TMLR/CABG group showed a faster recovery and a better outcome. In comparison to 57% of the TMLR group, 85% of the patients in the TMLR/CABG group reported an improvement ranging from good to significant in quality of life assessments. The TMLR/CABG rated from an average of initially 3.4 (+/- 0.6) to 2.1 (+/- 0.8) after 3 months at NYHA- and 3.3 (+/- 0.7) to 1.7 (+/- 0.8) at CCS-classification. The TMLR group rated from 3.6 (+/- 0.5) to 2.4 (+/- 0.8) in NHYA- and from 3.4 (+/- 0.5) to 1.9 (+/- 0.7) on the CSS-scales. A remarkable improvement was noted in the stress test with an increase in power and endurance from 21 to 89 watts for the combined group and 8 to 81 watts for the TMLR treated patients, who generally recovered more slowly. The perfusion scan showed the same tendencies as previously reported but in some cases the results were not congruent with other findings. Overall, our findings indicate that there is a benefit for terminally symptomatic CAD patients after TMLR, but an observation period of 3 months does not allow for final conclusions on this matter. Rehabilitation seems to be of value for TMLR-patients since they have shown a markedly better performance following 3-month treatment, but further data from clinical randomised trials are needed to determine the influence of TMLR with short- and long-term rehabilitation on the prognosis of the disease.

Immunosuppressive treatment for myocarditis and dilated cardiomyopathy.

This overview examines the immunological rationale for immunosuppressive and immunomodulating therapy in man and experimental animals. The controversy of whether immunosuppressive treatment is beneficial in myocarditis will continue even after the Myocarditis Treatment Trials has been published. It is known that in viral heart disease immunosuppressive drugs should be avoided, but in autoreactive forms of myocarditis with proven humoral and cellular effector mechanisms they may be used in controlled randomized trials to validate or refute their benefit. Immunomodulating factors, e.g. immunostimulatory or antiviral substances such as ribaverin, the interleukins and interferons have demonstrated some effect in experimental animal myocarditis but proof of their benefit in man is still lacking. Hyperimmunoglobulin therapy appears to be of particular interest because it incurs few side effects and has positive results in cytomegalovirus-associated myopericarditis in man and suspected myocarditis in children.

[Retrospective studies and prospects of therapy for hypertension]. / Retrospektive und Perspektiven der Hochdrucktherapie.

Future trends in hypertensive treatment have to rely on our past and present experience with antihypertensive drugs as well as on emerging concepts of blood pressure regulation, on which some new drugs in the "pipeline" are based. Early detection of hypertension, before organ manifestations particularly in the heart, the kidney and the vessels occur, remain mandatory since in most of the patients with mild and moderate hypertension the high blood pressure is not diagnosed at all or treated inadequately. Prevention of cardiac, vascular, renal or metabolic complications has always been better for the patient and less costly than their repair or reparation. Our present treatment goals have often not reached far enough. Normalisation of blood pressure demonstrates only surrogate efficacy of our treatment. Our ultimate goal has to be improvement of total or cerebrovascular or cardiovascular and cardiac mortality. Important steps on that road are the prevention or reparation of cardiac hypertrophy, of the increased extracellular matrix and collagen deposition, the conservation of vascular integrity including both coronary and systemic microangiopathy and macroangiopathy. For the patient this means integrated care of his associated disorders that is of coronary artery disease, diabetes mellitus, lipid disorders, overweight and the metabolic syndrome. True health efficacy (= reduction of total or cerebro- and cardiovascular mortality) has been demonstrated so far only by blood pressure reduction with diuretics (thiazides) and beta-blockers in long term studies, whereas sufficient surrogate efficacy, the lowering of blood pressure, has been demonstrated with almost all the others drugs either in mono- or in combinationtherapy. Together with ACE-inhibitors, which have demonstrated their prognostic value in patients with heart failure of different causes, thiazides (as the most representative diuretic) and betablockade can be considered first line drugs in the treatment of hypertension. Long-term mortality trials for ACE-inhibitors in hypertension are needed, however, to prove that the anticipated benefit from the heart failure megatrials can also be taken for granted for hypertensive patients without coronary artery disease as well. All other drugs should not or not yet be considered first line medication, although treatment behavior in the US and in Europe shows wide-spread use of calcium antagonists in short- and long-acting dihydropyridine type hypertensive patients. No peer reviewed journal has so far published a randomized double-blind trial with the endpoint of total or cardiovascular mortality in hypertension using calcium antagonists. A recent case control study, as well as the preliminary data from MIDAS and GLANT, for which event rates are available in abstract form, suggest that short acting calcium-antagonists of the dihydropyridine type, though controlling blood pressure well, are not reducing mortality but show a trend to increase cardiovascular events particularly when given in higher doses. In contrast the unpublished data from a Chinese megatrial with dihydropyridines (STONE) demonstrate effective blood pressure reduction and benefit in mortality in a population that differs from patients in Europe and in the USA because of the low prevalence of coronary artery disease. No randomized, double blindly acquired data on mortality as the primary end of antihypertensive treatment are yet available for verapamil, diltiazem and the new class of longer acting calciumantagonists. Only when speculating from trials with calcium antagonists in coronary artery disease e.g. the DAVIT II study, one could imagine so far that prognostic benefit may be expected from drugs that do not or very little activate the adrenergic and the renin-angiotensin-aldosterone system and the baroreceptors and reduce or at least maintain heart rate. The need for double blind, randomized trials with the different Ca-antagonists is obvious, before a further w

Pericardioscopy and epicardial biopsy--new diagnostic tools in pericardial and perimyocardial disease.

Pericardioscopy is a new diagnostic tool for macroscopic visualization of alterations in both the epicardium and pericardium. We report on 35 patients with pericardial effusion due to inflammatory perimyocardial disease. After puncture of the pericardial effusion, an 8F sheath was introduced over a guidewire under X-ray control. The pericardial pressures were measured; the fluid was removed by aspiration and exchanged with 100 ml of body-warm saline until the pericardial fluid was clear. To visualize the peri- and epicardium, for video- and photo documentation, two sorts of 8F endoscope were used, either a flexible fibreglass version or a rigid 110 degree one--both made by Storz. Cytology of the fluid and optically guided and controlled epicardial and pericardial biopsies were performed to classify the form of pericarditis. A specific diagnosis of viral pericarditis could thus be established in seven cases--by in situ hybridization for cytomegalovirus (n = 3) and by microneutralization test for enteroviruses and/or coxsackievirus B4 isolation (n = 4); of lymphocytic perimyocarditis in 16; of bacterial pericarditis in seven and antibody-mediated autoreactive pericarditis in five cases.

[Löffler endocarditis fibroplastica with simultaneous infectious endocarditis]. / Endocarditis fibroplastica Löffler mit gleichzeitiger infektiöser Endokarditis.

The clinical and immunological 8-year follow-up of a 45-year old female with hypereosinophilic syndrome and cardiac involvement of Löffler's fibroplastic endocarditis which was complicated by infective endocarditis during immunosuppressive treatment is presented. All 3 stages of the disease were documented by clinical and histologic data: stage 1 by biopsy proven eosinophilic myocarditis and arteritis, stage 2 with Berlin blue positive parietal thrombosis, and the fibrotic features of stage 3 both by fibrosis in the latest biopsies and by echocardiography. It was remarkable, however, that this classic clinical case of Löffler's endocarditis lacked a few serological markers postulated to be found regularly, e.g., a positive staining for the cationic protein and major ribonucleases. Instead, the patient demonstrated all the immunological features of autoreactive myocarditis with cytolytic, complement fixing antimyolemmal antibodies. After an initial loading dose of 120 mg prednisolone per day for 6 weeks (11/1986), the steroid dosage was reduced to 40 mg (12/1986) and diminished to 15 mg/day in 1988 to 1989. Finally, the patient was on 4 mg prednisolone per day for almost 4 years. In 1987, azathioprine was added in the dose of 150 mg/day for 6 weeks. In 3/1994 the patient developed infective endocarditis with streptococcus sanguis and presented with dyspnoea. By echocardiography a large floating structure was diagnosed on the anterior mitral leaflet and the left atrium was enlarged by severe mitral regurgitation. Infective endocarditis was successfully treated with antibiotics, but mitral regurgitation made valve replacement obligatory.

[Aortic and mitral valve endocarditis after infection of the pacemaker pocket]. / Aorten- und Mitralklappenendokarditis nach Schrittmachertascheninfektion.

The case of a 76-year-old diabetic patient with known aortic valve sclerosis is reported. One week after implantation of a permanent pacemaker system (indication: 2nd degree AV-block type Mobitz) he developed fever. Large endocarditic vegetations were found on the aortic and mitral valve (blood cultures: were positive for Staphylococcus aureus). Also from the pacemaker bed Staphylococcus aureus was isolated and an antibiotic treatment including vancomycin was started. Nevertheless the patient developed insufficiencies of both the aortic and mitral valves and became hemodynamically unstable. Due to cerebral embolisms and further deterioration of the patient's overall clinical state the already planned operative replacement of the aortic and mitral valve could not be performed. The patient died because of left ventricular failure after pacemaker infection which was complicated by endocarditis.

Immunosuppressive treatment in autoreactive myocarditis--results from a controlled trial.

It is still a matter of controversy whether immunosuppressive therapy is beneficial in patients with acute myocarditis, although autoimmune mechanisms play an important role in the development of myocarditis and its sequelae, for example, in dilated heart muscle disease, particularly because it is postulated that in man immunosuppression may aggravate the viral cell damage that is proposed to trigger the myocarditis. We report the clinical (NYHA-class), haemodynamic (improvement of left ventricular ejection fraction, left ventricular end-diastolic volume index), histological (infiltrate, fibrosis, myocyte hypertrophy) and immunohistological (immunoglobulin and C3-binding) findings in a controlled study including 17 patients with active myocarditis or acute perimyocarditis who were treated with a combination of prednisone and azathioprine for 3 months. We compared them with 21 patients of comparable clinical and haemodynamic compromise who underwent conventional treatment. Follow-up examinations were performed after 3 months. There was significant improvement of ejection fraction and NYHA-classification under immunosuppressive treatment. Infiltrates were reduced significantly in the immunosuppressed patients group only. Binding of IgG and IgM in the endomyocardial biopsy was diminished slightly but not significantly by both regimens. Fibrosis and myocyte hypertrophy were augmented in both treatment arms. There was no difference with respect to prognosis: four patients died or underwent heart transplantation in the immunosuppressive treatment group compared to five conventionally treated patients.

Cytomegalovirus associated inflammatory heart muscle disease.

Cytomegaloviruses(CMV) belong to a group of cardiotropic DNA-viruses with well-documented but sporadic cardiac involvement. By in situ hybridization with a biotinylated cDNA probe CMV-DNA was analysed in 2 different series of patients(1982-1988; 1989-1991) in the endomyocardial biopsy specimens of 35 patients with active myocarditis as defined by the Dallas criteria, and of 35 patients with acute perimyocarditis (pericardial effusion and cardiomegaly or segmental wall motion abnormality and/or an endomyocardial biopsy positive for active myocarditis) were analysed. 51% of patients with active myocarditis, 65% positive findings were observed in patients with perimyocarditis when all positive signals in the myocardium were taken into account. Since in interstitial cells and the vascular endothelium HCMV-DNA was also detected in controls we conclude that only HCMV-DNA in the nuclei are specific for HCMV-associated myocarditis. The incidence of positive signals in the myocytes was lower: 14% of all myocarditis patients and 8.5% of all pericarditis patients demonstrated this pattern. The results from in situ hybridization were compared to circulating anti-CMV antibodies from by an ELISA. As possible predisposing immunologic factors or associated alterations of effector functions we found a shift from normal to reduced natural killer cell activity and a marginal increase in B- and activated T-cells in the peripheral blood.

Ventricular arrhythmias in hypertensive heart disease with and without heart failure.

Forty-two patients with hypertensive heart disease but without coronary macroangiopathy were examined for ventricular arrhythmias by means of 24-h, long-term electrocardiograms (ECG). They were divided into two groups according to specific criteria. Group 1 was composed of 30 patients with left ventricular hypertrophy but normal ventricular volumes, as determined by ventriculography. Group 2 comprised 12 patients with left ventricular hypertrophy and dilated left ventricles. By means of two 24-h, long-term ECGs, the mean absolute number of ventricular extrasystoles was ascertained and severity was determined according to the classification of Ryan et al. On average, patients in group 2 showed 7.830 +/- 6.579 extrasystoles, a significantly higher (p less than 0.001) number than in patients in group 1 who had 1.132 +/- 2.639 extrasystoles/24 h. Moreover, 67% of patients in group 2 had Ryan's class 4a ventricular arrhythmias (couplets) or 4b disorders (ventricular tachycardia). However, corresponding rhythm disorders could be found in only 7% of the patients in group 1. A comparison of hemodynamic parameters and ventricular arrhythmias showed that a decreasing left ventricular ejection fraction (EF, expressed in %), a decreasing mass/volume ratio (LVMM/EDV), and an increasing systolic wall stress of the left ventricle (Tsyst) are accompanied by a nearly linear increase in ventricular extrasystoles and in the severity of the ventricular arrhythmias. During long-term ECGs, nine of 10 patients with systolic wall stress of greater than or equal to 300 dyn x 10(3)/m2 showed Ryan's class 4a or 4b ventricular arrhythmias or ventricular tachycardia during programmed ventricular stimulation. However, 12 patients with normal systolic wall stress (less than or equal to 200 dyn x 10(3)/m2) showed no or only Ryan's class 1 ventricular arrhythmias. Our investigations have shown that cardiac ventricular rhythm disorders frequently occur during decompensated hypertensive heart disease, but to a lesser extent in left ventricular hypertrophy without dilation. Further investigations are needed to demonstrate whether regression of left ventricular hypertrophy is accompanied by a reduction in the incidence of ventricular arrhythmias.

Hypertensive heart disease and endocardially recorded late potentials.

Thirteen patients with compensated (group 1) and six patients with decompensated hypertensive heart disease (group 2) were examined for ventricular late potentials using endocardial recording techniques. With endocardial catheter mapping, left ventricular late potentials could be recorded in six patients in group 2 (100%) but only in one patient from group 1 (8%); right ventricular late potentials could not be recorded in group 1 or in group 2 patients. The amplitudes of the late potentials were always in the microvolt range, with values ranging between 170 and 620 microV (with a mean of 349 +/- 152 microV). The coupling intervals of the late potentials--measured from the beginning of the preceding QRS complex to the beginning of the late potential--were found to be between 110 and 440 ms (with a mean of 311 +/- 122 ms). Late potentials could only be recorded in patients with reduced left ventricular pumping function--i.e., patients with an ejection fraction of less than 62% and a cardiac index of less than or equal to 2.9 L/min/m2, whereas patients with normal hemodynamic parameters had normal endocardial electrograms. Ventricular arrhythmias were recorded during 24-h, long-term electrocardiogram (ECG) in all patients in group 2 (100%) and in five patients from group 1 (38%). Ryan's class 2-4b malignant ventricular arrhythmias were only found in patients with demonstrable ventricular late potentials and reduced left ventricular pumping function. The present study shows that ventricular late potentials, and thus also ventricular arrhythmias, are found almost exclusively in patients with decompensated hypertensive heart disease.(ABSTRACT TRUNCATED AT 250 WORDS)

The human sinus nodal electrogram: techniques and clinical results of intra-atrial recordings in patients with and without sick sinus syndrome.

An intra-atrial recording technique previously employed in animal experiments was successfully used to record SNP from the anatomic sinus nodal region of the high right atrium in 29 out of 41 patients (71%) thus examined. Due to the low amplitudes (microvolt range, 40 to 120 microV, mean 79 +/- 20 microV), these potentials were discernible only on high amplification (A = 10(4) to 10(6)), but with a conventional electrode catheter. Against the background of a gradual diastolic depolarization (0.6 to 3.5 microV/msec, mean 1.9 +/- 0.71 msec), SNP stood out distinctly from the subsequent abrupt atrial depolarization. In four patients with SSS, first- and second-degree sinoatrial blocks, respectively, were recorded. SACT were measured both directly and indirectly, and the results were compared in all 18 patients without SSS and in 11 patients with SSS. Although the recordings were not made simultaneously, the paired values for the patients without SSS correlated well (r = 0.890, p less than 0.001), whereas no correlation was found in the patients with SSS (r = 0.163, p = 0.316). In spite of unresolved questions, direct recording of SNP appears to be of potential value in evaluating patients with SSS.

Sequential intervention procedures after intracoronary thrombolysis; balloon dilatation, bypass surgery, and medical treatment.

After successful intracoronary thrombolysis of an acute myocardial infarction in 145 patients subsequent intervention procedures were evaluated. In 48 of 62 patients (43%), percutaneous transluminal coronary angioplasty was performed successfully (success rate 77%), 41 patients (28%) were operated on and 56 patients (39%) were treated only medically. During the hospital phase in the angioplasty group, 4 reinfarctions were noted and 3 repeat angioplasties were required, while 41 of the 48 successfully treated patients (85.4%) remained clinically stable. In the surgical group, one cardiac failure occurred, while 40 patients (97.6%) were without cardiac event. In the medical group, 5 patients died (8.9%), 8 patients (14.3%) had a reinfarction, and 76.8% were clinically stable. During the follow-up period in the surgical group of 6 months 37 patients (90.2%) were clinically stable, all in functional classes I and II. In the angioplasty group 33 patients were stable (68.8%), and in the medical group 26 patients were stable (46.6%). In the whole group of 145 patients the hospital mortality together with that in the 6 months follow-up period was 9.7% with a reinfarction rate of 22.8%.

Frequency and significance of left and right ventricular late potentials after myocardial infarction in man.

Left and right heart catheterization was conducted on 45 patients with a history of myocardial infarction in order to detect so-called ventricular late potentials by means of endocardiac mapping. The endocardiac signals were amplified 100 to 10,000 times at a low noise level using bipolar electrode catheters. The signals were stored unfiltered and visualized directly on an oscilloscope. Consistently recurring late potentials were recorded after QRS complexes in 32 patients (71%). They ranged in amplitude from 50 to 780 microV, while the coupling intervals were measured in the range of 80 to 620 ms from the beginning of the QRS complex to the beginning of the late potential. In some patients, the intracardially registered and/or Holter-monitored ventricular ectopic beats occurred with a delay, corresponding to the delayed occurrence of the ventricular late potentials.

[Late potentials--endocardial lead following myocardial infarct]. / Spätpotential--Endokardiale Ableitung nach Herzinfarkt.

In 27 patients with myocardial infarction, late potentials were sought by means of diagnostic heart catheterization with endocardial left and right ventricular mapping. Signals of late potentials were amplified between 100 and 10,000 times at low noise level using bipolar electrode catheters. Late potentials were recorded reproducibly in 19 patients (70%). Their amplitudes ranged from 50 to 600 microV. The coupling interval in each individual patient was constant and in the total group ranged between 100 and 520 ms. There were no differences of amplitude, form, and coupling interval in patients with and without ventricular tachycardia. In conclusion, late potentials can be found by endocardial mapping in the majority of patients after myocardial infarction. Their clinical relevance, however, has not yet been sufficiently investigated.

Percutaneous transluminal coronary angioplasty immediately after intracoronary streptolysis of transmural myocardial infarction.

Percutaneous transluminal coronary angioplasty (PTCA) was performed in 21 patients with acute myocardial infarction (AMI) treated by intracoronary infusion of streptokinase within 8 hours after the onset of symptoms. Streptolysis therapy began a mean of 3.6 +/- 1.2 hours (+/- SD) after the onset of symptoms. The vessel was occluded in 14 patients and highly stenosed in seven. After the infusion of 67,300 +/- 63,200 IU of streptokinase over 26.1 +/- 21.5 minutes, patency of the occluded vessels was reached. PTCA as performed 20-60 minutes after the end of streptokinase treatment in 19 patients and 24 and 31 hours after treatment in two patients. The dilation was successful in 17 patients (81%). The degree of vessel obstruction was reduced from 90.2 +/- 7.3% to 58.6 +/- 19.5% (area method) and from 71.4 +/- 12.4% to 39.2 +/- 19.7% (diameter method). The improvement was 31.5 +/- 18.4% and 32.2 +/- 19.3%, respectively. No reocclusion was induced by PTCA. Twenty patients were discharged. One died during hospitalization; at autopsy, the treated vessel was still patent. During the follow-up period, two reinfarctions and one asymptomatic reocclusion occurred. The clinical findings during the hospital course and the follow-up period were compared with those of a control group of 18 patients with AMI and comparable coronary stenoses who were treated only with streptokinase infusion. Four of these patients had a reinfarction during the hospital course, and three died during the follow-up period. PTCA can be performed safely and successfully immediately after intracoronary infusion of streptokinase in patients with AMI. By reducing the subtotal stenosis, this treatment contributes to the reperfusion of the ischemic myocardium, diminishes the risk of a reocclusion and seems to improve the prognosis.

[Treatment of acute cardiac arrest. Observations in a cardiological intensive-care unit]. / Therapie akuter Kreislaufstillstände. Bilanz einer kardiologischen Intensivstation.

Between 1976 and 1980, 301 of 3106 patients in the cardiological intensive-care unit were treated for acute cardiac arrest (9.7%). As a result of better methods of prevention and the emergency doctor system, there has since 1968 been a 50% reduction in the number of cardiac arrests. Two-thirds of the patients were male, resuscitation was successful in 34% ("successful" means that the patient was transferred to a general ward from the intensive-care unit in a clinically and haemodynamically stable condition). The prognosis was better in those with posterior-wall myocardial infarction than in those with unstable angina, mitral-valve disease with congestive heart failure, and those with anterior-wall infarction, the latter generally being more extensive and thus in principle more dangerous than posterior-wall infarction. Cardiac arrest as part of cardiogenic shock proved irreversible in every instance. After three months the survival rate was 72%, after six months 66%, after one year 62% of all patients who had required resuscitation. They would not have been alive without intensive-care treatment. These figures contradict negative comments on the purpose and usefulness of cardiological intensive-care units.