[Reduction of in-hospital mortality and improved secondary prevention after acute myocardial infarction. First results from the registry of secondary prevention after acute myocardial infarction (SAMI)]. / Rückgang der Krankenhaus-Sterblichkeit und verbesserte Sekundärprävention nach akutem Myokardinfarkt. Erste Ergebnisse des SAMI-Registers.

BACKGROUND AND OBJECTIVE: In hospital mortality of acute myocardial infarction (AMI) has been reduced due to the availability of better therapeutic strategies. But there is still a gap between mortality rates in randomised trials and daily clinical practice. Thus, it was aim of the present registry to document the course and outcome of patients with AMI and to improve patient care by implementing recent guidelines. PATIENTS AND METHODS: In a nationwide registry study in hospitals in Germany with a cardiology unit or an internal medicine department data on consecutive patients were recorded for six to twelve months at admission, discharge and during a follow-up of one year. RESULTS: From 02/2003 until 10/2004 a total of 5,353 patients with acute myocardial infarction (65.7 % male, mean age of 67.6 +/- 17.7 years; 55.1 % of them with ST elevation myocardial infarction (STEMI) were included in the registry. Of the patients with STEMI, 76.6 % underwent acute intervention, 37.1 % had thrombolysis, 69.7 % percutaneous transluminal coronary angioplasty (PTCA). 40.0 % of those with non-Stemi (NSTEMI) had an acute intervention, 6.6 % thrombolysis, 73.5 % PTCA. Recommended secondary prevention consisted of ASS (93.2 %), beta-blockers (93.0 %), CSE-inhibitors (83.5 %), ACE-inhibitors (80.9 %) and clopidogrel (74.0 %). In-hospital mortality was 10.5 % (STEMI) and 7.4 % (NSTEMI). CONCLUSION: The 9 % mortality among patients with acute myocardial infarction treated in the hospitals participating in the SAMI registry is low compared to that in similar collectives. The high number of patients who had thrombofibrinolysis and coronary interventions as well as the early initiation of drug therapy contributed to these results. Medical treatment in the prehospital phase of these patients remains still insufficient and to a substantial extent contributes to the mortality of acute myocardial infarction.

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

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

Different determination of sinoatrial conduction time (SACT) in man.

Using intracardiac recordings of electrical activity and programmed electrical right atrial stimulation of the human heart, the sinoatrial conduction time (SACT) in the method of Strauss et al. 1973 (SACTc) was calculated in 80 patients with and without disturbances of rhythm and compared to the modified measurement of the SACT in the method reported by Narula et al. in 1978 (SACTN). The number of continuously stimuli varied from 4, 8 and 16 stimuli with a frequency of 10% just above the averaged spontaneous frequency. The best correlation was found between the SACTc and the SACTN16 (r = 0.74; p less than 0.001) with a regression line of: SACTN16 = 1.04 SACTc + 28.6. Under these conditions, as opposed to SACTN4 or SACTN8, the most favourable reproducibility and relative coefficient of variation (rVk) could be observed: SACTN16: rVk = 9.5%; r = 0.91; SACTN8: rVK = 12.3%; r = 0.89; SACTN4: rvK = 24.3%; r = 0.53. Higher individual values for SACTN16 were found by continuous atrial stimulation as compared to other methods of determination indicating mainly a higher depression of sinus node automaticity due to overdrive suppression. Under parasympathicolysis (1 mg atropine) the lowest values of SACT were found for SACTN4 (45.9 +/- 20.7 ms) coming closest the "true" SACT, since these conditions neither an increase of the refractory period nor an overdrive suppression exert an influence.

[Systolic time intervals in chronic calcifying pancreatitis caused by alcohol abuse]. / Die systolischen Zeitintervalle bei chronisch kalzifizierender Pankreatitis durch Alkoholabusus.

Systolic time intervals corrected for heart rate were measured non invasively in 12 male patients (32 to 59 years) with chronic calcifying pancreatitis of alcoholic origin and compared with 24 normal subjects without evidence for chronic alcoholism or heart disease. Systolic time intervals (in detail: the time from the beginning of QRS to the first heart sound (QS1), the isovolumic contraction time (IVCT), the total electromechanical systolic interval (QS2c), the pre-ejection period (PEPc), the left ventricular ejection time (LVETc) and the ratio PEPc/LVETc) in patients with chronic calcifying pancreatitis were not different when compared with healthy man. Therefore we conclude, that the amount of alcohol that induced a chronic calcifying pancreatitis was not able to alter systolic time intervals as seen in an alcoholic cardiomyopathy.

[Different determination of sinoatrial conduction time in patients with and without sinus node dysfunction]. / Zur differenten Bestimmung der sinuatrialen Leitungszeit bei Patienten mit und ohne Sinusknotenfunktionsstörungen.

Using intracardiac recordings of electrical activity and programmed electrical right atrial stimulation of the human heart, the sinoatrial conduction time (SACT) in the method of Strauss et al. 1973 (SACTc) was calculated in 80 patients with and without disturbances of rhythm and compared to the modified measurement of the SACT in the method reported by Narula et al. in 1978 (SACTN). The number of continuous stimuli variied from 4, 8 and 16 stimuli with a frequency of 10% just above the averaged spontaneous frequency. The best correlation was found between the SACTc and the SACTN16 (r = 0.74; p less than 0.001) with a regression line of: SACTN16 = 1.04 SACTc + 28.6. Under these conditions, as opposed to SACTN4 or SACTN8, the most favourable reproducibility and relative coefficient of variation (rVk) could be observed: SACTN16: rVk = 9.5%; r = 0.91; SACTN8: rVk = 12.3%; r = 0.89; SACTN4: rVk = 24.3%; r = 0.53. Higher individual values for SACTN16 were found by continuous atrial stimulation as compared to other methods of determination indicating mainly a higher depression of sinus node automaticity due to overdrive suppression. Under parasympathicolysis (1 mg atropine) the lowest values of SACT were found for SACTN4 (45.9 +/- 20.7 ms) coming closest the "true" SACT, since under these conditions neither an increase of the refractory period nor an overdrive suppression exert an influence.

[Interatrial communication through the coronary sinus]. / Interatriale Kommunikation durch den Sinus coronarius.

An unusual case of an interatrial communication through a defect of the coronary sinus together with coarctation of the aorta is reported. In spite of two cardiac catheterization studies, this diagnosis was missed by two different cardiology departments, and anomalous pulmonary vein connection was suspected instead. This illustrates the preoperative diagnostic difficulties which continue during surgery, when exploration of the right atrium fails to detect the suspected atrial defect. This rare anomaly should be considered in the differential diagnosis of an atrial left-to-right shunt, when the largest "oxygen step-up" is at the level of the lower right atrium, and no evidence of an atrial septal defect or transposition of the pulmonary veins can be found.

[Cardiac electrophysiologic effect of various catecholamines and parasympatholytic agents]. / Kardiale elektrophysiologische Wirkung verschiedener Katecholamine und Parasympathikolytika.

Using His-bundle-electrography and programmed atrial stimulation the effects of different catecholamines (dopamine, dobutamine, orciprenaline), parasympatholytics like atropine, ipratropiumbromide and the xanthine derivative aminophylline have been studied on the conduction system of the human heart in 119 patients with and without different disturbances of rhythm. In contrast to dopamine a moderate effect was found by dobutamine (3 or 6 micrograms/kg/min) in patients with sinus node dysfunction and delayed AV-conduction. In comparison it must by pointed out, that orciprenaline has the greatest positive dromotropic and chronotropic effect on sinus and AV-node. No effect was seen by these catecholamines on electrophysiological properties of the atrium and the intraventricular conduction (HPS). Particularly the fatigue-phenomenon of the Tawara-fibers were not influenced. 0,24 g aminophylline has only a minimal electrophysiological effect, only the sino-atrial conduction time was shortened significantly. The parasympathomimetic agents atropine (1,0; 2 mg i.v.) and ipratropiumbromide (0,5; 1 mg i.v.) are able to improve the sinuatrial and AV-dysfunction. In some patients, however, paradoxical effects were seen in patients with sick sinus syndrome. The refractory periods of the HPS were not influenced - otherwise a secondary impulse - generator was accelerated, which seems to indicate that the AV-node is localized in the NH-region.

[Electrophysiologic effects of dopamine on the cardiac conduction system (author's transl)]. / Elektrophysiologische Wirkung von Dopamin auf das Erregungsleitungssystem des menschlichen Herzens.

The electrophysiologic effects of dopamine (Dop.) (3 microgram; n = 11) 6 microgram/kg/min; n = 14) were studied in 20 patients (5 females, 15 males) with and without different disturbances of rhythm utilizing His-Bundle electrography and right atrial pacing. The blood pressure increased significantly (p less than 0.01) about 10% (3 microgram Dop.) or 16% (6 microgram Dop.) respectively. Electrophysiologic parameters of the sinus node (spontaneous cycle length before and during carotid sinus pressure, max. sinus node recovery time = SKEZmax, sinoatrial conduction time = SACTc were not changed significantly. In single cases the sinus node function was improved by 3 microgram Dop., otherwise 6 microgram Dop. aggravated them partially. In 5 patients with sick-sinus syndrome the prolonged SKEZmax and SACTc were not reduced significantly. The electrophysiologic parameters of the atrium (Ah-t, effective-relative-functional refractory period) were not influenced by Dop. The AV-node conduction (AH,AH in response to right atrium stimulation, max. 1 : 1 conduction, refractory periods) was not altered by the catecholamine concentration of 6 microgram Dop. The intranodal conduction was improved by 3 microgram Dop. irrelevantly. No influence was seen in 3 patients with a delayed AV-conduction. The possible mechanism of the ineffective shortening of the AV-conduction may be the baroreceptor reflex caused by the enhanced blood pressure. The intraventricular conduction time (HV) was improved in some cases insignificantly, no differences was seen in the aberrant conduction of the His-Purkinje system provoked by paired stimulation.

[Investigations of the etiology of bradycardial rhythm disturbances (author's transl)]. / Untersuchungen zur Atiologie bradykarder Herzrhythmusstörungen.

As a possible etiology of cardiac conduction disturbances the sclerosis of coronary arteries and an idiopathic fibrosis are considered. In recent time also a diabetes-typical process in the coronary artery system has been discussed. Therefore we studied the distribution of atherosclerotic risk factors in 238 patients with severe cardiac conduction disturbances. The results were: 1. The incidence of risk factors in patients with cardiac conduction disturbances is relatively high. 2. Nearly all risk factors were more frequent in patients with diabetes than in patients without this disease. 3. The average number of risk factors per patient is significantly higher in diabetic than in non diabetic patients. 4. The risk factors associated with diabetes mellitus--as hypertriglyceridaemia and hypercholesterolaemia--follow the same distribution function in diabetic patients and are therefore influenced by the diabetes in a similar fashion. Our results demonstrate that the atherosclerosis is the most probable cause of cardiac conduction disturbances. It seems unlikely that a diabetes-typical vessel disease is the primary cause of conduction disturbances in diabetic patients. Our results rather seem to demonstrate that the diabetes mellitus in general advance the process of atherosclerosis.

[Hemodynamic and electrophysiologic effects of the new calcium antagonist Ro 11-1781 (author's transl)]. / Hämodynamische und elektrophysiologische Wirkungen des neuen Calcium-Antagonisten Ro 11-1781.

In a 3-part study the new calcium-antagonist Ro 11-1781 was investigated in respect to hemodynamic, electrophysiologic and antiarrhythmic effects. In the first part of the investigation, systolic time intervals were determined as an indicator of left ventricular performance in 10 patients without cardiac disease before and 5 min after i.v. injection of Ro 11-1781 (1 mg/kg/body weight). At the same time blood pressure was measured. There was a significant decrease in systolic and diastolic blood pressure (p < 0.01). Due to the resulting activation of the sympathetic nervous system by baroreflex, heart rate increased by 7 bpm (p < 0.01), there was a shortening of the pre-ejection period PEPc by 15 ms (p < 0.01), whereas left ventricular ejection time LVETc was not changed significantly. The ratio PEPc/LVETc decreased significantly (p < 0.01), reflecting the increase of left ventricular contractility, which results from the activation of the sympathetic nervous system. The PQ interval was increased (16 ms, p less than 0.01), an atrioventricular block however was not seen. In the second part of the investigation, sinus node function was studied in 8 patients by His-bundle electrography and programmed stimulation of the right atrium. There was no significant change in sinus-node recovery time, sinu-atrial conduction time, sinus-node rate and atrial conduction time in response to Ro 11-1781. However, in 2 patients with sinus-bradyarrhythmia a second-degree sinu-atrial block was provoked by the calcium-antagonist. The drug was shown to have a negative dromotrope effect to the AV node, reflected by an increase of the PQ interval (p < 0.01), AH interval (p < 0.01) and a decrease (p < 0.01) of the maximal 1:1 conduction of the AV node, whereas the HV interval was not changed significantly. The antiarrhythmic effects of Ro 11-1781 were studied in 13 patients with atrial flutter, atrial fibrillation or paroxysmal supraventricular tachycardia: In 10 patients the injection of the calcium-antagonist produced a marked decrease in ventricular rate for a short time reflecting a neagative dromotrope effect in the AV node. In 5 patients conversion to sinus rhythm was observed.

[Electrophysiologic effects of dobutamine on cardiac conduction system (author's transl)]. / Wirkung von Dobutamin auf das Reizleitungssystem des Herzens.

The electrophysiologic effects of dobutamine (D) (3 and/or 6microgram/kg/min), a new beta1 stimulator, was studied in 12 patients with different disturbances of rhythm (sinus-node dysfunction, AV-block, sinus-bradycardia, paroxysmal tachycardia) utilizing His-bundle electrography and right atrial pacing. During infusion of D sinus-rate (HR) increased significantly from 61 to 71/min. Not only in cases with enhanced sinus-node-recovery-time (SKEZ) both, the absolutely (p less than 0.05) and the corrected SKEZ(-18%,-26%) were reduced by D otherwise the calculated sino-atrial-conduction time (SACTc) was shortened only in single cases. No effect could be registered in intraventricular (HV) conduction time, whereas the AV-nodal conduction time (AH) was significantly (p less than 0.05) reduced, more effect was seen at increasing stimulation of heart rate. The intraatrial conduction time (Ah-t) was shortened not significantly. In connection with reduced AH-interval the maximum of conduction frequency of the AV-node was significantly enhanced (10%, 13%). D shortened the refractory-period (RP) of atrium and AV-node, the effect was significant (p less than 0.05) only in the functional-RP of the atrium and relative RP of the AV-node.