Influence of age on pain perception in acute myocardial ischemia: a possible cause for delayed treatment in elderly patients.

BACKGROUND: Elderly patients tend to seek later for medical help during myocardial infarction. This may be caused by impaired pain perception with ageing. The aim of our study was to prospectively evaluate age-dependent differences in pain perception during temporary induced coronary ischemia. METHODS: In 102 patients (68 male, age 68±11 years) undergoing percutaneous coronary intervention, ischemia was induced by balloon inflation for up to 120 s. Time to onset of perceived pain, pain characteristics and pain severity (0=no pain, 100=worst pain possible) was registered. This was repeated twice to evaluate ischemic preconditioning. A 12 lead ECG-tracing was simultaneously recorded. Patients were divided by their median age into 2 groups with comparable demographics: ≤69 years (group 1) and >69 years (group 2). RESULTS: Group 1 patients demonstrated earlier onset of pain (most apparent during the second inflation: 31±15 s vs. 46±26 s; p<0.001), and greater pain severity (inflation #1: 64±21 vs. 51±25 [p=0.017]; #2: 66±23 vs.52±27 [p=0.008]; #3: 63±23 vs. 54±24 [p=0.085]). ST-changes did not differ (0.24±0.10 vs. 0.20±0.14, [p=0.18]; 0.27±0.17 vs. 0.20±0.14, [p=0.11]; 0.19±0.13 vs. 0.16±0.09; [p=0.32]). Time from occlusion to onset of ECG changes did not differ between the groups, but increased with repetitive inflations (inflation #1: 29±11 s vs. 29±11 s; #2: 31±14 vs. 33±11; #3: 39±21 vs. 40±15 s [increase p=0.017; p<0.001]). CONCLUSION: These data suggest that the perception of pain from myocardial ischemia in the elderly is significantly less severe and delayed compared to younger patients.

Clinical outcome and quality of life after interventional treatment of left main disease with drug-eluting-stents in comparison to CABG in elderly and younger patients.

INTRODUCTION: The aim of this study was to prospectively assess the clinical outcome and quality of life of elderly patients who underwent either coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI) with drug-eluting stents (DES) for treatment of significant left main disease (LMD) compared to a younger patient population. METHODS: Consecutive patients, admitted into our institution between 04/2004 and 12/2007 with LMD and a life expectancy of >1 year were prospectively included and stratified in two groups (either CABG or left main stenting [LMS] with DES) based on the patients' age at inclusion (> or ≤75 years). Rates of death, myocardial infarction (MI), stroke, and target lesion revascularization (TLR) were evaluated over a 12 month follow-up. Six months after the initial procedure, additionally, quality of life was assessed using the SF-36 questionnaire. RESULTS: A total of 300 patients was included; 56 of the 95 PCI patients (59%) were ≤75 years and 39 (44%) >75 years, whereas 155 of 205 patients in the CABG group were ≤75 years (76%), and 50 patients (24%) were >75 years. Mean follow-up was 312 ± 226 days in the PCI and 377 ± 286 in the CABG group. Rates of death and MI were not significantly different between the four groups at the end of follow-up. There was no difference in quality of life after 6 months. CONCLUSION: In this prospective trial, PCI of LM with DES in elderly patients was feasible with a short- and intermediate term outcome comparable to CABG procedure and to a younger patient cohort.

[Tissue Doppler imaging of the fetal heart--a new parametric ultrasound technique in prenatal medicine]. / Tissue Doppler Imaging am fetalen Herzen--eine neue parametrische Ultraschalltechnik in der pränatalen Medizin.

Tissue Doppler imaging is a new ultrasound technique for the acquisition and analysis of myocardial velocity and deforming parameters in the human heart. In cardiology this innovative technique is used to identify ischemic regions and stunned areas after cardiac infarction and to diagnose dyssynchrony. In the last two years, our research group has been using this technique extensively on fetal hearts. It is possible to establish the fetal cardiac cycle clearly just by analyzing the typical courses of myocardial velocity curves. The quality of the curves is comparable to the results in adult cardiology. Consequently, many innovative analysis options can be acquired, e.g., the comparison of the kinetics of several myocardial regions in the cardiac cycle, the determination of pre- and post-systolic intervals (isovolumic contraction time, isovolumic relaxation time), the evaluation of diastolic function by analyzing the E(m) and A(m) waves and the detection of the atrial contraction. These parameters are currently used in cardiology for extended function analysis. Tissue Doppler imaging is the first step in parametric imaging of the fetal heart and consequently marks the beginning of a new era in fetal echocardiography.

[Are neurohumoral parameters predictive for the efficacy of cardiac resynchronization therapy? The role of natriuretic peptides]. / Sind neurohumorale Blutparameter wegweisend für die Effizienz der kardialen Resynchronisationstherapie? Die Rolle der natriuretischen Peptide.

During recent years, heart failure has been recognized as a complex disease involving both hemodynamic abnormalities caused by reduced contractile forces and neurohormonal changes characterized by an increase in sympathetic tone and an activation of the renin-angiotensin-aldosterone system as well as the endothelial pathways. Neurohumoral factors represent the natural response of the individual to heart failure. Among them natriuretic peptides, i. e., brain natriuretic peptide (BNP) and amino-terminal pro BNP (Nt-proBNP) release have recently been shown to be a reliable and rapid marker for diagnosis, optimization of pharmacological treatment and risk stratification in heart failure patients. This article summarizes important aspects of the release of natriuretic peptides as a guide for diagnosis, therapy and prognosis of patients with heart failure and cardiac resynchronization therapy.

Brain natriuretic peptide release in cardiac surgery patients.

Brain natriuretic peptide (BNP) release is a marker of increased myocardial wall tension, which is elevated in patients with disturbed left ventricular function. As it is increasingly being used as a reliable marker for diagnosis, optimization of pharmacological treatment, and risk stratification, BNP measurement might be also relevant for patients undergoing cardiac surgery. Measured BNP levels can be used to predict postoperative complications and the risk of further cardiac events. Preoperative BNP levels support the decision for the timing of aortic valve replacement in asymptomatic severe aortic stenosis. An increase in BNP levels early predicts allograft rejection after cardiac transplantation or ineffective cardiac resynchronization therapy. Moreover, BNP levels can be used to differentiate between cardiac and non-cardiac reasons for acute dyspnea in the management of surgical patients. Finally, the application of recombinant human BNP seems to improve recovery after cardiac surgical procedures. Thus, BNP can be a helpful tool for monitoring and treating patients before, during, and after cardiac surgery to predict and improve the effectiveness of therapy and reduce hospitalization and costs.

[Improved identification of suitable patients for cardiac resynchronization therapy by transthoracic echocardiography]. / Verbesserte Identifizierung geeigneter Kandidaten für die kardiale Resynchronisationstherapie mittels transthorakaler Echokardiographie.

Transthoracic echocardiography provides numerous options for the evaluation and quantification of contractile cardiac asynchrony in patients with advanced heart failure. Important information on the presence of asynchrony can be obtained already during a standard routine examination with conventional techniques (2D, M-mode and Doppler). Newer techniques such as tissue Doppler imaging and real-time 3D-echocardiography enable us to better quantify the degree of asynchrony. The following article describes the echocardiographic features of asynchrony and algorithms for the improved identification of suitable patients for cardiac resynchronization therapy.

Detection of early systolic dysfunction with strain rate imaging in a patient with light chain cardiomyopathy.

Congestive heart failure (CHF) in cardiac amyloidosis has been attributed to the development of diastolic dysfunction, because severe CHF symptoms have been observed despite a normal or only mildly reduced LV ejection fraction (EF). An early impairment of longitudinal systolic function has been described by means of tissue Doppler-derived myocardial deformation imaging ('strain rate imaging', SRI). Our patient presented with signs of CHF and significantly increased brain-natriuretic peptide (BNP) levels. Conventional measures of systolic contractile function were within the normal range and mitral inflow Doppler showed only moderate diastolic dysfunction. Histopathological examination by endomyocardial biopsy revealed interstitial deposition of amyloid fibers. Quantitative assessment of myocardial velocities (TDI) and deformation properties (Strain) from the apical view demonstrated a significant impairement of systolic longitudinal myocardial function. In patients with isolated diastolic dysfunction detected by conventional Doppler echocardiography, the quantitative assessment of myocardial strain and strain rate can be helpful in the early detection of systolic dysfunction.

Established and evolving indications for cardiac resynchronisation.

Randomised trials involving large number of patients have demonstrated the benefits of cardiac resynchronisation therapy (CRT) in patients with heart failure who have failed optimal medical treatment. Echocardiography plays an important role in defining dyssynchrony which is key to optimal patient selection. The electrocardiographic criteria for patient selection is supplemented by the finding of dyssynchrony on Doppler myocardial imaging, and echocardiography with Doppler myocardial imaging may eventually replace the electrocardiographic criteria for selection of patients who derive benefit from CRT.

Mid-systolic septal deceleration. A new sign of left ventricular outflow tract obstruction obtained by color-coded tissue Doppler echocardiography.

Hypertrophic obstructive cardiomyopathy (HOCM) is characterized by the presence of a dynamic left ventricular outflow tract gradient. We studied septal longitudinal motion by color coded tissue Doppler echocardiography in a 69-year old HOCM patient during and after catheter based treatment by trans coronary alcohol ablation of septal hypertrophy. The presence of dynamic left ventricular outflow tract obstruction was associated with a characteristic abrupt mid-systolic septal deceleration pattern in the tissue Doppler velocity trace. Five weeks after treatment, this pattern was no longer visible at rest.