Nationwide but still inhomogeneous distribution of certified chest pain units across Germany : Need to strengthen rural regions.

AIM: The purpose of this work was to analyze structure, distribution, and bed capacities of certified German chest pain units (CPUs) to unveil potential gaps despite nationwide certification of 230 units till the end of 2015. METHODS: Analysis of number and structure of CPUs per state, resident count, and population density by standardized telephone interview, online research, and data collection from the registry of the Federal Statistical Office for all certified German CPUs. RESULTS: Nationwide, German health facilities provided a mean of 1 CPU bed within a certified unit per 65,000 inhabitants. Bremen, Hamburg, Hesse, and Rhineland-Palatinate provided more than 1 bed per 50,000 inhabitants. Most CPUs (49%) were located in the emergency room. All university hospitals in Germany provided a certified CPU. Most units were found in academic teaching hospitals (146 CPUs). Only 42 CPUs were found in nonacademic providers of primary health care. CONCLUSION: The absolute necessary number of CPUs to reach full nationwide coverage is still unknown. The current analysis shows a high number of CPUs and bed capacities within the cities and industrial areas without relevant gaps, but also demonstrates a certain undersupply in more rural areas as well as in some of the former eastern federal states of Germany.

On- versus off-hour care for patients with non-ST-segment elevation myocardial infarction in Germany : Exemplary results within the chest pain unit concept.

AIM: The aim of this study was to analyze differences in the timing of invasive management of patients with high-risk acute coronary syndrome without persistent ST-segment elevation (hr-NSTE-ACS) or myocardial infarction without persistent ST-segment elevation (NSTEMI) between on- and off-hours in a German chest pain unit (CPU). PATIENTS AND METHODS: We retrospectively enrolled 160 NSTEMI patients in the study, who were admitted to two German CPUs in 2013. Patients presenting on weekdays between 8 a.m. and 6 p.m. were compared with patients presenting during off-hours. Data analysis included time intervals from admission to invasive management (goals: for hr-NSTE-ACS, <2 h; for NSTEMI, <24 h) and the resulting guideline adherence. RESULTS: Guideline-adherent timing of an invasive strategy did not differ significantly between the on-hour (6.5 h [3.0-22.0 h], 79.9 %) and off-hour groups (10.5 h [2.0-20.0 h], 75.3 %; p = 0.94), without additional significant differences between admissions during off-hours Monday to Thursday and weekends (10.0 h [2.0-19.0 h], 75.6 % vs. 7.5 h [2.0-20.0 h], 76.2 %; p = 0.96). CONCLUSION: Our exemplary experience in two different German CPUs demonstrates adequate timing of coronary catheterization in over 75 % of cases, irrespective of admission during on- or off-hours. Nationwide validation of our findings by the German CPU registry is mandatory.

Ischemic Left Ventricular Perforation Covered by a Thrombus in a Patient Presenting with Cerebral Ischemia: Importance of Time-Sensitive Performance and Adequate Interpretation of Bedside Transthoracic Echography.

If myocardial infarction remains silent, only clinical signs of complications may unveil its presence. Life-threatening complications include myocardial rupture, thrombus formation, or arterial embolization. In the presented case, a 76-year-old patient was admitted with left-sided hemiparesis. In duplex sonography, a critical stenosis of the right internal carotid artery was identified and initially but retrospectively incorrectly judged as the potential cause for ischemia. During operative thromboendarterectomy, arterial embolism of the right leg occurred coincidentally, more likely pointing towards a cardioembolic origin. Percutaneous interventions remained unsuccessful and local fibrinolysis was applied. Delayed bedside echocardiography by an experienced cardiologist demonstrated a discontinuity of the normal myocardial texture of the left ventricular apex together with an echodense, partly floating structure merely attached by a thin bridge not completely sealing the myocardial defect, accompanied by pericardial effusion. The patient was immediately transferred to emergency cardiac surgery with extirpation of the thrombus, aortocoronary bypass graft placement, and aneurysmectomy. This didactic case reveals decisive structural shortcomings in patient's admission and triage processes and underlines, if performed timely and correctly, the value of transthoracic echocardiography as a noninvasive and cost-effective tool allowing immediate decision-making, which, in this case, led to the correct but almost fatally delayed diagnosis.

Guideline-conforming timing of invasive management in troponin-positive or high-risk ACS without persistent ST-segment elevation in German chest pain units. Urban university maximum care vs. rural regional primary care.

AIM: This study aimed to analyze guideline adherence in the timing of invasive management for myocardial infarction without persistent ST-segment elevation (NSTEMI) in two exemplary German centers, comparing an urban university maximum care facility and a rural regional primary care facility. METHODS: All patients diagnosed as having NSTEMI during 2013 were retrospectively enrolled in two centers: (1) site I, a maximum care center in an urban university setting, and (b) site II, a primary care center in a rural regional care setting. Data acquisition included time intervals from admission to invasive management, risk criteria, rate of intervention, and medical therapy. RESULTS: The median time from admission to coronary angiography was 12.0 h (site I) or 17.5 h (site II; p = 0.17). Guideline-adherent timing was achieved in 88.1 % (site I) or 82.9 % (site II; p = 0.18) of cases. Intervention rates were high in both sites (site I-75.5 % vs. site II-75.3 %; p = 0.85). Adherence to recommendations of medical therapy was high and comparable between the two sites. CONCLUSION: In NSTEMI or high-risk acute coronary syndromes without persistent ST-segment elevation, guideline-adherent timing of invasive management was achieved in about 85 % of cases, and was comparable between urban maximum and rural primary care settings. Validation by the German Chest Pain Unit Registry including outcome analysis is required.

Pitfalls in suspected acute aortic syndrome: impact of appropriate and if required repeated imaging.

The incidence of acute aortic syndrome is low, but the spontaneous course is often life-threatening. Adequate ECG-gated imaging is fundamental within the diagnostic workup. We here report a case of a 53-year-old man presenting with atypical chest pain, slight increase of D dimers at admission, and extended diameter of the ascending aorta accompanied by mild aortic regurgitation. Interpretation of an initial contrast-enhanced computed tomography was false negative due to inadequate gating and motion artifacts, thereby judging a tiny contrast signal in the left anterior quadrant of the ascending aorta as a pseudointimal flap. By hazard, cardiac magnetic resonance imaging demonstrated an ulcer-like lesion superior to the aortic root, leading to aortic surgery at the last moment. As sensitivity of imaging is not 100%, this example underlines that second imaging studies might be necessary if the first imaging is negative, but the clinical suspicion still remains high.

Cardiac MRI: estimation of changes in normalized myocardial gadolinium accumulation over time after contrast injection in patients with acute myocarditis and healthy volunteers.

PURPOSE: An increased normalized gadolinium accumulation (NGA) in the myocardium during early washout has been used for the diagnosis of acute myocarditis (AM). Due to the fact that the pharmacokinetics of contrast agents are complex, time-related changes in NGA after contrast injection are likely. Because knowledge about time-related changes of NGA may improve the diagnostic accuracy of MR, our study aimed to estimate the time course of NGA after contrast injection in patients as well as in healthy volunteers. MATERIALS AND METHODS: An ECG-triggered inversion recovery SSFP sequence with incrementally increasing inversion times was repetitively acquired over the 15 minutes after injection of 0.2 Gd-DTPA per kg body weight in a 4-chamber view in 15 patients with AM and 20 volunteers. The T 1relaxation times and the longitudinal relaxation rates (R1) of the myocardium and skeletal musculature were calculated for each point in time after contrast injection. The time course of NGA was estimated based on the linear relationship between R1 and tissue Gd concentration. RESULTS: NGA decreased over time in the form of a negative power function in patients with AM and in healthy controls. NGA in AM tended to be higher than in controls (p > 0.05). CONCLUSION: NGA rapidly changes after contrast injection, which must be considered when measuring NGA. Although we observed a trend towards higher NGA values in patients with AM with a maximum difference one minute after contrast injection, NGA did not allow us to differentiate patients with AM from healthy volunteers, because the observed differences did not reach a level of significance.

Concomitant atherosclerotic disease detected by whole-body MR angiography in relation to coronary artery calcification in patients with coronary artery disease.

PURPOSE: Patients with coronary artery disease (CAD) show a high prevalence for concomitant atherosclerotic peripheral arterial disease (PAD). On the other hand, PAD seems to be an additional risk factor for cardiac events. We evaluated the correlation between arterial pathologies as found in whole-body MR angiography and coronary artery calcification (CAC) detected by electron beam computed tomography (EBCT) and multislice CT (MSCT). MATERIALS AND METHODS: Two hundred and twenty-eight patients (161 men; 67 women) with suspicion for CAD/known CAD underwent whole-body contrast-enhanced MR angiography (wb-ce-MRA) and EBCT/MSCT. An atherosclerosis index was calculated for each patient Index = (40)Sigma(n=1) w(i) with w(i) being the grading of the stenosis of the i (ten) of 40 arteria segments (grade: 0 - no plaque; 1 - plaque - < or = 50 % stenosis; 2 - > 50 % stenosis - < or = 90 % stenosis; 3 - > 90 % stenosis - < 100 % stenosis; 4 - occlusion). Correlations between CAC and atherosclerosis index were performed. RESULTS: Wb-ce MRA and CAC correlate only moderately in this population. An atherosclerosis index 8 renders a positive predictive value for a CAC 100 of 63.3 %. CONCLUSION: An atherosclerosis index as defined in this study does not fully correlate with the extent of CAD as revealed by catheter angiography or EBCT/MSCT, but it might theoretically mirror the increased risk by PAD. It thus might be a promising complementary parameter for the prediction of cardiac events. Future studies need to show its possible additional predictive impact.

Levo-alpha-acetylmethadol (LAAM) induced QTc-prolongation - results from a controlled clinical trial.

BACKGROUND: Due to potential proarrhythmic side-effects levo-alpha-Acetylmethadol (LAAM) is currently not available in EU countries as maintenance drug in the treatment of opiate addiction. However, recent studies and meta-analyses underline the clinical advantages of LAAM with respect to the reduction of heroin use. Thus a reappraisal of LAAM has been demanded. The aim of the present study was to evaluate the relative impact of LAAM on QTc-interval, as a measure of pro-arrhythmic risk, in comparison to methadone, the current standard in substitution therapy. METHODS: ECG recordings were analysed within a randomized, controlled clinical trial evaluating the efficacy and tolerability of maintenance treatment with LAAM compared with racemic methadone. Recordings were done at two points: 1) during a run-in period with all patients on methadone and 2) 24 weeks after randomisation into methadone or LAAM treatment group. These ECG recordings were analysed with respect to QTc-values and QTc-dispersion. Mean values as well as individual changes compared to baseline parameters were evaluated. QTc-intervals were classified according to CPMP-guidelines. RESULTS: Complete ECG data sets could be obtained in 53 patients (31 LAAM-group, 22 methadone-group). No clinical cardiac complications were observed in either group. After 24 weeks, patients receiving LAAM showed a significant increase in QTc-interval (0.409s +/- 0.022s versus 0.418s +/- 0.028s, p = 0.046), whereas no significant changes could be observed in patients remaining on methadone. There was no statistically significant change in QTc-dispersion in either group. More patients with borderline prolonged and prolonged QTc-intervals were observed in the LAAM than in the methadone treatment group (n = 7 vs. n = 1; p = 0.1). CONCLUSIONS: In this controlled trial LAAM induced QTc-prolongation in a higher degree than methadone. Given reports of severe arrhythmic events, careful ECG-monitoring is recommended under LAAM medication.

Magnetic resonance coronary angiography: comparison between a Gd-BOPTA- and a Gd-DTPA-enhanced spoiled gradient-echo sequence and a non-contrast-enhanced steady-state free-precession sequence.

BACKGROUND: Several studies have demonstrated that the administration of contrast agents is advantageous in magnetic resonance coronary angiography (MRCA). PURPOSE: To compare a non-contrast-enhanced steady-state free-precession (SSFP) with a contrast-enhanced inversion recovery spoiled gradient-echo (IR-GE) sequence using two different contrast agents for MRCA. MATERIAL AND METHODS: Eight healthy volunteers were examined on a 1.5T MR scanner. For non-contrast-enhanced MRCA, a breath-hold three-dimensional (3D) SSFP sequence (repetition/echo time [TR/TE] 3.9/1.7 ms, flip angle [FA] 65 degrees) was used. Contrast-enhanced MRCA was performed repetitively in two imaging sessions over 30 min after injection of 0.2 mmol/kg body weight gadobenate dimeglumine (Gd-BOPTA) or gadolinium diethylenetriamine pentaacetic acid (Gd-DTPA) using a breath-hold 3D IR-GE sequence (TR/TE 4.1/1.7 ms, FA 15 degrees). The signal-to-noise ratios (SNR) of the coronary arteries, as well as the contrast-to-noise ratios (CNR) between coronary arteries and perivascular tissue, were calculated for all images. Blood T (1) values were repetitively estimated over 30 min using an SSFP sequence with incrementally increasing inversion times (TR/TE 2.4/1.0 ms, FA 50 degrees). RESULTS: Gd-BOPTA-enhanced images showed significantly (P<0.05) higher SNR and CNR compared to Gd-DTPA-enhanced images for all times after contrast injection (SNR: 1 min post injection [PI] 26.4+/-4.2 vs. 16.2+/-3.1; CNR: 1 min PI 21.4+/-3.7 vs. 13.2+/-2.6). Compared to the SSFP images, the Gd-BOPTA-enhanced images showed higher CNR values for all times after injection (1 min PI 21.4+/-3.7 vs. 13.8+/-5.5; P<0.05), whereas the Gd-DTPA-enhanced images did not (1 min PI 13.2+/-2.6 vs. 13.8+/-5.5; P>0.05). Blood T (1) estimates were not significantly different for either agent 1 min after administration (P>0.05), but they were significantly lower for Gd-BOPTA (P<0.05) from 7 to 25 min after injection. CONCLUSION: Compared to non-contrast-enhanced SSFP images, only Gd-BOPTA-enhanced images show a significantly improved contrast between the coronary arteries and the surrounding tissue.

Prevalence, pattern, and functional impact of late gadolinium enhancement in left ventricular hypertrophy due to aortic valve stenosis.

PURPOSE: To assess the prevalence and pattern of myocardial late gadolinium enhancement (LGE) and its functional impact on patients with left ventricular hypertrophy caused by aortic valve stenosis. MATERIALS AND METHODS: Cardiac magnetic resonance imaging of 40 patients (17 female, 23 male, mean age: 76.6 +/- 22.5 years) with known aortic valve stenosis (mean aortic valve area: 89.8 +/- 19.2 mm(2)) and without coronary artery disease was performed at 1.5 T using steady-state free precession sequences for aortic valve planimetry and for the assessment of left ventricular (LV) volumes and mass. Ten to 15 minutes after injection of 0.2 mmol Gd-DTPA per kilogram body weight, inversion-recovery prepared spoiled gradient echo images were acquired in standard long and short axis views to detect areas of LGE. RESULTS: LGE was observed in 32.5 % (13/40) of our patients. LGE was mainly located in the basal septal and inferior LV segments, and showed a non-ischemic pattern with sparing of the subendocardial region. Patients with LGE showed lower LV ejection fractions (55.5 +/- 13.8 % vs. 69.1 +/- 10.7 %, p = 0.0014), higher LV end-systolic volumes (59.8 +/- 33.3 ml vs. 36.6 +/- 16.0 ml, p = 0.0048), and LV masses (211.0 +/- 13.8 vs. 157.9 +/- 37.5 g, p = 0.0002) compared to patients without LGE. CONCLUSION: LGE is frequent in patients with hypertrophic left ventricles due to aortic valve stenosis and is associated with worse LV function.

Detection of myocardial fibrosis in systemic sclerosis by contrast-enhanced magnetic resonance imaging.

PURPOSE: Our study aimed to assess the prevalence and pattern of late gadolinium enhancement (LGE) as an in vivo correlate of myocardial fibrosis in cardiac asymptomatic patients with systemic sclerosis (SSc). MATERIALS AND METHODS: Cardiac magnetic resonance imaging was successfully performed in 34 patients (30 female, 4 male, mean age of 54 +/- 14 years) with proven SSc and in controls with matching age, sex and cardiovascular risk factors. All examinations were performed on a 1.5 T MR system (Avanto, Siemens, Germany). 2D inversion recovery spoiled gradient echo images (TR 8.0 msec, TE 4.0 msec, TI 180 - 240 msec, FA 20 degrees, slice thickness 8 mm, in-plane resolution 1.2 x 1.2 mm (2)) were acquired 10 to 15 min after injection of 0.2 mmol Gd-DTPA per kg body weight to detect myocardial LGE. RESULTS: Poorly defined, patchy as well as well-defined focal areas of LGE were detected predominantly in the mid-myocardial layer of the basal left ventricular segments in 5 of 34 (15 %) SSc patients. A focal area of LGE was observed within the apical septum in one control (3 %, p > 0.05). LGE was observed in a total of 15 segments of the SSc patients and in 1 segment of the controls (p < 0.005). CONCLUSION: Our results revealed a significantly higher number of LGE positive segments in patients with SSc compared to matched controls, and demonstrate the ability of contrast-enhanced MRI to detect myocardial fibrosis, the hallmark of scleroderma heart disease, in-vivo.

[Automatic external defibrillator--mode of operation and clinical use]. / Automatische externe Defibrillatoren--Funktionsweise und Einsatz.

Every year about 100,000 persons die from sudden cardiac death (SCD) in Germany. Although many efforts have been undertaken, mortality remains high. Only 2 - 10% of patients with out-off hospital SCD can finally be discharged from hospital after resuscitation. Observational studies show that ventricular fibrillation and ventricular tachycardia are the primary arrhythmias underlying SCD. For both arrhythmias the main determinant for survival is the time between onset and termination by defibrillation. The chance of survival declines by 10% for every minute of delay. These findings prompted the concept of early defibrillation by first responders. Many studies have shown that non-medical professionals, like police men, firemen or security officers, often arrive at the patient more early than emergency medical service. Thus, "smart" automated external defibrillators (AEDs), designed to identify VT/VF and prompt the user when to deliver a shock were introduced. These devices allow lay rescuers to terminate ventricular arrhythmias before the arrival of medical professionals. By this approach the time to defibrillation could be reduced and a significant reduction in mortality could be documented in selected situation. These encouraging results initialled the installation of AED at public places like aircrafts, airports, underground stations and shopping males. Due to the success of this approach doctors are more and more confronted with questions about technical details, reliability and cost effectiveness of these devices. The present review should give an overview about the current studies and guidelines.

MR characterization of cardiac abnormalities in HIV+ individuals with increased BNP levels.

OBJECTIVE: To characterize cardiac abnormalities in HIV+ patients with increased serum B-type natiuretic peptide (BNP) by contrast-enhanced cardiac magnetic resonance imaging (MRI). DESIGN: Non-blinded prospective consecutive cohort evaluation. METHODS: More than 400 HIV+ patients were screened for potential BNP alterations. 16 met the inclusion criteria of elevated BNP levels and 12 patients could finally be enrolled. MRI analysis comprised function, oedema and late enhancement sequences. RESULTS: Patients exhibited a median serum BNP level of 249 pg/ml. Based on MRI, diagnosis of left ventricular hypertrophy (n = 3), myocarditis (n = 2), chronic myocardial infarction (n = 2), dilated cardiomyopathy (n=1) and right ventricular failure (n = 1) was made. CONCLUSIONS: Although no specific MR pattern was found, MR allowed characterization of the underlying cardiac pathologies in 82% of HIV+ patients with elevated BNP levels.

Unilateral generalized morphea is a rare variant of localized scleroderma.

Localized scleroderma (LS) is a rare connective tissue disorder generally involving the entire dermis and usually limited to the subcutaneous tissue. However, it may progress to large indurated plaques, growth retardation, muscle atrophy, and even to flexion deformities or poorly healing ulcerations. LS has been classified as plaque, generalized, bullous, linear, and deep forms exhibiting different clinical subtypes. Recently, an unusual case of unilateral generalized morphea (UGM) in childhood extending from the middle dermis to the subcutaneous fat tissue has been reported. We here describe four young patients exhibiting a similar subtype of LS. All patients demonstrated a prominent unilateral skin involvement starting in childhood or adolescence. Histology revealed prominent accentuation of intradermal involvement. Except for positive anti-nuclear antibodies, no specific antibody pattern could be observed. In presenting these clinically homogenous cases we hereby introduce UGM as an extreme variant of the linear form of LS in childhood. As the onset of UGM usually occurs in pediatric patients, pediatricians should be cognizant of the presentation of this uncommon condition. Treatment with combined low-dose methotrexate and pulsed high-dose corticosteroid therapy might represent a promising treatment option for UGM.

Post-interventional homocysteine levels: failure as a predictive biomarker of in-stent restenosis.

OBJECTIVES: Purpose of our study was to determine if homocysteine plasma levels are related to the risk of in-stent restenosis after percutaneous coronary stent implantation in de novo lesions. BACKGROUND: The putative role of homocysteine as a predictive cardiovascular biomarker of coronary artery disease is well established. The impact of homocysteine levels in the development of in-stent restenosis, however, is controversially discussed. METHODS: A total of 177 patients with stable angina pectoris undergoing stent implantation in coronary de novo lesions were included. Laboratory determination comprised blood sample evaluation for homocysteine and other conventional risk factors before baseline coronary intervention and prior to six months control catheterization. Binary restenosis, late lumen loss, and late loss index after six months were assessed by quantitative coronary angiography. Endpoints included target lesion and target vessel failure, homocysteine levels as well as major adverse cardiac events. RESULTS: There was a significant correlation between the length of the implanted stent (p<0.006), the percentage of stenosis (p<0.003) and the pre-interventional luminal diameter (p<0.0001) with late loss index. Linear regression analysis demonstrated no significant impact of the initial or six months homocysteine levels on angiographic restenosis, late lumen loss, or late loss index. CONCLUSIONS: In contrast to homocysteine levels, luminal diameter, stent length and percentage of stenosis correlated with the appearance of restenosis. Taking our data into consideration, we hypothesise that homocysteine may not serve as a safe and independent biomarker of in-stent restenosis after a six months period following percutaneous coronary stenting.