[Long-term effects of rehabilitation of an outpatient "heart group". A case control study]. / Langzeitwirkungen der Nachsorge in einer ambulanten Herzgruppe. Eine Fall-/Kontrollstudie.

The effects of an outhospital cardiac rehabilitation program in "heart groups" (HG) are studied in a case-control design. The control group (KG) was collected by match-pairing from 12,560 cases of a rehabilitation clinic fitting in the relevant criteria to those of members of the HG. Patients of both groups (n = 75/group) after myocardial infarction and CABG were followed up over 7.5 years. There was no significant difference in risk factor modification. Exercise tolerance improved significantly in the HG by increasing maximum work capacity by 50% in spite of a mean age of 60 years at the beginning. Members of HG had significantly lesser cardiac complaints and lower need for cardiac medication. Cardiac morbidity was reduced by 54% and costs for medical care were lowered by 47% in HG. Although effects of secondary prevention on reducing risk factors were still insufficient, exercise tolerance in higher age and quality of life were improved, reduction in medication and in the morbidity saved costs for the health system.

[25-year experience with reusable heart catheters]. / 25 Jahre Erfahrung mit wiederaufbereiteten Herzkathetern.

For 25 years, cardiac catheters have been prepared for reuse in a hospital for heart and vessel diseases, in the beginning by the hospital itself, later on by a specialized company with a standardize, validated certified procedure. Experiences with almost 100,000 interventions with flow directed catheters, diagnostic left-heart- and angiography-catheters, balloon- and electrophysiology-catheters, which were performed with reused material in more than half of these cases, are reported. All patients were informed that disposable catheters were reused. Neither the duration of the intervention, the x-ray load for the patient, the consumption of contrast media and the change rate of catheters, nor the catheter dependent complication rates were increased for reused catheters in comparison to single use. Therefore the reuse of cardiac catheters does not affect patients' safety, but is a cost-saving strategy.

Variability over time of haemostatic and other cardiovascular risk factors in patients suffering from angina pectoris. ECAT Angina Pectoris Study Group.

The variability of haemostatic factor measurements in patients presenting with angina pectoris is investigated. In all, 219 middle aged patients (almost all men) provided repeat measurements 2.5 years apart on a battery of haemostatic and haematological tests and other cardiovascular risk factors. Correlations between repeat measurements were lower than might be expected in a healthy population, reflecting a relatively large degree of variability within individuals over time. The highest correlations observed for haemostatic factors were for von Willebrand factor related antigen (r = 0.48) and fibrinogen (r = 0.45). The correlations were generally lower amongst patients who had undergone coronary surgery or angioplasty between the two measurements. We conclude that the underlying relationship of fibrinogen to coronary risk must be much greater than is generally appreciated, since even single measurements are found to be important predictors of risk, despite only moderate stability over time. The very low correlations for beta-thromboglobulin (r = 0.10) and platelet factor 4 (r = 0.03) which were observed in this study casts doubt on their potential usefulness as predictors of long-term cardiovascular risk.

A field study on the immediate effects of exposure to low-altitude flights on heart rate and arrhythmia in patients with cardiac diseases.

Noise from low-altitude military flights differs from most other sources of noise by virtue of its unpredictability in space and time, its very high maximal levels, and the fast increase in noise level at high flight speeds. While this makes low-altitude flights a frightening and annoying experience, the potential immediate health hazards for exposed individuals with preexisting cardiovascular disease are unclear. A field study on the immediate effects of exposure to low-altitude flights on heart rate and arrhythmia was conducted among patients of a rehabilitation clinic for cardiac diseases in the summer of 1990 in Bad Rothenfelde, Germany. Twenty-four hour electrocardiograms of 68 patients taken on days when low-altitude overflights with peak sound pressure levels above 95 dB(A) were registered on the flat roof of the clinic were analyzed for changes in the heart rate or the occurrence of ventricular extrasystoles in four 2-min periods before, around, and after the overflights. Overall, 149 "overflight events" were included in the analysis. No major changes in the heart rate or in the frequency of ventricular extrasystoles were observed, but this could be partly due to problems inherent in the field approach. Nevertheless, the potential effects on heart rate and arrhythmia of low-altitude flights appear to be of limited magnitude compared to the potential effects of other factors, such as psychological or physical exposures, and they are probably too small to be proven under field conditions in an observational epidemiologic study in Germany following the limitations placed on the frequency and altitude of flights in September 1990.

Low-dose aspirin versus anticoagulants for prevention of coronary graft occlusion.

The prevention of graft occlusion by aspirin (100 mg/day) or heparin followed by phenprocoumon was investigated in a randomized trial in 235 patients after aortocoronary bypass operation. Aspirin treatment started 24 hours before, and heparin 6 hours and phenprocoumon 2 days after surgery. The results of the vein graft angiography and the clinical outcome 3 months postoperatively did not differ: 22% of 218 vein graft distal anastomoses in the aspirin group and 20% of 272 in the anticoagulant group were occluded. At least 1 occluded distal anastomosis was present in 38% of 74 patients in the aspirin-treated group and in 39% of 86 in the anticoagulant group. Worst-case analysis of all randomized patients showed graft occlusions, cardiovascular complications or lost to follow-up in 42% of 122 aspirin-treated patients compared with 41% of 113 patients treated with anticoagulants. For grafts with endarterectomy the occlusion rate was lower in the aspirin (12% of 49) than in the anticoagulant (22% of 41) group (p less than or equal to 0.05). Increased perioperative blood loss in the aspirin group (1,211 +/- 814 ml in the first 48 hours vs 874 +/- 818 ml in the anticoagulant group [p less than or equal to 0.001]) without a higher reoperation rate indicates effective platelet inhibition with low-dose aspirin. Because occlusion rates were equal but high in these patients with advanced stage of coronary artery disease, a combination of low-dose aspirin and anticoagulation should be investigated to reduce graft occlusion rates further.

[Psychological management of heart patients and their relatives in the pre- and postoperative phases: experiences from a 2 year model trial]. / Psychologische Betreuung von Herzpatienten und ihren Angehörigen in den prä- und postoperativen Phasen: Erfahrungen aus einem zweijährigen Modellversuch.

The psychological and neurological disorders as well as psychosocial problems experienced by cardiac patients and their relatives while waiting for coronary artery bypass surgery are outlined, as well as their intrapsychic situation following the operation. With a view to providing long-term psychological support and care of cardiac bypass patients and their relatives, a care model has been developed which emphasizes the following: (1) initial contact and individual counselling immediately following establishment of the indication for surgery (2) client-centered groups to prepare for the operation, involving both the patients and their partners (3) client-centered (therapy)/relaxation groups for postoperative patients. This model trial is described, covering its development, structure, and contents in some detail. An evaluation is given, as is an explanatory case presentation. The results obtained from 48 cardiac bypass patients in a follow-up study of their views concerning the psychological care provided, are presented in a summary account. Concluding, the authors outline future emphases for practical work and research.

[Preventive antifibrillatory treatment of sudden cardiac death in acute myocardial infarct]. / Antifibrillatorische Prophylaxe des Sekundenherztodes beim akuten Herzinfarkt.

The pathophysiological basis of sudden cardiac death due to ventricular arrhythmias in acute myocardial infarction has been extensively investigated in experimental as well as in some clinical studies. Numerous clinical studies have been performed with the aim to establish the feasibility of antifibrillatory prophylaxis of sudden cardiac death by pretreatment with antiarrhythmic drugs. Using class I-antiarrhythmic drugs the reported findings were contradictory. While the antiarrhythmic efficacy of Lidocaine and other, newer class I-antiarrhythmic drugs is well established, the antifibrillatory effects of these drugs in the early phase of acute myocardial infarction remain uncertain. In clinical studies with the endpoint of mortality in patients at risk, longterm administration of orally effective class I-antiarrhythmic drugs did not prove to be superior to placebo. However, beta-sympatholytic agents have been shown to reduce mortality in patients at risk in several large clinical studies. The basic mechanism seems to be primarily a reduction in sudden cardiac death which is caused predominantly by ventricular fibrillation. The antifibrillatory properties of beta-blockers was demonstrated as well by a reduction in the number of episodes of ventricular fibrillation. The recognition of patients at risk who profit most from chronic beta-blocker therapy remains the main problem when treatment of numerous low-risk patients is avoided. In the ISIS I-study with Atenolol intravenous administration of a beta-blocker in the early phase of acute myocardial infarction has been shown to be beneficial if hemodynamic monitoring, for example using flow-directed heart catherization is performed. In general this does not apply to the treatment with calciumantagonists, especially with Verapamil and Nifedipine. These drugs do not improve prognosis of acute myocardial ischemia, obviously because of hemodynamic side effects. The antifibrillatory efficacy of Verapamil-type calciumantagonists, shown in the experimental model, could not be demonstrated in the clinical setting. Nevertheless, further clinical studies performing longterm prophylactic treatment of patients at risk before the onset of myocardial ischemia seem to be worthwhile. Concerning class III-antiarrhythmic agents, clinical experience in the setting of acute myocardial infarction is limited; hence a final conclusion about their antifibrillatory efficacy under clinical conditions at present is impossible.

[Uses and risks of hemodynamic monitoring by inflow catheter in acute myocardial infarct]. / Nutzen und Risiken des hämodynamischen Monitorings durch Einschwemmkatheter beim akuten Herzinfarkt.

Using hemodynamic monitoring by flow-directed heart catheterization in acute myocardial infarction, left ventricular dysfunction can be analyzed and quantified. Differential therapy concerning substitution of volume and administration of drugs with influence on pre- and after-load is facilitated. Since the introduction of the Swan-Ganz flow-directed catheter the monitoring has been technically improved with the additional advantage of lower incidence of catheter-induced arrhythmias and the possibility to measure the pulmonary capillary wedge pressure. The Swan-Ganz thermodilution catheter further improved the technical assessment of cardiac output. Using hemodynamic monitoring during acute myocardial infarction different phases of cardiac failure can be discerned, e.g., backward failure with increased filling pressure, foreward failure with decreased cardiac output, and cardiogenic shock with the combination of both. In some cases a hyperkinetic hemodynamic status is observed. The differential diagnosis of pulmonary embolism, and cardiac and pulmonary shock can be clarified. Complications of myocardial infarction as acute mitral insufficiency due to papillary muscle rupture in inferior myocardial infarction, rupture of the septal myocardium in septal infarction, as well as myocardial rupture with pericardial tamponade show characteristic diagnostic findings. Drug therapy with influence on pre- and after-load and therapy with positive-inotropic agents can be adjusted to the individual hemodynamic status and to the monitored drug effects.(ABSTRACT TRUNCATED AT 250 WORDS)

Association of apolipoprotein E polymorphism, low-density lipoprotein cholesterol, and coronary artery disease.

We determined the frequencies of genetic apolipoprotein E isoforms in 570 survivors of myocardial infarction, all with demonstrable coronary heart disease, as compared with 624 healthy persons. In controls, E-4/E-3 heterozygosity was associated with total cholesterol concentrations of 1985 (SD 364) mg/L and low-density lipoprotein (LDL)-cholesterol concentrations of 1306 (SD 332) mg/L. Significantly lower values, 1811 (SD 312) mg/L and 1121 (SD 274) mg/L, respectively, were observed for E-3/E-2 heterozygous persons. In survivors of myocardial infarction, the respective values were significantly higher than in controls, differing between E-4/E-3 and E-3/E-2 heterozygous patients by 233 and 220 mg/L, respectively. Moreover, E-4/E-3 heterozygosity was accompanied by earlier age of myocardial infarction (48.8 +/- 7.4 years) as compared with E-3/E-2 heterozygosity (53.4 +/- 6.9 years) and E-3/E-3 homozygosity (51.2 +/- 7.7 years). Evidently, apolipoprotein E polymorphism can contribute to total and LDL-cholesterol concentrations in serum, thereby affecting risk of coronary heart disease and myocardial infarction.

[Aspects of vocational reintegration following myocardial infarct in relation to disease severity--follow-up of patients with after-care treatment]. / Aspekte der beruflichen Wiedereingliederung nach Herzinfarkt in Abhängigkeit vom Schweregrad der Erkrankung--Nachbefragung von Patienten mit Anschlussheilbehandlung.

Medical examination data were compared with psychosocial questionnaire findings in a retrospective study of 536 myocardial infarction patients. The average observation period was four years. On the basis of cardiac catheterization results, obtained during participation in post-clinical rehabilitation, four diagnostic groups were formed in order of disease severity. Return to work, early resumption of working following post-clinical rehabilitation, and the subjective perception of cardiac complaints did not show any clear-cut association with severity of the cardiac findings. The two conclusions drawn are that in addition to the somatic factors involved, psychosocial ones will have to be given greater emphasis in the rehabilitation process, and successful rehabilitation should not be determined exclusively on the criterion of vocational resettlement.

Hemodynamics before and after physical endurance training in patients with myocardial infarction under various physical and psychomotor stress tests.

This hemodynamic study was done in 23 post myocardial infarction patients. The peripheral and central hemodynamics were examined by repeated ergometer tests, heart volume estimations, and heart catheterizations under various provocative techniques such as dynamic bicycle ergometer load, static hand grip load, volume load, atrial pacing, and psychomotor stress. After a 5-week period of endurance training we found a marked and statistically significant increase (40%) of maximal work tolerance and a significant decrease (10%) in heart rate and atrial blood pressure at rest and on equal levels of work load. No significant influence was seen on central (pulmonary) pressure readings at rest or on equal levels of work load beside the higher venous oxygen extraction. These peripheral effects of physical training were seen for all provocative tests, and also for those which were not trained as static and volume load and psychomotor stress.

[Improved flow through aortocoronary venous bypasses after anticoagulant therapy. A prospective randomized study]. / Verbesserte Durchgängigkeit aorto-koronarer Venen-Bypasses nach Antikoagulantientherapie. Eine prospektive randomisierte Studie.

To evaluate the effect of oral anticoagulant therapy on graft patency rate during the first 2 months after bypass surgery 174 patients were randomly assigned to treatment with phenprocoumon (89) or to a control group (85) starting on day 7 after bypass surgery. Until day 7 all patients received low dose heparin. There was no significant difference between the two groups with respect to age, sex distribution, number of vessels diseased, left ventricular enddiastolic pressure, preoperative exercise tolerance or number of grafts constructed per patient. All patients underwent angiographic evaluation 8 weeks after bypass surgery. Graft patency rate was 90.4% in the treatment group versus 83.6% in the control group (p less than 0.015). None of the grafts with a flow rate of greater than 90 ml/min was occluded 8 weeks after surgery. Oral anticoagulation improved the patency rate of grafts with a flow of less then 90 ml/min.

Improved graft patency with anticoagulant therapy after aortocoronary bypass surgery: a prospective, randomized study.

We conducted a prospective, randomized study to evaluate the influence of oral anticoagulation on graft patency early after aortocoronary bypass surgery. Eighty-nine patients who received 251 distal venous anastomoses were treated with phenoprocoumon, a vitamin K antagonist, starting on the seventh postoperative day; 84 patients with 238 distal venous anastomoses received no anticoagulation. Both groups were comparable with respect to age, exercise hemodynamics, extent of coronary disease and left ventricular dysfunction. In each group, 2.8 distal anastomoses were constructed per patient. Graft patency after surgery was 90.4% in the treatment group and 84.6% in the control group (p less than 0.015). All anastomoses were patent in 81% and 67% of patients, respectively (p less than 0.02). Flow measurements in 279 grafts suggest that grafts with a flow of less than 90 ml/min benefit from oral anticoagulation. No graft with a flow of more than 90 ml/min was occluded.

[Partial atrial standstill with sick-sinus-syndrome accompanying a case of cardiomyopathy (author's transl)]. / Partieller Vorhofstillstand mit Syndrom des kranken Sinusknotens im Rahmen einer Kardiomyopathie.

In a patient with cardiomyopathy of unknown etiology and clinical manifestation of SSS (sick-sinus syndrome) the electro-physiological examination and the registration of pressure curves indicated a mechanical and electrical partial standstill of both atria. Some electro-physiologically interesting phenomena found during the His-catheterization are described.