[Dyspnea in left-sided heart disease]. / Dyspnoe bei Linksherzerkrankungen.

Shortness of breath (dyspnea) is a common symptom in left-sided heart disease but clinically, patient symptoms show a high variability. Echocardiography is the mainstay for evaluating whether left-sided heart disease is the cause of dyspnea. If left-sided heart failure is diagnosed, this symptom complex must then be subjected to further etiological evaluation. Hypertensive, ischemic and valvular heart diseases are common, as well as atrial fibrillation. If the patient does not have angina pectoris, testing for ischemic heart disease should be done non-invasively by coronary computed tomography or testing for regional myocardial ischemia. Coronary revascularization is indicated only when a prognostically relevant ischemia of more than 10 % of the left ventricle is diagnosed. Diuretics are important for the relief of dyspnea but do not improve the prognosis of patients. In patients with reduced left ventricular function, combination therapy with angiotensin-converting enzyme (ACE) inhibitors, beta blockers and aldosterone antagonists improve the symptoms and prognosis. For treatment of heart failure with preserved ejection fraction evidence-based measures are still lacking. In this case the recommended therapy consists of optimal treatment of comorbidities, regulation of heart rate and blood pressure and participation in structured exercise programs. Angiotensin receptor blockers and aldosterone antagonists can be given in patients with more severe symptoms even though the available data are very sparse.

[Comments on the 2013 ESC/EASD guidelines on diabetes, prediabetes and cardiovascular diseases]. / Kommentar zur ESC/EASD-Leitlinie zu Diabetes, Prädiabetes und kardiovaskulären Erkrankungen 2013.

Patients with type 2 diabetes mellitus have an increased cardiovascular risk compared with non-diabetics. The new guidelines provide physicians with orientation with respect to disorders in glucose metabolism and the risk of occurrence of cardiovascular diseases. An HBA1c level in the range of 6-8% is currently recommended, depending on cardiovascular comorbidities: in young diabetics 6% is recommended to avoid hypoglycemia and in older individuals with cardiovascular complications 8%. The target blood pressure given in the new guidelines is <140/85 mmHg. The guidelines still recommend bypass surgery instead of percutaneous coronary intervention (PCI) for diabetics; however, this recommendation is based on studies that do not reflect current practice and is disputable. Diagnostic measures and therapy of cardiac failure and arrhythmic disorders in the guidelines do not essentially differ between patients with and without diabetes, basically due to a lack of studies.

[Percutaneous coronary intervention versus bypass surgery in patients with diabetes and multivessel coronary disease. Coronary revascularization after FREEDOM]. / Perkutane koronare Intervention versus Bypass-Operation bei Patienten mit Diabetes und koronarer Mehrgefäßerkrankung. Koronarrevaskularisation nach FREEDOM.

Is coronary revascularization required in a patient with chronic stable coronary artery disease or can optimized medical therapy (OMT) alone be a sufficient alternative? This question has been controversially discussed for non-diabetics as well as for diabetics since the COURAGE and BARI 2D trials. According to our present knowledge, a patient will benefit from coronary revascularization only when either a non-invasive test method, such as single photon emission computed tomography (SPECT) or positron emission tomography (PET) myocardial scintigraphy, stress echocardiography or stress nuclear magnetic resonance imaging, can detect relevant, objective evidence of ischemia >10% of the left ventricular myocardium or when a pathological fractional flow reserve (FFR) <0.80 can be measured in an invasive procedure for an angiographically detectable coronary stenosis. If similar relevant ischemia can be non-invasively or invasively objectified in a patient with chronic stable multivessel coronary artery disease, the often controversially discussed question arises particularly in diabetics whether a percutaneous coronary intervention (PCI) with implantation of drug-eluting stents or coronary artery bypass surgery should be favored. The FREEDOM study (Future Revascularization Evaluation in Patients with Diabetes Mellitus: Optimal Management of Multivessel Disease), published in November 2012, was the first prospective randomized study to examine this issue in diabetic patients with multivessel coronary artery disease. Despite a higher rate of stroke in the surgical cohort, after an average follow-up time of 3.8 years a significant prognostic advantage in favor of bypass surgery was detected for a combined primary endpoint of all-cause mortality, nonfatal myocardial infarction and nonfatal stroke. Thus, in the new ESC guidelines on diabetes, pre-diabetes and cardiovascular diseases developed with the EASD of the European Society of Cardiology and published in 2013, coronary bypass surgery has a class I, level of evidence A recommendation for patients with diabetes mellitus, chronic stable multivessel coronary disease and a synergy between PCI with taxus and cardiac surgery (SYNTAX) score >22. The decision for or against a PCI/stent implantation or coronary bypass surgery in a diabetic patient with chronic stable multivessel coronary artery disease should therefore be made with the patient only after a detailed informed consent discussion and comprehensive explanation of both treatment options. In controversial cases, particularly with an equivocal SYNTAX score around 22, relevant comorbidities or anticipated method-specific complications, a one-stage ad hoc intervention during the diagnostic coronary angiography should be rejected in favor of a two-stage procedure with prior discussion of both treatment options in the heart team comprising noninvasive cardiologists, interventional cardiologists and cardiac surgeons.

[Management of acute myocardial infarction with ST-segment elevation: Update 2013]. / Management des akuten ST-Strecken-Hebungsinfarktes: Update 2013.

This article gives an update on the management of ST-segment elevation myocardial infarction (STEMI) according to guidelines released in 2012 by the European Society of Cardiology. To ensure a reliable diagnosis the updated universal definition of myocardial infarction will also be covered which is defined by myocardial necrosis. Criteria for diagnosis are a rise or fall of cardiac biomarkers, preferably troponin, in conjunction with symptoms of myocardial ischemia, new repolarisation disorders or left bundle branch block, development of pathological Q-waves, new hypokinesia/akinesia or loss in viability or the detection of intracoronary thrombi during cardiac catheterization or autopsy. The current recommendations for primary diagnosis and treatment by the first medical contact will also be discussed and contains decision-making for the optimal reperfusion strategy. Primary percutaneous coronary intervention remains the preferred reperfusion strategy; however, specifications with respect to time for diagnosis and reperfusion have been introduced. Furthermore, establishing a STEMI network has been emphasized in more detail. Special attention is paid to the new antiplatelet agents and anticoagulation therapy where prasugrel and ticagrelor are currently preferred over clopidogrel.

[Hybrid imaging in diagnostics and therapy of chronic myocardial ischemia. Clinical value]. / Hybridbildgebung in Diagnostik und Therapie der chronischen Myokardischämie. Klinischer Stellenwert.

Clinical studies have consistently shown that there is only a very weak correlation between the angiographically determined severity of coronary artery disease (CAD) and disturbance of regional coronary perfusion. On the other hand, the results of randomized trials with a fractional flow reserve (FFR)-guided coronary intervention (DEFER, FAME I, FAME II) showed that it is not the angiographically determined morphological severity of coronary artery disease but the functional severity determined by FFR that is critical for prognosis and the indications for revascularization. A non-invasive method combining the morphological image of the coronary anatomy with functional imaging of myocardial ischemia is therefore particularly desirable. An obvious solution is the combination of coronary computed tomography angiography (CCTA) with a functional procedure, such as perfusion positron emission tomography (PET), perfusion single photon emission computed tomography (SPECT) or perfusion magnetic resonance imaging (MRI). This can be performed with fusion imaging or with hybrid imaging using PET-CT or SPECT-CT. First trial results with PET CCTA and SPECT CCTA carried out as cardiac hybrid imaging on a 64 slice CT showed a major effect to be a decrease in the number of false positive results, significantly increasing the specificity of CCTA and SPECT. Although the results are promising, due to the previously high costs, low availability and the additional radiation exposure, current data is not yet sufficient to give clear recommendations for the use of hybrid imaging in patients with a low to intermediate risk of CAD. Ongoing prospective studies such as the SPARC or EVINCI trials will bring further clarification here.

[Diagnostic work-up of coronary artery disease: Clinical value of different imaging methods]. / Diagnostik der koronaren Herzkrankheit : Stellenwert der verschiedenen bildgebenden Verfahren.

This continuing medical education (CME) article describes the different non-invasive imaging methods with the exception of positron emission tomography for ischemia and viability testing. While stress methods, such as myocardial scintigraphy, stress echo or stress magnetic resonance imaging can detect the functional relevance of coronary artery stenosis, multislice computed tomography allows the visualization of the coronary anatomy and potential stenoses. Recently developed hybrid imaging allows the coronary anatomy and simultaneous functional testing of ischemia to be depicted. The different imaging methods for ischemia and viability testing are described.