[Gender aspects in cardiovascular diseases]. / Genderaspekte bei kardiovaskulären Krankheiten.

Cardiovascular diseases are the main cause of death in women and men worldwide, and, especially as far as coronary heart disorders are concerned, this is true of an increasing number of older and elderly persons. For decades, Gender Medicine research has shown gender differences in cardiology to the detriment of women, for example it takes longer for them to receive and they are less likely to have access to high-tech medicine, such as the ICU, heart catheters, bypass surgery, and they have a poorer outcome. Meanwhile, numerous scientific studies and awareness campaigns have been conducted. However, the more recent publications still show the same trends, albeit at a decreasing rate. Thanks to the emphasis placed on prevention and, thus, also the attention called to the leading heart risk factors such as smoking, high blood pressure, blood lipids, diabetes mellitus and overweight, namely for women and men, heart death is no longer exclusively male. In order to promote equal opportunity, Gender Medicine must be further implemented in medical training and post-graduate training, and-above all-the scientific findings concerning Gender Medicine must be incorporated into the guidelines of our professional societies.

Calibrated nanoscale capacitance measurements using a scanning microwave microscope.

A scanning microwave microscope (SMM) for spatially resolved capacitance measurements in the attofarad-to-femtofarad regime is presented. The system is based on the combination of an atomic force microscope (AFM) and a performance network analyzer (PNA). For the determination of absolute capacitance values from PNA reflection amplitudes, a calibration sample of conductive gold pads of various sizes on a SiO(2) staircase structure was used. The thickness of the dielectric SiO(2) staircase ranged from 10 to 200 nm. The quantitative capacitance values determined from the PNA reflection amplitude were compared to control measurements using an external capacitance bridge. Depending on the area of the gold top electrode and the SiO(2) step height, the corresponding capacitance values, as measured with the SMM, ranged from 0.1 to 22 fF at a noise level of ~2 aF and a relative accuracy of 20%. The sample capacitance could be modeled to a good degree as idealized parallel plates with the SiO(2) dielectric sandwiched in between. The cantilever/sample stray capacitance was measured by lifting the tip away from the surface. By bringing the AFM tip into direct contact with the SiO(2) staircase structure, the electrical footprint of the tip was determined, resulting in an effective tip radius of ~60 nm and a tip-sample capacitance of ~20 aF at the smallest dielectric thickness.

Coronary heart disease: sexual bias in referral for coronary angiogram. How does it work in a state-run health system?

This study examined the effects of a state-run health system on the gender-specific differences in cardiology worldwide, taking coronary angiography as an example. In a prospective study, 476 angiographed patients (155 female, 321 male) were enrolled in consecutive order over a study period of 9 months and asked to answer a standardized questionnaire. The responses showed a discrepancy in the heart death statistics (52.7% female, 47.3% male) and the demographic statistics (51.8% female, 48.2% male). This was true for all age groups. The duration of complaints before undergoing a coronary angiogram was reported to be acute for 4.5% of the women and 13.7% of the men, <1 year for 27.1% of the women and 34% of the men, and >1 year for 68.4% of the women and 52.3% of the men. Women take longer to access coronary angiogram. This is confirmed by New York Heart Association (NYHA) classes I (1.9% female, 7.8% male), II (46.5% female, 65.4% male), III (41.9% female, 21.8% male), and IV (9.7% female, 5.0% male). Prior to angiogram, all of the women and most of the men (98.4%) were under treatment for heart complaints, more women (87.1%) than men (78.8%) took heart medication, but fewer women (29.7%) than men (37.1%) had been referred to a cardiologist. Major differences were seen in the social situation; that is, 68.4% of the women but 93.5% of the men lived with their family, 30.3% of the women but only 5% of the men lived alone, and 1.3% of the women together with 1.6% of the men lived in a care-giving facility. The results of our study show that even in a state-run health system with free access to high-tech medicine at no charge and no age limits, there is a marked gender bias in access to high-tech medicine.

[Pacemaker therapy in heart failure]. / Schrittmachertherapie bei Herzinsuffizienz.

Drug therapy is the standard therapy for heart failure. The current state of the art does not permit pacemaker therapy as a general recommendation for left ventricular failure. Numerous controversial reports have been published on the success of pacemaker therapies for congestive heart failure. Iskandrian reported on tachycardiac atrial stimulation in 1986. Since 1990 several papers have been published on DDD-pacemakers with short AV-time. From the data available to us, congestive heart failure is generally not considered a new pacemaker indication. In carefully selected patients, however, an improvement in hemodynamics as well as in NYHA-classification can be expected, both in acute cases and on a long-term basis. In 16 patients Hochleitner demonstrated a significant increase in left ventricular ejection fraction, a significant drop in NYHA-classification, heart size and an increase in systolic and diastolic blood pressure. Using echocardiography Brecker showed a decrease in mitral regurgitation, an increase in ventricular filling time and, by means of ergometry, a major increase in cardiac output. The hypothesis for the working mechanism is that a shorter AV-time optimizes the time needed for AV-contraction, thereby reducing mitral regurgitation, lengthening ventricular filling time and thus increasing ejection fraction. Identification of the patients to whom this hypothesis can be applied is difficult but imperative. The optimal AV-time for each patient must be established on an individual basis using echocardiography, Doppler sonography and ergometry and must be finetuned in follow-up controls. Optimization of AV-time in patients with the classic indications for a pacemaker as well as a combination of cardioverters and DDD-pacemakers should be aimed for in patients with congestive heart failure and high NYHA-classification.

Aura phenomena during syncope.

We studied the frequency and clinical characteristics of aura phenomena in 60 patients with cardiac and 40 subjects with vasovagal syncopes. The majority (93%) of all syncope patients recalled having experienced an aura. Aura phenomena were similar in both groups and were mostly compound auras comprising epigastric, vertiginous, visual, or somatosensory experiences, but were more detailed in the noncardiac group. The localizing significance of auras preceding a syncope was generally poor. Although hard to distinguish from epileptic auras from their structure and shape, syncope-related auras lacked symptoms that are commonly reported after epileptic seizures such as tastes, smells, déjà vu phenomena, scenic visual perceptions, and speech impairments. A detailed anamnestic exploration of auras seems worthwhile in unexplained disorders of consciousness.

Long-term efficacy of physiologic dual-chamber pacing in the treatment of end-stage idiopathic dilated cardiomyopathy.

The long-term efficacy of physiologic dual-chamber (DDD) pacing in the treatment of end-stage idiopathic dilated cardiomyopathy was evaluated in a longitudinal study of up to 5 years in 17 patients. The considerable clinical improvement achieved after implantation of a pacemaker programmed for DDD pacing at an atrioventricular delay of 100 ms was maintained throughout the follow-up period or until death and was associated with a consistent decrease in New York Heart Association class and an increase in left ventricular ejection fraction. Cardiothoracic ratio, heart rate and echocardiographic dimensions progressively decreased, and systolic and diastolic blood pressures increased. Median survival time was 22 months. During follow-up, 4 patients received donor hearts, 9 had a sudden death at home without defined cause or after a thromboembolic event, and 1 died from adenocarcinoma. Three patients survived the follow-up. No patient needed rehospitalization owing to a worsening of heart failure after pacemaker implantation. An interruption of pacing in DDD mode for 2 to 4 hours was followed within the first months by a marked decrease in left ventricular ejection fraction and an increase in cardiothoracic ratio and echocardiographic dimensions, but this response consistently decreased during follow-up. The data indicate that DDD pacing can be recommended as a useful tool in the long-term treatment of end-stage idiopathic dilated cardiomyopathy, with progressive improvement in cardiac function and a reduction of the dilatation of the left ventricle.

Usefulness of physiologic dual-chamber pacing in drug-resistant idiopathic dilated cardiomyopathy.

The beneficial effects of physiologic dual-chamber (DDD) pacing in the treatment of end-stage idiopathic dilated cardiomyopathy were evaluated in 16 patients in whom conventional drug therapy had failed. Candidates for cardiac transplantation as well as patients not accepted for transplantation participated. During DDD pacing at an atrioventricular delay of 100 ms, left ventricular ejection fraction increased from 16.0 +/- 8.4 to 25.6 +/- 8.6% (p less than 0.001) accompanied by a striking improvement in clinical symptoms, such as severe dyspnea at rest and pulmonary edema. The New York Heart Association class decreased from 3.6 +/- 0.4 to 2.1 +/- 0.5 (p less than 0.001). The decrease in cardiothoracic ratio from 0.60 +/- 0.06 to 0.56 +/- 0.05 (p less than 0.001) coincided with a decrease in left atrial and right ventricular echocardiographic dimensions, indicating a decrease in preload. Systolic blood pressure increased from 108 +/- 29 to 126 +/- 21 mm Hg (p less than 0.01) and diastolic blood pressure from 67 +/- 15 to 80 +/- 11 mm Hg (p less than 0.01). Normalization of heart rate was achieved. No major complications developed as a consequence of DDD pacing. All patients could be discharged from the hospital within 3 weeks after pacemaker implantation and return to a relatively normal life. Within 1 year after onset of DDD pacing only 4 of the patients died (from either sudden death or stroke). DDD pacing could represent an alternative approach to the management of chronic heart failure due to dilated cardiomyopathy, especially for heart transplant candidates and patients who are not accepted for cardiac transplantation, but no longer respond to drug therapy.

[Type, number and mode of distribution of cases of poisoning at the University Department of Internal Medicine, Innsbruck]. / Art, Zahl und Verteilungsmodus von Intoxikationsfällen an de Universtiätsklinik für Innere Medizin, Innsbruck.

In the course of one year 357 patients were treated in our department for poisoning, nearly always with suicidal intent. Altogether 249 patients were admitted to the wards for 24 hours or longer, and 108 of these (44.6%) were taken into the intensive care unit. Apart from myocardial infarction (276 patients/year), poisoning is the most common reason for admission to the intensive care unit. The age distribution showed a maximum between 15 and 20 years. Only one case proved fatal, representing a mortality rate of 0.3%.

[Therapy of paroxysmal supraventricular tachycardias by rapid patient-activated atrial stimulation]. / Therapie von paroxysmalen supraventrikulären Tachykardien durch patientenaktivierte rasche Vorhofstimulation.

Recurrent, drug refractory supraventricular tachycardia may present a therapeutic challenge. Following invasive electrophysiological study and the prospectively controlled therapeutic failure of all available drugs 3 patients were treated by permanent implantation of a system for atrial burst stimulation. The system consists of an implanted receiver with electrodes connected to the right atrium and a radiofrequency stimulator that requires patient activation for burst pacing. During a follow-up period of 6 to 39 months numerous attacks of recurrent tachycardia were successfully terminated without complication. The therapeutic approach which has allowed stoppage of all antiarrhythmic drugs and has obviated the need for frequent hospital admissions has met with patient approval and is highly regarded as providing an improvement in quality of life.

[Clinical and electrophysiological observations in a case of Romano-Ward syndrome ]. / Klinische und elektrophysiologische Beobachtungen bei Romano-Ward-Syndrom.

Syncope associated with atypical ventricular tachycardia of the "torsades de pointes" type was observed in a 16 year-old girl with hereditary QT prolongation. The arrhythmia occurred only during maximal prolongation of the QTc to 0.77 sec, which had possibly been aggravated by exercise and hypokalaemia. Electrophysiological studies were performed when the QTc was 0.59 sec. Incremental as well as premature ventricular pacing with single or double premature ventricular beats did not initiate ventricular arrhythmias, but revealed AV nodal and bundle branch reentry. It is postulated that these types of macroreentry are involved in the twisting of the QRS complexes in the surface ECG in torsades de pointes.

Effect of tiapamil in the preexcitation syndrome.

The effects of tiapamil were studied in 10 patients with antegrade preexcitation using programmed stimulation of the heart. Before administration of the drug, it was possible to initiate sustained orthodromic tachycardia in 7 patients, antidromic tachycardia in 2 and atrial echoes in 1 case by premature atrial and/or ventricular stimulation. An intravenous bolus of 2 mg/kg tiapamil terminated the tachycardia in 7 out of 8 cases by blocking the A-V node. The tachycardia continued at a reduced heart rate in 1 case with a nodoventricular bypass. Tiapamil lengthened the effective A-V nodal refractory period in 1 patient in whom it could be measured and the atrial effective refractory period in 1 case but did not prolong the antegrade or retrograde refractory periods of the accessory pathway. Only in 1 case was the antegrade effective refractory period of the accessory pathway shortened by tiapamil. The A-V nodal conduction time (A-H interval) was prolonged. Following tiapamil it was not possible to initiate the tachycardia in 4 cases and atrial echoes in 1 case; in 2 patients the tachycardia zone widened and in 3 it was not altered. In the latter, the cycle length of the tachycardia increased. Tiapamil appears to be of therapeutic value for the termination of tachycardia and also for its prevention in some cases. In others, it may facilitate the initiation of tachycardia. The delayed A-V nodal conduction during sinus rhythm augments the area of ventricular preexcitation which may facilitate the electrocardiographic localization of the accessory pathway.

[Cytogenetic and clinical investigations in trisomia 22 (author's transl)]. / Zytogenetische und klinische Untersuchungen einer Patientin mit einer Trisomie 22

Since the introduction of new cytogenetic methods, as the "Pancreatin-Giemsa"-stain and similar methods, it is possible for the first time to determine the chromosomes of group G accurately. There are few cases reported in the literature with an additional small chromosome which could be associated with group G. None of those children presented the classical signs of a Down-Syndrome, therefore a trisomy 22 was discussed. This is the report of a female patient, on whom trisomy 22 was confirmed cytogenetically. So far it was only in a small number of cases possible to prove this thesis by cytogenetic studies. We compare our findings with previous reports of suspected or proven cases of trisomy 22.