[Current treatment of tachycardia]. / Aktuelle Therapie tachykarder Herzrhythmusstörungen.

Tachycardias including atrial fibrillation often require hospitalisation. A diagnostic algorithm from the surface ECG allows discrimination between supraventricular and ventricular tachycardias. For acute treatment, only a few antiarrhythmic drugs such as adenosine, ajmaline and amiodarone, and in case of hemodynamic instability electrocardioversion are required. For long-term treatment catheter ablation is the option of choice for almost all patients with supraventricular tachycardias, atrial flutter, idiopathic ventricular tachycardias and for many patients with symptomatic atrial fibrillation. Chronic antiarrhythmic drug therapy is less often used. In patients with ventricular tachyarrhythmias in the setting of severe structural heart disease, risk stratification must be performed and ICD therapy is often indicated. Anticoagulant therapy according to risk score analysis is often indicated in patients with atrial fibrillation.

[Epidemiological and prognostic data from 2054 patients of an internal medicine intensive care unit]. / Epidemiologische und prognostische Daten von 2054 Patienten einer internistischen Intensivstation.

BACKGROUND: Computer-based data collection and objective gathering of degree of illness severity and risk of death with a prognostic scoring system make it possible to obtain, in addition to epidemiological and aetiological data, risk-related outcome values for patients in an intensive care unit. PATIENTS AND METHODS: All 2054 patients who during a 2-year period (1995-1996) had stayed in a medical intensive care unit (MICU) for more than 4 hours were studied prospectively. The simplified acute physiology score II (SAPS II), risk of death, duration of stay in the MICU and in the hospital, and death rates during MICU and hospital stay were determined. Mean and median values and histograms of the various parameters as well as the standardized mortality index (SMI: observed/ predicted death rate with 99% confidence limits) were calculated for each of the patients and certain defined subgroups (basic disease, age, risk). Receiver operating characteristics curves (discrimination) and calibration curves were obtained for SAPS II. RESULTS: Mean age for the cohort was 59.8 years, duration of stay in the MICU 3.1 days, in hospital 14.7 days, SAPS II was 30.3 points, death risk 0.17, death rate during ICU stay was 8.3%, during hospital stay 13.9% and the SMI 0.8% (0.74-0.88). Cardiac disease was the most common underlying condition (60%), while the small group of neurological conditions was remarkable for the high degree of severity and unfavourable prognosis. Both death rate and degree of disease severity increased with age. But the SMI was not significantly higher than 1.0 in both the elderly patients and the high-risk group of patients (on ventilator, renal replacement procedures, death risk > 0.5). CONCLUSIONS: Most patients in a MICU have underlying cardiac disease. Permanently available neurological consultation is essential. The high hospital death rate for elderly patients and those requiring respiratory support is a problem of disease severity, not of the quality of treatment. The risk of death is high on transfer to a general ward. Determination of the SMI is recommended for internal quality control in an ICU.

[Successful valvuloplasty of a calcified, high-grade pulmonary valve stenosis with removal of a right-left shunt at the atrial level]. / Erfolgreiche Valvuloplastie einer verkalkten hochgradigen Pulmonalklappenstenose mit Beseitigung eines Rechts-Links-Shunts auf Vorhofebene.

HISTORY AND CLINICAL FINDINGS: A 68-year-old woman, with a cardiac murmur known since childhood and suffering from increasing dyspnoea for several years, was admitted to hospital after echocardiography had suggested pulmonary valve stenosis and an atrial septal defect. While her general condition was satisfactory, she had marked central cyanosis with clubbed fingers and moderate bilateral oedema of the lower legs. A rough, diamond-shaped systolic murmur was heard, loudest over the left 2nd intercostal space. In addition to a cardiac defect with right to left shunt, primary pulmonary disease with cor pulmonale was considered in the differential diagnosis. EXAMINATIONS: Haemoglobin content was 25.1 g/dl, haematocrit 72.4%, red cell count 7.44 x 10(6). Arterial oxygen partial pressure was 40 mm Hg, arterial oxygen saturation 81.8%, Echocardiography further revealed right ventricular enlargement, marked tricuspid regurgitation and a stenosed calcified pulmonary valve. At right heart catheterization a right to left interatrial shunt was calculated at 47% of systemic flow and a systolic pressure gradient between right ventricle and pulmonary artery of 131 mm Hg was measured. TREATMENT AND COURSE: Haemoglobin content was lowered to 19.4 g/dl after bloodletting. Balloon pulmonary valvuloplasty reduced the transvalvular systolic gradient to 31 mm Hg. The further course was without complication: 4 months later the patient had only grade II (NYHA) dyspnoea, the oxygen saturation was 91.3%. CONCLUSION: Severe pulmonary valve stenosis with right to left interatrial shunt can be successfully treated by balloon dilatation even in elderly patients.