ABSTRACT
The Ethics Section of the German Interdisciplinary Association of Critical Care and Emergency Medicine (DIVI) recently published a documentation for decisions to withhold or withdraw life-sustaining therapies. The wish to donate organs was not considered explicitly. Therefore the Ethics Section and the Organ Donation and Transplantation Section of the DIVI together with the Ethics Section of the German Society of Medical Intensive Care Medicine and Emergency Medicine worked out a supplementary footnote for the documentation form to address the individual case of a patient's wish to donate organs.
ABSTRACT
Deep vein thrombosis and pulmonary artery embolisms share pathophysiological features and are therefore collectively referred to as venous thromboembolisms (VTE). While the incidence of VTE has been increasing for years as a result of demographic changes and improved diagnostics, the morbidity and mortality are decreasing. This is particularly due to more sensitive diagnostics, improvements in risk stratification and more effective anticoagulation strategies. The aim of effective anticoagulation therapy is the avoidance of early events up to death and prevention of recurrent events. Anticoagulation treatment should be started with either heparins (unfractionated or low molecular weight), the pentasaccharide fondaparinux or direct oral anticoagulants. Patients with recurrent events qualify for indefinite anticoagulation treatment. For a first episode of VTE anticoagulation treatment for at least 3 months is recommended (maintenance therapy). Subsequently, prolonged maintenance therapy for secondary prevention can be meaningful, depending on the individual patient risk (provoked event, risk for recurrence or bleeding). The non-vitamin K antagonist oral anticoagulants (NOACs) have now also been approved for this indication. As a result of a probably permanently high risk for recurrent events of up to 10% per year after cessation of anticoagulation, insufficient scores for estimation of the risk of bleeding and recent data documenting the safety and efficacy of NOACs for secondary prevention, a shift towards prolonged anticoagulation of 3-6 months or even indefinite (>1 year) treatment can be anticipated for patients after thromboembolic diseases.
Subject(s)
Anticoagulants/therapeutic use , Pulmonary Embolism/drug therapy , Venous Thrombosis/drug therapy , Administration, Oral , Algorithms , Drug Administration Schedule , Fondaparinux/therapeutic use , Heparin/therapeutic use , Heparin, Low-Molecular-Weight/therapeutic use , Humans , Long-Term Care , Pulmonary Embolism/diagnosis , Pulmonary Embolism/mortality , Recurrence , Risk Factors , Secondary Prevention , Survival Rate , Venous Thrombosis/diagnosis , Venous Thrombosis/mortalitySubject(s)
Critical Care , Decision Making , Emergency Medicine , Withholding Treatment , Documentation , HumansSubject(s)
Peripheral Arterial Disease , Ticagrelor , Clopidogrel , Humans , Platelet Aggregation InhibitorsABSTRACT
Hypertrophy of the left ventricular myocardium is a common finding and can be reliably detected by echocardiography, CT and MRI. Common causes include diseases associated with increased cardiac afterload as well as primary and secondary cardiomyopathy. With the opportunity to determine functional parameters and myocardial mass precisely as well as to detect structural changes of the cardiac muscle simultaneously, cardiac MRI is the most precise imaging method for quantifying left ventricular hypertrophy as well as determining the cause and the exact characterization of the myocardial changes. It is mandatory, however, to create a flexible, individually adapted examination protocol. This review presents useful diagnostic algorithms in relation to different underlying pathologies in patients with left ventricular hypertrophy.
Subject(s)
Echocardiography , Hypertrophy, Left Ventricular/diagnosis , Magnetic Resonance Imaging , Tomography, X-Ray Computed , Cardiomyopathies/diagnosis , Cardiomyopathies/etiology , Contrast Media/administration & dosage , Diagnosis, Differential , Heart Septum/pathology , Heart Ventricles/pathology , Hemodynamics/physiology , Humans , Hypertrophy, Left Ventricular/etiology , Organ Size , Reference ValuesABSTRACT
Cardiac magnetic resonance imaging (MRI) and computed tomography (CT) have been developed rapidly in the last decade. Technical improvements and broad availability of modern CT and MRI scanners have led to an increasing and regular use of both diagnostic methods in clinical routine. Therefore, this German consensus document has been developed in collaboration by the German Cardiac Society, German Radiology Society, and the German Society for Pediatric Cardiology. It is not oriented on modalities and methods, but rather on disease entities. This consensus document deals with coronary artery disease, cardiomyopathies, arrhythmias, valvular diseases, pericardial diseases and structural changes, as well as with congenital heart defects. For different clinical scenarios both imaging modalities CT and MRI are compared and evaluated in the specific context.
Subject(s)
Cardiac Imaging Techniques/methods , Heart Defects, Congenital/diagnosis , Heart Diseases/diagnosis , Magnetic Resonance Imaging/methods , Tomography, X-Ray Computed/methods , Adult , Child , Cooperative Behavior , Germany , Heart Defects, Congenital/physiopathology , Heart Defects, Congenital/therapy , Heart Diseases/physiopathology , Heart Diseases/therapy , Humans , Infant , Interdisciplinary Communication , Prognosis , Sensitivity and SpecificityABSTRACT
The advent of drug-eluting balloon (DEB) therapy has represented an important development in interventional cardiology. Nevertheless, preclinical data with this technology remain scant, and comparative studies have not previously been published. Bare metal stents were implanted in the coronary arteries of 15 pigs followed by balloon angioplasty. Animals were allocated to treatment with a 60-second inflation of one of four different balloon catheters: a conventional untreated plain angioplasty balloon (PBA, Biotronik AG), the Pantera Lux DEB (3.0 µg/mm2 paclitaxel; BTHC excipient, Biotronik AG), the Elutax DEB (2.0 µg/mm2 paclitaxel; no excipient; Aachen Resonance), or the SeQuent Please DEB (3.0 µg/mm2 paclitaxel; iopromide excipient: B. Braun). Twenty-eight days following balloon deployment, animals underwent repeat angiography for quantitative coronary angiography analysis and euthanasia for histopathologic assessment. By histology, the mean neointimal thickness was 0.44 ± 0.19 mm with PBA, 0.35 ± 0.13 mm with Pantera Lux , 0.61 ± 0.20 mm with Elutax , and 0.47 ± 0.21 mm with SeQuent Please DEB (p=0.02). In comparison with PBA, deployment of the Pantera Lux or the SeQuent Please DEB resulted in delayed healing characterised by significant increases in fibrin, neointimal cell vacuity and delayed re-endothelialisation. In conclusion, investigation of comparative DEB performance in a porcine model of advanced coronary restenosis reveals significant heterogeneity of neointimal suppression between the devices tested with numerically lowest values seen in the Pantera Lux group. On the other hand, evidence of delayed healing was observed in the most effective DEB groups.
Subject(s)
Angioplasty, Balloon , Coronary Restenosis/therapy , Coronary Stenosis/therapy , Coronary Vessels/pathology , Endothelium, Vascular/metabolism , Animals , Coronary Restenosis/etiology , Coronary Restenosis/pathology , Coronary Restenosis/physiopathology , Coronary Stenosis/complications , Coronary Stenosis/pathology , Coronary Stenosis/physiopathology , Coronary Vessels/drug effects , Coronary Vessels/surgery , Disease Models, Animal , Drug-Eluting Stents/adverse effects , Endothelium, Vascular/drug effects , Endothelium, Vascular/pathology , Fibrin/metabolism , Humans , Neointima , Paclitaxel/administration & dosage , Swine , Wound Healing/drug effectsSubject(s)
Anaphylaxis/drug therapy , Bee Venoms/adverse effects , Bites and Stings/complications , Epinephrine/adverse effects , Takotsubo Cardiomyopathy/chemically induced , Adult , Anaphylaxis/etiology , Epinephrine/administration & dosage , Female , Humans , Injections, Intravenous , Sympathomimetics/administration & dosage , Sympathomimetics/adverse effects , Takotsubo Cardiomyopathy/diagnosisABSTRACT
The prognosis of patients presenting with Tako-Tsubo cardiomyopathy (TTC) is generally considered to be favorable. However, in the acute phase of the disorder complications are not infrequent and, therefore, continuous monitoring and consistent therapy in an intensive care unit is essential. Typical complications in patients with TTC are cardiogenic shock, obstruction of the left ventricular outflow tract (LVOT), occasionally accompanied by acute mitral regurgitation, arrhythmias, predominantly torsade de pointes tachycardias due to QT prolongation, left ventricular (LV) thrombus formation with or without consecutive thromboembolic events, and LV rupture. After confirmation of TTC by coronary angiography, repeat echocardiography should be performed. A standardized therapy for patients with TTC has so far not been established. Recommendations for the acute phase include the administration of anxiolytic agents for patients who present with preceding emotional stress, consistent therapy of physical stressors (such as pain or asthma) and avoidance of catecholamine therapy. Shock due to LVOT obstruction is treated by administration of volume and ß-blockers. With respect to the occurrence of torsade de pointes tachycardias, drugs which might cause QT prolongation should not be given. The notable incidence of LV thrombus formation justifies therapeutic anticoagulation. Systematic studies and treatment recommendations for the prophylaxis of recurrent TTC do not exist. The recently reported association between TTC and malignant disorders should prompt tumor screening and subsequent preventive medical checkups in patients affected by TTC.
