Physical work capacity with rate responsive ventricular pacing (VVIR) versus dual chamber pacing (DDD) in patients with normal and diminished left ventricular function.

To determine the benefit of atrial contribution on work capacity in relation to left ventricular ejection fraction, we studied 17 patients (68 +/- 13 years) with dual chamber pacemakers (DDD) implanted for high degree atrioventricular (AV) block. In random order they were assigned to rate responsive ventricular (VVIR) and to atrial triggered ventricular (VDD) stimulation. Maximum oxygen uptake (max VO2), that correlates best with work capacity, was measured by spiroergometry at a respiratory quotient of 1.1 during treadmill exercise test. Left ventricular ejection fraction at rest was determined by radionuclide ventriculography during VDD-stimulation and an AV delay of 150 ms. There were no differences between these two pacing modes relating heart rate, blood pressure, minute ventilation, exercise duration and maximal work load. In eight patients with an ejection fraction > 50% (60 +/- 10%), but not in nine patients with an ejection fraction < 50% (41 +/- 10%), maximum oxygen uptake was significantly higher (P < 0.01) during atrial triggered ventricular pacing (1440 +/- 533 ml/min) compared with rate responsive ventricular pacing (1328 +/- 536 ml/min). Thus, rate responsive single chamber pacemakers largely enable the same work capacity as dual chamber pacemakers in patients with high degree AV block. Patients with normal left ventricular function may profit most from preserved AV synchrony as shown by the higher maximum oxygen uptake on exercise.

Importance of an individually programmed atrioventricular delay at rest and on work capacity in patients with dual chamber pacemakers.

Despite higher costs, expenditure, and the necessity of repeatedly reprogramming of dual chamber pacemakers, they are increasingly implanted to achieve an optimal work capacity. The influence of an individually programmed atrioventricular (AV) delay between 100-250 msec on physical work capacity in 12 patients (68 +/- 16 years) with dual chamber pacemakers implanted for high degree AV block was studied. During radionuclide ventriculography at rest the "optimal AV delay" with the maximal achieved left ventricular ejection fraction and the "most unfavorable AV delay" with the least achieved ejection fraction were determined. The ejection fraction at rest with the "optimal AV delay" was 51 +/- 14% and with the "most unfavorable AV delay" 45 +/- 15% (P < 0.001). In random order each patient was assigned to either AV delay and a spiroergometry was performed to determine maximum oxygen uptake (max VO2), which correlates best with work capacity, at a respiratory quotient of 1.1. The results show neither a difference in maximum oxygen uptake (1,262 +/- 446 mL/min with the optimal AV delay, 1,248 +/- 400 mL/min with the most unfavorable AV delay, respectively) nor in heart rate, blood pressure, exercise duration, maximal workload, and minute ventilation. Thus, an individually programmed AV delay affects left ventricular ejection fraction at rest. In contrast, an individually programmed AV delay has no influence on physical work capacity in patients with a dual chamber pacemaker.

[Inadequate treatment compliance, patient information and drug prescription as causes for emergency hospitalization of patients with chronic heart failure]. / Ungenügende Behandlungsdisziplin, Patienteninformation und Medikamentenverschreibung als Ursachen für die Notfallhospitalisation bei chronisch herzinsuffizienten Patienten.

UNLABELLED: Causes of decompensation of treated chronic congestive heart failure in patients referred for emergency hospitalization were examined prospectively. 111 consecutive patients (76 +/- 11 years) were interviewed and their records examined on admission. The diagnosed underlying diseases were coronary artery disease (80%), hypertensive heart disease (40%), valvular heart disease (11%), and idiopathic dilated (7%) and alcoholic (5%) cardiomyopathy. The grounds for decompensation of chronic congestive heart failure were: insufficient compliance 47% (n = 52, irregular or not intake of medication [25%], salt [9%] or fluid [7%] excess, stopping medication because of side effects [6%]), uncontrolled hypertension (27%), insufficient diuretic therapy in spite of progressive symptoms (23%), treatment with negative inotropic drugs (21%), acute rhythm disturbances (14%), acute myocardial infarction or unstable angina pectoris (14%), infections (6%). 80% of the patients were treated with diuretics, 34% with digoxin, 31% with ACE-inhibitors. Insufficient basic knowledge about the disease (regular weighing, diet, behavior if symptoms worsen) was found in 78% of patients, complete lack of knowledge concerning the prescribed drugs in 29%. Only 44% were regularly followed by their physicians, 53% had either no regular follow-ups or they were set at too long intervals. CONCLUSIONS: In the majority of patients, one or more avoidable causes leading to decompensation of chronic congestive heart failure can be identified. The main potential for intervention aiming at a reduction of the hospitalization frequency lies in improving patient compliance and state of the art medication by the primary care physician. Equally unsatisfactory is the low frequency of follow-up checks to reassess and renew drug therapy.

[Heart contusions: pathological findings and clinical course]. / Contusio cordis: Pathologische Befunde und klinischer Verlauf.

After blunt chest trauma, myocardial contusion is frequently suspected, but diagnostic criteria are difficult to define and commonly accepted recommendations for duration and form of patient monitoring are lacking. We therefore conducted a retrospective review of the hospital records of 50 consecutively hospitalized patients with the diagnosis of myocardial contusion after blunt chest trauma, and analyzed the pathological laboratory, ECG and echocardiography findings as well as the associated injuries and cardiac-related complications. The average injury severity score was 25 +/- 8. Initially 98% of the patients were hemodynamically stable. In 90% there were abnormal enzyme levels consistent with myocardial injury. Typically, the maximum level of CPK-MB, LDH and CPK-MB/CPK (MB-fraction) was found initially and these values declined rapidly. The MB fraction normalized within 8 hours. In 32% of the patients there were the following ECG changes consistent with myocardial contusion transient: ventricular tachycardia (12%), ST/T changes (12%), complete right bundle branch block (10%), atrial fibrillation (4%), first degree AV block (2%). The episodes of ventricular tachycardia were registered within the first 24 hours; in 5 of these 6 patients the admission ECG was normal. An echocardiography was done in 64% of the patients and in 37% showed either a pericardial effusion, regional wall motion abnormalities, a pneumopericardium or an intramyocardial hematoma in the free wall of the right ventricle. One patient died of multiorgan failure during this hospitalization. There were no sudden cardiac deaths. The diagnosis of myocardial contusion is vital in unstable patients but also very important in hemodynamically stable patients, despite its low morbidity. The minimum program we recommend for diagnosis and monitoring should include enzyme levels (CPK, CPK-MB) and ECG controls. Echocardiography may be necessary as well. If during the initial compulsory 24 hour monitoring of ECG and hemodynamics no complications occur, further monitoring is not necessary.

[Spontaneous left atrial echo contrast in trans-esophageal echocardiography]. / Der spontane Echokontrast im linken Vorhof in der transösophagealen Echokardiographie.

Left atrial spontaneous contrasts (LASC) are found almost exclusively with transesophageal echocardiography (TEE), usually in patients with mitral stenosis or mitral prosthetic valves. The prevalence of LASC was examined in 143 consecutive patients undergoing TEE and transthoracic echocardiography (TEE). LASC of variable intensity were observed in 31 patients (22%) with TEE, in contrast to none with TTE. There was a significant correlation between the presence of LASC and atrial fibrillation (p less than 0.001), left atrial dilatation (p less than 0.005) and presence of mitral valve prosthesis or mitral stenosis (p less than 0.02). In 48% of patients with LASC the mitral valve was entirely normal. Multivariance analysis showed atrial fibrillation and left atrial dilatation to be independent predictors for the presence of LASC. There were significantly more ischemic strokes in patients with LASC (35% vs 12% in patients without LASC). LASC are a frequent observation with TEE. As sensitivity of the echocardiography instruments steadily improves, LASC are also found in increasing numbers of patients with minimal structural change of the heart. LASC may indicate the presence of microthrombi and thus be involved in the pathogenesis of thromboembolic complications; their clinical relevance and prognostic significance needs to be further investigated.

[Toxic shock syndrome in infection due to Streptococcus pyogenes]. / Toxisches Schock-Syndrom bei Streptokokkus-pyogenes-Infektionen.

Acute infections with group A beta-hemolytic streptococcus normally take a favourable course under therapy with penicillin. Only in a few cases has a completely different manifestation been described with multisystem failure similar to toxic shock syndrome induced by Staphylococcus aureus. We report on 4 patients (1990/91) who showed this manifestation in spite of immediate antibiotic therapy. In 3 patients the suspected portal of entry was the skin, in 1 patient it was unknown. Group A streptococci were grown from blood cultures from all 4 patients. Without an underlying immune deficiency all 4 patients (age 22, 24, 38 and 51) went into septic shock with high fever, hepatic and renal impairment, diarrhea, DIC and cerebral confusion. 2 patients died within a few days after developing acute respiratory distress syndrome and cerebral edema. All strains isolated from the patients were penicillin-sensitive, group A streptococci. 3 of them were M-type 1, which are known to be more invasive. The bacteremia by itself is not sufficient to explain all complications and the high mortality rate. It is probable that streptococcal toxins, such as pyrogenic exotoxin A, streptolysin O, or a new unknown one, play a decisive role.

[Mortality in 709 patients with acute myocardial infarct treated in the intensive care unit]. / Die Letalität auf der Intensivbehandlungsstation bei 709 Patienten mit akutem Myokardinfarkt.

To control the quality of our care and to define the potential for lifesaving early intervention in patients with acute myocardial infarction, we analyzed the course of 709 patients (66.4 +/- 10.8 yrs) admitted to the coronary care unit for acute myocardial infarction over a period of 36 months. 77 patients (70.2 +/- 9.3 yrs) died in the coronary care unit, and thus early mortality was 10.9%. Only 8% died from disturbances of cardiac rhythm and 19% from rupture of a ventricle. 73% died in cardiogenic shock, of whom 21 were below 70 years old and represent a potential group for early intervention. In 13 patients of this subgroup possibilities of better management in the pre-hospital phase were found retrospectively. In 5/77 patients the optimal treatment was not achieved during clinical course. Cardiogenic shock is the major cause of death in the early phase of acute myocardial infarction. A further substantial reduction of mortality will be achieved only by reaching more risk patients in the pre-infarction phase and by shortening the pre-hospital phase.

[Illness behavior: design for an empirical study of the determining factors]. / Krankheitsverhalten: Entwurf für eine empirische Untersuchung der bestimmenden Faktoren

A large gap is existing between the system of medical services and the "consumer". It is necessary to reinforce preventive attitudes and behavior should prepare the fundamental concepts. A research design is presented.

[Illness behavior: preliminary results of an empirical study in Basel]. / Krankheitsverhalten: Erste Ergebnisse einer empirischen Untersuchung in Basel

Preliminary data of inquiry on illness behavior are presented. 94% of the subjects (N =472 people working in administrative and industrial firms) reported at least one symptom within 1 month. Their consecutive activities are described.