[Core curriculum Medical intensive care medicine of the German Society of Medical Intensive Care and Emergency Medicine (DGIIN)]. / Curriculum Internistische Intensivmedizin.

Medical intensive care medicine treats patients with severe, potentially life-threatening diseases covering the complete spectrum of internal medicine. The qualification in medical intensive care medicine requires a broad spectrum of knowledge and skills in medical intensive care medicine, but also in the general field of internal medicine. Both sides of the coin must be taken into account, the treatment with life-sustaining strategies of the acute illness of the patient and also the treatment of patient's underlying chronic diseases. The indispensable foundation of medical intensive care medicine as described in this curriculum includes basic knowledge and skills (level of competence I-III) as well as of behavior and attitudes. This curriculum is primarily dedicated to the internist in advanced training in medical intensive care medicine. However, this curriculum also intends to reach trainers in intensive care medicine and also the German physician chambers with their examiners, showing them which knowledge, skills as well as behavior and attitudes should be taught to trainees according to the education criteria of the German Society of Medical Intensive Care and Emergency Medicine (DGIIN).

[Short version of the 2nd edition of the German-Austrian S3 guidelines "Cardiogenic shock complicating myocardial infarction-Diagnosis, monitoring and treatment"]. / Kurzversion der 2. Auflage der deutsch-österreichischen S3-Leitlinie "Infarkt-bedingter Kardiogener Schock ­ Diagnose, Monitoring und Therapie".

BACKGROUND: The present guidelines ( http://leitlinien.net ) focus exclusively on cardiogenic shock due to myocardial infarction (infarction-related cardiogenic shock, ICS). The cardiological/cardiac surgical and the intensive care medicine strategies dealt with in these guidelines are essential to the successful treatment and survival of patients with ICS; however, both European and American guidelines on myocardial infarction and heart failure and also position papers on cardiogenic shock focused mainly on cardiological aspects. METHODS: Evidence on the diagnosis, monitoring and treatment of ICS was collected and recommendations compiled in a nominal group process by delegates of the German Cardiac Society (DGK), the German Society for Medical Intensive Care Medicine and Emergency Medicine (DGIIN), the German Society for Thoracic and Cardiovascular Surgery (DGTHG), the German Society for Anaesthesiology and Intensive Care Medicine (DGAI), the Austrian Society for Internal and General Intensive Care Medicine (ÖGIAIM), the Austrian Cardiology Society (ÖKG), the German Society for Prevention and Rehabilitation of Cardiovascular Diseases (DGPR) and the German Interdisciplinary Association for Intensive Care and Emergency Medicine (DIVI), under the auspices of the Working Group of the Association of Medical Scientific Societies in Germany (AWMF). If only poor evidence on ICS was available, general study results on intensive care patients were inspected and presented in order to enable analogue conclusions. RESULTS: A total of 95 recommendations, including 2 statements were compiled and based on these 7 algorithms with defined instructions on the course of treatment.

[Presumed consent for organ donation? : A survey among members of the German Society of Medical Intensive Care and Emergency Medicine]. / Widerspruchslösung bei der Organspende? : Eine Umfrage bei Mitgliedern der Deutschen Gesellschaft für internistische Intensivmedizin und Notfallmedizin.

BACKGROUND: Since 2010, the number of organ donations has decreased by 30% in Germany; however, stricter organizational structures in clinics and improved payment for hospital services associated with organ removal should increase the current decline in the number of organ donations in Germany. In addition, the Federal Minister of Health proposed introduction of the double presumed consent solution for organ donation. This proposal is currently being discussed very controversially. Against this background, we conducted an online survey of all members of the German Society of Medical Intensive Care and Emergency Medicine (DGIIN) in order to evaluate the attitude towards organ donation. METHOD: The present work is an anonymous online survey among the members of DGIIN, which took place from 10-23 September 2018. In addition to a few demographic queries, the personal opinion on the regulation of organ donation was collected. RESULTS: A total of 1019 (51.9%) of 1964 invited DGIIN members took part at the survey: 79.3% of the participants were male; average age 47.5 ± 11.2 years; 97.7% were physicians, of whom 89.2% were specialists and 62.7% had the additional degree in critical care; 20.6% voted for the current decision-making solution, 43.1% for the presumed consent, 33.1% for the double presumed consent, whereas 3.2% of the respondents were uncertain in their decision. CONCLUSION: A clear majority of the surveyed members of DGIIN support the concept of presumed consent.

[Relationship between body temperature, neuron-specific enolase, and clinical course in patients after out-of-hospital cardiac arrest]. / Zusammenhang zwischen Körpertemperatur, neurononspezifischer Enolase und klinischem Verlauf bei Patienten nach prähospitaler Reanimation.

BACKGROUND: According to ILCOR (International Liaison Committee on Resuscitation) recommendations (released in 2003), use of therapeutic hypothermia is recommended for unconscious adult patients who have survived a cardiac arrest regardless of the initial monitored cardiac rhythm. Thereby, the treatment goal is to achieve and maintain a body temperature of 32-34 °C for a period of 12-24 h. According to the October 2015 recommendations of the European Resuscitation Council (ERC), targeted temperature management (TTM) remains part of treatment, but, as an option, it is advised that the targeted body temperature be 36 °C rather than 32-34 °C. PATIENT POPULATION AND METHODS: For a non-randomized retrospective observational study, a total of 149 patients were treated with cardiopulmonary resuscitation (CPR) between May 1999 and September 2009. For the first 4 days after CPR, data associated with demography, resuscitation, therapy (temperature course, neuron-specific enolase [NSE]) and clinical-neurological development (Glasgow Outcome Scale [GOS]) were collected. In the study, patients receiving mild hyperthermia were compared with those who did not receive hypothermia. RESULTS: Of the 149 patients included, 90 were treated with mild hypothermia (as decided by the attending physician), while 59 received no hypothermia therapy. Assessment reveals that mild hypothermia positively influences clinical-neurological progression, but not survival. On day three and four, patients with an unfavorable neurological progression exhibited significantly increased serum levels of NSE (day 4: 108.7 ± 137.3 ng/ml versus 25.5 ± 15.4 ng/ml). Patients receiving hypothermia showed lower average NSE levels compared with persons not receiving hypothermia. Furthermore, during the first 4 days, their NSE values tended to increase slower (NSE value at day 4: 55.9 ± 64.9 ng/ml versus 129.9 ± 174.9 ng/ml). The best cut-off-value for an unfavorable neurological result was 74.2 ng/ml at day four (specificity 100%, sensitivity 48.6%). For the group of patients who received hypothermia, the best cut-off-value was 74.2 ng/ml at day four (specificity 100%, sensitivity 40.9%), and, for the comparison group, best cut-off-value was 25.5 ng/ml at day three (specificity 100%, sensitivity 88.2%). CONCLUSION: After out-of-hospital resuscitation, there is a trend for improved clinical-neurological progression with mild hypothermia but it does not influence the prognostic significance of serum NSE. After assessment of available data, it is not possible to recommend uniform cut-off values for patients who received mild therapeutic hypothermia and for those who did not receive hypothermia treatment.

[Prognostic relevance of tissue oxygen saturation in patients in the early stage of multiple organ dysfunction syndrome]. / Prognostische Relevanz der Gewebesauerstoffsättigung bei Patienten in der Frühphase eines Multiorgandysfunktionssyndroms.

BACKGROUND: Patients in circulatory shock exhibit insufficient peripheral perfusion to ensure adequate oxygenation of vital organs such as the heart and brain. Early detection of reduced tissue oxygen saturation (StO2) could be used for rapid therapeutic intervention and thus improve the prognosis of patients in the early stage of multiple organ dysfunction syndrome (MODS). MATERIALS AND METHODS: A total of 60 patients in the early stage of MODS (APACHE [Acute Physiology and Chronic Health Evaluation] II score ≥20) were investigated in a monocentric, prospective, randomized phase II study. StO2 was measured using the InSpectraTM StO2 system and compared with known indicators of hypoxia (peripheral oxygen saturation [SpO2], arterial oxygen saturation [SaO2], central venous oxygen saturation [ScvO2], pH, serum lactate). Clinical endpoints of the study were 28-day and 6­month mortality as well as the need for invasive mechanical ventilation and renal replacement therapy during the hospital stay, respectively. RESULTS: An increased 28-day and 6­month mortality is found for patients with StO2 <75% in contrast to patients with StO2 ≥75%. Correlations of StO2 with SpO2, ScvO2, and serum lactate are confirmed. Patients with reduced StO2 tend to show a higher disease severity as measured by APACHE II score. CONCLUSION: StO2 shows prognostic relevance in patients at the early stage of MODS. Thus, the rapid and noninvasive assessment of StO2 could be useful in risk stratification of these patients.

[Infarct-related cardiogenic shock : Prognosis and treatment]. / Infarktbedingter kardiogener Schock : Prognose und Behandlung.

Patients with ST segment elevation myocardial infarction (STEMI) and non-ST segment elevation myocardial infarction (NSTEMI) experience cardiogenic shock in about 6-10% of cases during the hospital treatment. In recent years, the incidence seems to be decreasing due to invasive diagnostics and therapy after myocardial infarction. Early diagnosis is important to initiate immediate revascularization using percutaneous coronary intervention (PCI) with stent implantation as part of cardiogenic shock treatment. Thus, a significant improvement in survival can be achieved. Pharmacological and mechanical support is needed to maintain perfusion of the myocardium and organs. Drug therapy for infarct cardiogenic shock relies on dobutamine for inotropic agent and norepinephrine as a vasopressor. For further inotropic support, data on additional levosimendan treatment are available. The pharmacological therapy is supplemented by mechanical support systems such as Impella (ABIOMED, Danvers, MA, USA) or extracorporeal membrane oxygenation (ECMO). The intra-aortic balloon pump (IABP) is hardly used anymore. The majority of cardiogenic shock survivors have little functional cardiac impairment in the long term. This shows the transient damage component (stunning, inflammation), which underlines the need for a fast and effective cardiovascular supportive therapy.

Single nucleotide polymorphisms in long noncoding RNA, ANRIL, are not associated with severe periodontitis but with adverse cardiovascular events among patients with cardiovascular disease.

BACKGROUND AND OBJECTIVE: Biological plausibility of an association between severe periodontitis and cardiovascular disease (CVD) has been proven. Genetic characteristics play an important role in both complex inflammatory diseases. Polymorphisms (single nucleotide polymorphisms [SNPs]) in the long noncoding RNA, antisense noncoding RNA in the INK4 locus (ANRIL), were shown to play a leading role in both diseases. The primary objectives of the study were to assess, among cardiovascular (CV angiographically proven ≥50% stenosis of a main coronary artery) patients, the impact of ANRIL SNPs rs133049 and rs3217992 on the severity of periodontitis and the previous history of coronary events, as well as on the occurrence of further adverse CV events. MATERIAL AND METHODS: The prevalence of severe periodontitis was analyzed in 1002 CV patients. ANRIL SNPs rs133049 and rs3217992 were genotyped. The prognostic value of both ANRIL SNPs for combined CV endpoint (stroke/transient ischemic attack [TIA], myocardial infarction, death from a CV-related event, death from stroke) was evaluated after a 3-year follow-up period. Hazard ratios (HRs) were adjusted for established CV risk factors applying Cox regression. RESULTS: ANRIL SNPs rs133049 and rs3217992 were not associated with severe periodontitis or history of CVD in CV patients. In the Kaplan-Meier survival curve including the log rank-test (P = .036) and Cox regression (hazard ratio = 1.684, P = .009) the AA genotype of rs3217992 was shown to be an independent predictor for adverse CV events after 3 years of follow-up. CONCLUSION: SNPs in ANRIL are not risk modulators for severe periodontitis and history of CVD in CV patients. The AA genotype of ANRIL SNPs rs3217992 possesses prognostic power for further CV events within 3 years of follow-up.

[Choosing wisely recommendations in cardiology]. / Klug-entscheiden-Empfehlungen in der Kardiologie.

This article describes controversially discussed Choosing wisely recommendations presented by the German Cardiac Society: anticoagulation therapy in patients with atrial fibrillation and "only" moderate stroke risk, on the one hand, and goal-directed low-density lipoprotein (LDL) cholesterol-lowering, on the other. Presuming an adequate regime, patients with atrial fibrillation and only moderate risk of stroke (CHA2DS2-VASc Score of 1 in men and of 2 in women) also benefit from anticoagulation therapy, even in elderly patients. In patients with coronary heart disease, the German Cardiac Society recommends reducing LDL-cholesterol serum levels with a statin to values lower than 70 mg/dl (1.8 mmol/l) or at least reducing the basal level by 50%. With this recommendation, the German Cardiac Society unequivocally prioritizes the "goal-oriented statin therapy" above the "statin strategy of fixed dose". The reasons for this preference are discussed.

Serum IgG levels and mortality in patients with severe sepsis and septic shock : The SBITS data.

BACKGROUND: The role of intravenous immune globulin (Ig) therapy in patients with severe sepsis and septic shock is discussed controversially. Low initial IgG levels could help to identify those patients who might benefit from an adjunctive Ig treatment. OBJECTIVES: To investigate the effect of initial serum IgG levels on 28-day mortality in patients with severe sepsis and septic shock. MATERIALS AND METHODS: In this retrospective analysis of the SBITS trial data, 543 patients were allocated to four groups (quartiles) depending on their initial serum IgG levels (1: IgG ≤ 6.1 g/l; 2: IgG 6.2-8.4 g/l; 3: IgG 8.5-11.9 g/l; 4: IgG > 11.9 g/l). The third quartile was taken as the reference quartile. For the applied logistic regression model clinically relevant confounders were defined and integrated into further risk-adjusted calculations. RESULTS: Patients with the lowest IgG levels had a mortality rate similar to those patients with initial IgG levels in the second and third quartile, representing the physiological IgG range in healthy people. Surprisingly, patients with the highest IgG levels even showed a significantly higher mortality in a risk-adjusted calculation compared to the reference quartile (OR 1.69, CI 1.01-2.81, p = 0.05). Subgroup analyses revealed that initial IgG levels were of no prognostic value in patients presenting with vasopressor-dependent septic shock on admission as well as in patients with either gram-positive or gram-negative sepsis. CONCLUSIONS: Initially low IgG levels do not discriminate between survival and nonsurvival in patients with severe sepsis and septic shock. Therefore, low IgG cannot help to identify those patients who might benefit from an adjunctive IgG sepsis therapy. Whether a high initial IgG serum level is an independent mortality risk factor needs to be investigated prospectively.

Influence of the serum levels of immunoglobulins on clinical outcomes in medical intensive-care patients.

INTRODUCTION: Endogenous immunoglobulins (Igs) are of fundamental importance in the host defense after microbial infections. However, the therapeutic administration of intravenous IgG (IVIgG) has not yet been shown to improve clinical outcomes in patients suffering from sepsis, and in the case of IgM-containing preparations (IVIgGMA) the positive evidence is only weak. Recently published studies implicate that Ig levels on admission could have an impact on the patient's response to IVIg treatment and on outcomes of critically ill patients. METHODS: In this noninterventional study, the serum levels of IgG, IgM, and IgA were determined in 340 medical patients on ICU admission, and clinical outcomes were prospectively recorded (ICU mortality, need for renal replacement therapy (RRT), need for mechanical ventilation, substitution of coagulation factors, and amount of red cell transfusions). Patients were prospectively grouped according to their main reason for ICU admission (sepsis, respiratory failure, cardiovascular diseases, acute renal failure, postoperative condition, state after cardiopulmonal resuscitation, gastrointestinal diseases, and others). RESULTS AND DISCUSSION: There was no correlation between the Ig levels on admission and ICU mortality neither in the total cohort of medical ICU patients nor in any prespecified subgroup. However, in a logistic regression model that was adjusted for APACHE II score on admission, an increase in serum IgG was associated with a reduced need for mechanical ventilation in patients suffering from cardiovascular disease. On the other hand, in patients suffering from sepsis, an increased level of IgM was linked to an increased administration of coagulation factors. CONCLUSION: Our data do not support the hypothesis that serum levels of immunoglobulins are linked to mortality in medical ICU patients.

[National disease management guidelines (NVL) for chronic CAD : What is new, what is particularly important?]. / Nationale Versorgungsleitlinie (NVL) Chronische KHK : Was ist neu, was ist besonders wichtig?

Coronary heart disease (CAD) is widespread and affects 1 in 10 of the population in the age group 40-79 years in Germany. The German national management guidelines on chronic CAD comprise evidence and expert-based recommendations for the diagnostics of chronic stable CAD as well as for interdisciplinary/multidisciplinary therapy and care of patients with stable CAD. The focus is on the diagnostics, prevention, medication therapy, revascularization, rehabilitation, general practitioner care and coordination of care. Recommendations for optimizing cooperation between all medical specialties involved as well as the definition of mandatory and appropriate measures are essential aims of the guidelines both to improve the quality of care and to strengthen the position of the patient.

Lung protective ventilation and hospital survival of cardiac intensive care patients.

OBJECTIVE: To detect connections between parameters of ventilation and outcomes of cardiac intensive care patients. DESIGN AND SETTING: Noninterventional study. Between 05/11 and 05/12 all patients with acute heart failure and post cardiopulmonary resuscitation were registered. Lung protective ventilation was defined as peak inspiratory pressure (PIP) < 30 mmHg and tidal volume (Vt) < = 6 ml/kg. RESULTS: In total, 129 patients were included in the study, 68.2 % male, age 67.9 ± 13.4 years, weight 71.4 ± 37.2 kg, predictive body weight 66.9 ± 8.8 kg, mortality 47.3 %. Lung protective ventilated patients at day 1: 17.3 % with a significant difference between surviving and nonsurviving patients (24.1 % vs. 9.6 %; p < 0.05). Logistic regression models showed a strong connection between PIP and survival (odds ratio 1.13; p < 0.05). Vt showed no significant influence on survival. CONCLUSION: Our data recommends a strict observance of a low PIP for cardiac intensive care patients, whereas Vt seems to be of secondary importance.

Educational level and chronic inflammation in the elderly--the role of obesity: results from the population-based CARLA study.

This study aimed to assess the mediating role of anthropometric parameters in the relation of education and inflammation in the elderly. Cross-sectional data from the population-based CARdio-vascular Disease, Living and Ageing in Halle study were used after excluding subjects with a plasma level of high-sensitive C-reactive protein (hsCRP) above 10 mg L(-1) (916 men/760 women remaining). Education was categorized in accordance with International Standard Classification of Education. As inflammation parameters, the soluble tumour necrosis factor type 1 (sTNF-R1), hsCRP and interleukin 6 (IL-6) were taken into account. Anthropometric parameters were the body mass index (BMI), waist-to-hip ratio (WHR) and waist-to-height ratio (WHeR). We used covariate adjusted mixed models to assess associations. Effect measures were the natural indirect effect (NIE), controlled direct effect and total effect (TE). Education was associated with sTNF-R1, hsCRP and IL-6 in men, and sTNF-R1 and hsCRP in women. Anthropometric parameters correlated with all inflammation parameters after covariate adjustment. BMI and WHeR were strong mediators of educational differences in sTNF-R1 (percentage of NIE of TE: 28% in men; 33% in women) and hsCRP (percentage of NIE of TE: 35% in men; 52% in women), while WHR was the weakest mediator. General obesity mediates roughly one-third of the association of education with chronic inflammation in the elderly.

Overexpression of protein phosphatase 2A in a murine model of chronic myocardial infarction leads to increased adverse remodeling but restores the regulation of ß-catenin by glycogen synthase kinase 3ß.

BACKGROUND/OBJECTIVES: Increased activity of cardiac protein phosphatases is an important feature in human heart failure. Several different protein phosphatases (PP) are involved in the regulation of excitation-contraction-coupling of the myocardium. Protein phosphatase 2A (PP2A) is a serine/threonine phosphatase consisting of a dimeric core enzyme and tissue-specific subunits. In this study we used transgenic mice overexpressing PP2A to further investigate the role of PP2A in cardiac remodeling after myocardial infarction. METHODS AND RESULTS: Adult male CD-1 mice overexpressing the catalytic subunit α of PP2A (αMHC-PP2A; TG) underwent chronic LAD-ligation or sham surgery, respectively; wildtype littermates (WT) were used as controls. Cardiac function was determined by echocardiography before and 28 days after LAD-ligation. 28 days after MI, the animals were sacrificed and cardiac remodeling was analyzed in histological sections and by Western blots. PP2A overexpression leads to dilated cardiomyopathy in mice, and increased cardiomyocyte hypertrophy and fibrosis of the remote myocardium can be seen after myocardial infarction. However, we found an improved survival of TG in the subacute phase after MI in comparison to WT. On the molecular level, TG shows reduced expression of SERCA and CaMKII alpha both under basal condition as well 28 days after MI. Additionally, the regulation of the Akt/GSK3ß/ß-catenin pathway is severely disturbed in TG at baseline where a significant activation of Akt is found that coincides with the typical phosphorylation of GSK3ß. However, this does not lead to the accumulation of ß-catenin - on the contrary: phosphorylation-induced degradation of ß-catenin is significantly enhanced. CONCLUSION: Transgenic overexpression of myocardial PP2A causes adverse remodeling which coincides with a disruption of the classical Akt/GSK3/ß-catenin pathway under baseline conditions that is restored to normal values in chronic myocardial infarction. Even so overall survival of TG after myocardial infarction was not constrained and survival after day 2 post MI was improved.

[Individualization of exercise load control for inpatient cardiac rehabilitation. Development and evaluation of a HRV-based intervention program for patients with ischemic heart failure]. / Individualisierung der Belastungssteuerung in der kardiologischen stationären Rehabilitation. Entwicklung und Evaluation eines HRV-gesteuerten Interventionsprogramms für Patienten mit ischämisch bedingter Herzinsuffizienz.

BACKGROUND: The effective use of rehabilitation programs is of primary importance in order to improve the physical performance of cardiac disease patients. A modular program has been developed which is intended to structure and individualize conventional, exercise-based rehabilitation programs according to the individual needs and physical condition of each patient. The individualization of the program is based on detailed diagnostics before patients enter the program and daily measurements of heart rate variability (HRV) during cardiac rehabilitation. METHODS: A total of 30 patients with ischemic heart disease were randomly assigned either to the intervention group (IG), completing the modular individualized rehabilitation program [n=15, mean age 54.4±4.2 years and mean left ventricular ejection fraction (LVEF) 28.53±6.25%) or to the control group (CG) taking part in the conventional rehabilitation program (n=15, mean age 56.4±4.4 years and mean LVEF 27.63±5.62). Before and after the intervention, cardiorespiratory fitness was assessed by measurement of maximal oxygen consumption (relative VO2max) during bicycle ergometry and the 6-minute walk test (6-MWT). Pre-post comparisons of cardiorespiratory fitness indicators were used to evaluate the effectiveness of the rehabilitation program. In addition to the results of the basic clinical investigations and the cardiorespiratory testing, results of standardized HRV measurements of 10 min at morning rest served as criteria for program individualization. RESULTS: The relative VO2max increased significantly (p<0.05) in the IG whereas no change was found in the CG. Similar results were found for maximum power output during bicycle ergometry (p<0.01) and for 6-MWT distance (p<0.001). Although patients in the IG completed less aerobic exercise sessions than those in the CG (p<0.001) the physical performance of the IG improved significantly. DISCUSSION: The results prove the effectiveness and efficacy of the modular individualized rehabilitation program. They further suggest the need for an individual program matrix instead of a maximum performance matrix in cardiac rehabilitation. Individualization should be based on clinical and performance diagnostics before and accompanying assessments of training condition, e.g. by HRV measurements, during rehabilitation programs. Each patient should only perform those intervention programs which match the results of the basic clinical investigation and additional analyses during rehabilitation.

Use of floss/interdental brushes is associated with lower risk for new cardiovascular events among patients with coronary heart disease.

BACKGROUND AND OBJECTIVE: Periodontitis has been found to be associated with coronary heart disease (CHD) and stroke. However, only little is known about whether periodontitis and associated confounders are associated with new cardiovascular events among patients with CHD. MATERIAL AND METHODS: A total of 942 inpatients with CHD were examined regarding periodontitis, oral care habits, bacteria in the subgingival biofilm and the expression of interleukin-(IL)-6 c. (coding DNA)-174 genotypes (rs 1800793) to determine whether these confounders are associated with new cardiovascular events within a 1-year follow-up period. Adjusted hazard ratios (HR) with respect of age, gender, smoking, body mass index, use of aids for interdental hygiene, plaque index, occurrence of severe periodontitis and further internal diseases such as diabetes, hypertension, dyslipoproteinemia, number of missing teeth, serological parameters and IL-6 genotypes were generated with Cox regression. RESULTS: In all, 941 cardiovascular patients completed the 1-year follow up and 7.3% of the patients achieved the primary endpoint (myocardial infarction: 2.1%, stroke/transient ischemic attack: 1.8%, cardiovascular deaths: 3.4%). Patients who reported practicing interdental cleaning were younger, less likely to be male or to have severe periodontitis, had a reduced tobacco exposure, had fewer missing teeth, less indices for plaque and bleeding on probing and a significant decreased adjusted risk for new cardiovascular events (HR = 0.2, CI 0.06-0.6, p = 0.01) than those patients with CHD who did not report practicing interdental cleaning. We did not obtain significant increased HR for patients with severe periodontitis (HR = 1.2, CI 0.7-2.1, p = 0.53), carriers of the IL-6 genotypes GC or CC (HR = 1.4, CI 0.8-2.5, p = 0.24) and did not find a significant association between the number of detected various oral species and the incidence of the combined endpoint (HR = 0.9, CI 0.8-1.01, p = 0.07). CONCLUSIONS: These findings suggest that flossing and brushing of interdental spaces might reduce the risk for new cardiovascular events among patients with CHD. The hypothesis that interdental cleaning per se reduces the risk of new cardiovascular events should be examined in an interventional study.