Non-invasive ventilation: comparison of effectiveness, safety, and management in acute heart failure syndromes and acute exacerbations of chronic obstructive pulmonary disease.

Continuous positive airway pressure ventilation (CPAP) and non-invasive positive pressure ventilation (NPPV) are accepted treatments in acute cardiogenic pulmonary edema (ACPE) and acute exacerbation of chronic obstructive pulmonary disease (AECOPD). The aim of the study was a comparison of effectiveness, safety, and management of NPPV in ACPE and AECOPD trying to find an approach for standard management in intensive care. Thirty patients with acute respiratory failure (14 due to ACPE, 16 due to AECOPD) were prospectively included into the study. If clinical stability could not be achieved by standard therapy (pharmacological therapy and oxygen) patients were treated by non-invasive ventilation (NPPV) using a BiPAP-Vision device in S/T-mode. During the first 90 min after the onset of NPPV respiratory and vital parameters were documented every 30 min. Additional relevant outcome parameters (need for intubation, duration of ICU stay, complications and mortality) were monitored. We found that 85.7% of the ACPE patients and 50.0% of the AECOPD patients were treated successfully with NPPV. Intubation rate was 31.2% in the AECOPD group and 14.3% in the ACPE group. 78.6% of the ACPE patients and 43.8% of the AECOPD patients were regularly discharged from hospital in a good condition. In the first 90 min of NIV, there was a significant amelioration of respiratory and other vital parameters. In ACPE patients there was a significant increase in PaO2 from 58.9 mmHg to 80.6 mmHg and of oxygen saturation (SaO2) from 85.1% to 93.1% without changing the inspiratory O2 concentration. This effect was comparable in the AECOPD group, but only could be achieved by increasing the inspiratory ventilation pressure. In the ACPE group inspiratory ventilation pressure could be reduced. In conclusion, in acute respiratory failure, ACPE patients comparably profit from NPPV as do patients with AECOPD, but the algorithm of titration for non-invasive ventilation pressure is different.

[Acute life-threatening bradycardia: food poisoning by Turkish wild honey]. / Akute lebensbedrohliche Bradykardie: Nahrungsmittelintoxikation durch türkischen Waldhonig.

HISTORY AND FINDINGS: A 49-year-old Turkish man, previously well, suddenly developed severe vertigo and a feeling of retrosternal compression. The symptoms had set in within one hour of eating Turkish wild honey. The patient was in a poor general state with a heart rate of 38/min after administration of atropine by the general practitioner who had been called. Arterial blood pressure was 90/45 mmHg. INVESTIGATION: All routine biochemical tests were normal. The electrocardiogram merely showed sinus bradycardia of 38 beats/ min. TREATMENT AND COURSE: Under purely symptomatic treatment the heart rate and blood pressure returned to normal within 24 hours. The history of eating wild honey and typical symptoms indicated acetylandromedol poisoning. CONCLUSION: Turkish honey from the Black Sea coast occasionally contains concentrations of acetylandromedol (formerly called andromedotoxin) high enough to cause poisoning. The substance is obtained by bees from some species of Rhododendron which they then incorporate into their honey. Typical of the poisoning are gastrointestinal symptoms and marked, even life-threatening, bradycardia and arterial hypotension.

[Diastolic left ventricular dysfunction--significance for differential diagnosis and therapy of heart failure in the aged]. / Diastolische linksventrikuläre Dysfunktion--Bedeutung für die Differentialdiagnostik und -therapie der Herzinsuffizienz im Alter.

The discrimination of the pathogenesis of the clinical picture "heart failure" as caused by a dominant systolic or diastolic LV-dysfunction is of a special importance in the elderly patient because of the consequences for the choice of pharmacological therapy, resulting from the age-related physiological increase of stiffness of the myocardium. The pathophysiology of diastolic dysfunction is characterized by a prolonged relaxation period as well as by compromised passive filling properties, caused by myocardial and external determinants. Typical clinical signs of diastolic dysfunction are dyspnea or pulmonary edema. Cardiac disorders with a dominance of diastolic dysfunction are coronary and hypertensive heart disease as well as hypertrophic or uremic cardiomyopathies. Diagnosis of diastolic dysfunction easily can be performed noninvasively by means of Doppler-echocardiography. Pharmacological therapy in diastolic dysfunction should prefer beta blocking drugs and calcium-antagonists against vasodilators or digitalis.

[Treatment of chronic stable angina pectoris with angiotensin converting enzyme inhibition--a randomized, placebo-controlled, double-blind cross-over study]. / Behandlung der chronisch stabilen Angina pectoris durch Angiotensin-Converting-Enzym-Hemmung--Eine randomisierte, placebokontrollierte, Doppelblind-cross-over-Studie.

To investigate the potential anti-ischaemic effects of benazepril (10 mg bid) in comparison to placebo, this new ACE-inhibitor was given to 11 patients with chronic stable angina, reproducible exercise-induced ST-segment depression and angiographically verified coronary artery disease. Blood pressure at rest, plasma renin activity, and plasma concentration of atrial natriuretic peptide were measured after treatment periods of two weeks. Bicycle exercise tests at the same time should evaluate ST-segment depression at comparable maximal workload, work capacity, blood pressure, and heart rate at exercise. In comparison to placebo, benazepril reduced arterial blood pressure significantly from 140 +/- 14/90 +/- 11 mm Hg to 125 +/- 16/84 +/- 10 mm Hg (p less than 0.05) and increased plasma renin activity from 2.19 +/- 3.76 ng/ml/h to 9.62 +/- 8.49 ng/ml/h (p less than 0.005). In contrast, ST-segment depression decreased only slightly and not significantly from 2.09 +/- 1.22 mm to 1.91 +/- 1.00 mm. Benazepril had neither an effect on the frequency of episodes of angina pectoris nor did it reduce the amount of GTN-consumption. Also, work capacity and plasma concentration of atrial natriuretic peptide were not changed in comparison to placebo. Although the significant reduction of blood pressure and the highly significant increase of plasma renin activity demonstrate the specific action of benazepril, a significant anti-ischaemic effect could not be established.

[Transdermal nitroglycerin systems with continuous and discontinuous drug release. A comparison of the anti-ischemic and hemodynamic acute and long-term effects]. / Transdermale Nitroglycerinsysteme mit kontinuierlicher und diskontinuierlicher Substanzfreisetzung. Vergleich antiischämischer und hämodynamischer Akut- und Langzeitwirkung.

The anti-ischaemic and haemodynamic effects of two transdermal nitroglycerin systems, each offering 15 mg of nitroglycerine, the first giving continuous release (group 1) and the other discontinuous release (group 2), were compared in 30 men (mean age 56.5 [33-70] years) with coronary heart disease confirmed by angiography. Resting and exercise haemodynamics together with the degree of exercise-induced ST segment depression were measured on the first day, before and two hours after application of the plaster. After one week's therapy these measurements were repeated 24 hours after the application of the plaster on the previous day and two hours after the last application. Two hours after the first application both groups showed significant reduction (P less than 0.01) in exercise-induced ST segment depression (group 1: -60%, group 2: -50%) and in mean pulmonary artery pressure during exercise (group 1: -10%; group 2: -7%). After one week's therapy the reduction in exercise-induced ST segment depression was still significant in group 1 (-60%; P less than 0.01), but in group 2 (-30%) it was no longer significant. After one week had passed there was no longer any significant reduction in mean pulmonary artery pressure in either group (group 1: -6%; group 2: 0%). The acute anti-ischaemic and haemodynamic efficacy of both transdermal nitroglycerin systems was hence comparable; however, the emergence of nitrate tolerance during long-term use was not prevented even by phased release of the drug.

[Doppler echocardiography description of diastolic function disorder in terminal renal failure--new characterization of uremic cardiomyopathy]. / Dopplerechokardiographische Beschreibung einer diastolischen Funktionsstörung bei terminaler Niereninsuffizienz--Neucharakterisierung der urämischen Kardiomyopathie.

In order to characterize left ventricular diastolic filling abnormalities in uremic cardiomyopathy in 50 patients on hemodialysis, the ratio VE/VA of peak early (VE) and late (VA) filling velocity was calculated using CW-Doppler echocardiography. Compared with normal subjects of identical age, VE/VA was found to be significantly lower in patients younger than 40 years, but without, however, significant differences in patients aged 40-60 years and older than 60. Thus, the incidence of diminished VE/VA-ratios fell from 64% in patients younger than 40 years to 5% in patients older than 60. Whereas duration of dialysis, extent of renal anemia and interdialytic volumeload showed no influence, diastolic malfunction was correlated to renal hypertension. Therefore, an actualized characterization of uremic cardiomyopathy can be achieved by CW-Doppler echocardiography, describing diastolic malfunction in most patients with terminal renal failure. In elderly patients, however, a distinction from physiologic alteration of diastolic filling is not possible. Clinical significance of diastolic malfunction is characterized by reduced tolerance of interdialytic volume-expansion, as well as intradialytic volume-depletion.

[Resting and exercise hemodynamics in essential arterial hypertension]. / Ruhe- und Belastungshämodynamik bei essentieller arterieller Hypertonie.

Various haemodynamic functions were studied in 70 patients (51 men and 19 women; mean age 53.0 +/- 7.0 years) with essential hypertension. The following parameters were measured, at rest and on exercise: systolic and diastolic blood pressure, heart rate, mean pulmonary artery pressure, cardiac output and peripheral vascular resistance. 15 normotensive subjects (11 men and four women; mean age 54.4 +/- 7.2 years) without significant cardiovascular disease served as controls. Resting peripheral vascular resistance (PAP) in the hypertensives was, at 1634.7 +/- 239.0 dyn/s.cm-5, higher by 41%, on exercise at 1029.4 +/- 105.9 higher by 14%, than in the controls (at rest 1157.1 +/- 118.9 dyn/s.cm-5, on exercise 706.9 +/- 94.1 dyn/s.cm-5; P less than 0.0001). Cardiac output at rest was 9.6% lower, on exercise 8.0% lower than in the controls (neither change significant). Thus the increased peripheral vascular resistance was the sole cause of the increased blood pressure. Mean PAP, as a measure of left-ventricular filling pressure, in hypertensives was 14.7 +/- 3.9 mm Hg at rest, 34.9 +/- 7.8 mm Hg on exercise, an increase of 14% and 40%, respectively, over the control values of 12.7 +/- 1.9 mm Hg at rest and 24.4 +/- 2.8 mm Hg on exercise (P less than 0.0001). The raised left-ventricular filling pressure is an indication of early hypertensive heart disease.

[Conventional and Doppler echocardiography in the differential diagnosis of right heart failure]. / Konventionelle sowie Doppler-Echokardiographie in der Differential-diagnose der isolierten Rechtsherzinsuffizienz.

In the differential diagnosis of isolated right heart failure 1- and 2-dimensional echocardiography and Doppler echocardiography have proved to be of an increasing significance. In right ventricular dysplasia associated ventricular arrhythmias and regional abnormalities in wall motion of the right ventricle are characteristic. The evaluation of pulmonary heart disease has been extended by the estimation of pulmonary artery pressure using doppler echocardiography. In isolated right heart infarction, echocardiography can detect regional wall motion abnormalities and potential complications like intracavitary mural thrombi. In addition to pericardial calcification on chest x-ray and "dip and plateau" sign on pressure wave form, the abnormal diastolic hemodynamics can be demonstrated studying motion of interventricular septum and posterior left ventricular wall by echocardiography. Separating patients with restrictive cardiomyopathy may be difficult, if demonstration of the characteristic findings--increase of ventricular wall thickness, small ventricular cavities--is impossible. The evaluation of isolated tricuspid valve diseases has become possible non-invasively by Doppler echocardiography. In the diagnosis of the rare right atrial myxomas 2-D-echocardiography is the method of choice.

[Hemodynamic effects of different antihypertensive combinations]. / Hämodynamische Wirkungen verschiedener antihypertensiver Kombinationen.

The haemodynamic effects of combinations of antihypertensive drugs were tested in an open trial on 15 patients with essential arterial hypertension. The following combinations were used: Piretanid/Captopril, Piretanid/Urapidil and Acebutolol/Piretanid. All three combinations significantly lowered arterial pressure at rest and on exercise. Both Piretanid/Captopril and Piretanid/Urapidil reduced the arterial pressure exclusively by reduction of the peripheral resistance, while cardiac output rose. On the other hand, Acebutolol/Piretanid reduced the blood pressure through reduction of cardiac output, less so by lowering the peripheral resistance. Mean pulmonary arterial pressure, as a measure of left-ventricular filling pressure, fell under Piretanid/Captopril and Piretanid/Urapidil, remaining high under Acebutolol/Piretanid. Thus the combinations of Piretanid/Captopril and Piretanid/Urapidil are most likely to fulfill the demands to be placed on an "ideal" antihypertensive treatment.

[Modification of resting and effort hemodynamics in essential arterial hypertension using antihypertensive agents]. / Beeinflussung der Ruhe- und Belastungshämodynamik bei essentieller arterieller Hypertonie durch Antihypertensiva.

The haemodynamic effects of piretanide, acebutolol and nifedipine were tested and compared at rest and on exercise in an open study of patients with essential hypertension, grade II (WHO). All three drugs lowered the blood pressure significantly, both at rest and on exercise. There was no significant difference between the three drugs in their effect on resting blood pressure, but nifedipine and acebutolol were significantly more effective than piretanide in lowering it on exercise. Piretanide lowered the blood pressure by reduction in cardiac output and peripheral resistance, nifedipine entirely through a reduction of peripheral resistance, and acebutolol entirely through a reduction in cardiac output. Mean pulmonary arterial pressure, taken as a measure of left-ventricular filling pressure, was significantly reduced by piretanide and nifedipine, while it rose significantly under acebutolol. Taking into account the haemodynamics of essential hypertension (raised peripheral resistance, decreased cardiac output, frequently increased left-ventricular filling pressure), nifedipine most nearly fulfilled the role of an "ideal" antihypertensive agent.

[Demonstration of intra- and paracardiac space-occupying processes using magnetic resonance tomography]. / Darstellung intra- und parakardialer raumfordernder Prozesse mit der magnetischen Resonanztomographie.

Magnetic resonance tomography (in three planes) was performed on 21 patients in whom echocardiography, angiocardiography or a chest X-ray had indicated or was suspicious of intra- or paracardiac space-occupying lesions. MR imaging demonstrated bronchial carcinoma with aortic displacement in two (one of them also with vena cava occlusion); hypernephroma with displacement of the right atrium in one; paracardiac teratoma in two and lipoma in one; aortic aneurysm in two; atrial tumour in five; atrial thrombi in one; ventricular thrombi in four; and exclusion of intra-cardiac lesions in two. Thus the method distinguished between vascular and tumourous paracardiac space-occupying lesions and demonstrated origin and structural relationship of paracardiac tumours, especially to the great vessels. Size, shape and mobility of intracardiac tumours was also demonstrated. For both intra- and paracardiac space-occupying lesions there were the beginnings of structural differentiation.

[Hemodynamics during long-term combination therapy of arterial hypertension]. / Hämodynamik bei Langzeit-Kombinationstherapie der arteriellen Hypertonie.

In 20 patients with essential arterial hypertension, grade II or III, the haemodynamic effect of a fixed combination of antihypertensive drugs (bemetizide, triamteren, bupranolol and dihydralazine) was studied by percutaneously-introduced flow-guided catheter in the pulmonary artery before, after three weeks and at the end of a six-month period of treatment; systemic arterial blood pressures were measured by the cuff method. Mean pressures, both at rest and on exercise were significantly and persistently lowered. Mean blood pressure at rest fell from 184/110 mmHg before treatment to 167/98 mmHg after three weeks, and to 158/93 mmHg after six months. The initial blood pressure on exercise was 226/129 mmHg, which fell after three weeks to 199/113 mmHg and after six months to 190/106 mmHg. At the same time, pulmonary artery pressure (as a measure of preload) fell by 23% at rest and 30% on exercise. Exercise tolerance of the patients rose by 28%. Pressure-heartrate product fell by 18%, as a pointer to an additional favourable effect on left ventricular oxygen consumption.

[Hemodynamic effects of isosorbide-5-mononitrate in coronary heart disease. A comparison of acute and chronic treatment]. / Hämodynamische Effekte von Isosorbid-5-mononitrat bei koronarer Herzkrankheit. Vergleich von akuter und chronischer Therapie.

The haemodynamic effect of isosorbide-5-mononitrate (ISMN) was studied in 20 patients with coronary heart disease. Three hours after the first and single dose of 50 mg ISMN, both at rest and on exercise there was a significant decrease in pulmonary artery mean pressure of 30%, while heart rate and systemic blood was an anti-anginal effect, as objectified by the angina threshold and return to normal of previously depressed S-T segments during exercise. After administration of 50 mg ISMN, three times daily for seven days, a single dose of 50 mg ISMN on the eighth day produced a fall in pulmonary artery mean pressure three hours after administration, of only 25% at rest and 20% on exercise, while the anti-anginal effect remained unchanged. Six hours after administration there were no significant changes in haemodynamic variables compared with the initial values. The reduced fall in pulmonary artery mean pressure during chronic administration is interpreted as the development of tolerance with decreased venous pooling, while the unchanged anti-anginal effect is explained by the site of action of the nitrate on the coronary arteries and on the collateral circulation with positive blood redistribution.