Carotid artery stenting in clinical practice results from the Carotid Artery Stenting (CAS)-registry of the Arbeitsgemeinschaft Leitende Kardiologische Krankenhausarzte (ALKK).

BACKGROUND: Carotid artery stenting (CAS) for symptomatic and asymptomatic carotid stenosis seems to be on the doorstep of more widespread use. However, its feasibility and safety in clinical practice at a broad spectrum of hospitals needs to be determined. METHODS: We analyzed data of the prospective multi-centre Carotid Artery Stenting (CAS) Registry of the German Arbeitsgemeinschaft Leitende Kardiologische Krankenhausarzte (ALKK). RESULTS: From 7/1996 to 5/2004 1888 patients from 28 hospitals were included in the CAS Registry. The median hospital stay from CAS until hospital discharge was 3 days (quartiles: 2-6 days). Median patients age was 70 years (quartiles: 64-76 years) with 72.1% males. CAS for symptomatic stenosis was performed in 55% of cases. Patients treated with CAS suffered from coronary artery disease in 66.5%, had arterial hypertension in 91.7%, hyperlipidemia in 86.3% and 34.2% were diabetics. The intended CAS procedure was completed in 98.1% of cases. A stent was implanted in 97.3% of completed cases. The median intervention time was 43 min (quartiles: 30-60 min). During the hospital stay death rate was 0.3% (5/1888) and the rate of ipsilateral stroke 3.2% (58/1840). A contralateral ischemic event occurred in 1.4% (26/ 1840) of patients. The combined rate of all death or strokes was 3.8% (70/1841). Between 1996 and 2004 there was a steady increase in the use of protection devices during CAS (0% in 1996 and 97.9% in 2004; p for trend <0.0001). There was also an increase in the proportion of patients treated for asymptomatic stenoses (p for trend <0.0001). We observed a decrease of the combined endpoint of death or stroke from 6.3% in 1996 to 1.9% in 2004 (p for trend=0.021). CONCLUSION: The multi-centre ALKK CAS Registry data confirm the feasibility and shot-term safety of CAS even in daily clinical practice. There was a rapid penetration of the use of embolic protection devices, an increase in treatment of asymptomatic carotid stenoses and a decrease in acute complication rates from 1996 to 2004.

Prognostic value of non-sustained ventricular tachycardias after acute myocardial infarction in the thrombolytic era: importance of combination with frequent ventricular premature beats.

PURPOSE: of this study was to re-evaluate the association between ventricular arrhythmias and long-term mortality after acute myocardial infarction (AMI) in the thrombolytic era. METHODS: MITRA (maximal individual therapy in patients with AMI) is a multicenter registry of 54 hospitals in Germany investigating patients with AMI. RESULTS: 2420 patients received Holter ECG. Positive Holter ECG was defined: > or =10 ventricular premature beats (VPB)/h, or > or =4 couplets/d, or > or =1 non-sustained ventricular tachycardia (nsusVT)/d, or their combination. Mortality rates (median 17 months) were 6.5% without ventricular arrhythmias, with > or =10 VPB/h 15.2% and with the combination of > or =10 VPB/h plus either > or =4 couplets/d or > or =1 nsusVT/d 23.4%. In multivariate analysis, none of the ventricular arrhythmias alone correlated with mortality. There was a significant association between mortality and the combination of > or =10 VPB/h plus > or =4 couplets/d (OR 2.3) or > or =10 VPB/h plus > or =1 nsusVT/d (OR 2.8). CONCLUSION: Non-sustained VTs are only associated with poor prognosis if combined with frequent VPBs.

[Hybrid technique for myocardial revascularization: value of combined minimal invasive bypass technique (MIDCAB) with interventional therapy (PTCA)]. / Hybrid-Verfahren zur Myokardrevaskularisation: Stellenwert der Kombination von minimal-invasiver Bypasstechnik (MIDCAB) mit interventioneller Therapie (PTCA).

BACKGROUND: Minimally invasive direct coronary artery bypass (MIDCAB) grafting without cardiopulmonary bypass (CPB) through an anterolateral minithoracotomy has become a promising therapeutical option especially in multimorbid, elderly and reoperative patients with single vessel disease. However, this procedure precludes complete revascularization in multivessel disease because the minithoracotomy limits the surgical access either to anterior or lateral or posterior vessels of the beating heart. To expand the benefits of the MIDCAB concept to patients with multivessel disease, new interdisciplinary approaches have recently been introduced. METHODS: Since December 1996, 26 patients (21 male, 5 female, mean age 56.6 +/- 18.8 years) underwent a "hybrid" revascularization performed as a primary MIDCAB procedure for grafting of the left anterior descending artery (LAD) with the left internal mammary artery (LIMA) followed by staged angioplasty and stenting of additional coronary lesions. RESULTS: After MIDCAB grafting, the postoperative course was uneventful in all patients. Coronary re-angiography after a median of 7 days revealed patent and functioning LIMA grafts in all patients. Applying subsequent percutaneous transluminal coronary angioplasty (PTCA) and occasional stenting (n = 8), a total of 31 lesions were treated successfully. Procedure related complications did not occur. All patients remained angina-free and no stress electrocardiographic changes were recorded. CONCLUSION: Our preliminary results of a "hybrid" approach to myocardial revascularization suggest that this concept is a safe and effective approach of complete revascularization for selected patients with multivessel involvement. Especially elderly and reoperative patients with significant comorbidity may benefit from hybrid procedures avoiding cardiopulmonary bypass and midsternotomy.

HBW 023 (recombinant hirudin) for the acceleration of thrombolysis and prevention of coronary reocclusion in acute myocardial infarction: results of a dose-finding study (HIT-II) by the Arbeitsgemeinschaft Leitender Kardiologischer Krankenhausärzte.

OBJECTIVE: To define an optimal dose of hirudin that would improve early coronary artery Thrombolysis in Myocardial Infarction grade 3 (TIMI 3) patency and prevent reocclusions in patients with acute myocardial infarction treated with front-loaded recombinant tissue-type plasminogen activator (rt-PA). METHODS: Recombinant hirudin (HBW 023) was tested in a sequential dose-escalating study as adjunct to front-loaded rt-PA in 143 patients with acute myocardial infarction. The sequential model was assigned two 'decision boundaries': it triggered an increase in dosage if the 60-min TIMI 3 flow rate in a dosage group was statistically not consistent with a target patency rate of 75%, or if the deterioration in coronary blood flow (of at least one TIMI grade, from TIMI 2 or 3, from one angiography to the next) exceeded 5%. RESULTS: The decision boundary for TIMI 3 flow grade at 60 min was crossed when 18 patients were treated with 0.1/0.06 mg/kg (bolus/infusion per hour over 48 h) r-hirudin (dosage group I), 42 patients treated with 0.2/0.1 mg/kg (dosage group II), and 83 patients with 0.4/0.15 mg/kg (dosage group III). TIMI 3 flow at 60 min was 50%, 58%, and 63% in dosage groups I-III, respectively (P = 0.15). Early, complete, and sustained patency (TIMI 3 flow at 60 min, 90 min and 48 h) were 44%, 55% and 64% (P = 0.07). Reocclusion between 90-min and 48-h angiograms or reinfarction occurred in 0 to 15, two of 36, and one of 72 patients, respectively (P = 0.5). Four patients (2.8%) died in hospital and 14 patients suffered a major bleeding event, but no intracranial bleeding was encountered. CONCLUSIONS: With increasing doses of hirudin, there was a trend towards greater early and complete patency, but no clear dose--response relationship was observed. A borderline significant effect was observed with respect to early, complete, and sustained patencies. In all groups, reocclusions or reinfarctions were rare. Neither clinical nor laboratory data predicted the imbalance in haemorrhagic events observed in a subsequent, prematurely terminated, phase III trial with hirudin and rt-PA.

PTCA registry of German community hospitals. Arbeitsgemeinschaft Leitender Kardiologischer Krankenhausärzte (ALKK) Study Group.

BACKGROUND: Percutaneous transluminal coronary angioplasty (PTCA) is widely used, but no quality control has been systematically performed as yet. METHODS: A registry of all PTCA procedures has been established since October 1992 for the majority of the German community hospitals performing PTCA, representing about one third of all PTCA activity in Germany. Baseline demographic data, indication for PTCA, primary success and in-hospital clinical events were recorded. Each centre was visited at regular intervals to assure completeness and reliability of the data. RESULTS: Of 52453 procedures performed from October 1992 to December 1994 the catheter laboratory and discharge forms were 99.7% and 98.1% complete, respectively. In 85.9% a single lesion was dilated per procedure, but 48.7% of the patients had multivessel disease. The success rate was 66.5% in complete occlusions (residual stenosis < 70%) and 91.2% in non-occluded vessels (residual stenosis < 50%). Abrupt vessel closure occurred in 3.4%, of which 77.5% could be recanalized by repeat intervention. In procedures not done for acute myocardial infarction, the in-hospital mortality was 0.52%, the procedure-related mortality 0.37%. In 3.02% of all patients a severe complication occurred (procedure-related death, myocardial infarction or emergency bypass surgery). CONCLUSION: Complete recording of all PTCA procedures is feasible even on a nationwide basis. This is a pre-requisite for continuous quality control. The reporting of the procedures by itself very probably, has an impact on the quality which is, however, not measurable quantitatively.

A comparison of electrophysiologically guided antiarrhythmic drug therapy with beta-blocker therapy in patients with symptomatic, sustained ventricular tachyarrhythmias.

BACKGROUND: Antiarrhythmic drug therapy guided by invasive electrophysiologic testing is now widely used in patients with symptomatic, sustained ventricular tachyarrhythmias. METHODS: We conducted a prospective, randomized trial in 170 patients to investigate whether this approach would improve long-term outcome. Patients whose arrhythmia was inducible by programmed electrical stimulation were assigned to treatment with electrophysiologically guided drug therapy based on serial testing (61 patients) or with metoprolol (54 patients). Electrophysiologically guided therapy consisted of serial testing of antiarrhythmic agents to identify the first one that rendered the arrhythmia noninducible. The 55 patients whose arrhythmia was noninducible during the initial electrophysiologic test were also treated with metoprolol. RESULTS: During a mean (+/- SD) follow-up period of 23 +/- 17 months, recurrent, nonfatal arrhythmia occurred in 44 patients and sudden death due to cardiac factors in 27. The incidence of symptomatic arrhythmia and sudden death combined was virtually the same in the two groups with inducible arrhythmia after two years of observation (electrophysiologically guided therapy vs. metoprolol therapy, 46 percent vs. 48 percent). The outcome was more favorable in the patients with noninducible arrhythmia at base line (75 percent had neither adverse event) than in those with inducible arrhythmia who were assigned to metoprolol therapy (P = 0.009 by log-rank test). Only 6 of the 29 patients (21 percent) with inducible arrhythmia that became noninducible during drug therapy had recurrent arrhythmia or sudden death, as compared with 21 of the 32 patients (66 percent) with arrhythmia that continued to be inducible (P less than 0.001). A multivariate regression analysis identified continued inducibility of the arrhythmia as an independent predictor of recurrent arrhythmia or sudden death (relative risk, 7.3; 95 percent confidence interval, 2.3 to 23.2; P less than 0.001). CONCLUSIONS: As compared with metoprolol therapy, electrophysiologically guided antiarrhythmic drug therapy did not improve the overall outcome of patients with sustained ventricular tachyarrhythmias. However, effective suppression of inducible arrhythmia by antiarrhythmic drugs was associated with a better outcome than was lack of suppression.

Importance of quantitative analysis of ventricular arrhythmias for predicting the prognosis in low-risk postmyocardial infarction patients. European Infarction Study Group.

In 378 placebo patients enrolled in the European Infarction Study (EIS), a secondary prevention study after acute myocardial infarction, 24-h baseline Holter monitoring was done 14 to 31 days after MI, and the relationship of electrical (ventricular arrhythmias) and mechanical (clinical signs of ventricular dysfunction) risk factors was analysed on the basis of mortality during the subsequent 2 years of follow-up. There was a rather low overall 2-year mortality rate of 6.9%. Consecutive arrhythmias (ventricular pairs and runs of ventricular premature beats) and left-ventricular dysfunction alone were associated with a low mortality of 4.0% and 3.6%, respectively. However, the combination of both defined a high-risk group characterized by a 2-year mortality rate of 16.7%. Additionally, the risk of dying was dependent on the frequency of consecutive arrhythmias: 22.2% of the patients with greater than 10 ventricular pairs per day died during the follow-up period in contrast to 9.9% of those with only 1-10 ventricular pairs per day. Thus, only the combination of electrical and mechanical risk factors, and especially the frequency of consecutive VPB, is helpful in identifying a subgroup of postMI patients with poor clinical outcome. An intervention study should restrict itself to this risk population only.

[Patients with transient ischemic attacks. Their cardiac status and its prognostic significance]. / Patienten mit transitorischer ischämischer Attacke. Ihr kardialer Status und seine prognostische Bedeutung.

In 51 consecutive patients with acute transitory cerebral ischaemia cross-sectional echocardiograms, 24-hour electrocardiograms (ECG) and exercise ECGs were recorded. The subsequent observation period averaged 13 (3-30) months. The echocardiogram was abnormal in 27 of 46 patients (58%). A holosystolic mitral-valve prolapse was found in eight: cerebral ischaemia recurred in five. There was no correlation between arrhythmias in the 24-hour ECG and renewed cerebral ischaemia. In addition to the 14 patients who--according to history and resting ECG--had already had a myocardial infarction, the exercise ECG revealed probably coronary heart disease in a further 11, i.e. half of the patients had coronary heart disease. Renewed attacks of cerebral ischaemia occurred in 13 patients during the follow-up period; four patients died, all of them also having had coronary heart disease. Because of the high prevalence of coronary heart disease (often previously undiagnosed) in the whole group, routine exercise ECGs are recommended for patients with transitory ischaemic attacks, protracted ischaemic neurological deficit or "minimal stroke", while 24-hour ECG monitoring does not seem essential. Randomized trials are needed to determine whether patients with cerebral ischaemia and echocardiographic evidence of mitral-valve prolapse should be treated prophylactically.

[Noninvasive registration of spontaneous ventricular potentials in patients with healthy hearts and in patients with intraventricular impulsive conduction disorders. Method and results of the signal averaging technic]. / Nichtinvasive Registrierung ventrikulärer Spätpotentiale bei Herzgesunden und bei Patienten mit intraventrikulären Reizleitungsstörungen. Methode und Ergebnisse der Signalmittelungstechnik.

For registration of delayed depolarizations 50 healthy persons (age: 49.4 +/- 6.2 years) and 43 patients with bundle-branch block (age: 65.1 +/- 11.8 years; 23 of them with right and 20 with left bundle-branch block) underwent high-resolution electrocardiography at the body surface using signal-averaging technique. The findings were compared with results obtained in the 24-hour long-term ECG. In 2 normal persons (4%), delayed depolarizations were recorded whose configuration, however, differed from that of pathological findings in patients with coronary heart disease. 2 other subjects evidenced repetitive ventricular arrhythmias. Detection of delayed depolarizations in patients with coronary heart disease is indicative of an increased risk of malignant or even fatal arrhythmias. The low prevalence in healthy subjects underlines the specificity of this finding and represents the prerequisite for identifying patients with an increased risk. Delayed depolarizations were found also in 3 patients with right and 4 patients with left bundle-branch block (16.3% in all). 8 patients had repetitive ventricular arrhythmias, and one of them with a left bundle-branch block also revealed delayed depolarizations. Thus delayed depolarizations can be registered in some patients with intraventricular conduction defects. The incidence rate corresponds to that found in patients with coronary heart disease, so that detection of delayed depolarizations in this patient group is not helpful in the assessment of prognosis.

[Comparative study of the anti-arrhythmia effect of flecainide acetate and prajmalium bitartrate in patients with tachycardiac ventricular rhythm disorders]. / Vergleichende Untersuchung über den antiarrhythmischen Effekt von Flecainidacetat und Prajmaliumbitartrat bei Patienten mit tachykarden ventrikulären Rhythmusstörungen.

In an open randomized therapeutic study, 20 patients known to have frequent ventricular premature beats (VPB) and/or ventricular pairs (VP) were treated with both 2 X 200 mg flecainide (F) and 4 X 20 mg prajmalium-bitartrate (P) for 3 months each. There was a drug-free interval of one week between the two therapy phases. 24-hour long-term ECG-registrations were carried out before the start of the therapy phases as well as 1 week, 1 month, 2 months and 3 months after the initiation of antiarrhythmic therapy. After one week, the group as a whole evidenced a VPB reduction of 94% under F and only 57% under P (p less than or equal to 0.05). The percentage of individual patients in whom there was a statistically significant VPB reduction was also higher under F than under P (65% vs. 40%). In the group as a whole, there was a VP reduction of 99% under F and 88% under P (p less than or equal to 0.05) after one week. Of the 13 individuals with frequent VP (over 16 VP/24 h), a significant reduction was seen in 77% under F and only 38% under P. The difference between the two antiarrhythmic agents registered after one week was also observed in the further course of therapy but could no longer be statistically confirmed for the ventricular pairs. An aggravation of ventricular arrhythmias was observed in 2 patients under F and in 3 under P.(ABSTRACT TRUNCATED AT 250 WORDS)

[Are anti-arrhythmia agents superior to a beta blocker in treating life-threatening ventricular arrhythmias? Preliminary results of a controlled study]. / Sind Antiarrhythmika einem Betablocker überlegen in der Behandlung lebensbedrohlicher ventrikulärer Rhythmusstörungen? Vorläufige Ergebnisse einer kontrollierten Studie.

UNLABELLED: The results of serial electrophysiologic testing in patients with sustained ventricular tachycardia or ventricular fibrillation indicate that if the arrhythmia is suppressible with antiarrhythmic drugs, the prognosis is better than when arrhythmias continue to be inducible despite antiarrhythmic drug treatment. Whether electrophysiologically guided antiarrhythmic drug therapy improves outcome or merely selects groups of patients with good and bad prognosis, is not known. To answer this question, a prospective randomized trial was conducted with 166 patients (sustained ventricular tachycardia n = 84; primary ventricular fibrillation n = 46; syncope n = 36). When the arrhythmia was inducible by programmed stimulation during control, patients were allocated to receive either electrophysiologically guided antiarrhythmic drug therapy (group I), or metoprolol (daily dose up to 200 mg) without invasive testing (group II). Patients with non-inducible arrhythmias were also treated with metoprolol (group III). RESULTS: During a follow-up of 10 +/- 8 (SD) months, there were arrhythmia recurrences in 30 patients, and sudden cardiac death in 17. Follow-up did not differ between group I (n = 59) and group II (n = 53). There was a tendency for the outcome to be better in patients of group III (n = 54) than in those of group II (Log-rank test p = 0.057). In group I, patients whose arrhythmias became suppressed did much better during follow-up than those with still inducible arrhythmias (p less than 0.0001). Thus, while invasive testing is a good predictor of outcome, electrophysiologically guided antiarrhythmic drug therapy is not better than a beta blocker in patients with sustained ventricular tachyarrhythmias.(ABSTRACT TRUNCATED AT 250 WORDS)

Methods for non-invasive detection of ventricular late potentials--a comparative multicenter study.

To evaluate the methodological problems of the non-invasive registration of late potentials the results obtained with four different averaging devices in the same 109 patients were compared. The high-resolution ECG was obtained from the body surface, high-gain amplified and filtered. With the averaging technique, the improved signal-to-noise ratio was able to detect low-amplitude cardiac activity. The incidence of late potentials detected with the four averaging systems, whose characteristics are described, ranged between 12% and 21%. Corresponding positive results were obtained in 5.5%, corresponding negative results in 68.8%. The reasons for differing results were mainly due to differences in visual or automatic interpretation of the registered fractionated electrical cardiac activity. Additionally, the determination of the end of QRS using the QRS width, obtained from reference leads, may influence the specificity of the methods.

Effect of oxprenolol on ventricular arrhythmias: the European Infarction Study experience.

In 736 patients, 24 hour electrocardiographic recordings were performed 14 to 36 days after acute myocardial infarction before the start of randomized treatment with 320 mg of slow release oxprenolol (n = 358) or placebo (n = 378). Follow-up 24 hour electrocardiographic recordings were obtained 5 to 12 days (median 10) and 3, 6 and 12 months after the first administration of the study medication. Oxprenolol-treated patients had a significantly lower daytime heart rate as compared with the placebo group, whereas no difference was found at night. At baseline, 22.1% of the patients allocated to oxprenolol treatment and 29.6% of the placebo group had more than 30 ventricular extrasystoles in 1 hour at least once during 24 hour monitoring; multiform ventricular extrasystoles were present in 58.4 and 62.7%, ventricular couplets in 29.6 and 33.9% and ventricular tachycardia (3 or more consecutive ventricular extrasystoles) in 21.5 and 20.9% of the oxprenolol-treated and placebo-treated patients, respectively. During the 1 year follow-up period, the prevalence of these arrhythmias did not change significantly in either treatment group. There was a trend toward a reduction in the daytime frequency of ventricular couplets in the oxprenolol group. After 3 and 6 months, only multiform ventricular extrasystoles were significantly less frequent in the oxprenolol group than in the placebo group (47.4 and 42.7% versus 59.7 and 57.9%, respectively). Twelve months after the acute event, however, multiform ventricular extrasystole frequency was the same in both groups of patients (52.1 versus 51.0%, respectively). Thus, oxprenolol had a weak suppressant effect on ventricular tachyarrhythmias in survivors of myocardial infarction.

[A new method for the evaluation of the success of anti-arrhythmic drug therapy and a paradoxical drug-induced arrhythmogenic effect in individual patients]. / Neue Methode zur Beurteilung eines antiarrhythmischen Therapieerfolges und eines paradoxen arrhythmogenen Medikamenteneffektes beim Einzelpatienten.

The aim of this study was to develop standards to define both antiarrhythmic drug efficacy and a drug-induced arrhytmogenic effect. In 45 patients with frequent and complex ventricular tachyarrhythmias 3 continuous 24-hour Holter recordings were performed. The spontaneous variability of ventricular premature beats and ventricular pairs was calculated using a new statistical method (transformation model). If two 24-hour Holter monitoring periods, one period before and the other with antiarrhythmic therapy, are compared, at least 75% reduction of ventricular premature beats and 90% reduction of ventricular pairs is necessary to be reasonably certain that one is measuring a drug response rather than spontaneous arrhythmia reduction (p less than or equal to 0.05). On the other hand, drug-induced aggravation can be assumed if ventricular premature beats and ventricular pairs have increased by more than 144% and 227%, respectively (p less than or equal to 0.05).

[Standardized psychological stress test for the provocation of tachycardial ventricular arrhythmias. Comparison with long-term ECG and stress ECG]. / Standardisierter psychischer Belastungstest zur Provokation tachykarder ventrikulärer Rhythmusstörungen. Vergleich mit Langzeit-EKG und Belastungs-EKG.

The effect of a standardized psychological stress test on frequency and severity of ventricular extrasystoles was compared in 42 patients with the results of 24-hour ECG monitoring and of an exercise ECG test. Frequent ventricular extrasystoles (greater than 1/min) occurred in the 24-hour-ECG in 22, in the psychological stress test in 24 and on physical exercise in 22 patients. 24-hour monitoring gave the only positive finding in ten, the psychological stress test in six, the exercise test in four. Complex arrhythmias (coupled or runs of ventricular extrasystoles) occurred in the 24-hour ECG in 30, with the psychological stress test in 16 and the exercise test in 12 patients. The 24-hour ECG was alone positive in 16, the psychological test in two, the exercise test in one. Thus in an individual patient the psychological stress test may provoke additional arrhythmias which are not recorded in either the 24-hour ECG or after exercise. The findings point to an independent significance of the psychological stress test in the diagnosis of simple and complex ventricular arrhythmias.

[Prognostic significance of noninvasively detected ventricular late potentials]. / Prognostische Bedeutung nichtinvasiv registrierter ventrikulärer Spätpotentiale.

The amplitude of delayed ventricular depolarizations, if detected from the body surface, is in the microV range. High amplification and signal averaging technique for improvement of the signal-to-noise ratio are necessary prerequisites to allow the registration of these signals. Delayed depolarizations are rather frequent findings in patients with coronary heart disease and marked left ventricular wall motion abnormalities. Additional spontaneous occurrence of ventricular tachyarrhythmias in these patients further increases the incidence of delayed depolarizations. They have also frequently been described in patients who suffer from malignant ventricular tachyarrhythmias or in whom programmed ventricular stimulation can provoke a repetitive response. Ongoing follow-up observation of altogether 1200 patients with coronary heart disease, who are involved in three prospective studies, suggest that delayed depolarizations have some prognostic significance to predict mortality from all cardiac causes and sudden death. But the predictive value of these potentials seems to be too low to draw definite conclusions or to indicate the need for specific therapy in the individual patient. The data published so far do not answer the question whether the results obtained from studies involving patients with coronary heart disease will have significance also for patients free from heart disease or for those with other than coronary heart disease.

[Trial for digitalis withdrawal in hemodialysis patients]. / Digitalis-Auslassversuch bein Hämodialyse-Patienten.

The indication for digitalis treatment was investigated in a controlled and prospective study lasting 12 months in 110 patients on long-term haemodialysis. In ten patients, digitalis was needed because of tachyarrhythmia due to atrial fibrillation and in five because of recurrent pulmonary edema. In 57 patients receiving digitoxin, therapy was discontinued for 4 to 6 weeks, whereas 13 patients not yet treated with digitalis, received digitoxin for 4 weeks. Without digitoxin, trial fibrillation occurred in 4 patients, while no patient experienced atrial fibrillation with digitoxin (P = 0.002). In 13 patients, radiological findings (heart enlargement, pulmonary congestion) were better with digitoxin than without. Thus digitoxin appeared to be clearly indicated in 29% of the haemodialysed patients. Additionally, digitalis was indicated in 31 patients because of heart enlargement, pulmonary congestion and (or) previous pulmonary edema. Initially, 76% of the patients were receiving digitoxin, whereas, after the investigation, the rate was only 57% (P less than 0.001). The prospective frequency of clinically apparent digitoxin intoxication was low (3%) and so were the overall toxic plasma digitoxin levels (5%). Digitalis should be given deliberately but not restrictively to haemodialysis patients, since atrial fibrillation (13%) and heart failure (50%) are frequent and often concealed.

[Non-invasive determination of left ventricular ejection fraction using a mobile ECG-triggered scintillation measuring probe. Comparison of cineventriculography, echocardiography and radionuclide ventriculography]. / Nichtinvasive Bestimmung der linksventrikulären Ejektionsfraktion mit einer mobilen EKG-getriggerten Szintillationsmesssonde. Korrelation zu Cineventrikulographie, Echokardiographie und Radionuklidventrikulographie.

In 29 unselected patients, the left ventricular ejection fraction was evaluated using a mobile ECG-gated scintillation probe (Nuclear Stethoscope) after in vivo labeling of the erythrocytes with 15 mCi technetium-99m. To validate the method, the Nuclear Stethoscope measurements were correlated to the results of: 1. Single-plane contrast cineventriculography in the right and left anterior oblique projections (RAO, LAO), 2. Radionuclide ventriculography with a gamma camera computer system, 3. Two-dimensional echocardiography from the apical two- and four-chamber views. The ejection fraction measured by the Nuclear Stethoscope showed a close correlation to the values obtained by cineventriculography in the RAO projection (r = 0.748) and radionuclide ventriculography (r = 0.785). In this group of unselected patients, the correlations with the results of two-dimensional echocardiography were poor (r = 0.451 and 0.557). Cineventriculographic findings and radionuclide ventriculography correlated well (RAO: r = 0.786; LAO: r = 0.758). The Nuclear Stethoscope provides a simple, reliable, and noninvasive method for measuring ventricular ejection fraction. Ongoing studies indicate that the Nuclear Stethoscope is a valid method even at a lower dose of 5 mCi technetium-99m.