[Dyspnea in left-sided heart disease]. / Dyspnoe bei Linksherzerkrankungen.

Shortness of breath (dyspnea) is a common symptom in left-sided heart disease but clinically, patient symptoms show a high variability. Echocardiography is the mainstay for evaluating whether left-sided heart disease is the cause of dyspnea. If left-sided heart failure is diagnosed, this symptom complex must then be subjected to further etiological evaluation. Hypertensive, ischemic and valvular heart diseases are common, as well as atrial fibrillation. If the patient does not have angina pectoris, testing for ischemic heart disease should be done non-invasively by coronary computed tomography or testing for regional myocardial ischemia. Coronary revascularization is indicated only when a prognostically relevant ischemia of more than 10 % of the left ventricle is diagnosed. Diuretics are important for the relief of dyspnea but do not improve the prognosis of patients. In patients with reduced left ventricular function, combination therapy with angiotensin-converting enzyme (ACE) inhibitors, beta blockers and aldosterone antagonists improve the symptoms and prognosis. For treatment of heart failure with preserved ejection fraction evidence-based measures are still lacking. In this case the recommended therapy consists of optimal treatment of comorbidities, regulation of heart rate and blood pressure and participation in structured exercise programs. Angiotensin receptor blockers and aldosterone antagonists can be given in patients with more severe symptoms even though the available data are very sparse.

[Hybrid imaging in diagnostics and therapy of chronic myocardial ischemia. Clinical value]. / Hybridbildgebung in Diagnostik und Therapie der chronischen Myokardischämie. Klinischer Stellenwert.

Clinical studies have consistently shown that there is only a very weak correlation between the angiographically determined severity of coronary artery disease (CAD) and disturbance of regional coronary perfusion. On the other hand, the results of randomized trials with a fractional flow reserve (FFR)-guided coronary intervention (DEFER, FAME I, FAME II) showed that it is not the angiographically determined morphological severity of coronary artery disease but the functional severity determined by FFR that is critical for prognosis and the indications for revascularization. A non-invasive method combining the morphological image of the coronary anatomy with functional imaging of myocardial ischemia is therefore particularly desirable. An obvious solution is the combination of coronary computed tomography angiography (CCTA) with a functional procedure, such as perfusion positron emission tomography (PET), perfusion single photon emission computed tomography (SPECT) or perfusion magnetic resonance imaging (MRI). This can be performed with fusion imaging or with hybrid imaging using PET-CT or SPECT-CT. First trial results with PET CCTA and SPECT CCTA carried out as cardiac hybrid imaging on a 64 slice CT showed a major effect to be a decrease in the number of false positive results, significantly increasing the specificity of CCTA and SPECT. Although the results are promising, due to the previously high costs, low availability and the additional radiation exposure, current data is not yet sufficient to give clear recommendations for the use of hybrid imaging in patients with a low to intermediate risk of CAD. Ongoing prospective studies such as the SPARC or EVINCI trials will bring further clarification here.

[MRI in chronic myocarditis]. / Stellenwert der MRT bei chronischer Myokarditis.

In most cases inflammatory changes of the myocardium are asymptomatic. If inflammatory changes of the myocardium manifest with clinical symptoms, the condition is termed myocarditis. Myocarditis is regarded as a major cause for sudden death of young adults and accounts for up to 20% of the cases. In Europe viral infections represent the most important cause of myocarditis. In chronic myocarditis, viremia is often absent and myocardial fibrosis and dilated cardiomyopathy (DCM) resulting in heart failure can occur. The role of cardiac MRI in chronic myocarditis is not yet well understood. MRI is a sensitive tool detecting myocardial fibrosis on late images after application of paramagnetic contrast agents. The region of contrast accumulation is defined as "late enhancement" (LE). Data are available now suggesting that differentiating fibrosis due to myocardial infarction from inflammatory causes is facilitated using MRI late images. Fibrosis after ischemic infarction includes the subendocardial layer of the myocardium. If the subendocardial layer of the myocardium is not involved in the fibrosis, infarction is unlikely and can be reliably excluded as an important differential diagnosis in the vast majority of affected patients.