Age-dependence of lipid parameters in the general population and vegetarians.

Age-dependent changes of lipid metabolism may arise both as a result of mechanisms of biological ageing and factors influencing age-dependent changes. To study possible influences of nutrition and life-style of vegetarians on age-dependence of lipid parameters, subjects of general population were compared with vegetarians. In the frame of population-based lipid screening projects in the city of Leipzig/Germany (Lipid Study Leipzig, LSL) 10 550 subjects (3,816 men and 6,734 women, age 18-99 years) of general population were compared with 417 vegetarians (vegans, lacto-vegetarians, lacto-ovo-vegetarians, 148 men and 269 women, age 18-93 years). Most of the vegetarians included in the study were members of the German Society of Vegetarians. The study program included capillary blood cholesterol measurements and the determination of high-density lipoprotein (HDL)-cholesterol, the measurement of other cardiovascular risk factors and the evaluation of dietary and life-style factors. Evaluation of cardiovascular risk profile within LSL was connected with individual consultation. The mean total cholesterol and non-HDL-cholesterol level and the total: HDL-cholesterol ratio showed the expected age-dependence, with maximum values within the decade 60-70 years. Vegetarians showed lower total and non-HDL-cholesterol levels in comparison with the general population. Furthermore, the age-dependent increase of these parameters is less pronounced under the conditions of vegetarian nutrition and life-style. Especially in young adulthood a significant difference is observed. Thus, the results of the present study reveal the role of nutritional and life-style factors that determine the lipid profile on a population basis and suggest that the known age-dependent rise of the level of atherogenic plasma lipoproteins is partly preventable.

[Importance of left ventricular function for active early ambulation following acute myocardial infarct]. / Bedeutung der linksventrikulären Funktion für die aktive Frühmobilisierung nach akutem Myokardinfarkt.

On the 4th postmyocardial infarction day a risk group determination among n = 80 patients was undergone on the base of LDH-isoenzyme-monitoring. The active early mobilization was carried out following corresponding risk groups: less risk (38%) until the 14th, middle risk (23%) until the 21st and high risk (38%) until the 28th postmyocardial infarction day or longer. The average period of hospitalization was 21.1 day. The exercise load test was done successful in 97% by patients with low risk and in 40% by patients with high risk. The ejection fraction was 51.3% for patients with low risk and 38.5% (p less than 0.01) for patients with high risk. The exercise test at discharge is usefull for check of the risk from the acute phase and for the determination of high-risk patients for physical conditioning.

[Modified bedside diagnosis in patients at risk for aortocoronary venous bypass surgery]. / Modifizierte Bed-side-Diagnostik bei Risikopatienten zur aortokoronaren Venenbypass-Operation.

Early detection of perioperative complications during cardiosurgical operations is of differential diagnostic and differential therapeutic importance. Various risk groups of aortocoronary venous bypass operations have been analysed under different aspects: age, (not significant), implemented bypass rate (aneurysm resection 1.75/p less than 0.01 compared with 2.65-2.9), death rate (= greater than 21 days) 4 to 6.3% (including patients with "bad ventricle", p less than 0.05), and the proportion of clinically relevant complications of 19 to 40% (aneurysm resection 40%/p less than 0.001). Monitoring the marker proteins is an appropriate method of judging the perioperative risk of perioperative myocardial damage in preoperatively defined high-risk patients (approximately 25% modified according to centre conditions). Patients who died always had early pathologic dynamics of marker proteins. Patients with perioperative risks (aneurysm resection and ejection fraction global less than = 30%), left main artery stenosis and unstable angina pectoris symptoms) were found to have pathologic dynamics of marker proteins to a significantly varying extent (compared to a test group). This modified approach of bedside diagnostics of risk patients confirms the preoperative selection of risk patients and forms the economically viable future basis for an individualized perioperative course control.

[The surgical risk in patients with cardiac diseases]. / Risiko chirurgischer Eingriffe bei Patienten mit kardialen Erkrankungen.

The increase in the number of patients with heart and circulatory diseases during selective surgical operations in the past decades is due to both the epidemiologic situation and the increase in the number of old and very old people. To ensure optimum perioperative care of these patients, the anaesthetist must know the degree of illness of each individual and the functioning state of the haemodynamic system. In this paper we show factors which increase the perioperative risk of cardiac complications. These factors are traceable on a semiquantitative basis by the remaining function of the myocardium or the risk of ischaemia of the cardiac muscle. Many clinical symptoms or diagnoses do not affect the perioperative risk. To judge preoperative risks and specific perioperative changes in medication, cooperation between the anaesthetist and cardiologist is required.

[Experiences from general practice: use of acetylsalicylic acid and anticoagulants in patients following acute myocardial infarct]. / Erfahrungen aus der Praxis: Einsatz von Acetylsalicylsäure und Antikoagulantien bei Patienten nach akutem Myokardinfarkt.

An effective therapy with coumarin derivatives within the secondary prevention after acute myocardial infarction makes great demands on the dispensary care. The risk of serious complications is relatively high. The risk of therapy with acetyl salicylic acid (ASS) in low dosage is significantly smaller. A significant decrease of the rate of reinfarctions and lethality by acetyl salicylic acid was made evident. The retrospective evaluation of the duration of treatment and effectiveness of the therapy with anticoagulants in postinfarction patients (n = 260) had the following result: reduction of the anticoagulant therapy from 75% in the year 1985 to 35% in the year 1989. Increase of the acetyl salicylic acid therapy (250 mg/day) from 23% to 60% in the same period. Up to 1987 the average duration of treatment with anticoagulants was 61.2 +/- 33.6 months, since 1988 only 9.6 +/- 2.6 months. 80% of the patients had a temporary ineffective therapy with anticoagulants, 50% were transitorily in the therapeutic risk region. At present only patients with an increased thromboembolic risk received an obligatory anticoagulant therapy.

[Drug therapy under physical conditioning and during phase III rehabilitation in patients following acute myocardial infarct]. / Medikamentöse Therapie unter physischer Konditionierung und während der Rehabilitationsphase III bei Patienten nach akutem Myokardinfarkt.

In the framework of the secondary prevention after acute myocardial infarction the interaction between physical conditioning (pK) and medicamentous therapy was analysed and a retrospective evaluation of the therapy was performed during the rehabilitation phase III. During the physical conditioning (n = 110) in 31% of the patients changes of the medicamentous therapy rendered themselves necessary (15% increase of the dose, 16% reduction of the dose and withdrawal of a medicament, respectively). In the rehabilitation phase III (n = 277) 72% of the patients were given nitrates, 68% calcium antagonists and 55% beta-receptor blocking agents (43% double, 29% triple combinations) and 15% digitoxin. The aim of the medicamentous therapy is the treatment of the myocardial ischaemia and its sequels, taking into consideration the positive effects of the physical conditioning and the influence on the quality of life.

[Perioperative complications in at-risk patients undergoing heart valve surgery]. / Perioperative Komplikationen bei Risikopatienten mit Herzklappenersatzoperation.

The success of operations of the replacement of heart valves is disturbed by perioperative complications and early lethality. A valuation of the perioperative risk individually of patients with operations of the replacement of heart valves according to defined subgroups is controlled by the perioperative course. In order to achieve the registration of patients with perioperative lesion of the myocardium and/or low output syndrome, the bedside performance of a marker protein monitoring consisting of enzymes/isoenzymes (CK, CK-MB, ALAT) and the muscle protein myoglobin, respectively, is necessary. In 38% of the patients with operation of the replacement of heart valves the preoperative risk constellation was objectified early-postoperatively with the proof of complication and thus the strategy of the preoperative individual valuation of the risk confirmed. Altogether patients with replacement of the aortic valve showed the smallest rate of perioperative complications in comparison to patients with replacement of the mitral valve (re-operation in replacement of the mitral valve, double valve replacement, replacement of the mitral valve with restricted left-ventricular function).

[Drug therapy following heart valve prosthesis]. / Medikamentöse Therapie nach Herzklappenersatz.

Patients with prostheses of the cardiac valve are, related to the total population, only a small part. But their number permanently increases. Alone in our clinic since 1973 3,250 patients have been provided with artificial cardiac valves. Thus more and more physicians are confronted with the problems of these patients. The long-term results after replacement of the cardiac valves are very essentially influenced by the prevention and well-timed recognition of complications, respectively. For this reason the medicamentous therapy is demonstrated on the basis of own experiences and modern literature. It is clearly pointed out that after replacement of the cardiac valve a permanent cardiologic control is necessary. In detail is reported on the therapy of cardiac insufficiency including disturbances of the cardiac rhythm, on the prophylaxis of thromboembolism as well as on the prophylaxis of endocarditis.

[Therapy of perioperative myocardial damage in aortocoronary venous bypass surgery]. / Therapie des perioperativen Myokardschadens bei aortokoronarer Venenbypass-Operation.

The perioperative lesion of the myocardium in heart-lung machine operation can on principle not be prevented despite complex measures of the protection of the myocardium and the individual monitoring of the patients, this particularly by including patients with high risk of ischaemia of the myocardium (instable angina pectoris, stenosis of the trunc and greatly restricted left-ventricular function, respectively) in former years. In a proved perioperative lesion of the myocardium the limitation of the myocardial lesion stands in the centre of intensive-medical measures with vasodilators and positive inotropic substances.

[Thrombolytic therapy in acute myocardial infarct. 2. Clinical studies with thrombolytic therapy]. / Thrombolysetherapie beim akuten Myokardinfarkt. Teil 2. Klinische Studien zur Thrombolysetherapie.

The highly dosed short-term therapy of thrombolysis with intravenous streptokinase at the beginning of therapy less than or equal to 6 angina pectoris time has with a high probability as a consequence the early recanalisation of a coronary thrombosis. A reduction of the lethality is significant, however, furthermore also patients with longer angina pectoris time have advantages. The combination of the intravenous streptokinase therapy with the immediate medication of acetyl salicylic acid (ASA) is a decisive factor for the decrease of the reocclusion and the reinfarction rate, respectively, and thus for the limitation of the lethality. The early intracoronary streptokinase therapy is no more indicated today. In comparison to the intravenous streptokinase the early recanalisation rate is higher in t-PA and APSAC. However, at present the results are identical at dismission from hospital. Studies in the nineties must make evident the advantages of the various substances only in the direct comparison (Sk, t-PA, APSAC).

[Localization and type of acute myocardial infarct in relation to myocardial infarct size--patients with acute re-infarct]. / Lokalisation und Typ des akuten Myokardinfarktes in Beziehung zur Myokardinfarktgrösse--Patienten mit akutem Re-Infarkt.

A differentiated estimation of the acute re-infarction is individually necessary for the estimation of risk and prognosis. Thereby the methodical approach is of particular importance, since the further restriction of the remaining function of the myocardium in re-infarction is of fundamental significance. A monitoring for the establishment of CKmax as well as the measuring of the ejection fraction globally (EFg) allow a semiquantitative determination of the size of the myocardial infarction. This forms the basis for the evidence of smaller acute Q-wave re-infarctions and also of smaller acute re-infarctions of the posterior wall localization. The increase of the risk in non-Q-wave infarction (mean risk) and Q-wave infarction (high risk) in re-infarction could be confirmed by the ejection fraction globally. Thus significant differences of the surviving persons after acute re-infarction in comparisons to the primary infarction were elaborated.

[Thrombolytic therapy in acute myocardial infarct. 1. Markers for evaluating effectiveness and thrombolytic substances]. / Thrombolysetherapie beim akuten Myokardinfarkt. Teil 1: Marker zur Effektivitätsbewertung und thrombolytische Substanzen.

By means of serial investigations of coronary angiographies and acute dissections in the acute myocardial infarction (AMI) in the vast majority of the patients fresh thrombi could be made evident as cause of the vascular occlusion. By lysins produced within the body parts of the thrombi can be lyzed (spontaneous lysis up to 20%). However, thrombolytically effective substances considerably increase the recanalization in the first hours after the beginning of the symptomatology. These substances with clinical significance are as follows: streptokinase (SK), urokinase, tissue plasminogen activator (TPA) and acylated streptokinase (APSAC). The broad application of the thrombolytic therapy (TT) is possible only by the intravenous, highly dosed short-term method and demands non-invasive parameters for the judgment of effectiveness [(ECG, ejection fraction globally (EFg), marker protein monitoring)]. Though the ECG allows only conditionedly quantitative statements concerning the size of the myocardial infarction, an estimation of the successful TT in sufficient early recanalization is possible by a dynamics of criterias of ECG and electrocardiographic signs are less distinctly expressed, respectively. The limitation of the size of the myocardial infarction by the successful reperfusion which finds its expression in the remaining left-ventricular function is the decisive link for the influence on the quality of the life and the prognosis of these patients. A dynamics of the ejection fraction globally in the effective thrombolytic therapy is to be expressed. For this purpose at least two single measurements (acute phase, control 1st and 2nd week) are necessary. A non-invasive monitoring of marker proteins (enzymes/isoenzymes: CK, CK-MB, LDH and myoglobin, respectively) is suitable for the recognition of the effective thrombolytic therapy.(ABSTRACT TRUNCATED AT 250 WORDS)

[Site and type of acute myocardial infarct in relation to myocardial infarct size--dynamics of global ejection fraction in acute myocardial infarct]. / Lokalisation und Typ des akuten Myokardinfarktes in Beziehung zur Myokardinfarktgrösse--Dynamik der Ejektionsfraktion global beim akuten Myokardinfarkt.

By the ejection fraction global (EFg) statements concerning the remaining function of the myocardium in acute myocardial infarction and thus individually concerning the prognosis (classification of risk groups) become possible. For the valuation of the dynamics of the EFg in a period up to 6 months after an acute myocardial infarction the EFg was multifariously controlled. Only patients with first myocardial infarction in localization on the anterior wall and Q-wave showed a significant dynamics of the EFg between the measurements acute and third week as well as acute and 6th month (absolutely 5.2%). --In re-infarction/Q-wave this could be confirmed also for the localization of the posterior wall in the period acute till third week. For the localization on anterior and posterior wall a dynamics of the EFg could also be calculated for the period acute and 6th month. Thereby the absolute increase of the EFg was between 4.0 and 4.6%. The dynamics of the EFg in the region of the anterior wall was 5.2% for the first infarction and only 4% for the reinfarction. Thus it is below the dynamics of the EFg in an effective thrombolytic therapy.

[The significance of thrombolytic therapy in acute myocardial infarct in advanced age]. / Bedeutung der Thrombolyse-Therapie beim akuten Myokardinfarkt im höheren Lebensalter.

The thromboticgenesis and the close time dependence of the development of the acute myocardial infarction (AMI) are decisive findings of the dynamic development in the past ten years. Therapy started in time including the elimination of the thrombotic coronary occlusion as soon as possible leads to the reperfusion of the vessel affected by the infarction and thus to the limitation of the size of the myocardial infarction. Because of the temporally limited tolerance of ischaemia of the myocardium, an efficient thrombolytic therapy (TT) with an objectifiable improvement of the left-ventricular function (ejection fraction global-EFg) is possible up to the 4th ApS hour. The median value of the maximum creatine kinase activity (CKmax) time was 11.8 h with effective TT; with ineffective TT 21.5 h (p less than 0.001). There is no significant difference of the CKmax-t between the age groups (less than 60 and greater than 60 years). CKmax significantly differentiates between the deceased and ineffective/effective TT (p less than 0.001). Monitoring the EFg shows significant differences in the deceased (16.3), ineffective TT (34.0), and effective TT (42.5%) both in the acute phase and in the first weeks after AMI by the dynamism of the EFg. So, - EFg was verified to be 6% with effective TT to - EFg to be 1.6% (absolute) with ineffective TT. The percentage of cases of death was restricted also for patients greater than 60 years. After effective TT less patients are found in the high and medium risk group after AMI. 70% of the patients had an effective TT.(ABSTRACT TRUNCATED AT 250 WORDS)

[Creatine kinase risk groups in acute myocardial infarct]. / Kreatinkinase-Risikogruppen beim akuten Myokardinfarkt.

The individual valuation of risks in patients with acute myocardial infarction on the basis of a monitoring of the creatine kinase (CK) is made evident as relevant to practice for the basic medical care. Thereby a classification of risk groups on the basis of CKmax (less than or equal to 23; greater than 23 less than or equal to 40; greater than 40 less than or equal to 60; greater than 60 mumol/l.s) is controlled. The measurement of the ejection fraction global was performed also according to risk groups (greater than 60; greater than 45 less than or equal to 60; greater than 30 less than or equal to 45; less than or equal to 30%). Parallel to this a classification of the patients according to the electrocardiogram (non-Q-wave, Q-wave) was retrospectively performed. The anamnestic information Re-AMI was individually taken into consideration for the evaluation of CKmax. In 2.5% of the patients in comparison to the ejection fraction the risk group classification of CKmax was globally carried out into a higher group without an an principal incorrect evaluation of the risk (slight, middle, high) in the first AMI. No patient with middle or high risk in the first AMI was incorrectly grouped according to the risk group CKmax or ejection fraction global.

[The significance of the performance-lactate quotient in patients following acute myocardial infarct in a preliminary stress test]. / Bedeutung des Leistungs-Laktat-Quotienten bei Patienten nach akutem Myokardinfarkt zum orientierenden Belastungstest.

According to the risk group classification on the basis of an isoenzyme monitoring n = 67 patients (of them 12 females) with acute myocardial infarction were temporarily differentiated: slight risk (n = 26) on the 14th day, medium risk (n = 16) on the 21st day and high risk (n = 25) greater than or equal to 28. By means of orientating tolerance test and measurement of the lactate concentrations examinations were performed on the day post infarction. All patients with slight risk achieved the physical performance of 375 Watt/min in slight lactate concentrations (less than 4 mmol/l). The performance/lactate quotient (WL-Q) for a slight risk was 1.23 for males and 0.98 for females, for a high risk only 0.66 (males) and 0.53 (females) for a high risk. Patients with high risk were reliably recognized and underwent an individually adapted physical conditioning, taking into consideration the sex-specific differences.

[The acute phase of myocardial infarct in the elderly]. / Die akute Phase des Myokardinfarktes im höheren Lebensalter.

The percentage of older patients with AMI in the total of patients is predominating and is still increasing differentiatedly. The essential cause of there is an increase in complications and in mortality until the 28th day. In a prospective study over 48 months with n = 390 patients we analyzed the age groups less than 65 years (A) and greater than or equal to 65 years (B) regarding their different rates of complications. For the semiquantitative determination of myocardial infarction sizes we used: -Monitoring of ECG, creatinine kinase (CK), and ejection fraction global (EFg). In group A 81% survived, whereas in group B only 60% survived. The average age of the surviving patients was 56.2 years, that of the deceased 64.4 years. The percentage of surviving patients with transmural AMI was 96% in A and 57% in B. In both A and B. CKmax with p less than 0.01 was to be differentiated between non-transmural and transmural AMI. In the deceased CKmax was 89.7 (A) to 59.3 mumol/lxs (B) (p less than 0.05). The percentage with AMI extension was 4% in A and 43% in B, p less than 0.005. Patients of group B showed a significant difference (p less than 0.001) of EFg for non-transmural AMI 59.1 (36-70)%, transmural AMI 31.5%, and deceased 17.3%. In patients with Re-AMI EFg was generally measured to be less than 45%. Re-AMI could be diagnosed in 13% of A and in 29% of B (p less than 0.001). The ICU stay of the surviving patients of the total number of patients could be reduced by 1.1 days in the period from 1984 through 1987. With group B it could be reduced by 0.8 days. The overall stay in hospital (1984-1987) was 19.6 days (A = 18.3; B = 22.4). AMI extension and the Re-AMI result are the decivise factors to the essential increase in complications and cases of death with AMI at older age. The semiquantitative determination of the myocardial infarction size by monitoring makes up an efficient basis for the early assessment of the residual function of the myocardium and of the risk classification.

[Perioperative risk of valve replacement surgery in the elderly]. / Perioperatives Risiko bei Klappenersatz-Operation im höheren Lebensalter.

The indication of surgical valva replacement also at older age (greater than 60 years) with chronically rheumatic valvular diseases requires both the assessment of the pre-operative constellation of findings and perioperative complications. From this combined point of view statements concerning the strategy of valve replacement at older age seem to be concludable. In the frame of a prospective study perioperative parameters were monitored in n = 90 patients with preoperative high-risk constellation out of a total of n = 300 patients for the quick recording of additional complications (such as perioperative myocardial damage, cardiac low output syndrome, and cases of death at the ICU). The average age of the whole group of patients was 52 years (25-68 years), that of the patients greater than 60 years was 63.6 years (61-68 years). In 72% of the older patients the preoperative high-risk constellation was confirmed by 50% deceased; 16% cLOS; 6% perioperative myocardial damage (PMD). On a total of 41% of the patients a combined operation was performed (valve replacement and bypass operation), there of 2/3 with aortic valve replacement and 1/3 with mitral valve replacement. The ejection fraction restricted heavily already before the operation (less than or equal to 30%) was the essential cause of perioperative complications (cases of death, cLOS) together with the combined operation. The immedicable pulmonary hypertension complicated the already preoperatively impaired left-ventricular function in a high percentage of patients with mitral valve replacement.(ABSTRACT TRUNCATED AT 250 WORDS)