OCT and IOP findings in a healthy worker cohort: results from a teleophthalmic study in occupational medicine.

PURPOSE: To avoid significant loss of vision in employees, the working population could be examined with ophthalmic methods as OCT and IOP measurement for detection of serious eye diseases. The value of "virtual eye clinics" in occupational preventive medicine has been previously shown. We used a telemedical approach to gather epidemiological information about prevalence of eye diseases such as glaucoma, ocular hypertension, hypertensive retinopathy, diabetic retinopathy, epiretinal membrane, AMD, adult vitelliform maculopathy, cystoid maculopathy, choroidal nevi, and macular drusen. METHODS: The study included 931 people ranging from age 39 to 65 years. Using a telemedical approach, all medical examinations and the ophthalmic examination were performed by a technician using an optical coherence tomography (SD-OCT) and a pulse air tonometer. The data were saved in the web-based patient chart MedStage® of the Talkingeyes® Collaboration Network. RESULTS: We found a high prevalence of eye diseases in a group representative for the working-age population by telemedical examination. 13.47% of the workers examined showed ocular findings necessitating treatment or control by an ophthalmologist, including ocular hypertension (5.7%), hypertensive retinopathy with loss of temporal retinal nerve fiber thickness (2.3%), epiretinal membrane (1.07%), glaucoma (0.97%), age-related macular degeneration and adult vitelliform maculopathy (0.53%), and diabetic retinopathy (0.2%). Two of the examined persons presented ocular findings requiring urgent treatment to prevent serious vision loss. CONCLUSION: Using a telemedical approach, we collected epidemiological information about prevalence of eye diseases in the working-age population. Virtual eye clinics in occupational preventive medicine are a useful method to improve sight and reduce vision loss of workers by reducing travel time and inconvenience associated with an in-person appointment with an ophthalmologist.

[Acute coronary syndrome : Prevention]. / Akutes Koronarsyndrom : Prävention.

For life style modifications primary and secondary prevention of acute coronary syndrome (ACS) are approximately similar, even though in the postinfarction situation functional diagnostic programs have to be performed in a rehabilitative manner. All three life style pillars of fitness, nutrition and relaxation implicate prognostic significance and the efficacy is higher for secondary prevention than for primary. The pharmacotherapeutic indications for thrombocyte aggregation inhibition are connected to the presence of atherosclerosis and statin medication is already connected to cardiovascular risk factor stratification, for which scores are used. Depending on the postinfarction myocardial destruction after ACS, additional pharmacotherapies, such as angiotensin-converting enzyme (ACE) inhibitors, angiotensin-II receptor antagonists, beta blockers and also mineral corticoid receptor antagonists are evident. New potential for prevention is ascribed to the new oral anticoagulants (NOAC) in the context of coincidental atrial fibrillation.

[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.

Increased frequency of cardioembolism and patent foramen ovale in patients with stroke and a positive travel history suggesting economy class stroke syndrome.

OBJECTIVE: To investigate the frequency of acute stroke in patients with a recent travel history and to analyse risk factors, stroke patterns and presence of a patent foramen ovale (PFO) in this patient group. DESIGN: One-year prospective observational study. SETTING: Single-centre study. METHODS: Enrolling all patients presenting with a first cerebral ischaemia and complementing the usual history with a standardised travel history. RESULTS: Of 338 patients with acute stroke, 42 had a positive travel history (PTH) (12.4%). Patients with a PTH were significantly younger (56.6 (SD 13) years) than patients (66.9 (13.2) years, p = 0.0001) with a negative travel history (NTH). Frequency of PFO in the PTH group (13; 44.8%) was significantly higher than in the NTH group (7; 10.8%) (p = 0.0001), even after patients were dichotomised into two age groups (younger and older than median of all PATIENTS: 31% v 6.1%, p = 0.007 and 13.8% v 4.6%, p = 0.022, respectively). PTH patients had fewer stroke risk factors (2.2 (1.4) v 3.3 (1.6), p = 0.0001) and a different risk profile with a lower frequency of diabetes (11.9% v 31.4%, p = 0.009), hypertension (52.4% v 78.7%, p = 0.0001), atrial fibrillation (7.1% v 22%, p = 0.025) and others (16.7% v 38.9%, p = 0.005). In contrast, PTH patients had significantly more cardioembolic (35.7% v 19.3%, p = 0.023) and cryptogenic strokes (50% v 19.9%, p = 0.0001) and more often ischaemia in the territory of the posterior cerebral artery (29.6% v 6.3%, p = 0.0001). CONCLUSIONS: The finding that more PTH patients had a PFO and a cardioembolic stroke pattern but that fewer had other typical stroke risk factors led to the hypothesis that PFO is a risk factor for economy class stroke syndrome.

[Cardiovascular imaging in preventive medicine]. / Kardiovaskuläre Bildgebung in der Präventionsmedizin.

Atherosclerosis is a systemic, over a long period silent, but at least in many cases severe illness with fatal events which in most Europeans represent the reason of death. The primary reduction of causative factors is very efficient, but, however, is not readily enough established within dominant curative treatment. In contrary, a cost effective risk modification is possible, especially by individualized risk stratification. The assessment of traditional risk factors (like lipid disorders, arterial hypertension) can not display the individual progression within the pathophysiologic continuum. Imaging modalities that examine morphology and function are able to assess preclinical data that represent validated surrogate parameters of the atherosclerotic process and in addition to traditional risk factors predictive informations. Predominantly, they allow the concept of primary and secondary preventive strategies.

Dose-dependent disintegration of human endothelial monolayers by contrast echocardiography.

Biological effects on endothelium induced by contrast ultrasound (US) may be relevant for transferring drugs into the tissue. An in vitro tissue-mimicking phantom was developed to simulate clinical precordial echocardiography of three modalities (two-dimensional (2DE), pulsed wave (PW), and Power Doppler echocardiography) with gradual increases of acoustic output (mechanical index (MI) 0.0-1.6 and thermal index soft tissue (TIS) 0.0-1.3, respectively; transmit-frequency 1.8 MHz in second harmonic mode (SHI) by 2DE, 1.8 MHz for PW-Doppler, and 3.2 MHz for Power Doppler) as well as contrast agent (CA) concentrations (0.002-4 mg/mL Levovist). Disintegration of the endothelial monolayer was quantitatively analyzed by counting intercellular gaps in light microscopy. No gaps were observed in CA application without sonication. Only few gaps appeared at sonication without CA application in 2DE at MI=1.6 and in PW- and Power Doppler at TIS > or =0.4 and MI > or =0.4. The number of gaps increased significantly with the gradual increase of US output and to a comparably lesser but also significant extent with CA concentrations. Diagnostic contrast echocardiography may induce endothelial disintegrations dependent on US output as well as on CA concentrations. This aspect might be helpful in further in vivo series on local drug delivery.

[Thrombus attached to a Sideris septal occluder system 6 years later]. / Thrombus am Sideris-Okkludersystem nach 6 Jahren.

HISTORY AND CLINICAL FINDINGS: A 61-year-old man was admitted to hospital because of right-sided hypaesthesia. Additionally he reported a brief speech disturbance some weeks before. Neurological examination indicated right-sided sensomotoric hemiparesis and left-sided upper quadrant anopia. 6 years ago recurrent transient ischaemic attacks (TIA) was diagnosed caused by paradoxical embolism through a persistent foramen ovale (PFO). The PFO was closed with a 45 mm Sideris button occluder device. After this, he reported no symptoms of cerebral ischaemia and he did not take any antiplatelet therapy. INVESTIGATIONS: Transesophageal echocardiography (TEE) showed a left atrial thrombus attached to the occluder. Cerebral computed tomography revealed infarction in regions supplied by the right posterior cerebral artery and left media cerebral artery. As additional risk factor for thrombosis a heterozygous factor V Leiden mutation was diagnosed. DIAGNOSIS: Multiple cerebral infarctions caused by a thrombus attached to an occluder system 6 years after interventional closure of persistent foramen ovale in a patient with heterozygous factor V Leiden mutation. TREATMENT AND COURSE: The patient was anticoagulated (phenprocoumon) and the thrombus gradually dissolved. CONCLUSION: A thrombosis on a Sideris occluder device may cause cerebral infarctions even years after transcatheter closure of a PFO.

Low molecular weight heparin for prevention of thromboembolic complications in cardioversion--rationale and design of the ACE study (Anticoagulation in Cardioversion using Enoxaparin).

The modality and duration of anticoagulation before, during, and after cardioversion of atrial fibrillation--either with or without guidance by transesophageal echocardiography (TEE)--is still an unresolved issue. Intravenous infusion of unfractionated heparin until effective anticoagulation with phenprocoumon or warfarin is used as the standard therapy. However, this approach may be associated with several days of hospitalization because of the necessity for intravenous heparin administration. Moreover, there may be an increased risk of bleeding complications or, conversely, episodes of undercoagulation. Low-molecular weight heparin is an attractive alternative as it not only provide a safe and predictable level of anticoagulation with fewer side effects but can also be administered safely on an outpatient basis. In addition, no anticoagulation monitoring is needed. The ACE study (Anticoagulation in Cardioversion using Enoxaparin) is a randomized, prospective, open-label multicenter trial comparing the safety and efficacy of subcutaneous enoxaparin with intravenous heparin/oral phenprocoumon before and after cardioversion (stratified to TEE guidance or no TEE guidance). This article presents the rationale, design and status of the ACE study.

Native tissue second harmonic imaging improves endocardial and epicardial border definition in dobutamine stress echocardiography.

AIMS: Native tissue second harmonic imaging (SHI) implemented in two-dimensional (2D) echocardiography was found to improve left ventricular (LV) endocardial border delineation. Dobutamine stress echocardiography (DSE) depends on the ability to adequately visualize these borders. We analysed whether SHI, compared to fundamental imaging (FI), can improve echogenicity qualitatively and quantitatively, as well as looking at the diagnostic accuracy of the stress test. METHODS AND RESULTS: Fifty consecutive patients with suspected or known coronary artery disease (history of myocardial infarction and/or coronary artery bypass grafting) underwent DSE sequentially by SHI as well as FI 3 days before or after quantitative coronary angiography. Regional mean echogenicity scores (0=uninterpretable; 4=excellent imaging) for SHI and FI at peak dobutamine titration were 1.8 +/- 0.8 and 1.0 +/- 0.6 (P=0.0020) for the anterior region, 2.3 +/- 0.8 and 1.5 +/- 0.7 (P=0.0002) laterally, 2.7 +/- 1.0 and 1.9 +/- 0.8 (P=0.0001) posteriorly, 2.9 +/- 0.8 and 2.2 +/- 0.7 (P<0.0006) inferiorly, 3.0 +/-0.7 and 2.2 +/- 0.7 (P=0.0001) septally, and 3.1 +/- 1.0 and 2.1 +/-0.8 (P=0.0001) anteroseptally, respectively. Medians [upper; lower quartiles] of a global endocardial visualization index (calculated analogously with the wall motion score index based on a 16-segment model recommended by the American Society of Echocardiography) for the harmonic and the fundamental techniques were 2.59 [2.91; 2.22] and 1.87 [2.19; 1.53] (P=0.0001) at rest, 2.62 [2.94; 2.13] and 1.84 [2.19; 1.50] (P=0.0001) at low dose dobutamine, 2.51 [3.00; 2.13] and 1.74 [2.00; 1.44] (P=0.0001) at peak dose dobutamine, and 2.52 [2.94; 2.19] and 1.76 [2.19; 1.38] (P=0.0001) at recovery, respectively. For repeated quantitative LV volumetry in the harmonic and fundamental modality by the same observer, coefficients of variation were 4.4 +/- 0.4 vs. 6.0 +/- 0.5 (P<0.0001) for end-diastolic volume, 7.4 +/- 0.8 vs. 9.2 +/- 1.1 (P<0.0001) for end-systolic volume, and 5.2 +/- 1.1 vs. 8.2 +/- 1.3 (P<0.0001) for ejection fraction, respectively. Sensitivity and specificity related to coronary angiography for both methods were 80% and 60% as well as 90% and 93%, respectively. CONCLUSION: Native tissue SHI enhances LV image quality in all stress stages of DSE in unselected patients. This translates into beneficial effects on not only qualitative but also quantitative testing and diagnostic accuracy. SHI should be recommended as a standard tool in DSE and extends its applicability to difficult-to-image patients previously deemed unsuitable.

[Assessment of myocardial vitality with dobutamine echocardiography: current review]. / Myokardialer Vitalitätsnachweis mit der Dobutamin-Echokardiografie: Aktuelle Ubersicht.

Myocardial stunning (contractile dysfunction in the presence of normalized perfusion) and myocardial hibernation (contractile dysfunction matching reduced perfusion) have represented separate concepts of viable, but dyssynergic myocardium in the past. However, in vivo experimental and clinical work suggests that repetitive ischemia due to coronary artery disease may induce a gradual transition between stunned and hibernating myocardium. Myocardial hibernation itself can result from a spectrum of ischemic conditions ranging from impaired myocardial blood flow reserve to frank hypoperfusion. With increasing severity and duration of ischemia, degeneration of cardiac myocytes, accumulation of glycogen and cell death ensue. Additionally, there is an increase of extracellular matrix protein content leading to reparative fibrosis, which in turn limits functional recovery. In the light of these structural features, the available methods for detection of viable myocardium, in particular dobutamine echocardiography and nuclear imaging techniques, offer complementary rather than contradictory information. Dobutamine echo has satisfactory sensitivity, excellent specificity, and high diagnostic accuracy for the detection of viable dyssynergic myocardium. While in the past only its predictive accuracy for segmental recovery has been validated, newer data show an improved survival after revascularization if at least four viable dyssynergic left ventricular segments in a 16 segment model can be identified by dobutamine echocardiography. The complete (low and high dose) dobutamine protocol can elicit several types of contractile responses (sustained improvement in contraction or monophasic response, biphasic response, new wall motion abnormality) which should be interpreted in view of other clinical data including a previous infarction. The test protocol can be used safely at the end of the first week after myocardial infarction. If ischemia or viability is documented, revascularization should be performed promptly. A similar strategy should be followed in the setting of chronic coronary heart disease with left ventricular dysfunction. Since the structural changes of hibernating myocardium are progressive, time to revascularization is critical. On the other hand, responsible therapeutic planning requires proof of ischemia or viability before initiating a potentially hazardous revascularization procedure.

[Stress echocardiography]. / Stressechokardiographie.

Within the last decade of this millennium, stress echocardiography has been established for the diagnosis and follow-up of coronary artery disease. The basis is the technical development of the echo machines: first, the improved echocardiographic resolution and, second, the digital image storage of a whole cineloop, which may be interpreted frame-by-frame in an ECG synchronized manner for several exercise levels simultaneously. Myocardial ischemia can be detected much earlier by regional contraction abnormalities of the left ventricular myocardium than in conventional ECG exercise tolerance testing explaining the higher sensitivities. Furthermore, the extent and localization, including the correlation with the stenotic coronary anatomy, is possible. The usage of pharmacological stress agents (dobutamine, arbutamine, dipyridamole, adenosine) or electrical stimulating methods (transesophageal, intracardial) allow the examination of patients unable to exercise in similar accuracy.