Herz

Das Blutgerinnungssystem besteht aus einer Kaskade komplexer, ineinander greifender Einzelschritte, die an verschiedenen Stellen selektiv gehemmt werden können. Dadurch bieten sich verschiedene therapeutische Optionen sowohl im Bereich der primären Hämostase, die in der Entstehung eines plättchenreichen Thrombus resultiert, als auch der sekundären Hämostase, dem plasmatischen Gerinnungssystem, das zur Fibrinbildung führt. Bei Patienten mit koronarer Herzkrankheit, die sich einer Koronarintervention unterziehen müssen, ist aufgrund des aktivierten Gerinnungssystems eine ausreichende gerinnungshemmende Strategie zur Prävention ischämischer Ereignisse entscheidend. Neben der antithrombozytären Therapie hat sich hierbei unfraktioniertes Heparin (UFH) als intravenöse Begleittherapie während einer perkutanen Koronarintervention (PCI) bewährt. Auch niedermolekulare Heparine (NMH) werden aufgrund ihrer günstigen pharmakodynamischen Eigenschaften zunehmend in diesem Bereich eingesetzt. Der genaue Stellenwert dieser Substanzen im Vergleich zu UFH muss noch evaluiert werden.

In October 2011, a 72-year-old man was referred from a peripheral hospital with subsequent diagnosis: fungal sepsis with suspicion for endocarditis of a bioprosthetic aortic heart valve. In May 2010, a bioprosthetic aortic valve implantation (Edwards Magna) and CABG (LIMA graft on LAD) were performed. At the time of admission, the patient was in good general condition; the physical examination was unremarkable. Hemoculture detected Streptococci thermophilus and Candida parapsilosis. Neither an oscillating intracardiac mass on the valve nor an abscess could be detected in several transesophageal echocardiographies (TEEs). The F18-FDG PET-CT showed an increased tracer uptake in the area of the prosthetic aortic valve. The findings argued for a fungal endocarditis of the prosthetic aortic valve. Heart surgeons refrained from implantation of a new prosthetic aortic valve because of the unfavorable prognosis. Therefore, highdose i.v. therapy with liposomale amphotericin B (5 mg/kg BW) and voriconazol (4 mg/kg BW twice a day) was started. A new F18-FDG PET-CT after 2 weeks showed no tracer uptake in the area of the prosthetic aortic valve. The hemoculture was also negative. The patient recovered; CRP values were within normal limits. Life-long antifungal therapy with fluconazol (400 mg/day) was recommended. There are no definitive treatment recommendations for fungal endocarditis. Surgical therapy is the first choice in prosthetic valve endocarditis, which however cannot be performed in all patients. In these cases high dose and life-long medical therapy is necessary to prevent re-infection of the valve, even if (transient) deterioration of renal and liver function occurs.

The prognostic importance of high-sensitivity cardiac troponin T (hs-cTnT) has recently been reported in patients with heart failure. The myocardial performance index (MPI), which combines parameters of both systolic and diastolic ventricular function, provides a better marker of left ventricular dysfunction in hypertensive patients with preserved left ventricular ejection fraction (LVEF). We aimed to investigate the relationship between hs-cTnT and tissue Doppler-derived MPI in newly diagnosed hypertensive patients with preserved LVEF. We studied 306 patients with newly diagnosed hypertension. The patients were divided into two groups according to their median MPI values: MPIlo and MPIhigh groups. The MPI was calculated from the pulsed-wave Doppler recordings. Left ventricular mass index (LVMI) was determined according to the Devereux formula. hs-cTnT, uric acid, and high-sensitivity C-reactive protein (hs-CRP) levels were measured in all patients. Hs-cTnT, hs-CRP, and uric acid levels were higher in the MPIhigh group compared with the MPIlow group (p < 0.05, for all). The LVMI values in the MPIhigh group were higher than in the MPIlow group (p < 0.05). MPI was independently associated with age, uric acid, hs-cTnT, and LVMI in multivariate analysis. Multivariate logistic regression analysis showed that MPI and LVMI were independent predictors of high hs-cTnT level in newly diagnosed hypertensive patients with preserved LVEF. Hs-cTnT was independently associated with LV dysfunction and LV hypertrophy assessed with MPI in newly diagnosed hypertensive patients.

Die kontrastmittelinduzierte Nephropathie ist mit die häufigste Ursache eines akuten Nierenversagens bei Herzpatienten. Je stärker die Nierenfunktion durch die kontrastmittelinduzierte Nephropathie beeinflusst wird, desto höher ist die Mortalität der Patienten. Definitionsgemäß liegt eine kontrastmittelinduzierte Nephropathie dann vor, wenn ohne sonstige Gründe nach einer Kontrastmittelapplikation das Serumkreatinin um > 25% oder 0,5 mg/dl ansteigt. Ziel der vorliegenden Studie war es, festzustellen, inwieweit sich niederosmolare ionische und isoosmolare nichtionische Kontrastmittel hinsichtlich ihres nephrotoxischen Potentials unterscheiden. Studienleiter war R. Mehran, New York, NY, USA. In dieser multizentrischen, doppelblinden Studie konnte zwischen den beiden Kontrastmittelgruppen kein signifikanter Unterschied im Anstieg des Serumkreatinins gezeigt werden. Die wichtigsten Maßnahmen, um eine kontrastmittelinduzierte Nephropathie insbesondere bei Patienten mit chronischer Niereninsuffizienz zu vermeiden, bestehen demnach darin, besonders gefährdete Patienten zu identifizieren, die Patienten ausreichend zu hydrieren und eine optimale Kontrastmitteldosis zu verabreichen. B. Bischoff, München

Dilated cardiomyopathy (DCM) is a multifactorial disease of the heart muscle and a leading cause of congestive heart failure. Human genetic studies and the establishment of suitable animal models such as mice and zebrafish have already revealed parts of its genetic etiology. With the next generation of genomic sequencing technologies (NGS) on the rise, the comprehensive genetic dissection of DCM patients will reveal clinically relevant information, novel causes, and modifiers of this complex disorder. The recent exploration of the epigenome as another mechanism of cardiac gene regulation will further elucidate unexplained variations observed in the correlation between the patient’s genotype and phenotype. Some of these intriguing advances being made in basic genetic research will soon find their way into clinical practice for more individualized treatment of cardiomyopathy patients.

Riociguat treatment might be beneficial for pulmonary arterial hypertension. However, the results of studies to date are controversial. We conducted a systematic review and meta-analysis to explore the influence of riociguat treatment on pulmonary arterial hypertension. The PubMed, Embase, Web of science, EBSCO, and Cochrane Library databases were systematically searched. Randomized controlled trials (RCTs) assessing the effect of riociguat treatment on pulmonary arterial hypertension were included. Two investigators independently searched articles, extracted data, and assessed the quality of included studies. This meta-analysis was performed using the random effects model. Seven RCTs were included in the meta-analysis. Compared with a control intervention in pulmonary arterial hypertension, riociguat treatment was able to substantially improve results of the six-minute walking distance (6-MWD; standardized mean difference [SMD] = 0.53; 95% CI = 0.36–0.69; p < 0.00001), EQ-5D score (SMD = 0.35; 95% CI = 0.15–0.54; p = 0.0005), and cardiac index (SMD = 0.94; 95% CI = 0.59–1.29; p < 0.00001). The Living With Pulmonary Hypertension (LPH) score (SMD = −0.33; 95% CI = −0.50–−0.17; p < 0.0001) and pulmonary vascular resistance (PVR; SMD = −0.88; 95% CI = −1.05–−0.70; p < 0.00001) were significantly reduced after riociguat treatment. There was no increase in adverse events with riociguat treatment compared with the control intervention (RR = 1.04; 95% CI = 0.98–1.09; p = 0.19). Riociguat treatment for pulmonary arterial hypertension led to a significant increase in the 6‑MWD, EQ-5D score, and cardiac index, as well as a decrease in LPH score and PVR.

Seit der Gründung des ambulanten kardiologischen Rehabilitationszentrums Düsseldorf (Berliner Allee) im Jahr 1990 wurden hier rund 500 ambulante Rehabilitationsmaßnahmen, überwiegend in Form einer Anschlußheilbehandlung, durchgeführt. Das Zentrum nimmt jetzt an zwei wichtigen Modellprojekten in der ambulanten kardiologischen Rehabilitation der Rentenversicherungsträger und der Krankenkassen teil. Ein ganzheitlich orientiertes Therapiekonzept ist die Grundlage für eine intensive Rehabilitation der kardial Erkrankten vor Ort. Neben einer Bewegungstherapie bilden ein intensives Gesundheitstraining und die umfassende psychologische Betreuung die Basis des Therapieplans. Eine kontinuierliche Anwendung von Maßnahmen zur Sicherung der Strukturund Prozeßqualität soll positives subjektives Erleben des Rehabilitanden sowie das Erreichen der definierten individuellen Rehabilitationsziele sicherstellen.

Sildenafil has proven effective in the therapy of male erectile dysfunction. However, little is known about other potential beneficial effects of sildenafil. Meanwhile, first observations have been made in numerous medical disciplines and disorders. Small doses of sildenafil may be a useful adjunct to inhaled iloprost in the management of pulmonary hypertension. In female sexual dysfunction and infertility, genital blood flow and endometrial thickening are enhanced after application of the compound. In gastrointestinal disorders, sildenafil also exerts several effects which might be of clinical relevance. In patients with heart failure, endothelial dysfunction is influenced by the phosphodiesterase-5 (PDE 5) inhibitor and exercise capacity might be improved. Moreover, in the treatment of Raynaud's phenomenon, a disease without highly effective medical treatment option yet, first observations with sildenafil seem to be promising.