M Möckel

Publications (52)139.36 Total impact

• Article: „Standard operating procedures“ zur Umsetzung der Leitlinien bei Patienten mit Brustschmerz

  J. Leick, J. Vollert, M. Möckel, P. Radke, Task Force „Patientenpfade“ der Deutschen Gesellschaft für Kardiologie – Herz- Kreislaufforschung, C. Hamm
  [show abstract] [hide abstract]
  ABSTRACT: Der akute Thoraxschmerz zählt zu einem der häufigsten Gründe einer ärztlichen Konsultation. Eine Vielzahl von Erkrankungen geht mit Thoraxschmerzen einher. Hierzu gehören kardiovaskuläre, pulmonale, mediastinale, gastroösophageale sowie hämatologische Erkrankungen und Erkrankungen des Bewegungsapparates. In 20–30% der Fälle kann ein akutes Koronarsyndrom (ACS) diagnostiziert werden. Es stellt für den klinisch tätigen Arzt eine Herausforderung dar, die Patienten mit lebensbedrohlichen von nicht vital bedrohlichen Ursachen des Brustschmerzes zu differenzieren. Der Prozess des „ersten medizinischen Kontaktes“ (EMK) wird in Form einer erweiterten Ereignisprozesskette (eEPK) allgemeingültig dargestellt. An entscheidenden Prozessschritten der eEPK sind Handlungsanweisungen in Form von „standard operating procedures“ (SOPs) hinterlegt. Diese beinhalten die EKG-Anfertigung, ärztliche Anamnese, körperliche Untersuchung sowie Erhebung der Vitalparameter und differenzialdiagnostische Überlegungen. Im Rahmen der Erstevaluation müssen eine Verdachtsdiagnose gestellt und eine erste Risikostratifizierung durchgeführt werden. Als Ergebnis des beschriebenen Prozesses wird der Patient spezifischen Algorithmen und weiteren Behandlungspfaden, entsprechend der gestellten Verdachtsdiagnose, zugewiesen. Die vorliegende Arbeit soll somit für jeden klinisch tätigen Arzt einen anwendbaren Algorithmus zur Verdachtsdiagnosestellung bei akutem Thoraxschmerz liefern. Weiterhin wird durch eine Standardisierung der Prozessabläufe sowie Implementierung der bestehenden Leitlinien in die SOPs die Leitlinienadhärenz gesteigert. Acute onset chest pain is one of the main causes for a medical consultation. Chest pain can be triggered by a range of different illnesses, including cardiac, pulmonary, mediastinal, gastrointestinal, musculoskeletal and hematologic diseases. About 20–30% of patients with chest pain suffer from acute coronary syndrome (ACS). The clinical challenge is therefore to distinguish those patients with life-threatening causes from those with benign etiologies. Based on an advanced event-driven process chain (EPC) standard operating procedures (SOPs) were developed for the first medical contact. The central element is the basic diagnostic work-up including clinical assessment, medical history, evaluation of vital signs and electrocardiograph (ECG) as well as early risk stratification. In the course of the first evaluation a working diagnosis should be made based on which the patient should be directed for further specialized treatment. The present manuscript provides the basis for a rational diagnostic work-up during the first medical contact of patients presenting with acute chest pain. Standardized process guidance using SOPs and implementation of the national and international guidelines will lead to an increased adherence to clinical guidelines and potentially improved outcomes. SchlüsselwörterLeitlinien–Akutes Koronarsyndrom–Erster medizinischer Kontakt–Erweiterte Ereignisprozesskette–„Standard operating procedures“ KeywordsGuidelines–Acute coronary syndrome–First medical contact–Event-driven process chain–Standard operating procedures
  Der Kardiologe 05/2012; 5(6):443-457.
• Article: Kardiale Biomarker in der Notfallmedizin

  M. Möckel, J. Searle, O. Danne, C. Müller
  [show abstract] [hide abstract]
  ABSTRACT: Die Evaluierung von Patienten mit Herzinfarktverdacht ist eine der größten Herausforderungen in der Notfallmedizin. Biochemische Marker spielen hier eine herausragende Rolle und werden häufig bereits präklinisch oder früh in der innerklinischen Notfallmedizin eingesetzt. Aktuell werden die kardialen Troponine T+I und vereinzelt natriuretische Peptide verwendet. Als kardiospezifischste Biomarker werden die kardialen Troponine in den Richtlinien eindeutig als bevorzugte Marker für die Diagnostik und Risikostratifizierung von Patienten mit akutem Koronarsyndrom angegeben. Da die Troponine als Marker myokardialen Zelluntergangs ausschließlich stattgehabte Gewebeschädigung anzeigen und erst mit Zeitverzögerung nach Symptombeginn im Blut messbar sind, besteht der Bedarf nach einer neuen Generation von Markern und Assays, die frühzeitig vor Eintritt einer irreversiblen Schädigung Risikopatienten identifizieren und einer Therapie zugänglich machen. Diese Übersichtsarbeit befasst sich mit einer Reihe neuer kardialer Biomarker, die aufgrund ihres Pathomechanismus oder ihrer Assayeigenschaften versprechen, diesen Bedarf zukünftig abzudecken und in den Klinikalltag integrierbar zu sein. Dazu gehören die hochsensitiven kardialen Troponine, Copeptin, „h-fatty acid binding protein“, Cholin, natriuretische Peptide und die lipoproteinassoziierte PhospholipaseA2. The evaluation of patients with suspected myocardial infarction is one of the biggest challenges in emergency medicine. Biochemical markers play an important role in the evaluation process and can be applied either pre-clinically or early in clinical emergency management. Troponin T and I and to a certain extent natriuretic peptides are well known markers that are being used in routine clinical practice. The cardiac troponins I and T are the most cardio-specific and sensitive cardiac biomarkers available and current guidelines specify them as the preferred markers for the diagnosis and risk stratification in patients with acute coronary syndrome. As troponins only measure myocardial cell damage that has already occurred, levels start increasing with a time delay after symptom onset. There is an unmet need for a new generation of markers which can identify high risk patients earlier or even before irreversible tissue damage occurs to be able to allocate patients to their personalized and appropriate therapy. This review article addresses a number of new cardiac biomarkers which, due to their pathomechanism or to the characteristics of their assay, hold the promise to meet this requirement and can be integrated into routine practice. The biomarkers included are high sensitive troponins, copeptin, h-fatty acid binding protein, choline, natriuretic peptides und lipoprotein-associated phospholipase A2. SchlüsselwörterTroponine–Copeptin–H-FABP–Cholin–Natriuretische Peptide–Lipoproteinassoziierte Phospholipase A2 KeywordsTroponins–Copeptin–Choline–H-FABP–Natriuretic peptides –Lipoprotein-associated phospholipase A2
  Notfall 05/2012; 14(3):229-242. · 0.54 Impact Factor
• Article: Erratum zu: „Standard operating procedures“ zur Umsetzung der Leitlinien beim Nicht-ST-Hebungsinfarkt

  M. Moser, T. Lickfeld, M. Möckel, P. Radke, J. Vollert, Task Force „Patientenpfade“ der Deutschen Gesellschaft für Kardiologie – Herz- Kreislaufforschung, C. Bode
  Der Kardiologe 05/2012; 4(6):486-487.
• Article: „Standard operating procedures“ zur Umsetzung der Leitlinien beim Nicht-ST-Hebungsinfarkt

  M. Moser, T. Lickfeld, M. Möckel, P. Radke, J. Vollert, Task Force „Patientenpfade“ der Deutschen Gesellschaft für Kardiologie – Herz- Kreislaufforschung, C. Bode
  [show abstract] [hide abstract]
  ABSTRACT: Die leitliniengerechte Diagnostik und Therapie eines Patienten mit NSTE-ACS stellt nicht nur eine medizinische, sondern auch eine organisatorische Herausforderung dar. Obwohl die Leitlinien der nationalen und internationalen Fachgesellschaften den Rahmen der Therapie vorgeben, verbleibt noch großer Spielraum, der zum einen eine Individualisierung der Therapie ermöglicht, zum anderen aber Ursache von Problemen an diagnostischen und therapeutischen Schnittstellen, wie z.B. der Interaktion Notarzt – Klinikarzt sein kann. Der Prozess der Diagnostik und Akuttherapie des NSTE-ACS wird in Form einer erweiterten Ereignis-Prozess-Kette (eEPK) allgemeingültig dargestellt und beispielhaft in ein individualisiertes Flowchart umgesetzt. Zusätzlich wurden für kritische Elemente des Ablaufs „standard operating procedures“ (SOPs) formuliert, deren Anwendung sowohl in der eEPK als auch im Flowchart erkennbar ist. Kritische Elemente der Diagnostik und Therapie des NSTE-ACS sind die Basisdiagnostik mit Klinik, EKG und Biomarker, die frühe und im Verlauf zu wiederholende Risikostratifizierung, die Wahl der antithrombotischen Therapie und die zeitgerechte Indikationsstellung sowie Planung der Koronarangiographie. Die standardisierte Modellierung und Prozesssteuerung mit SOPs unterstützt lokale Abläufe, indem Fehler vermieden und ärztliche Ressourcen für das entscheidende Element der klinischen Einschätzung freigehalten werden. The therapy of patients with NSTE-ACS according to current guidelines is a major challenge in terms of medical treatment and process organisation. Although the guidelines of national and international medical societies translate research data into operational recommendations with varying levels of evidence, they leave several alternative options for the specific treatment which allows the individualisation of therapy but can also lead to problems at interfaces such as the interaction between pre-hospital and hospital-based care. Based on an advanced Event-driven Process Chain (EPC), a flowchart and exemplary standard operating procedures (SOPs) were developed for the diagnosis and treatment of NSTE-ACS. Critical elements in the diagnosis and therapy of NSTE-ACS are the basic diagnostic workup including clinical assessment, ECG and biomarkers, early and repeated risk stratification, the choice of antithrombotic medications and the timely indication for coronary angiography. Standardized modelling and process guidance using SOPs support the local practise by avoiding errors and ensuring the availability of physician resources for the key element of clinical assessment of the patient. SchlüsselwörterDGK-Leitlinien-Nicht-ST-Streckenhebungs-Akutes Koronarsyndrom (NSTE-ACS)-Nicht-ST-Streckenhebungsinfarkt (NSTEMI)-Ereignis-Prozess-Ketten (EPK)-Standard operating procedure (SOP) KeywordsGerman Cardiac Society Guidelines-Non-ST segment elevation acute coronary syndrome (NSTE-ACS)-Non-ST segment elevation myocardial infarction (NSTEMI)-Event Process Chains (EPC)-Standard operating procedure (SOP)
  Der Kardiologe 05/2012; 4(5):389-399.
• Article: Prozessorientierte und standardisierte Umsetzung von DGK-Leitlinien

  J. Vollert, C. Hamm, AG SOP Kardiologie, M. Möckel
  [show abstract] [hide abstract]
  ABSTRACT: Die Leitlinien der DGK haben das Ziel deutschlandweit gleichartige Qualitätsstandards in der Kardiologie zu etablieren. Neben den rein medizinischen Inhalten und Qualitätssicherungsaspekten sind die Leitlinien auch bei Zertifizierungsverfahren und als normativer Standard bei juristischen und gesundheitspolitischen Fragestellungen hilfreich. Die Umsetzung der DGK-Leitlinien ist in der klinischen Praxis jedoch abhängig von den lokalen und regionalen Strukturen, was zu großen Unterschieden zwischen verschiedenen Kliniken führt. Dies erschwert ein einheitliches Qualitätsmanagement und schränkt die Nutzung der DGK-Leitlinien als standardisiertes Hilfsinstrument bei klinischen, juristischen und gesundheitspolitischen Fragestellungen ein. Zudem lassen sich Kennzahlen für die Versorgungsrealität nicht unmittelbar aus den vorhandenen Dokumentationssystemen ableiten, sondern müssen über den zusätzlichen Aufwand von Registern erzeugt werden. Schließlich sind Leitlinien für die klinisch-praktische Arbeit im Einzelfall nicht detailliert genug, da natürlicherweise auch alternative Behandlungsverfahren bei guter Datenlage parallel dargestellt werden müssen. Eine IT-gestützte standardisierte Prozessmodellierung der Leitlinien kann bei ihrer praktischen Umsetzung helfen und bietet dem Kardiologen eine mögliche Basis für eine prozessorientierte Sichtweise inklusive eines Qualitätsmanagements, einer Hilfe für Zertifizierungsprozesse und einer optimierten Prozessdokumentation. Individuelle und flexible Gestaltungsmöglichkeiten bieten dabei die Möglichkeit, optional vorgegebene Arbeitsabläufe, die aus verbindlichen Prozessen der DGK-Leitlinien zu Präventions-, Diagnose-, Therapie- oder Rehabilitationsmaßnahmen abgeleitet wurden, individuell und flexibel anzupassen. Die Umsetzung dieser Prinzipien wird anhand der Leitlinien zum ST-Strecken-Hebungsinfarkt (STEMI) konkretisiert. The guidelines of the German Cardiac Society (DGK) are aimed at achieving nationwide, uniform quality standards in cardiology. In addition to their medical and quality assurance aspects, the guidelines are also helpful in certification processes and as a normative standard in legal and health care policy questions. However, the implementation of DGK guidelines in clinical practice depends on local and regional structures, which can lead to significant differences between the various hospitals. This makes standardised quality management difficult and reduces the use of the DGK guidelines as a standardised tool in clinical, legal and health-policy issues. In addition, the figures relating to the health-care reality cannot be inferred from the available documentation system, but need to be generated by means of additional registers. Finally, the guidelines are not detailed enough for clinico-practical work in individual cases, since naturally alternative treatment procedures for which there is good supporting evidence must also be represented. IT-supported standardised process modelling of the guidelines can help in their practical implementation and offers cardiologists a possible basis for a process-oriented perspective including quality management, a tool for certification processes and optimised process documentation. Individual and flexible organisation possibilities offer the opportunity to tailor optionally available procedures derived from the obligatory DGK guideline procedures on prevention, diagnosis, therapy or rehabilitation. The implementation of these principles is put into concrete terms on the basis of ST elevation myocardial infarction (STEMI) guidelines.
  Der Kardiologe 05/2012; 3(5):388-405.
• Article: C-reaktives Protein als unabhängiger Prognosemarker beim akuten Koronarsyndrom im Vergleich zu Troponin T

  M. Möckel, G. Heller, C. Müller, F. -R. Klefisch, M. Riehle, J. Searle, U. Frei, T. Störk
  [show abstract] [hide abstract]
  ABSTRACT: Grundproblematik und Fragestellung: Die akute Entzündungsreaktion spielt wahrscheinlich eine wichtige Rolle in der Pathogenese aber auch der Diagnosefindung und Prognoseeinschätzung des akuten Koronarsyndroms. Es fehlen Daten zur Frage, ob hochsensitive Messungen des C-reaktiven Proteins (CRP) zusätzliche Aussagen zum etablierten Risikomarker Troponin T (TnT) ermöglichen.¶Patienten und Methodik: Wir untersuchten 50 Patienten mit akutem Koronarsyndrom (59,4 SD 13,9 Jahre) innerhalb einer Stunde nach Aufnahme und im Intervall von 4–24h in Hinblick auf TnT (Elecsys®, Roche Diagnostics) und CRP (biokit, modifizierter Quantex CRP plus, analytische Sensitivität 0,02mg/dL). 50% der Patienten wurden retrospektiv als instabile AP klassifiziert. Alle Patienten wurden bis 6 Wochen nach Entlassung hinsichtlich des primären Endpunktes Tod oder erneutes akutes Koronarsyndrom beobachtet.¶Ergebnisse: Die kumulative Ereignisrate lag bei Patienten mit positivem CRP und TnT 42 Tage nach Entlassung bei 62,5% im Vergleich zu 35,3% der TnT positiven und CRP negativen Patienten. Die TnT negativen und CRP positiven Patienten erreichten in 33,3% der Fälle den primären Endpunkt. Für die TnT und CRP negativen Patienten wurden in 28,8% der Fälle Ereignisse beobachtet. Die logistische Regression hinsichtlich des primären Endpunktes mit TnT und CRP (jeweils nach 4–24h), Alter, Geschlecht und Diagnose ergab einen unabhängigen Einfluss von TnT (Cutoff 0,1μg/L, p=0,048, Odds Ratio=7,5) und CRP (Cutoff 0,862mg/dL, p=0,026, Odds Ratio=5,3). Sensitivität/Spezifität für die Diagnose AMI waren 69,6%/75% für TnT bzw. 12%/72% für CRP in der ersten Stunde und 91,3%/68,2% für TnT bzw. 68%/72% für CRP im 4–24h Verlauf.¶Folgerungen: Hochsensitive CRP- Bestimmungen sind neben Troponin T für die akute Infarktdiagnostik wenig hilfreich. Die Einschätzung der Prognose der Patienten durch TnT wird jedoch mittels CRP 4–24h nach Aufnahme signifikant unabhängig ergänzt und damit wesentlich verbessert. Background: It has been suggested that inflammatory processes play a role in the pathogenesis of acute coronary syndromes (ACS). C-reactive protein (CRP) is a classic acute phase protein. It is yet unclear whether, in addition to established markers as troponin T (TnT), determination of CRP in patients admitted for ACS contributes significantly to the diagnosis and prognosis of ACS.¶Patients and Methods: We investigated 50 patients with ACS (59.4 SD 13.9 years) in the first hour after admission and 4–24h later with respect to TnT (Elecsys®, Roche Diagnostics) and CRP (biokit, modified Quantex CRP plus, analytical sensitivity 0.02mg/dL). Fifty percent of the patients were classified as having unstable angina retrospectively. All patients were followed in the 6 weeks post discharge regarding death and recurrent ACS.¶Results: The cumulative event rate at 6 weeks after discharge was 62.5% for patients being CRP and TnT positive compared to 35.3% in TnT positive and CRP negative patients. In TnT negative patients a positive CRP test predicted 33.3% of events and 28.8% of patients negative for CRP and TnT had events at 42 days post discharge.¶   Logistic regression analysis regarding the primary endpoint including TnT and CRP (4–24h values), age, gender and diagnosis resulted in independent prediction of ACS or death by TnT (cutoff 0.1μg/L, p=0.048, odds ratio=7.5) and CRP (cutoff 0.862mg/dL, p=0.026, odds ratio=5.3). Sensitivity/specificity for AMI diagnosis were 69.6%/75% for TnT and 12%/72% for CRP in the first hour and 91.3%/68.2% for TnT and 68%/72% for CRP 4–24h later.¶Conclusions: Besides TnT, high sensitivity CRP determination has no additional value for early AMI diagnosis. The prognosis of these patients during the first 24 hours is significantly and independently predicted by CRP measurements in addition to troponin T. Schlüsselwörter¶C-reaktives Protein – Troponin T –¶akutes koronares Syndrom –¶RisikostratifizierungKey words C-reactive protein – troponin T – acute coronary¶syndrome – risk assessment
  Zeitschrift für Kardiologie 04/2012; 89(8):658-666. · 0.97 Impact Factor
• Article: Lipoprotein-associated phospholipase A2 for early risk stratification in patients with suspected acute coronary syndrome: a multi-marker approach: the North Wuerttemberg and Berlin Infarction Study-II (NOBIS-II).

  M Möckel, R Müller, J O Vollert, C Müller, O Danne, R Gareis, T Störk, R Dietz, W Koenig
  [show abstract] [hide abstract]
  ABSTRACT: Numerous markers have been identified as useful predictors of major adverse cardiac events (MACE) in patients with suspected acute coronary syndrome (ACS). However, only little is known about the relative benefit of the single markers in risk stratification and the best combination for optimising prognostic power. The aim of the present study was to define the role of the emerging cardiovascular risk marker lipoprotein-associated phospholipase A2 (Lp-PLA2) in a multi-marker approach in combination with troponin I (TnI), NT-proBNP, high sensitivity (hs)CRP, and D-dimer in patients with ACS. A total of 429 consecutive patients (age 60.5+/-14.1 years, 60.6% male) who were admitted to the emergency room with suspected ACS were analysed in the study. Biochemical markers were measured by immunoassay techniques. All patients underwent point-of-care TnI testing and early coronary angiography if appropriate, in accordance with the current guidelines. Classification and regression trees (CART) and logistic regression techniques were employed to determine the relative predictive power of markers for the primary end-point defined as any of the following events within 42 days after admission: death, non-fatal myocardial infarction, unstable AP requiring admission, admission for decompensated heart failure or shock, percutaneous coronary intervention, coronary artery bypass grafting, life threatening arrhythmias or resuscitation. The incidence of the primary end-point was 13.1%, suggesting a mild to moderate risk population. The best overall risk stratification was obtained using NT-proBNP at a cut-off of 5000 pg/mL (incidence of 40% versus 10.3%, relative risk (RR) 3.9 (95% CI 2.4-6.3)). In the remaining lower risk group with an incidence of 10.3%, further separation was performed using TnI (cut-off 0.14 microg/L; RR=3.1 (95% CI 1.7-5.5) 23.2% versus 7.5%) and again NT-proBNP (at a cut-off of 140 ng/L) in patients with negative TnI (RR=3.2 (95% CI 1.3-7.9), 11.7% versus 3.6%). A final significant stratification in patients with moderately elevated NT-proBNP levels was achieved using Lp-PLA2 at a cut-off of 210 microg/L) (17.9% versus 6.9%; RR=2.6 (95% CI 1.1-6.6)). None of the clinical or ECG variables of the TIMI (Thrombolysis In Myocardial Infarction) risk score provided comparable clinically relevant information for risk stratification. In the setting of stateof- the-art coronary care for patients with suspected ACS in the emergency room, NT-proBNP, troponin I, and Lp-PLA2 are effective independent markers for risk stratification that proved to be superior to the TIMI risk score. Lp-PLA2 turned out to be a more effective risk marker than hsCRP in these patients.
  Clinical Research in Cardiology 10/2007; 96(9):604-12. · 2.95 Impact Factor
• Article: Reference values for cardiac troponins I and T in a goal-oriented concept of health: cardiac marker values in a series of outpatients without acute coronary syndromes.

  M Möckel, O Danne, A Schmidt, M Goldmann, C Müller, R Dietz, A H B Wu
  [show abstract] [hide abstract]
  ABSTRACT: Cardiac troponins are part of the new definition of acute myocardial infarction (AMI) by the European Society of Cardiology and the American College of Cardiology (ESC/ACC). In the new guidelines, it was suggested to establish reference values for cardiac troponins to calculate the 0.99 quantile (Q99) as cutoff for AMI diagnosis. We run a prospective series of troponin measurements in unselected outpatients who had no suspicion of cardiac ischemia. The selection of patients as reference population is based on a "goal-oriented concept of health". One hundred and ninety-five patients agreed that 10-ml additional blood was drawn at the occasion of the venous puncture done routinely in the evaluation of their case. Cardiac troponin I was measured using a point of care (POCT) device (Stratus CS, DadeBehring, TNI-PO). Additionally, heparin-plasma was obtained and immediately deep-frozen to -80 degrees C for later batch measurement of cardiac troponin T (Elecsys 2010, Roche Diagnostics, TnT) and troponin I (Centaur, Bayer, TnI-CL). The Q99 values were 0.14 microg/l for TnI-PO, 0.023 microg/l for TnT and 0.07 microg/l for TnI-CL in patients with creatinine levels below 1.5 mg/dl. These values lay above those obtained from people at good health for reference study purposes. On the level of our cutoffs, CVs were 7.5%, 6.4% and 23.7% for TnI-PO, TnT and TnI-CL, respectively. Only the TnI-PO and TnT tests fulfilled the imprecision criteria in our study. TnI-PO values between 0.10 and 0.14 microg/l and TnT values between 0.01 and 0.03 microg/l have to be interpreted carefully. Patients presenting with chest pain will be possibly true positives, but patients without chest pain and nondiagnostic ECGs should be subjected to repetitive troponin measurements and further noninvasive investigation and maybe not directly sent to the cardiac catheter laboratory.
  Clinica Chimica Acta 05/2004; 342(1-2):83-6. · 2.54 Impact Factor
• Article: Prognostischer Wert hämostatischer Marker bei Patienten mit akutem Myokardinfarkt und Fibrinolysetherapie

  M. Riehle, T. Störk, G. Heller, J. Vollert, O. Danne, F. Klefisch, U. Frei, M. Möckel
  [show abstract] [hide abstract]
  ABSTRACT: Patienten mit akutem Myokardinfarkt und einer Fibrinolysetherapie unterliegen auerhalb randomisierter Studien trotz verbesserter pharmakologischer und invasiver Strategien einer hospitalen Letalitt von ber 10%. Der prognostische Wert der hmostatischen Marker Thrombin-Antithrombin-III-Komplex (TAT), Prothrombinfragment F1.2 (F1.2) und Plasmin-2-Antiplasmin-Komplex (PAP) fr das Erreichen des kombinierten primren Endpunktes Tod, Re-Myokardinfarkt oder Notwendigkeit zur ungeplanten Revaskularisierung innerhalb von 30 Tagen wurde an 34 konsekutiven Patienten (62,4 11,9 Jahre, 79% Mnner) bei Aufnahme sowie nach 4, 8, 12 und 24 h mittels ELISA-Technik untersucht. Die multivariate Analyse hinsichtlich des kombinierten primren Endpunktes wurde fr die Variablen Alter und Geschlecht kontrolliert.15 Patienten erhielten eine Streptokinaselyse, 19 Patienten wurden mit rt-PA behandelt. Eine Reperfusion wurde bei 56% der Patienten erreicht. Die TAT-Spiegel der Ereignisgruppe betrugen im Median (25/75%-Perzentilen) nach 4 h 21,3 (9,5/41,0) g/l und in der Gruppe ohne Ereignis 8,2 (5,2/ 15,6) g/l (p = 0,012), zum Zeitpunkt 12 h 12,2 (7,1/40,3) g/l und 6,0 (4,6/15,3) g/l (p = 0,036). Fr die anderen TAT-Abnahmezeitpunkte sowie die F 1.2- und PAP-Werte wurden keine signifikanten Unterschiede festgestellt. Die Odds Ratio hinsichtlich des primren Endpunktes betrug fr Patienten mit TAT-Werten ber 20,1 g/l nach 4 h 7,16 (95%-Konfidenzintervall (KI): 1,25–41,16; p = 0,027) sowie mit TAT-Spiegeln ber 6,0 g/l nach 12 h 18,15 (95-KI: 1,88– 175,47; p = 0,012).Die frhe Bestimmung erhhter TAT-Werte nach 4 und 12 h bei Patienten mit akutem Myokardinfarkt und Fibrinolysetherapie ermglicht die Identifizierung von Hochrisikopatienten fr den weiteren klinischen Verlauf. Diese Patienten profitieren mglicherweise von einer aggressiveren antithrombotischen Therapie und sollten einer frhen Koronarangiographie zugefhrt werden.In-hospital mortality of patients with acute myocardial infarction and fibrinolytic therapy outside of randomized trials still exceeds 10% despite new pharmacologic and invasive strategies. The prognostic value for the occurrence of death, re-myocardial infarction or emergency revascularization (combined primary endpoint) by measurement of the thrombin-antithrombin-III complex (TAT), prothrombin fragments F1.2 and the plasmin--2-antiplasmin complex (PAP) was investigated in 34 consecutive patients (62.4 11.9 years, 79% male gender) at admission and after 4, 8, 12 and 24 hours by the ELISA technique. The logistic regression analysis with respect to the primary endpoint was controlled for age and gender of the patients.A total of 15 patients were treated with streptokinase, 19 underwent fibrinolysis with rt-PA. Reperfusion was achieved in 56% of the patients. The median TAT values (quartiles) at 4 hours were 21.3 g/l (9.5/41.0) in patients with the primary endpoint and 8.2 g/l (5.2/15.6) in patients with no primary endpoint (p = 0.012). At 12 hours TAT values were 12.2 g/l (7.1/40.3) vs 6.0 g/l (4.6/15.3) (p = 0.036) respectively. TAT values at the other timepoints, F1.2 values and PAP values were not of significant difference in either group. The odds ratio for patients exceeding TAT values of 20.1 g/l 4 hours after fibrinolysis was 7.16 (95% Confidence limits (CI): 1.25– 41.2; p = 0.027) and for patients exceeding TAT levels of 6.0 g/l after 12 hours 18.15 (95-CI: 1.88– 175.47) (p = 0.012).The early measurement of elevated TAT levels 4 and 12 hours after fibrinolysis identifies patients with a high risk for clinical complications. Those patients possibly profit from a more aggressive antithrombotic regime and should be transferred for early coronary angiography.
  Intensivmedizin + Notfallmedizin 01/2004; 41(5):337-344.
• Article: [Music as adjuvant therapy for coronary heart disease. Therapeutic music lowers anxiety, stress and beta-endorphin concentrations in patients from a coronary sport group].

  J O Vollert, T Störk, M Rose, M Möckel
  [show abstract] [hide abstract]
  ABSTRACT: In a study with coronary patients it was estimated that music is able to lower stress and fear and contributing to relaxation in spite of physical exercise. 15 patients (13 male, two female, mean age 62,2 +/- 7,6 years) of a coronary sport unit were listening to an especially composed relaxation music while training their common heart-frequency adapted exercises. Before the exercises and after listening to music blood pressures were measured and blood was collected for determination of beta-endorphin. Simultaneous to blood collection the participants had to perform two psychometric test: the perceived stress experience questionnaire (PSQ) of Levenstein to measure the graduation of subjective perceived stress and the state-anxiety inquiry (STAI) of Spielberger as an indicator of coping. To practice the trial ("test trial"), the whole protocol was performed one week prior to the mean trial, but without listening to music and without blood collections and blood pressure measurements. In the test trial without music there were no significant changes in PSQ-data. In the mean trial, under the influence of music, values in the section "worries" decreased as a sign of lower worries (26.6 versus 27.6; p = 0.039). STAI-values were significantly lower as a sign of reduced fear after listening to music (31 versus 34; p = 0.045). beta-endorphin concentration (10.91 microg/l versus 15.96 microg/l, p = 0.044) and systolic blood pressure (130 mmHg versus 140 mmHg; p = 0.007) decreased significantly after listening to music. Regarding worries and fear, patients seemed to benefit by the intervention of music. beta-endorphin was lowered significantly after music despite physical activity.
  DMW - Deutsche Medizinische Wochenschrift 01/2004; 128(51-52):2712-6. · 0.53 Impact Factor
• Article: [Recommendations for prevention of roentgen contrast medium-induced nephropathy].

  M Möckel, F Bahr, Ch Leuner, H Kuhn, R Dietz
  Zeitschrift für Kardiologie 10/2002; 91(9):719-26. · 0.97 Impact Factor
• Article: [Persistent sinusoids of the left chamber wall].

  T Störk, M Simon, M Möckel, H Eichstädt
  [show abstract] [hide abstract]
  ABSTRACT: Angiographic pictures of persistent sinusoids of the left chamber wall are presented. The clinical significance of this very rare phenomen is not clear yet.
  Zeitschrift für Kardiologie 04/2002; 91(3):267-8. · 0.97 Impact Factor
• Article: [Suspected acute coronary syndrome in patients without ST-elevation. Exclusion of infarction, early clinical estimation and non-coronary diagnoses].

  T Störk, R Gareis, R Müller, M Hämmerle, M Müller-Bardorff, R Braun, E Fröhlich, W Koenig, M Möckel
  [show abstract] [hide abstract]
  ABSTRACT: Patients admitted to the hospital with suspected acute coronary syndrome (ACS) represent a collective at high risk. The NOWIS substudy aimed at evaluating 3 points: (1) Safe exclusion of myocardial infarction by history, symptoms, biochemical markers and the ECG, (2) value of the first diagnosis by the physician in the emergency room, and (3) prevalence and distribution of non-coronary leading diagnoses. In 164 patients admitted with suspected ACS without ST-segment elevation (73 % men, median age 66 years) the cardiac markers myoglobin, troponin T and CK/CK-MB were assessed on admission and 4 h later. In 2 of the NOWIS centers, the diagnosis on admission, derived from the ECG, history and clinical symptoms, was compared with the leading diagnosis at discharge, based on coronary angiography and, if negative, on additional esophago-gastroscopy. (1) Myoglobin was the biochemical marker with the highest sensitivity 4 h after admission for acute myocardial infarction (classic) definition by CK-MB elevation) with 90.4 %, followed by troponin T with 84.6 %. Four h after admission, in 15.4 % of the infarction patients (prevalence 31.7 %) troponin T was normal. (2) The admission diagnosis instable angina pectoris was confirmed in 46.7 % (57 of 122), suspected acute infarction in 76.2 % (32 of 42). On the other hand, 90.4 % (57 of 63) of the patients with instable angina as leading diagnosis at discharge were correctly diagnosed on admission, but only 61.5 % (32 of 42) of the patients with infarction. (3) At discharge, 29.9 % (49 of 164) of the patients had a non-coronary leading diagnosis. Here, the most common were gastro-intestinal (55.1 %), costo-vertebral (18.4 %) and broncho-pulmonary (16.3 %). (1) Troponin and myoglobin are helpful in patients without ST-segment elevation; yet, 4 h after admission, a safe exclusion of myocardial infarction is not possible. (2) The clinical diagnosis on admission is important. However, it corresponds with the leading diagnosis at discharge, based on coronary angiography, in only 50 to 75 %. Patients admitted with suspected ACS should be monitored for 24 h in the hospital (chest pain units or coronary care units). (3) Nearly one third of the patients initially admitted with suspected ACS show a non-coronary leading diagnosis, thus underlining the value of further investigations and of an interdisciplinary approach.
  DMW - Deutsche Medizinische Wochenschrift 03/2002; 127(6):260-5. · 0.53 Impact Factor
• Article: Glycoprotein IIb/IIIa receptor blockers in acute coronary syndromes.

  T Störk, E Fröhlich, M Möckel
  The Lancet 01/2002; 358(9297):1996-7. · 38.28 Impact Factor
• Article: Platelet activation through triathlon competition in ultra-endurance trained athletes: impact of thrombin and plasmin generation and catecholamine release.

  M Möckel, N V Ulrich, G Heller, L Röcker, R Hansen, H Riess, H Patscheke, T Störk, U Frei, A Ruf
  [show abstract] [hide abstract]
  ABSTRACT: The aims of this study were to evaluate whether platelets are activated during strenuous exercise in healthy athletes. Also, to determine the impact of plasmin and thrombin activity and catecholamine release. Previous studies have shown activation of the hemostatic system after competitive exercise, but platelet activation was thought to be absent in trained athletes. The impact of thrombin and other potent platelet activators is still a matter for debate. We examined 30 healthy triathletes during a triathlon competition. Flow cytometric detection of CD62p (P-selectin) was used to measure in vivo activation of platelets. Platelet-leukocyte aggregates were also determined. Thrombin concentration was assessed by the thrombin-antithrombin III complex (TAT) and the fibrinolytic state was characterised by the plasmin-alpha2-antiplasmin complex (PAP). Catecholamines were measured by means of high-pressure liquid chromatography. CD62p rose from baseline (2.3%) to 3.4% and was still elevated after 2 hours (3.1%, p = 0.0133). Platelet-leukocyte aggregates were elevated 30 min after exercise (4.3 % vs 3.6%) and decreased significantly after 60 min (2.9 %, p = 0.008). TAT increased from 3.9 microg/l to 8.3 microg/l after competition and to 5.4 microg/l 2 hours later (p < 0.001). PAP increased 10-fold from 350 microg/l to 3,267 microg/l after the triathlon and was still elevated after 2 hours (1,074 microg/l, p<0.001). No linear correlation was found between the hemostatic markers, catecholamines and platelet activation. Platelets, coagulation and fibrinolysis are activated by competitive exercise in athletes, whereby fibrinolytic changes are pronounced. Mechanisms of platelet activation during exercise include phenomena other than plasmatic hemostatic factors and catecholamines.
  International Journal of Sports Medicine 07/2001; 22(5):337-43. · 2.43 Impact Factor
• Article: Stent-supported recanalization of chronic iliac artery occlusions.

  D Scheinert, M Schröder, J Ludwig, S Bräunlich, M Möckel, F A Flachskampf, J O Balzer, G Biamino
  [show abstract] [hide abstract]
  ABSTRACT: Iliac artery occlusions that are more than a few centimeters in length are normally treated with surgical bypass grafting. The aim of this study was to evaluate the results of primary stent implantation after Excimer laser-assisted recanalization of iliac artery occlusions. We studied 212 consecutive patients with chronic unilateral iliac artery occlusions (mean [+/- SD] length 8.9 +/- 3.9 cm) who were treated with Excimer laser-assisted recanalization and stent implantation. Based on the criteria of the Society of Cardiovascular and Interventional Radiology, lesions were graded as class III occlusions (<5 cm) in 46 patients and as class IV (> or =5 cm) in 166 patients. A total of 527 stents (Palmaz stent, 346; Wallstent, 94; Strecker stent, 38; covered stents, 49) were implanted. Technical success was achieved in 190 (90%) patients. There was a clinical improvement of three grades in 112 (53%) patients and of two grades in 67 (32%) patients. The rate of major complications was 1.4%, which included arterial rupture (1) and embolic events (2). Primary patency rates were 84% at 1 year, 81% at 2 years, 78% at 3 years, and 76% at 4 years. Secondary patency rates were 88% at 1 year, 88% at 2 years, 86% at 3 years, and 85% at 4 years. Stent-supported angioplasty is an effective treatment for iliac artery occlusions, with less morbidity and mortality than is associated with surgery. However, reported long-term patency rates after bypass surgery are greater than those we observed with interventional treatment. The value of primary stenting as compared with angioplasty alone should be evaluated in a randomized trial.
  The American Journal of Medicine 06/2001; 110(9):708-15. · 5.43 Impact Factor
• Article: Diagnostik und Risikostratifizierung bei Patienten mit akutem Koronarsyndrom mittels Myoglobin, Troponin T und CK/CK-MB

  T. Störk, R. Gareis, R. Müller, M. Müller-Bardorff, W. Koenig, A. Both, H. Katus, M. Möckel, für die Teilnehmer der¶Nord-Württembergischen¶Infarktstudie (NOWIS
  [show abstract] [hide abstract]
  ABSTRACT: Zielsetzung NOWIS evaluierte multizentrisch und prospektiv Myoglobin und Troponin T bei Patienten mit akutem Koronarsyndrom. Methodik Bei 370 konsekutiven Patienten (Altersmedian 64 Jahre) wurden CK/CK-MB (Aktivität), Myoglobin (cut-off 80 ng/ml) und Troponin T (cut-off 0,1 ng/ml) bei Aufnahme, nach 4 h und nach 24 h bestimmt. Ein wesentlicher Beitrag der Labordiagnostik wurde insbesondere bei den 253 Patienten ohne ST-Hebung im EKG angenommen. Ergebnisse Ein akuter Myokardinfarkt innerhalb von 24 h (AMI) wurde bei 66 der 253 Patienten ohne ST-Hebung (26%) beobachtet. Von den 187 Patienten ohne AMI erlitten 17 Patienten (9%) ein schweres kardiales Ereignis (neuer AMI oder Tod) vom 2. Tag bis zur Entlassung. (1) Frühdiagnostik AMI. Die Sensitivität für die Diagnose AMI 4 h nach Aufnahme (kumulierte Werte) betrug 85% für Myoglobin, 73% für Troponin T und 85% für CK/CK-MB. Die Kombination von Myoglobin und CK/CK-MB (ein Wert positiv) erhöhte die Sensitivität auf 96%. (2) Ausschluss AMI. Bei Patienten mit negativem 4 h-Wert lag die AMI-Prävalenz bzw. der relative Anteil nicht erkannter AMIs bei 7% bzw. 27% für Myoglobin, bei 5% bzw. 20% für CK/CK-MB, bei 11% bzw. 41% für Troponin T, und bei 2% bzw. 8% für die Kombination Myoglobin und CK/CK-MB (beide Werte negativ). (3) Risikostratifizierung. Das relative Risiko für ein schweres kardiales Ereignis bei positivem Laborwert (bei Aufnahme oder nach 4 h) betrug 31 (95% KI 7–131) für Troponin T, und 5 (95% KI 2–12) für Myoglobin. Schlussfolgerung (1) Bei Patienten ohne ST-Hebung ist Myoglobin, 4 h nach Aufnahme, der Marker mit der höchsten Sensitivität für die Diagnose AMI. Die Kombination Myoglobin und CK/CK-MB erhöht die Sensitivität erheblich. (2) Ein sicherer AMI-Ausschluss anhand eines negativen 4 h-Laborwertes von Myoglobin oder Troponin T ist nicht möglich. Durch Kombination von Myoglobin mit CK/CK-MB kann der relative Anteil nicht erkannter AMI unter 10% gesenkt werden. (3) Troponin T eignet sich zur Risikostratifizierung, besonders unter Berücksichtigung zweier Werte. Aims NOWIS, using a multicenter and prospective approach, evaluated myoglobin and troponin T in patients with acute coronary syndrome. Methods In 370 consecutive patients (median age 64 years), CK/CK-MB (activity), myoglobin (cut-off 80 ng/ml), and troponin T (cut-off 0.1 ng/ml) were determined at admission, 4 h later and 24 h later. A substantial contribution of lab-based diagnosis was hypothesized in the subgroup of 253 patients without ST segment elevation in the ECG. Results Acute myocardial infarction within the first 24 h (AMI) was present in 66 of the 253 patients without ST elevation (26%). Of the 187 patients without AMI, 17 patients (9%) developed a severe cardiac event (new AMI or death) from day 2 to discharge. (1) Early diagnosis of AMI. Sensitivity for assessing AMI 4 h after admission (cumulative values) was 85% for myoglobin, 73% for troponin T, and 85% for CK/CK-MB. The combination of myoglobin and CK/CK-MB (one value positive) further increased sensitivity to 96%. (2) Ruling out of AMI. In test-negative patients 4 h after admission, the prevalence of AMI respectively the relative share of missed diagnosis of AMI was 7% rsp.27% for myoglobin, 5% rsp.20% for CK/CK-MB, 11% rsp.41% for troponin T, and 2% rsp.8% for a combination of myoglobin and CK/CK-MB (both values negative). (3) Risk stratification. The relative risk for a major adverse cardiac event (positive value at admission or 4 h later) was 31 (95% CI 7–131) for troponin T, and 5 (95% CI 2–12) for myoglobin. Conclusion (1) Myoglobin is, 4 h after admission, the marker with the highest sensitivity for AMI. The combination of myoglobin and CK/CK-MB substantially increases sensitivity. (2) By means of a negative 4 h value for myoglobin or troponin T, a safe exclusion of AMI is not possible. The combination of myoglobin and CK/CK-MB reduces the proportion of missed diagnosis of AMI below 10%. (3) Risk stratification should be performed by troponin T, and is increased by use of two values.
  Intensivmedizin + Notfallmedizin 05/2001; 38(5):385-393.
• Article: Continuous measurements of renal perfusion in pigs by means of intravascular Doppler.

  M Möckel, D Scheinert, E V Potapov, E Wellnhofer, V Combé, B A Nasseri, D Maier, S Meyer, C Yankah, R Hetzer, U Frei, K U Eckardt
  [show abstract] [hide abstract]
  ABSTRACT: Changes in renal blood flow are considered to play a significant role in the induction and maintenance of kidney failure, but are difficult to monitor with currently available techniques. The objective was to validate renal flow measurements with Doppler guidewires and to apply this technique to assess dose and time dependency of the renal vascular effects of norepinephrine (NE). In 10 anesthetized pigs, flow velocity in renal arteries (FVart) and veins (FVvein) and volumetric renal blood flow (VBF) were measured before and after intravenous bolus application of incremental doses of NE (2 to 200 microg). FVart curves exactly reflected the changes in VBF. Beat-to-beat analysis revealed a strong linear correlation over a mean VBF range of less than 0.05 to 0.35 L/min (median correlation coefficient with FVart, r = 0.998), and significant but less close relationships were also found between VBF and FVvein. Ten seconds after the administration of 200 microg NE, FVart dropped from 71 to 6 cm/sec and was 90% reversible after 48 seconds. Similarly, the renal vascular resistance temporarily rose from 988 to 13711 mm Hg. min/L. In contrast, NE-induced increases in systemic vascular resistance were on average a maximum of 1.5-fold but persisted for more than 60 seconds. Doppler flow measurements in the renal artery provide an excellent surrogate of volumetric blood flow, which may be useful for continuous monitoring of renal hemodynamics. The renal vasculature is more sensitive when compared with the systemic vasculature, but also appears to evoke more efficient counter-regulatory mechanisms in response to NE.
  Kidney International 05/2001; 59(4):1439-47. · 6.61 Impact Factor
• Article: Value of cardiac troponin I and T for selection of heart donors and as predictors of early graft failure.

  E V Potapov, E A Ivanitskaia, M Loebe, M Möckel, C Müller, R Sodian, R Meyer, R Hetzer
  [show abstract] [hide abstract]
  ABSTRACT: Cardiac troponin I and T (cTnI and cTnT) are sensitive and specific markers of myocardial damage. We evaluated them for the selection of heart donors and as predictors of early graft failure after heart transplantation. cTnI, cTnT, myoglobin, and creatine kinase (CK) levels and its isoenzyme MB (CKMB) activity and mass were measured in serum samples immediately before opening the pericardium from 126 consecutive brain-dead multi-organ donors over 10 years of age inspected by our harvesting team. Donors with serum creatinine >2.0 mg/dL (n=6) were excluded from the analysis. Donors for high-urgency status recipients (n=2) were also excluded. The remaining donors were retrospectively divided into three groups: group I (n=68), grafts with good function; group II (n=11), grafts with impaired function; and group III (n=39), grafts not accepted for transplantation. No differences in donor and recipient characteristics were found among the groups. The mean values of cTnI (0.36+/-0.88 microg/L, 4.45+/-3.28 microg/L, and 3.02+/-7.88 micog/L, respectively) and cTnT (0.016+/-0.029 microg/L, 0.134+/-0.114 microg/L, and 0.123+/-0.245 microg/L, respectively) were lower in group I when compared with groups II or III (cTnI: P<0.0001, P=0.018; cTnT: P<0.0001, P=0.012). The cTnI value was higher in group II compared with group III (P=0.023). The cTnT values were similar in groups II and III. A cTnI value >1.6 microg/L as a predictor of early graft failure had a specificity of 94%, and a cTnT value of >0.1 microg/L had a specificity of 99%. The odds ratio for the development of acute graft failure after heart transplantation was 42.7 for donors with cTnI >1.6 microg/L and 56.9 for donors with cTnT >0.1 microg/L. No differences of myoglobin, CKMB activity, or CKMB/CK ratio were found among the groups. Significantly higher cTnI and cTnT values were found in peripheral blood at the time of explantation in donors of hearts with subsequently impaired graft function and in not accepted donors. cTnI and cTnT are useful as additional parameters for heart donor selection.
  Transplantation 05/2001; 71(10):1394-400. · 4.00 Impact Factor
• Article: Validation of NACB and IFCC guidelines for the use of cardiac markers for early diagnosis and risk assessment in patients with acute coronary syndromes.

  M Möckel, W Gerhardt, G Heller, F Klefisch, O Danne, J Maske, C Müller, T Störk, U Frei, A H Wu
  [show abstract] [hide abstract]
  ABSTRACT: International guidelines have been established for the use of cardiac markers in the early diagnosis and risk assessment of patients with acute coronary syndromes. A single center, prospective observational study was conducted in a tertiary care university hospital on 200 consecutive patients with suspected acute myocardial infarction (AMI). Blood was drawn on admission and after 2, 4, 8, 12 and 24 h for the measurement of CK-MB/CK activity, myoglobin, CK-MB mass and troponin I. A 6-week follow-up was undertaken for the combined end point of acute coronary syndrome and death. Myoglobin showed an early diagnostic sensitivity of 0.65 on admission, 0.90 after 2 h and 0.92 after 4 h compared with 0.46, 0.74 and 0.88 for CK-MB/CK activity. The combination of myoglobin and cTnI increased the diagnostic value compared with myoglobin alone on admission, 2 and 4 h later. In multivariate analysis, cTnI and CK-MB/CK mass, but not myoglobin and CK-MB/CK activity, were shown to be independent predictors on the 6-week follow-up. Repetitive myoglobin measurements within 4 h of admission, combined with at least one early troponin test, was shown to be the strategy of choice in early AMI diagnosis and prognosis assessment.
  Clinica Chimica Acta 02/2001; 303(1-2):167-79. · 2.54 Impact Factor