[Show abstract][Hide abstract] ABSTRACT: Aims Sudden cardiac death (SCD) is among the most common causes of death in western countries including Germany. Whereas risk stratification and primary prevention is still insufficient, we also lack accurate incidence estimates. Current estimates vary widely (18.6–128/100 000/year), but data on SCD incidence in Germany are missing. Depending on SCD definitions, death needs to occur between 1 and 24 h after the onset of symptoms. Methods and results In the district of Aurich (190 000 inhabitants, Lower Saxony, Germany), emergency medical service (EMS) is provided by a district government operated single carrier and two hospitals. To evaluate all EMS calls in this district from 2002 to 2009, we obtained EMS protocols, medical records, and death certificates for data analysis and adjudication of SCD. We defined SCD according to the definition of the World Health Organization, considering patients with cardiac arrest within ≤1 h after the onset of symptoms. We also required cardiopulmonary resuscitation being performed by EMS personnel. The overall mortality rate in the district of Aurich (1060/100 000/year) corresponded well with the average mortality rate in Germany (1030/100 000/year). During the observation period, we adjudicated 1212 SCD cases, equivalent to an annual rate of 151 SCD cases (81 cases/100 000/year). Rates remained remarkably stable over time, and affected a con-siderable number of individuals of working age (32/100 000/year). Conclusion Consistent with prior reports, the SCD incidence in a district of Germany is substantial. Despite an elaborate EMS system and advanced medical care, SCD rates remain stable and necessitate improved, individualized risk stratification.
[Show abstract][Hide abstract] ABSTRACT: Chronic kidney disease (CKD) is associated with increased cardiovascular morbidity and mortality but there are few studies available about atrial fibrillation, the most frequent arrhythmia in CKD, and the applied treatment. Based on the prospective German Competence NETwork on Atrial Fibrillation, data of 3138 patients with atrial fibrillation were analyzed and categorized by their estimated glomerular filtration rate (stages 1-3 and 4 plus 5). With advanced CKD, significantly more patients suffered from a more severe form of atrial fibrillation. Despite significantly higher CHADS2 scores in advanced CKD, oral anticoagulation was not prescribed more frequently while antiarrhythmic drugs and catheter ablations were used significantly less often, in contrast to more pacemaker implantations. However, in multivariate hierarchical logistic regression analyses of in-hospital treatments and complications, only hemorrhages and pacemaker implantations turned out to be independently and significantly associated with higher CKD stages. This nationwide study shows that patients with CKD and atrial fibrillation suffer from a markedly higher comorbidity. Thus, while CKD patients have received cardioversions, ablations, antiarrhythmic, or anticoagulation drugs significantly less often in their history, current treatments were not different if adjusted for multiple comorbidities. This might indicate an improvement in the often reported therapeutic nihilism in CKD.Kidney International advance online publication, 4 June 2014; doi:10.1038/ki.2014.195.
[Show abstract][Hide abstract] ABSTRACT: Aims: We investigated the impact of the diameter of the valvuloplasty balloon (VB) used for predilation before transcatheter aortic valve implantation (TAVI) on atrioventricular block formation with consecutive need for permanent pacemaker (PP) implantation. Methods and results: TAVI was performed in 269 consecutive patients using the CoreValve prosthesis (Medtronic) via transfemoral access under local anaesthesia with mild analgesic medication. After exclusion of 32 patients with previously implanted PP, 237 patients were included in a retrospective analysis of the impact of VB size on subsequent PP incidence. Implantation success rate was 99.3%. Periprocedural mortality was 0%, and 30-day mortality was 5.9%. PP implantation after TAVI was required by 21.1%. Of 114 patients treated by 25 mm balloon valvuloplasty, a PP was implanted in 27.1%. In 123 patients, who were treated by VB with a ≤23 mm diameter, the PP implantation rate decreased to 15.4% (p=0.04). In univariate analysis, larger VB size resulted in a greater prevalence of PP implantation after TAVI. After adjustment by multivariate analysis for baseline clinical and operative characteristics, VB size remained an independent predictor of PP implantation. Conclusions: Moderate balloon predilation in patients undergoing TAVI with the Medtronic CoreValve prosthesis reduces the PP rate without affecting procedural success.
EuroIntervention: journal of EuroPCR in collaboration with the Working Group on Interventional Cardiology of the European Society of Cardiology 02/2014; 9(10):1151-7. · 3.17 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The effects of supplementation of the omega-3 fatty acids eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) on prevalence and severity of depression were evaluated in patients after a myocardial infarction.
A cross-sectional evaluation (posttest-only design) within the prospective, randomized, controlled, multicenter OMEGA trial was performed in patients after myocardial infarction at 12 months' follow-up (N = 2,081; age, mean = 64 years; men, 76.7%; women, 21.8%) from April 2005 to June 2007. Patients received supplementation with ethyl esters 90 (460-mg EPA and 380-mg DHA) or placebo for 12 months. Depression was assessed with the Beck Depression Inventory-II (BDI-II); a BDI-II cutoff score of ≥ 14 was used as diagnosis of depression.
When the total population was evaluated, no effects of EPA/DHA supplementation on depressive symptoms according to BDI-II score (mean [SD]) could be demonstrated: EPA/DHA (n = 1,046), 7.1 (6.9); placebo (n = 1,035), 7.1 (7.0); P = .7. The post hoc analyses of depressed patients with and without antidepressants revealed a tendency toward an antidepressant effect in patients with EPA/DHA supplementation as monotherapy: EPA/DHA (n = 125), 19.4 (5.8); placebo (n = 113), 19.9 (5.1); P = .07. However, in depressed patients with EPA/DHA supplementation as adjunctive to conventional antidepressants, a clinically relevant antidepressant effect was demonstrated: EPA/DHA (n = 33), 20.9 (7.1); placebo (n = 29), 24.9 (8.5); P < .05.
EPA/DHA supplementation in the total sample of patients after myocardial infarction had no effect on depressive symptoms. The clinically relevant antidepressant effect in the subgroup of depressed patients with EPA/DHA supplementation as adjunctive to conventional antidepressants that was revealed in the post hoc analysis might provide a basis for a controlled, prospective trial of omega-3 augmentation of antidepressants in patients after myocardial infarction.
ClinicalTrials.gov identifier: NCT00251134.
The Journal of Clinical Psychiatry 11/2013; 74(11):e1037-e1045. · 5.81 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: In this retrospective study, we investigated the impact of preconditioning of the right ventricle with the calcium sensitizer levosimendan immediately before left ventricular assist device (LVAD) implantation on outcome and survival. Nine consecutive LVAD patients (seven suffering from dilative cardiomyopathy and two from ischemic cardiomyopathy) with echocardiographic and invasive evidence of right heart insufficiency received levosimendan with 0.1 μg/kg body weight/min for 24 h before implantation of the assist device (seven HeartWare and two Jarvik 2000). Administration of levosimendan was safe and had not to be discontinued in any patient. We observed no relevant side effects. Twelve-month survival after implantation of the LVAD was 89% representing a superior outcome compared with the fifth INTERMACS registry data with 75% survival. Two temporary extracorporeal membrane-oxygenation implantations were necessary due to intraoperative right ventricular dysfunction. Only one patient died 5 weeks after LVAD implantation of multiorgan failure, five patients were successfully transplanted, and three patients underwent LVAD implantation for destination therapy. Levosimendan might improve clinical outcome and survival when used as pretreatment in patients with right heart insufficiency prior to LVAD implantation. However, we recommend a larger controlled trial in the future to confirm our preliminary results.
[Show abstract][Hide abstract] ABSTRACT: The management of atrial fibrillation (AF) has seen marked changes in past years, with the introduction of new oral anticoagulants, new antiarrhythmic drugs, and the emergence of catheter ablation as a common intervention for rhythm control. Furthermore, new technologies enhance our ability to detect AF. Most clinical management decisions in AF patients can be based on validated parameters that encompass type of presentation, clinical factors, electrocardiogram analysis, and cardiac imaging. Despite these advances, patients with AF are still at increased risk for death, stroke, heart failure, and hospitalizations. During the fourth Atrial Fibrillation competence NETwork/European Heart Rhythm Association (AFNET/EHRA) consensus conference, we identified the following opportunities to personalize management of AF in a better manner with a view to improve outcomes by integrating atrial morphology and damage, brain imaging, information on genetic predisposition, systemic or local inflammation, and markers for cardiac strain. Each of these promising avenues requires validation in the context of existing risk factors in patients. More importantly, a new taxonomy of AF may be needed based on the pathophysiological type of AF to allow personalized management of AF to come to full fruition. Continued translational research efforts are needed to personalize management of this prevalent disease in a better manner. All the efforts are expected to improve the management of patients with AF based on personalized therapy.
[Show abstract][Hide abstract] ABSTRACT: Current recommendations for anticoagulation management during cardioversion are largely based on historical data and expert consensus.
To characterize current practice of anticoagulation during and after elective cardioversion for AF and the risk of stroke and bleeding events, all patients enrolled into the Flec-SL trial were analyzed for stroke/transient ischemic attack and major bleeds after cardioversion. Flec-SL (ISRCTN62728743, NCT00215774) enrolled 635 patients (mean age 63.7±10.9, 66% male). 629 (99.1%) patients received periprocedural anticoagulation, 556 (87.6%) were adequately anticoagulated following current recommendations. 202 (31.8%) patients underwent transesophageal echocardiography-guided cardioversion. Electrical cardioversion was used in 508 patients (80.0%), pharmacological cardioversion in 127 (20%). Six patients suffered from stroke (n=5) or transient ischemic attack (3 TIAs in 1 patient, event rate 0.9%, 95% CI 0.4-2.1), five others from major bleeds (event rate 0.8%, 95% CI 0.3-1.9), consistent with the low reported event rates in prior studies. Three strokes occurred in the first 5days after cardioversion. Events were independent of type of cardioversion or the use of TEE to exclude thrombi.
Strokes are rare in this large, prospectively followed cohort of patients undergoing cardioversion for AF and receiving antithrombotic therapy following local routine. These results support adherence to current recommendations for anticoagulation during cardioversion of AF.
International journal of cardiology 07/2013; · 6.18 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: For the treatment of increasingly complex cardiac arrhythmias, new catheter designs as well as alternative energy sources are constantly being developed. However, there is presently no in vitro method available for assessment of the temperature changes induced at various myocardial levels during energy delivery. Therefore, our study was aimed at developing an in vitro model to record and display the temperature kinetics during ablation in the entire muscle cross section.
A sapphire glass pane was inserted into one wall of the in vitro experimental set-up. Due to its thermodynamic properties, the temperature distribution in an adjacent cross section of the cardiac muscle can be measured exactly (±1 °C) through this pane by means of a thermography camera. Computer-supported image processing enables the colour-coded and two-dimensional display of the temperature kinetics during the energy application at any location of the myocardial cross section (±0.5 mm). This new measuring methodology was validated by direct temperature measurements utilizing several intramyocardial thermo elements.
This new method allows a temporal and spatial analysis of the temperature phenomena during ablation without the interference and spatial limitation of intramyocardial temperature probes. New ablation technologies can thus be evaluated, independent of the catheter configuration or source of energy used.
Journal of Interventional Cardiac Electrophysiology 07/2013; · 1.39 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: BACKGROUND: Medical stimulation of endogenous progenitor cell circulation may serve as a new therapeutic tool for treatment of acute myocardial infarction. We analyzed the effects of antidiabetic gliptins plus GCSF (granulocyte colony stimulating factor) on myocardial regeneration after myocardial infarction in a mouse model. METHODS AND RESULTS: After surgical LAD-ligation (left anterior descending artery), Sitagliptin/Vildagliptin was applied yielding sufficient blood levels verified by mass spectrometry and significantly reducing activity of dipeptidyl peptidase (DPP) IV. GCSF or saline was administered intraperitoneally for 6days. We assessed stem cell mobilization and homing (flow cytometry), infarct size (histology), neovascularization and cellular proliferation (immunohistology), heart function (Millar tip catheterization) and survival (Kaplan-Meier-curves). Gliptins±GCSF administration increased mobilization and cardiac homing of bone-marrow derived stem cells by stabilization of cardiac SDF1 (stromal cell-derived factor). For Sitagliptin, it could be shown that resident cardiac stem cells were stimulated, neovascularization was enhanced and cardiac remodeling was reduced. These effects finally improved myocardial function and increased survival for both gliptins. Although gliptins as a mono therapy lead to remarkable effects in a dose dependent manner and were superior to G-CSF mono-therapy, dual application of GCSF and gliptins revealed the best results. Since both gliptins yielded comparable effects concerning stem cell homing, cardiac function and survival, we suggest a class-effect of DPP-IV-inhibitors. CONCLUSIONS: Thus, gliptins+GCSF and in high concentrations even as mono therapy have beneficial effects on cardiac regeneration after myocardial infarction beyond its anti-diabetic potential.
International journal of cardiology 05/2013; · 6.18 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: A 53-year-old man presented with a high grade stenotic tricuspid bioprosthesis and an inoperable state because of progressive lung disease. Valve replacement was performed transfemorally under local anaesthesia without rapid pacing. Valve positioning was facilitated by the radiopaque frame of the degenerated bioprosthesis. Echocardiography revealed a decrease of peak tricuspid valve gradient from 18 to 8 mm Hg. Valve-in-valve implantation of an Edwards Sapien XT valve in a failing tricuspid bioprosthesis is feasible via transfemoral access without general anaesthesia or rapid pacing.
The Canadian journal of cardiology 02/2013; · 3.12 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Marked prolongation of the QT interval on the electrocardiogram associated with the polymorphic ventricular tachycardia Torsades de Pointes is a serious adverse event during treatment with antiarrhythmic drugs and other culprit medications, and is a common cause for drug relabeling and withdrawal. Although clinical risk factors have been identified, the syndrome remains unpredictable in an individual patient. Here we used genome-wide association analysis to search for common predisposing genetic variants. Cases of drug-induced Torsades de Pointes (diTdP), treatment tolerant controls, and general population controls were ascertained across multiple sites using common definitions, and genotyped on the Illumina 610k or 1M-Duo BeadChips. Principal Components Analysis was used to select 216 Northwestern European diTdP cases and 771 ancestry-matched controls, including treatment-tolerant and general population subjects. With these sample sizes, there is 80% power to detect a variant at genome-wide significance with minor allele frequency of 10% and conferring an odds ratio of ≥2.7. Tests of association were carried out for each single nucleotide polymorphism (SNP) by logistic regression adjusting for gender and population structure. No SNP reached genome wide-significance; the variant with the lowest P value was rs2276314, a non-synonymous coding variant in C18orf21 (p = 3×10(-7), odds ratio = 2, 95% confidence intervals: 1.5-2.6). The haplotype formed by rs2276314 and a second SNP, rs767531, was significantly more frequent in controls than cases (p = 3×10(-9)). Expanding the number of controls and a gene-based analysis did not yield significant associations. This study argues that common genomic variants do not contribute importantly to risk for drug-induced Torsades de Pointes across multiple drugs.
PLoS ONE 01/2013; 8(11):e78511. · 3.53 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: In the setting of acute myocardial infarction and sinus rhythm, the heart rate (HR) has been demonstrated to correlate closely with mortality. In patients presenting with acute myocardial infarction and atrial fibrillation (AF) on admission, however, the prognostic relevance of the HR has not yet been systematically addressed. A post hoc subgroup analysis of the data from the OMEGA trial was conducted to analyze whether the admission HR determines the 1-year mortality in patients presenting with AF in the setting of acute myocardial infarction. Of 3,851 patients enrolled in the OMEGA study, 211 (6%) presented with AF on admission. This subgroup was dichotomized according to the admission HR (cutoff 95 beats/min). Multiple regression analysis revealed that an admission HR of ≥95 beats/min independently determined the 1-year mortality in patients with AF (odds ratio 4.69, 95% confidence interval 1.47 to 15.01; p = 0.01). In conclusion, this is the first study demonstrating that a high HR (≥95 beats/min) on admission in patients with AF and acute myocardial infarction is associated with an almost fivefold mortality risk.
The American journal of cardiology 12/2012; · 3.58 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: BACKGROUND: Coronary artery calcifications (CAC) are markers of coronary atherosclerosis, but do not correlate well with stenosis severity. This study intended to evaluate clinical situations where a combined approach of coronary calcium scoring (CS) and nuclear stress test (SPECT-MPI) is useful for the detection of relevant CAD. METHODS: Patients with clinical indication for invasive coronary angiography (ICA) were included into our study during 08/2005-09/2008. At first all patients underwent CS procedure as part of the study protocol performed by either using a multidetector computed tomography (CT) scanner or a dual-source CT imager. CAC were automatically defined by dedicated software and the Agatston score was semi-automatically calculated. A stress-rest SPECT-MPI study was performed afterwards and scintigraphic images were evaluated quantitatively. Then all patients underwent ICA. Thereby significant CAD was defined as luminal stenosis >=75% in quantitative coronary analysis (QCA) in >=1 epicardial vessel. To compare data lacking Gaussian distribution an unpaired Wilcoxon-Test (Mann--Whitney) was used. Otherwise a Students t-test for unpaired samples was applied. Calculations were considered to be significant at a p-value of <0.05. RESULTS: We consecutively included 351 symptomatic patients (mean age: 61.2+/-12.3 years; range: 18--94 years; male: n=240) with a mean Agatston score of 258.5+/-512.2 (range: 0--4214). ICA verified exclusion of significant CAD in 66/67 (98.5%) patients without CAC. CAC was detected in remaining 284 patients. In 132/284 patients (46.5%) with CS>0 significant CAD was confirmed by ICA, and excluded in 152/284 (53.5%) patients. Sensitivity for CAD detection by CS alone was calculated as 99.2%, specificity was 30.3%, and negative predictive value was 98.5%. An additional SPECT in patients with CS>0 increased specificity to 80.9% while reducing sensitivity to 87.9%. Diagnostic accuracy was 84.2%. CONCLUSIONS: In patients without CS=0 significant CAD can be excluded with a high negative predictive value by CS alone. An additional SPECT-MPI in those patients with CS>0 leads to a high diagnostic accuracy for the detection of CAD while reducing the number of patients needing invasive diagnostic procedure.