Christiane Tiefenbacher’s research while affiliated with Marien-Hospital Wesel and other places

Ergometry remains unchanged a basic diagnostic tool in clinical cardiology, even though its relevance in ischemia diagnostics has changed in light of the increased use of cardiac imaging. It plays an important role in patients with angina pectoris and ischemia without obstructive coronary disease with respect to the differential diagnosis of angina/ischemia and no obstructive coronary arteries (ANOCA/INOCA). Additionally, the importance of ergometry has recently increased in sports cardiology as well as in the risk stratification, for example in patients with arrhythmia or hypertrophic cardiomyopathy.

Zusammenfassung Unter den klassischen Risikofaktoren der Atherosklerose spielt neben dem Nikotinkonsum der Diabetes mellitus (DM) eine besondere Rolle für die Pathophysiologie der peripheren arteriellen Verschlusskrankheit (pAVK), englisch Peripheral Artery Disease (PAD). Zur Abgrenzung einer pAVK der Arterien der unteren Extremitäten wurde im englischen Sprachraum zusätzlich der Begriff LEAD (Lower Extremity Arterial Disease) etabliert. Morphologische Besonderheiten von Diabetikern mit pAVK erschweren die Diagnostik und führen zu einer schlechteren Prognose. Um die Entwicklung einer pAVK früh zu erkennen und adäquat behandeln zu können, wird in den aktuellen Leitlinien ein regelmäßiges Screening empfohlen. Die Sekundärprävention mit konsequenter Einstellung der Gefäßrisikofaktoren und Lifestylemaßnahmen wie Gehtraining und Selbstkontrolle der Haut der unteren Extremitäten ist bei diesem Patientenkollektiv besonders wichtig.

Interventions in electrophysiology and interventional cardiology are increasingly common. Many of these interventions are performed under sedation. This is necessary to ensure the patient’s comfort and safety to facilitate transesophageal echocardiography, pain control, or long procedure duration, e.g., with stable mapping conditions. This consensus document by the German Cardiac Society (DGK) together with the German Association of Anesthesia and Intensive Care (DGAI) describes—based on current evidence—the structured pathways for sedation in cardiovascular medicine. The major goal is patient safety for patients undergoing electrophysiology and endovascular cardiovascular procedures. This consensus document is also aligned to the published German S3 guideline for sedation in gastroenterology.

In recent years cardio-oncology has substantially gained in relevance and interest. For this reason, cardio-oncological guidelines were compiled for the first time by the European Society of Cardiology (ESC) in cooperation with the European Hematology Association (EHA), the European Society for Therapeutic Radiology and Oncology (ESTRO) and the International Cardio-Oncology Society (IC-OS). These European guidelines provide very detailed recommendations on the prevention and management of cancer treatment-related cardiac dysfunction and on other frequently asked questions in cardio-oncology. Nowadays, due to the longer survival of cancer patients and better chances of being cured, cardiac function is becoming increasingly more important and in individual cases can determine the prognosis. This comment provides a brief review of the most important points in the new European guidelines on cardio-oncology taking the current situation in Germany into account.

Coronary artery disease (CAD) and its complications continue to be the cause of most deaths in Germany. Cardiac computed tomography (CCT) and cardiac magnetic resonance imaging (CMR) allow for the precise diagnostic classification and risk stratification of patients with suspected and known CAD. The two methods are not additive to each other and should be used based on current guidelines to avoid unnecessary cardiac catheterization procedures. Thus, both CCT and CMR serve as “gatekeepers” for invasive procedures and ensure that only patients, requiring interventional treatment will undergo cardiac catheterization. In this context, the appropriate use of these two imaging modalities among specialists within the discipline of cardiology, who have profound knowledge and the necessary clinical expertise for the interpretation of the clinical symptoms and the assessment of the pre-test probability, is absolutely crucial. Thus, cardiologists need to thoroughly assess clinical variables, such as age, gender, the clinical presentation of angina and associated comorbidities, when considering such diagnostic procedures. In addition, potential therapeutic consequences need to be evaluated in a patient centered and not in a method-centered manner, whereas profound knowledge of the coronary anatomy is crucial for the correct interpretation of the resultant imaging findings by cardiac CT. The only way to avoid an uncontrolled volume expansion with both procedures, which would significantly increase costs for our healthcare system, is to use cardiac CT and CMR in line with current guidelines and recommendations. This position statement therefore aims at summarizing diagnostic and therapeutic algorithms for the appropriate diagnostic work-up of patients with suspected and known CAD, using cardiac CCT and CMR, based on current guidelines and the clinical likelihood of obstructive CAD.

Interventional treatment for acute pulmonary embolism (PE) offers great potential for reducing the morbidity and mortality in selected patients at intermediate-high and high risk. This policy paper summarizes the current scientific data. Furthermore, clinical decision making is supported by means of key statements and flow charts consented by the expert authors. Patients with acute pulmonary embolism at intermediate-high or high risk should therefore be presented to a multidisciplinary PE-Team for risk stratification immediately after diagnosis. Local expertise and resources should be taken into account when proactively building the team. The establishment of multidisciplinary PE-Team with a clear organization and standardized processes can improve the use of locally available treatment options. The aim of the PE-Team is repetitive risk-benefit analyses of net clinical benefit, taking into account PE severity, evolution of hemodynamics and gas exchange over time, as well as the benefit-risk ratio of any intervention (pharmacodynamic, catheter-based, surgical). Catheter-based, interventional treatment of acute pulmonary embolism should be considered in the case of manifest, treatment refractory circulatory instability, after unsuccessful systemic thrombolytic treatment as well as in the case of a high risk of bleeding and contraindication(s) to systemic thrombolysis. The final decision for or against interventions should be PE-Team-based.