Zeitschrift fur die gesamte innere Medizin und ihre Grenzgebiete最新文献

The antihypertensive efficacy and compatibility of 5 or 10 mg bisoprolol (Concor) was investigated in patients suffering from essential hypertension (stages I and II according to WHO) in a multicentre, open, non-randomized study. In total, 132 patients were included in the study of 11 outpatient departments. Seventeen patients dropped out because of personal reasons or mistakes of the protocol. If the diastolic blood pressure did not decrease to values < or = 90 mm Hg at the end of the first period of treatment with 5 mg bisoprolol, the dose was doubled to 10 mg within the second period of antihypertensive treatment. At the end of the first period the mean blood pressure decreased from 161.5/104.1 to 141.4/90.8 and after additional 4 weeks to 137.3/87.9 mm Hg. The mean heart rate decreased from 77.5 to 68.8 and 67.7/min, resp. The physicians who treated the patients rated the antihypertensive effect on 80.9% of the patients as good. Undesirable effects of bisoprolol were observed in 20 patients (15.2%). In total, bisoprolol has a good antihypertensive effect. It can be used in most patients as a monotherapeutic drug for treatment of stages I and II of hypertension with daily doses of 5 mg.

Between 1/1986 and 5/1992 a total of 5283 surgical procedures involving extracorporal circulation were performed at our clinic, including 44 patients who underwent a total of 54 operations for acute endocarditis. On the basis of a retrospective study, this paper presents the pre-operative findings and the results of surgery in relation to the duration of the case history. Pathogenic microorganisms were successfully grown from the blood cultures of 63.6% (n = 31) of the patients. Among these microorganisms were viridans streptococci (n = 12), coagulase-negative staphylococci (n = 5), staph. aureus (n = 5), beta-haemolytic streptococci (n = 2) as well as combined infections (n = 2) and miscellanea. Preoperatively, 38 patients were in NYHA stage III or IV. Surgery resulted in an average improvement of 1.6 NYHA classes from NYHA 3.3 to NYHA 1.7. The total-mortality rate was n = 13; early mortality was n = 3. The mean follow-up period was 3.9 years (minimum 5 weeks, maximum 6.4 years). The time elapsed between initial clinical manifestation of the disease and operation had a significant influence on mortality and on the prevalence of complications. Patients who died of endocarditis had a significantly longer case history (p < 0.05). The prognosis was poorer, according to our data, if the case history extended over more than 80 days. Our results demonstrate clearly the necessity for such patients to be referred to a heart surgeon without delay.

Toxic liver diseases coincide with oxidative stress correlating positively with the seriousness of the course of disease. For the purpose of elucidating the pathogenic significance of an increased radical generation. 56 patients suffering from acute alcohol-toxic hepatitis of the clinical grade of seriousness B and C according to Child/Pugh were classified randomly into antioxidant subgroups (n = 31) and control groups (= 25). The basis therapy being identical, the patients of the antioxidant group received additionally 600 mg of D-alpha tocopherol per day, 200 micrograms of selenium and 12 mg of zinc. Due to the supplementation of antioxidants there were quicker significant changes in the concentration of bilirubin, malondialdehyde and of ammonia in the serum. In comparison with the control group the length of stay in hospital could be reduced by 6 days. In the control group the mortality rates amounted to 40% (10 of 25), in the antioxidant group to 6.5% (2 of 31). The results confirm the pathogenic significance of oxidative stress in alcohol-toxic liver disease because a distinct improvement of prognosis could be achieved by using a low-cost adjuvant antioxidant supplementation.

The authors report on the influence of a single sauna-stay of patients following heart transplantation (HTX) during the rehabilitation phase III. Investigations of blood pressure, heart rate, changer in hemodynamics in the small and large vessels in 8 male patients following HTX (medium age: 42 years) showed that sauna-hyperthermia is well tolerated. We watched significant decreases of blood pressure (systolic and diastolic values), an improvement of the microcirculation in the small vessels, an increase of the left ventricular ejection fraction (LVEF) and a decrease of the total peripheric vascular resistance (TPVR). Possibilities and limitations of sauna-therapy for the therapy of risk factors following HTX especially under immunosuppression are discussed. First results are demonstrated.

Four patient groups (n = 28 patients) received in a randomised clinical trial a single intravenous infusion of 500 ml of 10% dextran 40, 3.5% oxypolygelatine, 6% hydroxyethyl starch 200/0.5 or saline solution, respectively. The haemorheological parameters haematocrit, plasma viscosity and erythrocyte aggregation were followed up during 48 hours. In our study oxypolygelatine showed better rheological results than HAES 200/0.5. Dextran 40 especially increased the plasma viscosity and erythrocyte aggregation, so that we cannot recommend this plasma substituent for hypervolemic haemodilution.

In patients with peripheral arterial occlusive disease diagnostics by Doppler-sonography at the toe arteries and by Doppler-pressure measurement at the ankle arteries is often difficult and sometimes impossible. Using the first dorsal metatarsal artery for Doppler-waveform analysis yields exact information on haemodynamically relevant circulatory disturbances. Painful ulcers, gangrene, oedemata, mediasclerosis, burns, plaster casts, posttraumatic or postoperative conditions prevent the application of cuffs at the lower leg or foot. This Doppler-waveform analysis evidently represents the degree and the specialties of a disturbed blood circulation and allows an additional assessment of the vessels distal from the ankle arteries and enables a functional test on the anastomosis of the artery tibialis posterior and the artery dorsalis pedis. Functional and pharmacological influences on the tone of the vessels can be shown. The typical diagnostic features of Doppler-wave-form analysis used at the proximal measuring points are also valid at the dorsal metatarsal artery. The results of own comparative investigations in 69 patients and 44 healthy test persons are demonstrated.

Contrary to patients with the WPW-syndrome and AV nodal reentry in whom radiofrequency catheter ablation is the therapy of first choice for cure from these arrhythmias instead of life-long medical therapy, pharmacologic therapy of atrial fibrillation and atrial flutter remains the treatment of choice in these patients. If, however, atrial fibrillation with rapid atrioventricular conduction is medically intractable and associated with severe haemodynamic impairment, these patients may be offered catheter ablation of AV conduction by radiofrequency energy. Compared to DC ablation, this approach is associated by an acceptable complication rate. Including the left ventricular approach in cases where it is not possible to ablate AV conduction using the venous approach, the success rate to achieve third degree AV block approaches 100%. With the development of temperature-controlled radiofrequency catheter ablation, a further reduction of side effects is anticipated. A disadvantage of this approach is the need for permanent pacemaker implantation (usually rate-adaptive VVI stimulation) after induction of complete AV block. Therefore, the advantage of normalization of ventricular rate by ablation of AV conduction has to be weighed against the risk of life-long pacemaker treatment for complete AV block in every patient. Patients with medically intractable typical atrial flutter may be offered the following alternative modes of electric treatment: selective ablation of the area of slow conduction sustaining circus movement in the right atrium underlying atrial flutter, by radiofrequency energy without interrupting AV conduction, implantation of a permanent antitachycardia pacemaker with electrodes positioned in the right atrium, radiofrequency catheter ablation of AV conduction.(ABSTRACT TRUNCATED AT 250 WORDS)

Thromboembolism is a frequent complication of atrial fibrillation. As could be demonstrated by several placebo-controlled prospective studies in the recent years the rate of thromboembolism was reduced significantly by anticoagulation of nearly all kinds of atrial fibrillation. These results are challenging to weigh risks and benefits in every patient. The principles which have to consider in this calculation are discussed with regard to the knowledge derived from the controlled studies.

Many new antiarrhythmic drugs effective in supraventricular tachyarrhythmia are now available. Since these compounds may lead to serious side-effects, the correct indication for the antiarrhythmic treatment has to be given regarding the ratio of risk and benefit. There is no doubt that aggravation of arrhythmia i.e. acceleration of tachycardia or even degeneration into ventricular flutter (including torsades-de-pointes tachycardia) and fibrillation may be related to the cardiac diagnosis depending on the extent of disease or left ventricular dysfunction and the presenting arrhythmia and possibly the electrophysiological effects of the drug. In general, negative inotropic effects of antiarrhythmic substances are overestimated; they may even be neglected as long as the antiarrhythmic agent leads to effective suppression of the symptomatic ventricular tachyarrhythmia. The best and most important consequence of the CAST study (Cardiac Arrhythmia Suppression Trial) showing an increase in mortality with antiarrhythmic drugs compared with placebo should be that physicians handle antiarrhythmic drugs now with more care than before. The problems with risks and side-effects in antiarrhythmic drug therapy of supraventricular arrhythmias underline the requirement for careful cardiological evaluation and monitoring in all patients receiving such drugs.

Recurrent supraventricular arrhythmias are associated with palpitations, weakness, syncopes, etc. Pharmacological treatment with antiarrhythmic agents aims to interrupt the tachyarrhythmia episodes (acute therapy) and to stabilize sinus rhythm thereafter (chronic therapy). Due to the newer curative options (transvenous ablation), the segment for the pharmacological therapy is shrinking. Treatment with antiarrhythmic agents is still indicated, if the recurrence of tachycardia episodes can be sufficiently controlled by a well-tolerated antiarrhythmic regimen. In the cohort of atrial fibrillation, total mortality and mortality from cardiovascular causes were increased under the influence of quinidine. The risk must, therefore, be weighed against the anticipated benefit from as well as the likelihood of arrhythmia suppression, before treating a patient with class I antiarrhythmic drugs. In some cases, reduction of ventricular rate by calcium antagonists will be the better choice. In case of recurrent atrial fibrillation without or with minimal structural abnormalities, propafenone or flecainide are recommended. Sotalol, and in rare cases amiodarone, will be applied in coronary artery disease. Atrial fibrillation of recent onset may be interrupted by bolus injection of ajmaline, propafenone, or flecainide. In case of impaired cardiac function, intravenous amiodarone can be applied safely. In summary, the scientific basis for the treatment of supraventricular tachycardias has been strengthened by clinical trials. Careful evaluation of the individual patient is warranted prior to institution of the pharmacological treatment.