Detlev Jäger

Comparison of the efficacy and safety of aspirin alone with coumadin plus aspirin after provisional coronary stenting: final and follow-up results of a randomized study.

BACKGROUND The antithrombotic benefit of the conventional treatment with coumadin after coronary stenting is limited by bleeding complications. However, the superiority of an antiplatelet therapy with aspirin alone compared with coumadin plus aspirin has not been proven by randomized studies. The efficacy and safety of treatment with aspirin alone in comparison to coumadin plus aspirin were evaluated in this randomized study. METHODS Out of 164 patients aged 59.7 +/- 9.2 years, 79 patients were randomly assigned to receive 100 mg aspirin daily (group A) and 85 patients randomly assigned to coumadin plus aspirin (group CA) after provisional coronary stenting with a high-pressure technique. The primary end point was defined as the absence of death, subacute closure of the target vessel, myocardial infarction, urgent coronary bypass surgery, repeated coronary angioplasty, and peripheral vascular complications requiring transfusion or surgery. High-pressure inflation technique was used, but ultrasound guidance was not. RESULTS During hospitalization (median 8 days), 135 patients (82. 3%) were free of events (A, 84.8%; CA, 80.8%; P =.42). Eleven (6.7%) subacute closures occurred (A, 10.1%; CA, 3.5%; P =.09); 2 of them were lethal in the aspirin group. Emergency bypass surgery was performed in 1 patient in each group. Peripheral vascular complications were observed in 13 patients (7.9%) (A, 1.3%; CA, 14. 1%; P <.01). At 3-month follow-up, 15 (9.1%) elective revascularization procedures (A, 7.6%; CA, 10.6%; P =.51) were performed. CONCLUSION Aspirin alone at the low dose of 100 mg administered or the combination of coumadin and aspirin after high-pressure coronary stenting does not prevent adverse clinical events when ultrasound guidance is not used.

Two-Dimensional Echocardiographic Assessment of Right Cardiac Pressure Overload in Patients with Chronic Obstructive Airway Disease

Two-dimensional echocardiography was used to estimate right cardiac pressure overload in patients with chronic obstructive airway disease. Area measurements of the four heart chambers were carried out from the apical four-chamber view. Additionally, the respiratory behaviour of the inferior vena cava was examined from the subcostal view. A good apical imaging of the four-chamber view for area measurement was obtained in 44 out of 48 patients with chronic obstructive airway disease. The respiratory behaviour of the inferior vena cava was investigated from the subcostal view in 38 patients. Within 8 days after echocardiography, right cardiac catheterization was carried out in order to measure pulmonary artery and right atrial mean pressures and to determine pulmonary vascular resistance. A good correlation was found between pulmonary artery mean pressure and the following echocardiographic parameters: area index (area/body surface) of the two right heart cavities (r = 0.83), right-to-left ventricular area ratio (r = 0.82) and right-to-left cardiac area ratio (ratio between the added areas of both right heart cavities on the one side and the added areas of both left heart cavities on the other; r = 0.82). Correlation between these parameters and pulmonary vascular resistance (r = 0.71, 0.66 and 0.71, respectively) and between the right atrial mean pressure and the right atrial area index was less close (r = 0.64). On the other hand, the respiratory behaviour of the inferior vena cava proved to be highly specific but not very sensitive in predicting a pathological right atrial pressure.(ABSTRACT TRUNCATED AT 250 WORDS)

fla@@@Problematik der klinischen Einschätzung der Ruhe- und Belastungshämodynamik bei chronisch Herzkranken@@@Prediction of hemodynamics at rest and during exercise in patients with chronic heart diseases: Zur Wertigkeit der Einschwemmkatheterisierung und Problematik klinischer Klassifikation

□ BackgroundNYHA classification is mostly used for graduation of clinical limitation due to cardiac failure. Right heart catheterization is not generally used to evaluate hemodynamics and to define the effects of drugs in patients with chronic cardiac failure. Clinical data and results from echocardiography, stress tests or nuclear cardiology seem to be sufficient. Our aim was to demonstrate subjectivity of a classification system (NYHA) comparing the graduation done by physicians and by patients and to represent the difficulty to prognosticate hemodynamic data of patients with heart failure.□ Patients and MethodsLimitation of 53 patients with heart diseases was classified by physicians and patients using NYHA classification. Pulmonary capillary wedge pressure (PCWP), stroke volume (SV) and cardiac output were predicted by physicians; they were allowed to utilize all examination data they could get. Predicted hemodynamic data were compared with the results of measurement at rest and during exercise.□ ResultsPatients classified themselves significantly worse than physicians did: 2.68±0.64 vs. 2.23±0.74 (p=0.0012). Similarity in NYHA classification was found in 29/53 cases. Correlation of predicted and measured hemodynamic data was low: PCWP (at rest) r=0.346; PCWP (during exercise) r=0.232; SV (at rest) r=0.476; SV (during exercise) r=0.445; HMV (at rest) r=0.412; HMV (during exercise) r=0.538.□ ConclusionClinical classification systems like NYHA are subjective, classification by physicians differs significantly from classification by patients. Prediction of hemodynamics is not possible despite all examination data had been available. Right heart catheterization is necessary to define hemodynamics at rest and during exercise.BACKGROUND NYHA classification is mostly used for graduation of clinical limitation due to cardiac failure. Right heart catheterization is not generally used to evaluate hemodynamics and to define the effects of drugs in patients with chronic cardiac failure. Clinical data and results from echocardiography, stress tests or nuclear cardiology seem to be sufficient. Our aim was to demonstrate subjectivity of a classification system (NYHA) comparing the graduation done by physicians and by patients and to represent the difficulty to prognosticate hemodynamic data of patients with heart failure. PATIENTS AND METHODS Limitation of 53 patients with heart diseases was classified by physicians and patients using NYHA classification. Pulmonary capillary wedge pressure (PCWP), stroke volume (SV) and cardiac output were predicted by physicians; they were allowed to utilize all examination data they could get. Predicted hemodynamic data were compared with the results of measurement at rest and during exercise. RESULTS Patients classified themselves significantly worse than physicians did: 2.68 +/- 0.64 vs. 2.23 +/- 0.74 (p = 0.0012). Similarity in NYHA classification was found in 29/53 cases. Correlation of predicted and measured hemodynamic data was low: PCWP (at rest) r = 0.346; PCWP (during exercise) r = 0.232; SV (at rest) r = 0.476; SV (during exercise) r = 0.445; HMV (at rest) r = 0.412; HMV (during exercise) r = 0.538. CONCLUSION Clinical classification systems like NYHA are subjective, classification by physicians differs significantly from classification by patients. Prediction of hemodynamics is not possible despite all examination data had been available. Right heart catheterization is necessary to define hemodynamics at rest and during exercise.

Gesundheitsförderung und kardiovaskuläre Risikofaktoren

Zusammenfassung□ Patienten und MethodeIn der vorliegenden Studie wurden 510 Patienten einer kardiologischen Akutklinik bezüglich ihres Wissens um kardiovaskuläre Risikofaktoren am Tag der Aufnahme und zum Zeitpunkt der Entlassung befragt. Mittels eines neu entwickelten Fragebogens wurden neben den allgemein anerkannten Risikofaktoren auch mehr oder weniger unwahrscheinliche Antwortmöglichkeiten vorgegeben. Das Antwortverhalten jedes Patienten wurde in einem Summenwert ausgedrückt.□ ErgebnisseDer Wissensstand der Patienten ist im allgemeinen niedrig: Von den Befragten gab ein fünftel nicht an, daß Übergewicht, hohes Cholesterin und Rauchen schädlich für die Herzkranzgefäße sind. Über 30% kreuzten arterielle Hypertonie, knapp zwei Drittel Diabetes mellitus nicht an. Es fand sich keine Änderung des Wissensstands im Laufe des stationären Aufenthalts trotz standardisierter, intensiver Aufklärungsgespräche. Die Ergebnisse des Entlassungsfragebogens entsprachen denen bei Aufnahme. Auch mehrfache Krankenhausaufenthalte trugen nicht zu einem höheren Wissensstand bei. Patienten mit einer diagnostizierten koronaren Herzkrankheit hatten keine besseren Werte als Patienten, die wegen einer anderen Krankheit behandelt wurden. Auch das tatsächliche Vorliegen eines Risikofaktors hatte nur wenig Einfluß auf das Wissen.□ SchlußfolgerungAus diesen Ergebnissen leitet sich emeut die Forderung nach besserer Aufklärung der Patienten ab. Die Daten zeigen aber auch, daß ein stationärer Aufenthalt in einer Akutklinik mit mehreren Gesprächen über dieses Thema den Wissensstand nicht verbessern kann. Es müssen demnach neue Wege gesucht werden, um Patienten über die kardiovaskulären Risikofaktoren aufzuklären.Abstract□ Patients and MethodsA total of 510 patients hospitalized on a cardiologic ward were questioned on cardiovascular disease risk factors using a questionnaire. The knowledge on these risk factors was assessed with a score system.□ ResultsKnowledge of patients on cardiovascular disease risk factors was generally low: One out of 5 did not know about the consequences of obesity, high blood cholesterol or smoking on the coronary vessels. Over 30% did not name hypertension. Only 1 out of 3 patients mentioned diabetes mellitus as a risk factor. There was no change in the knowledge during the hospital stay despite a standardized and intensive information program. The results of the second survey on the day of discharge were equal to the results of the admission day. Hospital stays in the past had no influence on the knowledge. Patients with a diagnosed coronary heart disease had the same results in the survey as patients with other diseases. The presence of risk factors had hardly any influence on the knowledge of these patients.□ ConclusionThe result of this study emphasizes the need for better health information for patients. The repetitive information on health related issues during inpatient treatment does not seem to have a positive effect on patients’ knowledge. Therefore other ways of health education have to be introduced and evaluated in acute care.