S. Dietz

Mechanisms of infective endocarditis: pathogen–host interaction and risk states

Patients with infective endocarditis (IE) form a heterogeneous group, ranging from those who are successfully treated with no adverse events, to those with severe complications and a high mortality. In this Review, we highlight pathogen–host interactions and the mechanisms underlying various risk factors for patients with IE. A temporal trend in the pattern of IE has been observed in high-income countries within the past 5 decades, with patients contracting IE at an increasingly old age, and a growing incidence of health-care-associated staphylococcal IE. Consequently, prevention strategies should no longer focus on prophylaxis of streptococcal bacteraemia during dental procedures, but instead encourage a more-general approach to reduce the incidence of health-care-associated IE. Much knowledge has been gained about the mechanisms of vegetation formation, growth, and embolization on damaged or inflamed cardiac valves, and on cardiac devices. Improved understanding of these mechanisms will help to combat the increasing problem of antimicrobial resistance. Two mechanisms of IE should increasingly be the focus of future research: the role of immunosenescence in elderly patients with IE, particularly after transcatheter aortic valve implantation, and the mechanisms that trigger septic shock, a condition that leads to a substantial increase in the risk of death in patients with IE.

Intra‐Aortic Balloon Counterpulsation in the Treatment of Infarction‐Related Cardiogenic Shock—Review of the Current Evidence

The European ST-elevated myocardial infarction (STEMI) guideline suggested the intra-aortic balloon pump (IABP) with a recommendation level I and a level of evidence C as an effective measure in combination with balloon angioplasty in patients with cardiogenic shock (CS), stent implantation, and inotropic and vasopressor support. Similarly, upon mechanical complication due to myocardial infarction (MI), the guideline suggests that in patients with a ventricular septal defect or in most patients with acute mitral regurgitation, preoperative IABP implantation is indicated for circulatory support. The American College of Cardiology/American Heart Association STEMI guideline recommends the use of the IABP with a recommendation level I and a level of evidence B if CS does not respond rapidly to pharmacological treatment. The guideline notes that the IABP is a stabilizing measure for angiography and early revascularization. Even in MI complications, the use of preoperative IABP is recommended before surgery. Within this overview, we summarize the current evidence on IABP use in patients with CS complicated by MI. From our Cochrane data analysis, we conclude that in CS due to acute MI (AMI) treated with adjuvant systemic fibrinolysis, the IABP should be implanted. In patients with CS following AMI, treated with primary percutaneous coronary intervention (PCI), the IABP can be implanted, although data are not distinctive (i.e., indicating positive and negative effects). In the future, randomized controlled trials are needed to determine the use of IABP in CS patients treated with PCI. When patients with CS are transferred to a PCI center with or without thrombolysis, patients should receive mechanical support with an IABP. To treat mechanical MI complications-in particular ventricular septal defect-patients should be treated with an IABP to stabilize their hemodynamic situation prior to cardiac surgery. Similar recommendations are given in the German Austrian guidelines on treatment of infarction-related CS patients (http://www.awmf.org/leitlinien/detail/ll/019-013.html).

Inflammation and echocardiographic parameters of ventricular hypertrophy in a cohort with preserved cardiac function

Objective To investigate the association between inflammation and selective echocardiographic parameters (EP) characteristic for ventricular hypertrophy in cross-sectional and longitudinal population-based analyses. Methods Baseline (711 men, 659 women: 45–83 years) and 4-year follow-up data (622 men, 540 women) of the prospective, population-based CARdio-vascular disease, Living and Ageing in Halle (CARLA)study after exclusion of participants with cardiacvascular diseases were analysed. Inflammation parameters: soluble tumour necrosis factor receptor 1 (sTNF-R1), high-sensitivity C reactive protein (hsCRP) and interleukin 6 (IL-6). EPs: left ventricular mass (LVM), left atrial systolic dimension (LADS), interventricular septum diameter (IVSD), posterior wall dimension (PWD), left ventricular diastolic diameter (LVDD), ejection fraction according to Teichholz (EF). For the longitudinal analyses baseline to follow-up differences were considered. Effect sizes were determined by using multiple linear regression and mixed models. Missing values were replaced by means of multiple imputations. Results Men had higher sTNF-R1 levels; means of hsCRP and IL-6 were similar in men and women. In multiple regression models, sTNF-R1 was associated with LADS (1.4 mm/1000 pg/mL sTNF-R1, 95% CI 0.6 to 2.1) in men. Respecting confounder hsCRP was associated with LVM (5.2 g/10 mg/L hsCRP, 95% CI 1.6 to 8.8), IVSD (0.2 mm/10 mg/L hsCRP, 95% CI 0 to 0.3) and PWD (0.2 mm/10 mg/L hsCRP, 95% CI 0.1 to 0.3) in women, while there were no relevant effects in analysis of IL-6 in both sexes. The baseline to follow-up change in EPs was not relevantly associated with sTNF-R1, hsCRP or IL-6. Conclusions STNF-R1, hsCRP and IL-6 were inadequate predictors for structural changes of the heart at follow-up, while weak cross-sectional associations are restricted to certain EPs and depend on sex.

Influence of the serum levels of immunoglobulins on clinical outcomes in medical intensive-care patients

IntroductionEndogenous immunoglobulins (Igs) are of fundamental importance in the host defense after microbial infections. However, the therapeutic administration of intravenous IgG (IVIgG) has not yet been shown to improve clinical outcomes in patients suffering from sepsis, and in the case of IgM-containing preparations (IVIgGMA) the positive evidence is only weak. Recently published studies implicate that Ig levels on admission could have an impact on the patient’s response to IVIg treatment and on outcomes of critically ill patients.MethodsIn this noninterventional study, the serum levels of IgG, IgM, and IgA were determined in 340 medical patients on ICU admission, and clinical outcomes were prospectively recorded (ICU mortality, need for renal replacement therapy (RRT), need for mechanical ventilation, substitution of coagulation factors, and amount of red cell transfusions). Patients were prospectively grouped according to their main reason for ICU admission (sepsis, respiratory failure, cardiovascular diseases, acute renal failure, postoperative condition, state after cardiopulmonal resuscitation, gastrointestinal diseases, and others).Results and discussionThere was no correlation between the Ig levels on admission and ICU mortality neither in the total cohort of medical ICU patients nor in any prespecified subgroup. However, in a logistic regression model that was adjusted for APACHE II score on admission, an increase in serum IgG was associated with a reduced need for mechanical ventilation in patients suffering from cardiovascular disease. On the other hand, in patients suffering from sepsis, an increased level of IgM was linked to an increased administration of coagulation factors.ConclusionOur data do not support the hypothesis that serum levels of immunoglobulins are linked to mortality in medical ICU patients.ZusammenfassungHintergrundEndogene Immunglobuline spielen eine bedeutende Rolle in der Immunabwehr von mikrobiellen Infektionen. Kürzlich veröffentlichte Studien legen nahe, dass die Immunglobulinspiegel bei stationärer Aufnahme eine prognostische Bedeutung bei Intensivpatienten haben könnten.MethodikIn einer nicht-interventionellen Studie wurden die Serumspiegel von IgG, IgM und IgA von 340 Patienten bei Aufnahme auf die Intensivstation sowie das Auftreten klinischer Endpunkte (Mortalität auf ITS, Nierenersatzverfahren, invasive Beatmung, Substitution von Gerinnungsfaktoren, Gabe von Erythrozytenkonzentraten) erfasst. Abhängig von der Hauptursache für den Intensivaufenthalt wurden die Patienten prospektiv einer der folgenden Gruppen zugeordnet: Sepsis, respiratorische Insuffizienz, kardiovaskuläre Erkrankung, akutes Nierenversagen, Zustand nach Operation, Zustand nach CPR, gastrointestinale Erkrankung, sonstige Erkrankungen.Ergebnisse und DiskussionEs findet sich weder in der Gesamtkohorte noch in einer der prädefinierten Subgruppen eine Korrelation zwischen den Immunglobulinspiegeln bei Aufnahme und der Mortalität während des Aufenthaltes auf der Intensivstation. In einer logistischen Regression unter Berücksichtigung des Confounders APACHE-II-Score bei Aufnahme findet sich eine Korrelation zwischen erhöhten IgG-Spiegeln und geringerem Bedarf von invasiver Beatmung bei der Patientengruppe mit kardiovaskulären Erkrankungen. Andererseits besteht bei Patienten mit Sepsis ein Zusammenhang zwischen erhöhten IgM-Spiegeln und erhöhter Substitution von Gerinnungsfaktoren.SchlussfolgerungIn unserer Studie kann kein Zusammenhang zwischen den Immunglobulinspiegeln im Serum und der ITS-Mortalität nachgewiesen werden.

Patienten mit Dyspnoe in der Notaufnahme

Dyspnea is a common symptom in emergency medicine and represents a diagnostic and therapeutic challenge. A multitude of differential diagnoses must be considered and checked but where there are indications of a life-threatening situation and also by rapidly reversible causes an (initial) treatment must be initiated without delay. Initially implemented should be those aspects relevant for an initial assessment and risk stratification which result from anamnestic details, clinical symptoms and immediately available screening tests. This article describes in detail the clinical and diagnostic instrumental armamentarium including implementation and interpretation. Also discussed are the relevance of individual methods in the respective clinical context and possible sources of error and limitations. A possible algorithm for the management of dyspnea in a clinical setting, from initial contact to admission or release, is presented graphically and textually.ZusammenfassungDas im Bereich der Notfallmedizin häufige Symptom Dyspnoe stellt eine diagnostische wie therapeutische Herausforderung dar. Eine Vielzahl an Differenzialdiagnosen ist zu berücksichtigen und zu überprüfen, doch bei Hinweisen auf eine Bedrohung quoad vitam wie auch bei rasch reversiblen Ursachen ist eine (Erst-)Behandlung möglichst ohne Zeitverzug einzuleiten. Aufgeführt werden die für eine initiale Einschätzung und Risikostratifizierung relevanten Aspekte, die sich aus anamnestischen Angaben, klinischem Eindruck und ersten, direkt verfügbaren Screeningtests ergeben. Ausführlich beschrieben wird das klinische wie das apparative diagnostische Instrumentarium, einschließlich der Durchführung und Interpretation. Eingegangen wird auf die Relevanz einzelner Methoden im jeweiligen klinischen Kontext und auf mögliche Fehlerquellen bzw. Limitationen. Ein möglicher Algorithmus für das Management von Dyspnoe im präklinischen Setting − vom ersten Kontakt bis zur Aufnahme bzw. bis zur Entlassung − wird graphisch wie schriftlich vorgestellt.AbstractDyspnea is a common symptom in emergency medicine and represents a diagnostic and therapeutic challenge. A multitude of differential diagnoses must be considered and checked but where there are indications of a life-threatening situation and also by rapidly reversible causes an (initial) treatment must be initiated without delay. Initially implemented should be those aspects relevant for an initial assessment and risk stratification which result from anamnestic details, clinical symptoms and immediately available screening tests. This article describes in detail the clinical and diagnostic instrumental armamentarium including implementation and interpretation. Also discussed are the relevance of individual methods in the respective clinical context and possible sources of error and limitations. A possible algorithm for the management of dyspnea in a clinical setting, from initial contact to admission or release, is presented graphically and textually.

Die infektiöse Endokarditis bei Intensivpatienten

ZusammenfassungDie infektiöse Endokarditis ist eine seltene Erkrankung mit hohem Mortalitätsrisiko. In den letzten Jahren haben epidemiologische Verschiebungen im Altersgefälle der betroffenen Patienten, das Auftreten neuer Risikofaktoren sowie die zunehmende Verwendung intravasaler prothetischer Materialien zu Veränderungen im klinischen Erscheinungsbild sowie in Diagnostik und Therapie der Endokarditis geführt.Von herausragender Bedeutung ist eine frühzeitige Diagnosestellung. Die unspezifischen Symptome, aber auch das zunehmend häufigere Auftreten „nosokomialer“ Endokarditiden, oft bei schwerkranken Patienten auf Intensivstationen, fordern die diagnostische Kompetenz des behandelnden Arztes. Hierbei stehen diagnostische und therapeutische Algorithmen zur Verfügung, die von einer zügigen Diagnose zur adäquaten Therapie der Erkrankung leiten sollen. Es kann gerade auf der Intensivstation wichtig sein, zum richtigen Zeitpunkt die Indikation zu einer chirurgischen Sanierung der Infektion zu stellen.Entsprechend den aktuellen Leitlinien wird in dieser Übersicht die gängige Praxis in der Diagnostik und Therapie der infektiösen Endokarditis dargestellt und für Intensivpatienten kommentiert.AbstractInfectious endocarditis is a rare disease with high mortality. Epidemiological changes in recent years, the emergence of new risk factors, and the increasing use of intravasal prosthetic materials has led to changes in not only the clinical appearance of this disease but also in its diagnosis and treatment.Early diagnosis of infectious endocarditis is crucial. However, the often unspecific symptoms and the changes in its epidemiologic profile pose a challenge for the treating physician. This is especially true since the incidence of hospital-acquired, “nosocomial” cases of infectious endocarditis is increasing and often affects severely ill patients in intensive care units (ICU). There are diagnostic and therapeutic algorithms to guide the physician from an early diagnosis to an adequate treatment of the disease. In some critically ill patients, only surgery in combination with antimicrobial treatment may lead to complete eradication of the infectious disease.This review aims to subsume the guidelines, paying special attention to aspects that are important for intensive care and emergency doctors.

Infektiöse Endokarditis@@@Infective endocarditis: Update zur Prophylaxe, Diagnostik und Therapie@@@Update on prophylaxis, diagnosis, and treatment

ZusammenfassungDie infektiöse Endokarditis wird im klinischen Alltag häufig erst mit einer erheblichen Latenz diagnostiziert. Die zeitnahe Diagnosestellung in Kombination mit antibiotischer Therapie ist von elementarer Bedeutung. Verschiebungen im Altersprofil der betroffenen Patienten, neue Risikofaktoren und die Verwendung intravasaler prothetischer Materialien haben das Keimspektrum und das klinische Erscheinungsbild verändert. Unspezifische Symptome, die Anzahl nosokomialer Endokarditiden und immunsupprimierte Patienten nehmen im klinischen Alltag zu.Die neue Leitlinie der European Society of Cardiology zur Endokarditis zeigt die verschiedenen diagnostischen Algorithmen und die Empfehlungen zur antibiotischen Therapie. Gemäß Leitlinie wird die Bildung eines Endokarditisteams mit unterschiedlichen Disziplinen und das frühzeitige Einbeziehen eines Herzchirurgen in die Behandlung gefordert, da in ungefähr der Hälfte der Erkrankungsfälle eine alleinige antibiotische Therapie nicht zu einer Sanierung der Endokarditis führt. Mit Eintreten von Komplikationen sollte frühzeitig eine operative Therapie angestrebt werden.Entsprechend den aktuellen Leitlinien wird in dieser Übersichtsarbeit der derzeitige Stand der Diagnostik und Therapie der infektiösen Endokarditis dargestellt.AbstractThe diagnosis of infective endocarditis is often delayed in clinical practice. Timely diagnosis and rapid antibiotic treatment is important. Higher age of patients, new risk factors, and increasing use of intravascular prosthetic materials resulted in changes in microbial spectrum. Nowadays, nonspecific symptoms, critically ill patients, and immunocompromised patients require a high level of diagnostic expertise.The new guidelines from the European Society of Cardiology provide various diagnostic algorithms and recommendations for antibiotic treatment. The new guidelines also recommend the formation of an endocarditis team with various medical disciplines, including a cardiac surgeon, to improve treatment because in half of all endocarditis patients, antibiotic therapy alone does not result in successful management of the infection. If complications occur, early surgical treatment should be performed.In this overview, diagnostic strategies and therapeutic approaches for the treatment of infectious endocarditis according to the current guidelines and aspects of surgical treatment are provided.The diagnosis of infective endocarditis is often delayed in clinical practice. Timely diagnosis and rapid antibiotic treatment is important. Higher age of patients, new risk factors, and increasing use of intravascular prosthetic materials resulted in changes in microbial spectrum. Nowadays, nonspecific symptoms, critically ill patients, and immunocompromised patients require a high level of diagnostic expertise.The new guidelines from the European Society of Cardiology provide various diagnostic algorithms and recommendations for antibiotic treatment. The new guidelines also recommend the formation of an endocarditis team with various medical disciplines, including a cardiac surgeon, to improve treatment because in half of all endocarditis patients, antibiotic therapy alone does not result in successful management of the infection. If complications occur, early surgical treatment should be performed.In this overview, diagnostic strategies and therapeutic approaches for the treatment of infectious endocarditis according to the current guidelines and aspects of surgical treatment are provided.

Infektiöse EndokarditisInfective endocarditis

ZusammenfassungDie infektiöse Endokarditis wird im klinischen Alltag häufig erst mit einer erheblichen Latenz diagnostiziert. Die zeitnahe Diagnosestellung in Kombination mit antibiotischer Therapie ist von elementarer Bedeutung. Verschiebungen im Altersprofil der betroffenen Patienten, neue Risikofaktoren und die Verwendung intravasaler prothetischer Materialien haben das Keimspektrum und das klinische Erscheinungsbild verändert. Unspezifische Symptome, die Anzahl nosokomialer Endokarditiden und immunsupprimierte Patienten nehmen im klinischen Alltag zu.Die neue Leitlinie der European Society of Cardiology zur Endokarditis zeigt die verschiedenen diagnostischen Algorithmen und die Empfehlungen zur antibiotischen Therapie. Gemäß Leitlinie wird die Bildung eines Endokarditisteams mit unterschiedlichen Disziplinen und das frühzeitige Einbeziehen eines Herzchirurgen in die Behandlung gefordert, da in ungefähr der Hälfte der Erkrankungsfälle eine alleinige antibiotische Therapie nicht zu einer Sanierung der Endokarditis führt. Mit Eintreten von Komplikationen sollte frühzeitig eine operative Therapie angestrebt werden.Entsprechend den aktuellen Leitlinien wird in dieser Übersichtsarbeit der derzeitige Stand der Diagnostik und Therapie der infektiösen Endokarditis dargestellt.AbstractThe diagnosis of infective endocarditis is often delayed in clinical practice. Timely diagnosis and rapid antibiotic treatment is important. Higher age of patients, new risk factors, and increasing use of intravascular prosthetic materials resulted in changes in microbial spectrum. Nowadays, nonspecific symptoms, critically ill patients, and immunocompromised patients require a high level of diagnostic expertise.The new guidelines from the European Society of Cardiology provide various diagnostic algorithms and recommendations for antibiotic treatment. The new guidelines also recommend the formation of an endocarditis team with various medical disciplines, including a cardiac surgeon, to improve treatment because in half of all endocarditis patients, antibiotic therapy alone does not result in successful management of the infection. If complications occur, early surgical treatment should be performed.In this overview, diagnostic strategies and therapeutic approaches for the treatment of infectious endocarditis according to the current guidelines and aspects of surgical treatment are provided.The diagnosis of infective endocarditis is often delayed in clinical practice. Timely diagnosis and rapid antibiotic treatment is important. Higher age of patients, new risk factors, and increasing use of intravascular prosthetic materials resulted in changes in microbial spectrum. Nowadays, nonspecific symptoms, critically ill patients, and immunocompromised patients require a high level of diagnostic expertise.The new guidelines from the European Society of Cardiology provide various diagnostic algorithms and recommendations for antibiotic treatment. The new guidelines also recommend the formation of an endocarditis team with various medical disciplines, including a cardiac surgeon, to improve treatment because in half of all endocarditis patients, antibiotic therapy alone does not result in successful management of the infection. If complications occur, early surgical treatment should be performed.In this overview, diagnostic strategies and therapeutic approaches for the treatment of infectious endocarditis according to the current guidelines and aspects of surgical treatment are provided.

Patienten mit Dyspnoe in der Notaufnahme@@@Patients with dyspnea in emergency admission

Dyspnea is a common symptom in emergency medicine and represents a diagnostic and therapeutic challenge. A multitude of differential diagnoses must be considered and checked but where there are indications of a life-threatening situation and also by rapidly reversible causes an (initial) treatment must be initiated without delay. Initially implemented should be those aspects relevant for an initial assessment and risk stratification which result from anamnestic details, clinical symptoms and immediately available screening tests. This article describes in detail the clinical and diagnostic instrumental armamentarium including implementation and interpretation. Also discussed are the relevance of individual methods in the respective clinical context and possible sources of error and limitations. A possible algorithm for the management of dyspnea in a clinical setting, from initial contact to admission or release, is presented graphically and textually.ZusammenfassungDas im Bereich der Notfallmedizin häufige Symptom Dyspnoe stellt eine diagnostische wie therapeutische Herausforderung dar. Eine Vielzahl an Differenzialdiagnosen ist zu berücksichtigen und zu überprüfen, doch bei Hinweisen auf eine Bedrohung quoad vitam wie auch bei rasch reversiblen Ursachen ist eine (Erst-)Behandlung möglichst ohne Zeitverzug einzuleiten. Aufgeführt werden die für eine initiale Einschätzung und Risikostratifizierung relevanten Aspekte, die sich aus anamnestischen Angaben, klinischem Eindruck und ersten, direkt verfügbaren Screeningtests ergeben. Ausführlich beschrieben wird das klinische wie das apparative diagnostische Instrumentarium, einschließlich der Durchführung und Interpretation. Eingegangen wird auf die Relevanz einzelner Methoden im jeweiligen klinischen Kontext und auf mögliche Fehlerquellen bzw. Limitationen. Ein möglicher Algorithmus für das Management von Dyspnoe im präklinischen Setting − vom ersten Kontakt bis zur Aufnahme bzw. bis zur Entlassung − wird graphisch wie schriftlich vorgestellt.AbstractDyspnea is a common symptom in emergency medicine and represents a diagnostic and therapeutic challenge. A multitude of differential diagnoses must be considered and checked but where there are indications of a life-threatening situation and also by rapidly reversible causes an (initial) treatment must be initiated without delay. Initially implemented should be those aspects relevant for an initial assessment and risk stratification which result from anamnestic details, clinical symptoms and immediately available screening tests. This article describes in detail the clinical and diagnostic instrumental armamentarium including implementation and interpretation. Also discussed are the relevance of individual methods in the respective clinical context and possible sources of error and limitations. A possible algorithm for the management of dyspnea in a clinical setting, from initial contact to admission or release, is presented graphically and textually.

Patients with dyspnea in emergency admission

Dyspnea is a common symptom in emergency medicine and represents a diagnostic and therapeutic challenge. A multitude of differential diagnoses must be considered and checked but where there are indications of a life-threatening situation and also by rapidly reversible causes an (initial) treatment must be initiated without delay. Initially implemented should be those aspects relevant for an initial assessment and risk stratification which result from anamnestic details, clinical symptoms and immediately available screening tests. This article describes in detail the clinical and diagnostic instrumental armamentarium including implementation and interpretation. Also discussed are the relevance of individual methods in the respective clinical context and possible sources of error and limitations. A possible algorithm for the management of dyspnea in a clinical setting, from initial contact to admission or release, is presented graphically and textually.ZusammenfassungDas im Bereich der Notfallmedizin häufige Symptom Dyspnoe stellt eine diagnostische wie therapeutische Herausforderung dar. Eine Vielzahl an Differenzialdiagnosen ist zu berücksichtigen und zu überprüfen, doch bei Hinweisen auf eine Bedrohung quoad vitam wie auch bei rasch reversiblen Ursachen ist eine (Erst-)Behandlung möglichst ohne Zeitverzug einzuleiten. Aufgeführt werden die für eine initiale Einschätzung und Risikostratifizierung relevanten Aspekte, die sich aus anamnestischen Angaben, klinischem Eindruck und ersten, direkt verfügbaren Screeningtests ergeben. Ausführlich beschrieben wird das klinische wie das apparative diagnostische Instrumentarium, einschließlich der Durchführung und Interpretation. Eingegangen wird auf die Relevanz einzelner Methoden im jeweiligen klinischen Kontext und auf mögliche Fehlerquellen bzw. Limitationen. Ein möglicher Algorithmus für das Management von Dyspnoe im präklinischen Setting − vom ersten Kontakt bis zur Aufnahme bzw. bis zur Entlassung − wird graphisch wie schriftlich vorgestellt.AbstractDyspnea is a common symptom in emergency medicine and represents a diagnostic and therapeutic challenge. A multitude of differential diagnoses must be considered and checked but where there are indications of a life-threatening situation and also by rapidly reversible causes an (initial) treatment must be initiated without delay. Initially implemented should be those aspects relevant for an initial assessment and risk stratification which result from anamnestic details, clinical symptoms and immediately available screening tests. This article describes in detail the clinical and diagnostic instrumental armamentarium including implementation and interpretation. Also discussed are the relevance of individual methods in the respective clinical context and possible sources of error and limitations. A possible algorithm for the management of dyspnea in a clinical setting, from initial contact to admission or release, is presented graphically and textually.