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Scientific progress with respect to the important role of various lipids in myocardial function and the dearrangements of lipid metabolism underlying ischaemic heart disease(s) has been con­ siderable in recent years. In 1986 alone, an overall number ofl 044 full papers covering the topics'Lipids-Heart-Heart Disease', have been published in a variety of biochemistry, physiology, pharmacology and cardiology journals (source: Index Medicus). They have broadened our in­ sight into the molecular basis of myocardial lipidology and the lipido-chemical basis of car­ diology in health and disease, and have narrowed the gap between promising pharmacological intervention in experimental animals and clinical treatment of patients suffering from an ischaemic heart. Furthermore, they illustrate the fundamental significance of the product of the union between basic and clinical science. The rapid development of knowledge in the'Lipids-Heart-Heart Disease'triad prompted us to organize the International Symposium on Lipid Metabolism in the Normoxic and lschaemic Heart, held in Rotterdam (The Netherlands) on September 22 and 23, 1986. This meeting was a coproject of the Department of Biochemistry I (Medical Faculty, Erasmus University Rotter­ dam) and the Department of Physiology (Medical Faculty, University of Limburg) and was held under the auspices of the GerritJan Mulder Foundation (named after a famous Rotterdam physi­ cian and chemist who lived from 1802-1880) whom we thank for their co-operation. The present volume is a compendium of invited papers and contributions selected from the posters presented during the symposium.

This book brings together papers presented at an international symposium on centrally­ acting antihypertensive agents held in Geneva, Switzerland, in association with the 10th Scientific Meeting of the International Society of Hypertension. A major focus of this symposium was the sympatholytic agent, clonidine, and was partly stimulated by the re­ cent development of an innovative transdermal system for administering this antihyper­ tensive drug. Although clonidine has been available to clinicians for several years, there has been a re­ cent reawakening of interest in this type of medication. The centrally-acting antihyper­ tensive agents appear to be effective both as monotherapy and in combination with other drugs. There are no significant contraindications to their use, and they do not appear to produce metabolic side effects. In this symposium we have paid attention to two types of patients: those with uncomplicated mild hypertension, and those with more difficult forms of hypertension associated with concurrent conditions.

Percutaneous Transluminal Coronary Angioplasty is presently the widest used non-surgi­ cal method for the treatment of stenotic lesions in coronary artery disease. Continuous development of the procedure and equipment has made complex and multi-vessel-inter­ ventions possible and has led to other techniques of intravascular angioplasty. In reviewing current results, this volume pays particular attention to causes, incidence, circumstances, recognition, treatment and outcome of complications of PTCA; it also considers restenosis, which still occurs at an unsatisfactory high rate after primarily successful procedures. To deal with these topics, experts on PTCA met to discuss their experiences and insights into peculiar aspects of complications in PTCA. The discussion was subdivided into: Recognition of complications; Complications in new interventional techniques; Management of complications; and Restenosis after angioplasty. The question of whether angiographic and pathological characteristics of sclerotic lesions allow the identification of complication-prone lesions in advance is discussed in the first chapter. One paper deals with the state of the art of digital cardiac imaging, which enables the operator to have an early knowledge of and adequate reaction to possible complications occurring during angioplasty. Special attention is directed to the so-called'high-risk'-PTCA, detailing the clinical variables, in order to have better knowledge about patients with a higher probability of unsuccessful or complicated procedures.

In addition to standardized casual blood pressure readings, ambulatory blood pressure monitoring (ABPM) - using automatic noninvasive (= indirect) devices for home readings and fully automated monitors for 24-h profiles - have become a widely used necessary tool in clinical research. This book summarizes the state of the art in the whole field of indirect blood pressure monitoring. It is based on two international meetings and on invited papers. We have divided the subject matter into two main areas: 1) Automatic blood pressure devices for discontinuous registration, and 2) Portable, fully automated programmable monitors for continuous monitoring. The availability of all new technologies is described in detail and current technical and physiological problems have been covered in depth. Both topics have been subdivided into a) Methods and Techniques, and b) Clinical Applications. Both parts are updated and have critically evaluated available automatic sphygmomanometers and portable computers equipped with different techni­ ques (e. g., auscultation, oscillometry, plethysmography). Reliability in the intensiv Care unit as well as in outpatients management, common clinical problems, clinical relevance compared to casual blood pressure are described in the first part. In the second part, ten years of experience on fully automated noninvasive methodology - compared to intraarterial techniques - have been elaborated by international experts; the possibilities and limitations are clearly demonstrated. Analyses in different clinical fields in the diagnosis of primary and secondary hypertension are given. Different statistical analyses of blood pressure variability and circadian rhythms are discussed.

Proceedings of a congress serve the purpose to provide the reader with the latest know­ ledge in the specific field. They present at least for a limited time period a reference book that allows rapid access to the latest information for the medical profession and for an ongoing of future research. This volume is addressed not only to the participants of the VIIth World Symposium on Cardiac Pacing but to everybody involved in diagnostic and therapeutic cardiac stimula­ tion. The experience has shown that proceedings of conferences of comparable size are usually published with a considerable time delay limiting its value as a source of prime informa­ tion. The editors of this volume decided therefore, that their most important task was to guarantee the actuality of the publication. Even if it seems desirable to include as many presentations of a conference as possible, the large number of excellent presentations at the VIIth World Symposium on Cardiac Pacing, 337 oral presentations and 236 posters, could not be published within an accepta­ ble time period. The experience from previous conferences has shown that a book which includes all the papers can only be edited with a large delay, which reduces the value and actuality of the information.

Dieses Buch erläutert nach Abhandlung der chemischen und physikalischen Grundlagen von Gewebeklebstoffen, ihre derzeitige Verwendung in der Humanmedizin, speziell in der Thorax- und Kardiovaskularchirurgie. Es begründet die Erweiterung und die Vorteile des Anwendespektrums durch neuartige Klebstoffe auf Resorcin-Basis. Diese Klebstoffe werden den bereits bekannten Cyanoacrylatklebstoffen sowie dem Fibrinkleber gegenübergestellt.

Die erste Auflage der Klinischen Vektorkardiographie meines früheren Ober­ arztes und jetzigen Vorstandes der III. Medizinischen Abteilung der Kranken­ anstalt Rudolfstiftung in Wien, Herrn Prof. Dr. RUDOLF WENGER, hat ihre Feuer­ probe bestanden. Als sie vor nunmehr zwölfJ ahren publiziert wurde, schien es -wie Prof. Dr. E. LAUDA in seinem Geleitwort zum Ausdruck brachte - ein Wagnis zu sein, diesem jungen Wissensgebiet eine Monographie zu widmen. Die Tatsache, daß WENGERS klinische Vektorkardiographie im deutschen Sprachraum die bisher einzige geblieben ist, bedeutet nicht, daß die Vektorkardiographie bedeutungslos ist, sondern betont die Stärke, di::: in WENGERS Arbeit gelegen war. Inzwischen hat das Wissen wesentlich zugenommen. Durch neue technische Verfahren und durch eine Vielzahl von inzwischen erschienenen Einzelarbeiten sind wesentliche neue Tatsachen erarbeitet worden, die die Neuauflage des Buches rechtfertigen. Eine Vermehrung der Seiten und der Zahl der Abbildungen war unvermeidlich. Durch Hinzuziehen zweier neuer Mitarbeiter konnte sowohl das technische Kapitel weiter ausgebaut (Dr. H. KAROBATH) als auch die moderne Datenverarbeitung mit her­ angezogen werden (Dr. Ing. R. KOECHLIN). Das Grundlegende an der Entwicklung der letzten Jahre ist aber, daß es sich eindeutig herausgestellt hat, daß die Vektor­ kardiographie nicht auf der konventionellen Elektrokardiographie aufbaut, sondern die Grundlage und Voraussetzung bildet, aus der sich die Kenntnis der konven­ tionellen Elektrokardiographie ableitet. So hat sich gezeigt, daß die Arbeit WEN­ GERS nicht einem Nebengeleise, sondern der Basis der Elektrokardiographie gewidmet war und ist. Möge dieser zweiten Auflage der'Klinischen Vektorkardio­ graphie'ein gleicher Erfolg wie der erstenbeschieden sein. E.

Ich habe die vorliegende Untersuchung schon vor dem II. Weltkrieg begonnen. Über die Höhe des Blutdruckes und die kardiavaskuläre Mortalität verschiedener weißer und namentlich farbiger Völker bestehen schwankende, unsichere und viel­ fach unrichtige Annahmen. Da diesem Problem eine physiologische, medizinische, anthropologische, entwicklungsgeschichtliche, versicherungsmedizinische und epi­ demiologische Bedeutung zukommt, so entschloß ich mich zu seiner Bearbeitung, und zwar auf Grund aller erreichbaren Blutdruckkollektive möglichst vieler weißer und farbiger Völker. Da die Literatur hierüber großenteils in schwer zugänglichen Organen verschiedener Wissenszweige in aller Welt verstreut ist, so war nicht nur die Auffindung, sondern auch die Beschaffung der einschlägigen Arbeiten sehr umständlich und sehr oft nur durch Einholung von Sonderdrucken möglich. Mit der Zeit sammelte sich aber doch ein unerwartet reiches Material bei mir an. Mit dem Einlangen neuer wichtiger einschlägiger Publikationen mußte das Manu­ skript mit seinen vielen Tabellen immer wieder ergänzt und umgearbeitet und wegen alsbald eingetretener Überschreitung des mir zugebilligten Buchumfanges schließlich mehrmals ausgiebig gekürzt werden. Alle damit verbundenen mühsamen und zeitraubenden Hilfsarbeiten oblagen ausschließlich meiner Frau MARGARETE STIGLER, deren äußerst gewissenhafte und verständnisvolle jahrelange Mitarbeit für die Vollendung meines Werkes unent­ behrlich war. Für die Herausgabe meines Buches spreche ich dem Verlag Dr. DIETRICH STEIN· KOPFF in Darmstadt und der Deutschen Forschungsgemeinschaft in Bad Godesberg für die Gewährung eines Druckkostenzuschusses meinen wärmsten Dank aus.

Since major prospective randomized multicenter studies (NASCET, ECST, ACAS) have assured the significant effect of the carotid reconstruction on stroke prevention, the main interest in carotid surgery focuses on modern radiologic procedures, new aspects in surgical technique, and perioperative region, paricularly of the carotid artery is, therefore, also best treated in an interdisciplinary way involving the neurologist, angioradiologist, and vascular surgeon. These current themes need to be discussed and constantly revised with new developing aspects.

Symposium, Munich, October 26-29, 1983

'Predisposing conditions for acute ischemic syndromes'contains the proceedings of a conference held in Garmisch-Partenkirchcn, West Germany, October 14 and 15, 1988. The editors of this volume arc most grateful to the authors for their effort to provide manuscripts before the meeting, to the sponsor, Bayer AG, for their gen­ erous support, and to the publishers for the efficient collaboration, all of which have made the appearance of this book possible. All authors contributed their manu­ scripts in advance and they arc combined with an edited version orlhe discussions to allow rapid publication. In coronary heart disease the prognosis for patients is largely determined by the occurrence of irreversible ischemic damage to the myocardium. Irreversible eveniS are certainly preceded by a destabilization of a former stable situation. This desta­ bilization may occur with increasing symptomatology or without apparent warning signs to patient and physician; it may occur over a longer time period or very sud­ denly. The statemenl, however, holds true that no patient has ever died from stable angina pectoris. Thus, if the prognosis for patients with ischemic heart disease is to be improved, the focus has to be set on recognition and treatment of unstable ischemic syndromes. It was the goal of the conference to gather scientists and clinicans from different fields of research, to get an up-to-date view of the different aspects of unstable ischemic syndromes and to foster interdisciplinary discussions.

Inotropic stimulation of the myocardium, as well as vasodilation and diuresis as essential principles in the treatment of congestive heart failure have recently met with considerable criticism and reevaluation. It is generally agreed that unloading of the heart, either through vasodilation and/or diuresis, improves the working conditions of the dilated, failing heart. It reduces myocar­ dial oxygen consumption through reduction of chamber radius and, thereby, wall tension as the major determinants of myocardial oxygen consumption. Inotropic stimulation, quite in contrast, does not conserve oxygen. It rather consumes energy and that may be disadvantageous in situations of compromised oxygen supply and energy metabolism of the working myocardium. However, under conditions of suf­ ficient oxygen supply and metabolic support inotropic stimulation may bring about in­ creased pumping and subsequent improvement of myocardial failure. In recent years it could convincingly be demonstrated that vasodilation leads to symp­ tomatic improvement of congestive heart failure, improvement of exercise tolerance, and it prolongs life - especially in the case of ACE-inhibitors and the combination of hydra­ lazine with long-acting nitrates. Quite in contrast, equally beneficial effects could not be demonstrated for inotropic agents in congestive heart failure. Only for the cardiac glyco­ sides has it been shown that beneficial effects can be achieved, especially if atrial fibril­ lation with absolute arrhythmia is present. The influence of the cardiac glycosides on the latter represents an effect which is independent of the inotropic action.

It was a great pleasure for us to welcome so many experts from all over the world to our symposium in Aachen. We are also pleased - and you can attribute this to my own vanity - with the success and acceptance of the concept of myocardial reperfusion and revascularization - specifically selective intracoronary lysis followed either by PTCA or bypass surgery - which we have been pursuing since 1979. But after the dramatic immediate effects of the first attempts, which you have to experience yourself, we did not expect it to be any different. We decided against performing a randomized study in which every patient is catheterized, and thrombolytic therapy only given to some of the patients, for which we have been criticized at times. At the previous symposium in Aachen in 1983 on the topic of thrombolysis for acute myocardial infarction, in the final session several speakers were asked directly about this topic, and replied that if they were patients they would not want to be randomized into the placebo group. In the meantime positive results from large, randomized studies have been recorded, which are presented in this volume. I mention in particular the Western Washington Study from Dr. Kennedy and the Interuniversity Study in Holland. Aachen, a relatively small city with 250,000 inhabitants, provided the opportunity to treat a relatively large patient population with acute myocardial infarction.

Herzerkrankungen und Sport – also Sportkardiologie – das medizinisch bedeutsame Thema stößt angesichts plötzlicher Todesfälle prominenter Sportler auch auf öffentliches Interesse. Im deutschsprachigen Raum existiert hiermit das erste Buch, das Empfehlungen zur Wettkampfsporttauglichkeit bei Herzkreislauferkrankungen gibt. Die einzelnen Sportarten mit ihren unterschiedlichen Beanspruchungsprofilen werden differenziert beurteilt. Unter Berücksichtigung des Schweregrades wird das gesamte Spektrum möglicher Fragestellungen, vom Top-Athleten bis zum vermindert belastbaren Patienten, behandelt. Darüber hinaus wagen die Autoren den Spagat zwischen Wettkampf- und Gesundheitssport im Sinne präventiver und rehabilitativer Betätigung. Anhand des derzeitigen Datenmaterials werden konkrete Empfehlungen für die Sportpraxis abgeleitet. Das Buch wendet sich in erster Linie an Sportmediziner und internistisch-kardiologisch tätige Ärzte, um deren Entscheidung bei der Beurteilung von Sporttreibenden zu erleichtern.

Detailed analyses of regional myocardial blood flow, function, metabolism and morphology in ischemic and reperfused myocardium have led to the identifi­ cation of important phenomena, i. e., myocardial hibernation, myocardial stun­ ning and ischemic preconditioning. Both the hibernating and the stunned myocardium characterize viable though dysfunctional as distinguished from necrotic tissue. With the advent of reperfusion procedures, the distinction between reversibly injured, hypofunctional myocardium from irreversibly injured, hypofunctional myocardium is of utmost clinical importance. The pathophysiological distinction of hibernating and stunned myocardium is con­ troversial, but reperfusion is mandatory anyway. Ischemic preconditioning is the most powerful maneuver known so far to delay infarct development. Its clinical significance has been suggested from retrospective analyses of data from patients suffering a myocardial infarction as well as from controlled PTCA studies. Whether or not preconditioning can be achieved pharmacologically in the clinical setting remains to be established. The mechanisms and signal cascade underlying myocardial hibernation, myocardial stunning and ischemic preconditioning are not clear in detail. Over the last year, focussed issues on myocardial hibernation, myocardial stunning and ischemic preconditioning were published in Basic Research in Car­ diology; they have received great interest and a good response. Therefore, these focussed issues are now combined and published as a separate monograph. We express our gratitude once more to all our colleagues who contributed to this monograph, to Ms. Ibkendanz of Steinkopff, and to Ms. Philipp and Mr. Heinrichs from Bayer AG Germany, who supported this additional publication.

The availability of new technologies that enable blood pressure to be measured and re­ corded continuously or repetitively during prolonged observation periods has created ex­ citing opportunities for studying the physiology of blood pressure regulation and the characteristics of clinical hypertension. Ambulatory blood pressure monitoring has been based on three types of approach. The first of these has utilized an intra-arterial catheter that allows blood pressure to be meas­ ured directly and continuously during a full 24-hour period. The second approach is based on non-invasive techniques, and utilizes devices capable of automatically inflating conventional arm cuffs and recording blood pressures at pre-set intervals throughout the day. The third, and most simple method, has depended upon semiautomated techniques that require the subject to inflate a cuff at convenient intervals during the period of obser­ vation. During the last few years, concerted research into these differing techniques has exposed their strengths and shortcomings. Overall, however, there has been a growing perception that these approaches to the measurement of blood pressure might add con­ siderably to the information obtained in the doctor's office by the traditional single or casual reading. This book summarizes the state of the art in ambulatory blood pressure monitoring.

Assessment of cardiac energetics at the level of ATP-synthesis, chemomechanical energy transformation and whole organ dynamics as a function of haemodynamic load, ventricular configuration and oxygen- and substrates supply is basic to understanding cardiac function under physiological and pathophysiological (hypertrophy, hypoxia, ischaemia and heart failure) conditions. Moreover, cardiac energetics should be an important consideration in the choice and application of drugs especially in the case of vasodilators, inotropic agents and in cardioprotective measures. Only by considering energetics at the subcellular, cellular, and whole-heart level we can arrive at a better understanding of cardiac performance and ultimately better clinical judgement and drug therapy. Quantification of myocardial energetics will also help to determine the optimal time for surgical interventions such as valvular replacement or aneurysm resection. The present volume is the outcome of an international symposium on cardiac energetics held in Gargellen/Montafon (Austria), June 1986. The contributions will certainly help bridge the existing gap between basic research involving isolated structures and that involving the whole organ, on the one hand, and render the results derived from basic research applicable to clinical problems, on the other hand.

Since the development of the first laser generator by Maiman in 1960, laser energy has gained increased interest and has subsequently been used in various fields of applica­ tion. Due to its high energy density, combined with a sharply defined irradiation field, laser has aroused great expectations, especially since laser beams have been used very successfully in various fields especially technology and medicine. Medical and surgical applications of the laser were among the first and have been of undisputed benefit in, for example, ophthalmologic interventions such as coagulation of the retina, or for endoscopic tumorectomy in the bronchial, gastrointestinal and urogenital tracts. Consequently, considerable research effort was made to also apply laser techniques in interventional cardiology for the treatment of atherosclerosis, aimed at removing plaque material from stenosed tissue or occluded ateries and recanalizing tough and calcified segments unsuitable for the well-extablished technique of balloon dilatation. Ablating atheroma rather than pushing it aside was thought to achieve better results. However, it was found that the laser may create rough-edged cuts partly with substantial thermal or mechanical damage to the surrounding tissue, consequently provoking preconditions for unwanted restenosis. Different types of laser generators and probes have therefore been investigated in arterial vessels, mostly focusing on indirect laser effects. Intravasal probes with laser­ heated metal tips were used, as well as balloon catheters with an incorporated laser fiber designed to heat the surrounding tissue outside the balloon and to, ineffect,'iron out the plaque'.

The bicentenary of William Withering's now famous medical report entitled'An Account of the Foxglove and Some of its Medical Uses'has given us the occasion to analyze the state of the art. Cardiac glycosides in 1985 are considered tobe the basis for medical treatment of myocardial failure, together with diuretics and vasodilators in the more severe cases. Nevertheless, the controversy as to their exact place in the treatment of heart failure with sinus rhythm has never ceased. Although cardiac glycosides are of unquestionable value in tachycardia caused by atrial fibrillation or atrial flutter, the chronic use of these drugs in sinus rhythm is not generally accepted. The development of tolerance has been reported. It is of interest that Withering hirnself wrote:'-let it (foxglove) be continued until it either acts on the kidneys, the stomach, the pulse, or the bowels; Iet it be stopped upon the first appearance of any of these effects, and I will maintain that the patient will not suffer from its exhibition, nor the practitioner be disappointed in any reasonable expectation.'In West Germany alone, more than three million patients (about 5% of the total population) are constantly taking cardiac glycosides. These drugs are the most prescribed medicaments in many countries. Thus, we considered it worthwhile and necessary to review in a critical way today's knowledge about the foxglove; to report new findings and to evaluate old Statements.