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Polypills used in cardiovascular prevention contain combinations of aspirin, lipid-lowering drugs and blood pressure-lowering drugs. The use of polypills can improve adherence while physicians express concerns about therapy safety and flexibility., Competing Interests: Philip Böhme ist Teilzeitmitarbeiter der Bayer AG. Alle anderen Autoren geben an, dass keine Interessenkonflikte bestehen., (© Georg Thieme Verlag KG Stuttgart · New York.)

The management of chronic medication in the perioperative phase represents as a serious challenge for the involved physicians. Especially patients with elevated ASA-scores frequently suffer from multiple co-morbidities which often need numerous medications. The probability of pharmacological interactions rises with the number of these medications. Moreover it must be taken into consideration that chronic medication potentially interferes with both intravenous and inhaled anesthetics and moreover, bleeding complications are more likely to occur in patients undergoing chronic pharmacotherapy. The aim of this article is to provide a summary of the existing evidence concerning perioperative medication in patients undergoing non-cardiac surgery. Several guidelines and advisories dealing with cardiovascular medication have been published during the last decade. The main scope of these publications was on beta-blockers and other cardiovascular medication. There is less evidence on not-cardiovascular medication as in most cases only case reports and expert opinions are published. Existing epidemiologic studies on this topic are rather heterogeneous., (© Georg Thieme Verlag KG Stuttgart · New York.)

In November 2009 the first European guidelines were presented regarding preoperative risk assessment and perioperative management in non-cardiac surgery. They were designed by the European Society of Cardiology (ESC) and endorsed by the European Society of Anesthesiology.In a standardized manner, patient-specific clinical variables, their exercise capacity and surgery-specific risk factors are summarized to a recommendation concerning medication and preoperative cardiac evaluation. These guidelines are straightforward and feasible for cardiologists as well as specialists in internal medicine and general practicioners. Nevertheless, some points still lack evidence.

All patients should undergo surgical procedures in the most stable and favourable condition with a continuation of chronic medication. Accordingly, this medication should be continued until the day before surgery in most patients. The preoperative period should be used to evaluate the completeness and quality of the medical treatment. Are all patient with cardiological indications for beta-receptor blocking agents, ACE-inhibitors and statins treated with these drugs? Is diabetes being adequately treated? Are the doses of the medication for the treatment of thyroid dysfunction within the optimal range? If there is room for improvement, adjustments should be done cautiously and well in advance. In contrast, there are no recognised situations in which a medication should be started preoperatively in the absence of a pre-established chronic indication. Management of antiplatelet agents and cumarins requires careful consideration. The hazards of continuing and withholding treatment must be evaluated. In patients who have suffered a cardiovascular event and/or have undergone (coronary) revascularisation, elective surgery must be delayed for weeks or months depending on the circumstances and the devices used.

Secondary prevention in patients with coronary heart disease includes treatment with platelet inhibitors, beta-blockers, ACE inhibitors or AT (1)-blockers, and statins. Initiation of therapy generally does not require a slow gradual dose increase. In treatment naive patients with acute coronary syndromes, administration of a loading dose of aspirin and/or clopidogrel is recommended. To reduce flushing, nicotinic acid should be initiated at low stepwise increasing dosages. beta-blocker therapy should not be stopped acutely in coronary heart disease patients. If beta-blocker therapy has to be terminated, blood pressure should be monitored closely and, if necessary controlled with other medication. Termination of statin therapy in the acute phase after strokes or acute coronary syndromes is associated with increased cardiovascular events and should therefore be avoided.

As a consequence of our "western" diet and lifestyle, the risk for cardiovascular diseases is increased in the western world. It can be decreased by influencing the LDL-cholesterol values, the blood pressure and the platelet aggregation. It is, however, not proven that lowering of serum homocysteine levels reduces the risk forcardiovascular diseases. Wald and Law suggest in their epidemiological study a polypill, which has as its ingredients a statin, an anti-hypertonic drug, folic acid, and aspirine. Overall, the risk reduction by a polypill is overestimated, since a threshold is currently not existing, in all drugs side effects and interactions are possible, pharmaceuticals are only labelled for specific indications, and with missing efficacy there could be a negative risk-benefit-relation. Indeed, a combined therapy with different drugs is in place in patients with higher risk and for secondary prevention, which is already risk-adjusted. The use of effective drugs, however, in patients without evidence of a positive risk-benefit-relation and without medical control cannot be justified. Therefore, the application of the polypill for subjects beyond 55 years of age is an illusion; by contrast, treatment of patients with a high risk for atherosclerotic diseases is already reality.

To prove the efficacy of drugs in patients with chronic systolic heart failure, taking into consideration certain criteria is necessary for the planning and performance of the clinical investigation of medicinal products. For the different stages and the collective of patients those criteria include the definition of the corresponding endpoints, adequate study design, appropriate randomisation, blinding, the choice of an appropriate dose, valid methods of examination, the correct sample size estimation and analysis. If these criteria will b e used, the besttherapy for the different stages can be ascertained.

In 18 horses, the pulmonary artery wedge pressure and the heart rate were measured during pharmacological stress load. 12 horses were healthy (4 trained, 8 untrained) and 6 horses had a heart disease (3 trained, 3 untrained). Pharmacological stress induction was carried out with the sympathomimetic drug dobutamine at a dosage rate of 7.5 microg/kg/min over 10 minutes of infusion. At the fourth minute, the parasympatholytic drug atropine was administered (5 microg/kg bw), and the heart rate and the pulmonary artery wedge pressure were continuously measured over 26 minutes. During sole dobutamine infusion, a significant decrease in heart rate and a significant increase in pulmonary artery wedge pressure were observed. After the application of atropine in the fourth minute, a significant increase in heart rate (from 35.7 +/- 6 up to 106 +/- 38/ min) and in pulmonary artery wedge pressure (from 15.7 +/- 3 up to 24 +/- 8.6 mmHg) were visible in the group of healthy horses. The horses with heart diseases had a significantly higher increase in both parameters (heart rate and pulmonary artery wedge pressure) with a significantly positive correlation (r = 0.7). The heart rate increased in the horses with heart diseases from 35.2 +/- 2,8 beats/min up to 132 +/- 45.7 beats/min and the pulmonary artery wedge pressure increased from 17.3 +/- 3,2 mmHg up to 32.7 +/- 13 mmHg. The cardiac status (healthy or heart disease) as well as the training level of the horses (untrained or trained) had a significant influence on the heart rate and the pulmonary artery wedge pressure. The untrained horses (healthy and heart disease) showed significantly higher values over a longer period of time than did the trained horses with the same cardiac status. Additionally the influence of pharmacological stress induction on echocardiographic parameters was investigated. The left atrial size (p = 0.015) and left ventricular diameter were significanly different in the systole (p = 0.008) and in the diastole (p = 0.001) between healthy horses and horses with heart diseases. All horses showed a positive correlation between the pulmonary artery wedge pressure and the left atrial size (r = 0.8), as well as between the left ventricular systolic (r = 0.6) and the diastolic diameter (r = 0.6). The correlation between the pulmonary artery wedge pressure and the left atrial size was nearly the same in the healthy horses (r = 0.74) and in the horses with heart diseases (r = 0.76). Regarding the training level, all untrained horses had a significantly higher correlation between the pulmonary artery wedge pressure and the left atrial size (r = 0.87) in comparison to the trained horses (r = 0.74). Particularly in the untrained horses with heart diseases, this correlation was remarcable (r = 0.99).

To prove the efficacy of the treatment of atherosclerotic stable peripheral arterial occlusive disease with drugs certain criteria are to be considered in the context of the design and performance of clinical trials. These criteria refer to the design of the study, randomisation, blinding, inclusion and exclusion criteria, definition of outcomes, methods of examination, sample size estimation, and evaluation of the results. If these criteria and conditions are not taken into consideration, false positive and negative results can arise. In the present study, the criteria to prove the efficacy of vasoactive substances in the treatment of atherosclerotic peripheral occlusive arterial diseases are presented.

Sepsis is the most important reason for death among intensive care patients. This review will cover the actual definition of septic shock, and the difficulties regarding the diagnosis of sepsis. The principles of management of sepsis, the recently established principles as early goal directed therapy, low dose steroid substitution, insulin therapy, and the activated protein C are discussed.

The pharmacological evaluation of medications used in secondary prevention of myocardial infarction offers interesting insights that facilitate the individualization of therapy. One example is the strong evidence of a reduced patient benefit with comedication of ACE inhibitors and acetylsalicylic acid after myocardial infarction. Over the past years, the effects of n-3-polyunsaturated-fatty acids after myocardial infarction have been investigated intensely. They act via several physiological mechanisms that are of potential benefit in reducing cardiovascular mortality. While epidemiological and study data suggest antiarrhythmic properties as the main reason for reduced mortality, recent papers also point to a intensification of plaque stability.

Chronic heart failure (CHF) impairs quality of life (QoL) much stronger than other chronic diseases. The objective of this evaluation was to assess the effect of a new integrated comprehensive outpatients rehabilitation program on somatic parameters and quality of life in 51 patients with stable CHF. After rehabilitation, left ventricular ejection fraction, NYHA class, and parameters of sub-maximum and maximum exercise capacity improved significantly between 11 and 20%, and 6-minute walking distance by 58% on average (p < 0.0001). Non-disease specific QoL (Short Form-36 questionnaire) improved in only 2 of 8 subscales (physical functioning [effect size 0.38, p < 0.001], and role functioning [effect size 0.17, p < 0.05]), and a mental component score [effect size 0.47, p < 0.0001]. Disease-specific QoL (Minnesota Living with Heart Failure questionnaire) improved in terms of sum score [effect size 0.24, p < 0.0001], and physical component score [effect size 0.35, p < 0.0001]. Improvement in exercise capacity correlated significantly with improvements in parameters of disease-specific QoL.

History and Clinical Findings: A 48-year-old patient with dilated cardiomyopathy complained of dyspnea at rest, severe sleeplessness and a slight pain in the stomach. The clinical examination was normal except for a murmur at the apex of the heart. There was no evidence of edema or congestion of the jugular veins., Investigation: The echocardiography demonstrated a dilated left ventricle with severely compromised function. No ventricular thrombi were present at this time. Coronary artery disease was excluded by coronary angiography. Endomyocardial biopsies were obtained from the right ventricular septum. The immunohistological analysis of the endomyocardial biopsy specimens revealed pathologically increased lymphocytic infiltrates and increased expression of interstitial and endothelial MHC I and II antigens. Flow cytometric analysis of platelets surface antigens (P-selectin, GP53, thrombospondin) was performed as a measure for intravasal platelet activation. Our patient compared to a healthy control group (> 4 SD) and to other patients with dilated cardiomyopathy (> 2 SD). A high grade increase of platelet activation was found., Treatment and Course: ACE inhibitor, diuretics, spironolactone and digitalis were used to treat the heart insufficiency. Due to the severe left ventricular dysfunction phenprocoumone and aspirin were also prescribed. A follow-up echocardiography was performed 6 months later. Comparable to the first examination left ventricular contractility was found to be severely reduced. In addition, a marginal thrombus was now present in the left ventricle despite antithrombotic therapy., Discussion: An increased platelet activation was found in the peripheral circulation of our patient with dilated cardiomyopathy. After 6 months, ventricular thrombi were found in the dilated ventricle, although aspirin and phenprocoumone had been administred. We speculate that an additional thrombotic treatment with clopidogrel is necessary in patients with dilated cardiomyopathy and increased platelet activation.

The prospective study compares prescribed drugs of 192 primarily cardiological patients at discharge and 7 weeks later in ambulatory care. The data were determined by discharge summaries and by standardized patient-questionnaires. The drug division was made with the ATC-classification according to the recommendations of the World Health Organisation for Drug Utilisation Studies. The intraindividual cost comparison was calculated by current pharmacy sale prices. The findings were changes in hospital discharge medications in ambulatory care in over 2/3 of the cases. The most frequent change was the additional prescribing of drug groups. The average daily tablet number increased in patients with the same or worsened subjective feeling after discharge. Additionally we found in a number of patients a change of drug therapy within the ATC-groups, or in fact, withdrawal of drug therapy all together. The frequency of changes increased with the number of patient/doctor contacts. The observation that the average daily therapeutical cost decreased just slightly could give an indication that cost saving was a minor part of the doctors decision for drug changing. However, the frequency of changes has shown to be dependent upon the specialities of the physician or pharmaceutical group.

Application of highly concentrated short-acting vasoactive drugs in the critically ill patient requires precisely working syringe pump systems for continuous intravenous drug delivery. We performed a bench study to investigate the consequences of small amounts of air entrapped within a 50-ml infusion syringe. In particular we studied the effect of entrapped air on drug delivery after moderate vertical displacement of the pump by 50 cm (e.g. in preparation for transport) and the effect on the time required to trigger the pressure alarm after occlusion of the infusion line. At a flow rate of 1 ml/h, lowering the syringe pump prolonged the zero-drug delivery time from (mean +/- SD) 4.1 +/- 0.8 min (without air) to 6.2 +/- 0.9 (with 1 ml air) and to 13.1 +/- 0.9 min (with 2 ml of air, p < 0.001 for all comparisons). Entrapping of 2 ml of air within the syringe resulted in a 2.6-fold prolongation of the occlusion alarm time after accidental occlusion of the infusion line and a 3-fold increase of the resulting infusion bolus after occlusion. Enclosed air within infusion syringes considerably affects the syringe compliance. It increases the susceptibility of constant drug delivery to vertical displacement of syringe pumps and impairs the occlusion alarm function. Therefore, any air in syringe of infusion pump systems should be carefully removed. To avoid infusion boluses of short-acting vasoactive drugs after accidental occlusions, the occluded infusion line should be released to ambient pressure first.

Hypertensive crisis is defined as an extreme elevation of arterial blood pressure, with diastolic pressure > 120 mm Hg, and represents an imminent risk to the patient. In such cases, a rapid orientating diagnosis and adequate antihypertensive treatment to avoid sequelae are needed, sometimes even before diagnostic tests are completed. Hypertensive emergencies and hypertensive urgencies can be distinguished. If the critical increase in blood pressure is associated with end-organ damage such as encephalopathy, acute left heart failure and pulmonary edema, angina pectoris, myocardial infarction or dissecting aortic aneurysm, a hypertensive emergency is present, that is an acute threat to the patient's life. A hypertensive emergency requires effective lowering of blood pressure within minutes, but not necessarily to normal range. The choice of suitable antihypertensive agents depends on clinical symptoms, contraindications, duration of pressure elevation and underlying conditions, prior cardiovascular, cerebrovascular and renal disorders. The risk of imminent end-organ damage must be weighed against the risk of rapid blood pressure lowering. In hypertensive urgencies without end-organ complications, blood pressure can be lowered more slowly over several hours, often with oral agents to avoid detrimental fall in blood pressure. The drugs of choice are mainly urapidil i.v. and nitroglycerine.

By the measures of basic life support (BLS) as well as those of advanced cardiac life support (ACLS) a large portion of the 8,000 to 10,000 victims of sudden circulatory arrest in Switzerland might be resuscitated successfully without permanent neurological deficits. Prerequisites are an early installation of measures as well as the control of the rationale and the individual techniques by trained personnel. The single most important measure is electric defibrillation of ventricular fibrillation. With the aid of automatic defibrillators it can be made available to a wider range of users. Pharmacotherapy is of minor importance.

Administration of highly concentrated, highly potent, and therefore highly dangerous drugs with syringe pumps is common in modern anaesthesia as well as in intensive care and emergency medicine. Because of their exact flow rates down to < 1 ml/h, these pumps are predestined for delivery of drugs with short half-lives, such as catecholamines and vasodilators. But intravenous application of drugs with syringe pumps is not without problems. While it is well known that syringes not fixed correctly into the pump can empty themselves by the influence of gravity, it seems not to be known that hydrostatic pressure can influence the flow rate of a correctly connected system even during continuous infusion. In this situation a change of height of the syringe pump in relation to the patient's position can have tremendous effects on hemodynamics due to unintended acceleration or deceleration of the flow rate. This case report demonstrates that the elevation of a connected epinephrine pump while moving a cardiac surgery patient after ACB operation from the operation table into his bed led to critical increases of heart rate, blood pressure and left atrial pressure. In order to quantify the problem we repeated the situation experimentally. It could be demonstrated that the elevation of the syringe pump by 80-100 cm delivers an additional bolus of 4-5 drops as the central venous catheter outlet. Lowering the pump consecutively leads to the opposite effect. In the case reported, the accidentally administered bolus of epinephrine was 12-15 micrograms (we use a concentration of 60 micrograms/ml epinephrine for continuous infusion with syringe pumps). From this accidental observation the following conclusion can be drawn: The change of height, in relation to the patient's position, of a running syringe pump during continuous infusion of highly concentrated cardiovascular drugs may cause considerable, even life-threatening hemodynamic disorders. Even in a closed infusion system (syringe-extension-central venous catheter), hydrostatic pressure influences infusion rate. Elevation of the pump leads to unintended bolus administration, and lowering of the pump is followed by an interruption of the infusion. In the knowledge of this phenomenon, unexpected hemodynamic reactions during transport of critically ill patients cannot always be interpreted as a result of inadequate anesthesia or volume load, but may be a consequence of incorrect handling of the syringe pumps as described in this report.

Aim: The perioperative risk in patients undergoing coronary artery bypass grafting (CABG) might be influenced by premedication procedures. This study was undertaken to evaluate present premedication regimens in CABG patients in Germany., Methods: Using a detailed written questionnaire, each of the 58 German centres of cardioanaesthesia were asked to complete it., Results: 37 (64%) of all questionnaires were returned and analysed. All centres used orally administered drugs for premedication in the evening before the operation. Flunitrazepam is the most often administered drug (54%), followed by dipotassium clorazepat (8%), and diazepam (8%). Premedication in the morning on the day of surgery is performed orally in 29 centres (78%), of which 18 centres (49%) prefer flunitrazepam and 6 centres (16%) midazolam as first choice. In contrast, 7 centres (19%) used intramuscularly administered regimens. 5 centres (14%) combined intramuscularly opioids with sedatives for that indication. If anaesthesia was induced late in the morning or in the afternoon, respectively, 11 centres (30%) administered additional benzodiazepines early in the morning. 68% of all centres maintained the administration of chronic treatment with ss-blockers until the morning of the operating day. Chronic treatment with nitrates is continued in 65%, treatment with calcium-channel blockers in 62%. Angiotensin converting enzyme inhibitors are continued in 30%, alpha 2-agonists in 27%, other antihypertensive drugs in 19%, and inotropic glycosids in 11%. 31 of 37 centres (84%) discontinued the administration of acetylsalicylic acid 5 or more days prior to surgery, but 68% tolerate individual exceptions from this principle., Conclusions: The results of our survey indicate that most of the German cardioanaesthesia centres use oral premedication regimens in patients undergoing coronary revascularisation. Anti-anginal medications, with the exception of anti-platelet agents, were continued until the day of surgery in most of the centres.

In a double blind pilot study, we examined the effects of the stable prostacyclin derivate taprostene compared to a combination of aspirin and dipyridamole on platelet uptake and clinical outcome after peripheral percutaneous angioplasty. Taprostene was administered to 19 patients as a continuous intravenous infusion from 2 hours before until 8 (n = 6) or 24 (n = 6) hours after angioplasty; 7 control patients were given a combination of 330 mg aspirin and 75 mg dipyridamole. Uptake of 111-indium labelled platelets at the site of the PTA was measured 3 hours before and 4 and 24 hours after angioplasty. Clinical parameters were obtained one day before PTA, on the following day and 3 months after the procedure. There was a tendency for slightly higher platelet uptake ratios in the taprostene groups as compared to the control group especially in patients requiring technically difficult procedures. There were no differences between the 3 groups with regard to primary success or periinterventional complications. In the taprostene patients, 3 early reocclusions were found up to 72 hours after the procedure and 1 late reocclusion within 3 months. In the control group, no reocclusion was apparent in the observation time. No advantages were found when taprostene was administered during angioplasty as compared to conventional treatment with aspirine and dipyridamole.

One of every four persons in the Western industrialised nations has cardiovascular disease. The perioperative setting in those patients is associated with the risk of myocardial ischaemia (PMI) and myocardial infarction, and also with the risk of perioperative stroke and dysfunction of the central nervous system (CNS). Perioperative cardiovascular morbidity represents a major healthcare challenge. The relevance of PMI is well documented. It has been demonstrated in early trials that both myocardial ischaemia and infarction are preventable in high-risk patients undergoing surgery, and that therapeutic agents such as adenosine-related agents, alpha 2-agonists, and other stress modulators can be safely administered to these patients. Regarding perioperative stroke, approximately 3 to 7% of patients undergoing cardiac surgery suffer stroke, with an additional 30% or more suffering in-hospital CNS dysfunction, and 10% suffering moderately severe long-term CNS dysfunction. Few data are available for noncardiac surgery. The number of outcome studies addressing prophylactic or therapeutic options in these patients is quite limited. In fact, only one recent study has established that perioperative stroke is preventable with the use of an adenosine-regulating agent. Thus, it appears that it may be possible to prevent stroke, even though these results require confirmation. Because of the aging of our population, and the medical, financial and social impact of cardiovascular disease, the development of anti-ischaemic therapy, particularly in the surgical patient, will be a critical area of medical research for the next several decades.

Physiological functions as well as pathophysiological events--angina pectoris, myocardial infarction, sudden cardiac death--display pronounced circadian rhythms. Clinical studies also give evidence for a circadian phase dependency in the pharmacokinetics of cardio-vascular active drugs. Thus, a circadian phase dependency in the dose-response relationship of drugs has to be taken into account.

In recent years, several of the shortcomings of coronary angioplasty have been successfully countered. With more effective measures of treating acute complications, better equipment and more experienced operators, there has been a subsequent expansion of the indications and the type of lesions suitable for angioplasty. In the long-term, however, the restenosis rate remains the limiting factor for the success of the procedure. To date, clinical studies using systemic therapy or alternative instrumental devices have not convincingly demonstrated a benefit in preventing restenosis. New devices have mostly been used to manage complications at angioplasty or to increase the type of lesions that can be tackled transluminally. This article will describe recent findings relating to the pathology of restenosis and then discuss a new therapeutic concept, local drug delivery to suppress restenosis. The aim of this method of drug application is to achieve a high local concentration of agents that inhibit restenosis, while avoiding systemic side-effects. Possible substances which could be utilized in this manner include conventional therapies such as platelet or calcium antagonists, or anti-thrombotic, anti-inflammatory or anti-proliferative treatments, and also novel agents such as gene therapy. The latter strategy might include inhibition of certain stimulatory factors that control restenosis, for example, through antisense oligonucleotides, or alternatively, augmentation of naturally occurring inhibitory factors, perhaps with expression vector plasmids and virus-mediated gene integration. The various ways in which these substances can be locally delivered to the arterial wall, together with results from initial experimental studies will be summarized. It is possible that eventually the combination of effective treatments with local drug delivery (LDD) may at last resolve the restenosis problem in patients.

Emergencies in pediatric cardiology are heart failure, cyanosis and rhythm disturbances. The signs of heart failure are tachycardia, tachypnea and hepatomegaly. The therapy consists of oxygen, diuretics and digoxin. Occasionally, intubation with mechanical ventilation and intravenous catecholamines are needed. Cyanosis is often the only sign of a severe heart malformation, and prompt hospitalization is mandatory. Oxygen and warm environment is important during transport, correction of a possible metabolic acidosis and prostaglandin infusion are done in the hospital. Beyond the newborn period, so-called cyanotic spells are seen, particularly in tetralogy of Fallot. In supraventricular tachycardia, vagal manoeuvres can be tried first, if not successful, intravenous adenosine or electroconversion will restore sinus rhythm. In the older child, intravenous isoptin can be given. Slow heart rates from total AV block or sinus node affection are treated with atrophic, isuprel or electrical pacing.

Left ventricular failure has been subdivided into different forms. Systolic pump failure (= systolic dysfunction) and diastolic filling failure (= diastolic dysfunction) are important entities in the overall framework of heart failure. The clinical patterns of both are presented in light of 2 case reports: systolic dysfunction involves the combination of left ventricular failure, cardiomegaly and depressed systolic ejection fraction. Diastolic dysfunction is accompanied by pulmonary congestion in the presence of a normal or only slightly enlarged ventricle and a normal ejection fraction. Prognosis of systolic dysfunction is poor, with a 5-year survival rate of 40%, compared to 70% in patients with isolated diastolic dysfunction. Medical treatment of systolic dysfunction is based primarily on ACE-inhibitors followed by diuretics and digitalis. Betablockers in low doses and spironolactone can provide additional benefit. Calcium channel blockers are rarely indicated, due to their negative inotropic effects. In patients with diastolic dysfunction, however, they are the first choice because of their positive lusitropic effect on relaxation and ventricular filling. ACE-inhibitors are suitable in hypertensive heart disease, while diuretics and betablockers are second line drugs. Digitalis should be avoided since worsening of diastolic function may occur.

Prevalence of type 1 silent myocardial ischemia (SMI; completely asymptomatic patients) is reported to appear 2 to 4% of the general population. The prognosis of these patients is said to be similar to that of patients with angina pectoris. Our study investigated a 10-year follow up of silent myocardial ischemia detected by bicycle exercise testing in comparison to a comparable control group. 10 years later 127 patients were reinvestigated by bicycle ergometry, 33 patients out of the SMI-group (group A) and 84 patients out of the control group (group B). Mean age in group A was 62 +/- 7 years (range 42 to 71 years), in group B 56 +/- 7 years (range 29 to 69 years). After 10 years there was no statistical significant difference between the 2 groups on using beta-blockers, calciumchannel-blockers and nitrates, on arterial hypertension, diabetes mellitus, smoking history and positive family-history as well as in total cholesterol, HDL- and LDL-cholesterol, triglycerides, blood glucose and uric acid. 1 patient of A and 2 of B died from a sudden cardiac death, 2 of A and 7 of B survived a myocardial infarction, 11 of A and 11 of B developed angina pectoris (p < 0.05). A statistical significant difference was found in the ergometric working capacity (maximal workload in Watt) between the 2 groups (p < 0.001) that did not change over the 10 years, the control group worked better in both investigations. SMI type 1, detected by bicycle ergometry seems to be only a risk factor for developing "loud ischemia" (= angina pectoris) but not for "hard events". A routine screening of completely asymptomatic persons with bicycle ergometry seems to have no prognostic relevance.

Treatment strategies in acute myocardial infarction are directed toward limitation of infarct size and reduction of frequency of complications. This goal is best achieved by early reperfusion of ischemic myocardium. All trials comparing thrombolytic treatment in acute myocardial infarction indicate that either streptokinase, APSAC, or rtPA reduce mortality significantly. Particularly patients at high risk (old patients, women) benefit most from thrombolytic treatment. Although, conservation of left ventricular function and risk reduction is best achieved by very early treatment, a reduction of mortality has even been shown if thrombolytic agents are if given before 12 hours after onset of symptoms. Primary PTCA is an attractive alternative to thrombolytic therapy particularly in patients with anterior wall myocardial infarction or cardiogenic shock. Routine PTCA early or late after thrombolytic treatment however does not alter the outcome of the patients. The value of rescue PTCA remains to be settled. Heparin as an adjunctive treatment of rtPA improves patency of the coronary arteries and reduces mortality. Newer anti-thrombotic agents like hirudin, argotraban, or monoclonal antibody 7E3 are even more promising for prevention of reocclusion after thrombolytic treatment. Of the conservative medical treatment aspirin, beta-blockade, nitrates, and magnesium all have been shown reduce mortality. Similar effects could not be proven for calcium antagonists or routine antiarrhythmic drugs. ACE-inhibitors are of value if given 3 days after onset of symptoms.

A rational therapy of the chronic cardiac insufficiency should be performed according to a certain scheme, in which case the knowledge of the basic disease is necessary for the causal treatment. Apart from the general measures the medicamentous therapy is of particular significance. Hereby up to now the digitalis glycosides remained the remedy of primary choice. They are without doubt indicated in the latent and manifest cardiac insufficiency, consequently from the transition of the NYHA stage II into stage III, in tachycardiac disturbances of rhythm also without cardiac insufficiency in form of auricular fibrillation and auricular flutter as well as in the paroxysmal supraventricular tachycardia. Prophylactic, preoperative applications of glycosides and such ones which are performed only for reasons of age are not justified. Also a maintenance therapy is in most cases no more necessary after removal of the cause of the cardiac insufficiency. - Diuretics are to be used in an insufficiency which continues existing despite application of glycosides. Their application must be performed as protracted as possible. - The therapies with vasodilators, such as prazosin, hydralazine and nitrates, which were performed during the last years, showed, indeed, initial success, but no long-term effect. Another fact it is, however, with the angiotensin-converting enzyme (ACE) inhibitors captopril and enalapril, which are to be regarded as second grade medicaments in combination with glycosides and diuretics. Whether or not they will supersede the glycosides, is at present still an open question. Other positively inotropic medicaments which in comparison to the glycosides show a larger therapeutic breadth are still being developed.(ABSTRACT TRUNCATED AT 250 WORDS)

This article reports on the problems associated with the development and use of a computer programme for computer-monitored blood pressure control by means of cardio- and/or vasoactive drugs. The computer, a monitoring device routinely used in hospitals, and an infusion pump on the one hand, and the patient on the other, are part of a closed loop control system. Regulation is effected in the manner practised in hospitals, the mean arterial pressure (MAP) serving as an auxiliary controlled variable. The computer programme analyses the directly measured blood pressure curve in two respects: Detection and assessment of external disturbing factors and endogenously conditioned changes in the blood pressure curve and determination of MAP via a special control algorithm. With the help of a prototype of the automatic controller, the programme was subjected to extensive clinical trials in more than 140 patients to date. The programme was particularly successful wherever a residual circadian rhythm leads to variable requirements of vasopressor or cardiovascular drugs. The use of technical control algorithms has proved unsuitable because of the complex nature of blood pressure control.

Highly efficient medicaments like catecholamines, vasodilators and antiarrhythmics require exact and safe application. So far, however, we have not been able to meet this requirement in our medical emergency service, as the appropriate dispensing equipment has not been available. Nevertheless, today potent medication must be administered during preclinical emergency care. A case report is given that shows the advantages of the use of an electronically controlled injection pump (IVAC 700) for dispensing highly efficient medicaments in emergency medicine.