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Stable chronic coronary artery disease (SCAD) encompasses several groups of patients including those with stable angina pectoris or other symptoms thought to be linked to CAD as well as patients with known prior acute coronary syndrome or prior coronary interventions, who have become asymptomatic with treatment and need regular follow-up. Patients with SCAD have an elevated risk for subsequent ischemic events and significantly benefit not only from lipid-lowering therapy with statins but also in particular from long-term antithrombotic treatment. These patients therefore need lifelong antithrombotic treatment with 100 mg acetylsalicylic acid (ASA) daily whereby clopidogrel 75 mg daily is indicated as an alternative in cases of aspirin intolerance. As chronic CAD may present with very different developmental phases spanning from chronic stable phases to acute coronary syndromes, antithrombotic treatment in SCAD patients needs continuous evaluation and adaptation. In addition, new concomitant diseases, such as atrial fibrillation may necessitate further adaptation of antithrombotic therapy. The current overview focuses on the description of the long-term antithrombotic treatment of SCAD as well as on the need for adaptation in the setting of elective percutaneous coronary interventions (PCI).

Patients with increased cardiovascular risk profile are frequently seen in general practice. Comprehensive management of modifiable risk factors, in particular dyslipidemia, is mandatory. Many studies in clinical practice have shown a gap between the recommendations in clinical guidelines and the actual situation. Current data on the management situation of patients with high cardiovascular risk is provided by the prospective registry LIMA. Primary care physicians in 2,387 offices throughout Germany documented 13,924 patients with coronary artery disease (CAD), diabetes mellitus or peripheral arterial disease (PAD). Treatment with simvastatin 40 mg was an inclusion criterion. Physicians documented drug utilization, laboratory values (lipids, blood glucose), blood pressure and clinical events over one year and received feedback about the target value attainment of their patients after data entry. Mean age of the patients was 65.7 years, and 61.6 % were men. CAD was reported in 70.6 %, diabetes mellitus in 58.2 % and PAD in 14.9 %. Most patients (68 %) received simvastatin as monotherapy also after the inclusion visit; 20.6 % of patients received in addition the cholesterol absorption inhibitor (ezetimibe) in the first 6 months, and 23.3 % in the second 6 months. Patients achieved the LDL-cholesterol target value in 31.8 % at entry and 50.0 % after one year. The blood pressure target < 140 /90 mmHg was reached by 65.8 % after one year. Of patients with diabetes mellitus 40.0 % reached an HbA1c value below 6.5 %. Clinical events (death, hospitalization, (cardio-) vascular events, and dialysis) were reported by 11.7 % of patients between entry and Month 6, and by 12.0 % between Month 7 and 12. In daily practice comprehensive management of risk factors in patients at high cardiovascular risk remains a challenge. For normalization of increased LDL cholesterol values addition of ezetimibe to existing statin therapy improves the chances of patients for target level attainment., (© Georg Thieme Verlag KG Stuttgart · New York.)

Patients with type 2 diabetes have an increased risk for developing symptoms of heart failure. These can be accompanied by a reduction of left ventricular ejection fraction (HFREF, systolic heart failure) or by a preserved function (HFPEF, diastolic heart failure). The pathophysiology of both entities is distinct and involves impairment of myocardial metabolism and coronary circulation alike. Although diabetes and heart failure often coincide, the management of these patients particularly with respect to the specific benefits or possible hazards of antidiabetic treatment is vague. Therefore, from a pathophysiological as well as clinical viewpoint, 1) diabetic patients with symptoms of heart failure have to be differentiated regarding systolic as well as diastolic left ventricular function by echocardiography and tissue doppler imaging. 2) Heart failure in diabetic patients needs similar attention due to a prognosis and interactions. 3) Optimized blood glucose lowering in combination with improvement of other cardiovascular risk factors is evident for HFREF and is assumed to be beneficial for HFPEF. 4) Antidiabetic medication has to be specifically adapted for both entities. As prospective, controlled studies are scarce, future interventional studies should specifically focus on clinical outcome in diabetic patients with different entities of heart failure., (© Georg Thieme Verlag KG Stuttgart · New York.)

Background and Objective: DYSIS (Dyslipidemia International Study) is an international multicenter cross-sectional trial. The objective of the regional analysis was to identify differences in lipid-lowering therapy and attainment of goal/normal lipid levels in Germany., Methods: 4,260 patients who were at least 45 years of age and receiving regular statin therapy at 748 centers (office practices / outpatient clinics) in Germany were assessed at a routine ambulant appointment. Results from centers in the northern, eastern, southern, and western part of Germany were compared., Results: The mean age of the patients was 66.6 - 67.9 years (p < 0.01, range over the four regions) and the proportion of males was 53 - 60 % (p < 0.01). There were significant regional differences in the number of cardiovascular risk factors and cardiovascular conditions, e. g. arterial hypertension (82 - 88 %), smoking (12 - 17 %), family history of coronary heart disease (CHD) (30 - 42 %), lack of exercise (38 - 48 %), CHD (only in women, 27 - 42 %), peripheral artery vascular disease (11 - 15 %), and heart failure (16 - 20 %). No regional differences were found for body mass index (BMI), waist circumference, metabolic syndrome, or diabetes mellitus. The mean LDL-cholesterol level in the four regions was 107 - 108 mg/dl (p = 0.53), HDL-cholesterol was 50 - 51 mg/dl (p = 0.62), and triglycerides 141 - 148 mg/dl (p = 0.68). The mean simvastatin (or simvastatin-equivalent) dosage was approximately 27 mg/day (p = 0.62). About half of the patients (49 - 53 %, p = 0.11) failed to attain their LDL-cholesterol target despite statin therapy. In addition to elevated LDL-cholesterol, 30 % of the patients had elevated triglycerides and/or low HDL-cholesterol., Conclusion: DYSIS showed the existence of significant regional differences in the characteristics of statin-treated patients but not in the type or dosage of statin therapy or in adherence to target/normal lipid levels as per guidelines. In a high proportion of patients the lipid-lowering therapy will need to be reviewed, as guideline target levels have not been attained., (© Georg Thieme Verlag KG Stuttgart · New York.)

Objective Among other adjunctive medication, heparin is widely used in the therapy of acute myocardial infarction (AMI) today. Large randomized trials, however, have shown inconclusive data on the benefit of adjunctive heparin therapy for patients with AMI. The aim of this study was to describe the use of heparin and complication rates in routine clinical practice today. Methods MITRA and MIR were multicenter registries of AMI patients in Germany. During the years 1994 to 1998, 22697 patients were registered with MITRA and MIR. Of these patients 49.9% received reperfusion therapy. Results 21004 patients (92%) received heparin during acute therapy of AMI. The following factors were associated with withholding heparin: Bleeding at admission (OR 4.7; CI 3.2-6.8), cardiogenic shock (OR 1.8; CI 1.4-2.3) and fibrinolytic therapy with streptokinase (OR 2.1; CI 1.8-2.3). Complication rates of patients with heparin were only slightly higher than among those without heparin: 1.7% strokes and 1.9% bleedings were reported among the patients with fibrinolysis and heparin compared to 1.3% strokes and 1.4% bleedings among patients without heparin (p=ns). Mortality rates were 14.1% for patients with and 27.3% for patients without heparin (p<0.001). Conclusions Of the patients in MITRA and MIR 92% received heparin during AMI. Patients with active bleeding or in critical condition received heparin significantly less often. The selection of critically ill patients may have contributed to the high mortality of patients without heparin for AMI. Bleeding complication rates of patients with adjunctive heparin were only sightly higher than reported in randomized trials.

Objective: Among other adjunctive medication, heparin is widely used in the therapy of acute myocardial infarction (AMI) today. Large randomized trials, however, have shown inconclusive data on the benefit of adjunctive heparin therapy for patients with AMI. The aim of this study was to describe the use of heparin and complication rates in routine clinical practice today., Methods: MITRA and MIR were multicenter registries of AMI patients in Germany. During the years 1994 to 1998, 22,697 patients were registered with MITRA and MIR. Of these patients 49.9% received reperfusion therapy., Results: 21,004 patients (92%) received heparin during acute therapy of AMI. The following factors were associated with withholding heparin: Bleeding at admission (OR 4.7; CI 3.2-6.8), cardiogenic shock (OR 1.8; CI 1.4-2.3) and fibrinolytic therapy with streptokinase (OR 2.1; CI 1.8-2.3). Complication rates of patients with heparin were only slightly higher than among those without heparin: 1.7% strokes and 1.9% bleedings were reported among the patients with fibrinolysis and heparin compared to 1.3% strokes and 1.4% bleedings among patients without heparin (p = ns). Mortality rates were 14.1% for patients with and 27.3% for patients without heparin (p < 0.001)., Conclusions: Of the patients in MITRA and MIR 92% received heparin during AMI. Patients with active bleeding or in critical condition received heparin significantly less often. The selection of critically ill patients may have contributed to the high mortality of patients without heparin for AMI. Bleeding complication rates of patients with adjunctive heparin were only slightly higher than reported in randomized trials.

Long-term follow-up after treatment with primary angioplasty compared to treatment with thrombolysis in patients with acute myocardial infarction (AMI) remains still to be determined. We therefore analyzed the data of the "Maximal Individual Therapy" in Acute Myocardial Infarction (MITRA-1) Registry. Follow-up data for a median of 17 months after discharge were available in 2090 out of 2195 (95%) AMI patients treated with thrombolysis, as well as 293 out of 312 patients (94%) treated with primary angioplasty. There were only small differences in patient characteristics between the two treatment groups. Compared to patients treated with thrombolysis, those treated with primary angioplasty had a higher prevalence of prior myocardial infarction (16.4% versus 12.2%, p = 0.04), longer prehospital delay: 10 minutes (130 minutes versus 120 minutes, p = 0.002), and a longer door-to-treatment time: 45 minutes (p < 0.001). Primary angioplasty patients were more likely to be treated with beta-blockers (primary angioplasty 79.8% versus thrombolysis 66.2%, p < 0.001) or statins (24.5% versus 16.5%, p < 0.001). There was no difference between the treatment groups for total mortality (p = 0.90) nor for the combined endpoint of death or re-infarction (p = 0.85). However, the combined endpoint of death, re-infarction or percutaneous coronary intervention or coronary bypass surgery was significantly lower in the primary angioplasty group (primary angioplasty 25.6% versus thrombolysis 32.3%, univariate odds ratio 0.72, 95% CI: 0.55-0.95, p = 0.02). This result was confirmed by multivariate analysis after adjusting for confounding parameters (multivariate odds ratio: 0.62, 95% CI: 0.42-0.91). The beneficial effect of primary angioplasty compared to thrombolysis achieved during the hospital stay after an AMI is maintained during a 17 month follow-up. AMI patients treated with thrombolysis were more likely to be treated with either percutaneous coronary intervention or coronary bypass surgery after discharge.

We investigated the use of statins in clinical practice in patients with acute myocardial infarction in Germany in 17,732 consecutively included patients of the registries MIR-1 and MITRA-1. A clinical follow-up has been performed in the MITRA-1 study after a mean period of 18 months. In total 30% of all patients with acute myocardial infarction received statins at discharge. From 1994 to 1998 the use of statins increased from 6% to 44%; however in 1998 still less than half of the patients with acute myocardial infarction received statins at discharge. In a logistic regression model, concomittant diseases as renal failure (OR 0.7), heart failure (OR 0.7) and diabetes mellitus (OR 0.9) were associated with a lower use of statins. Age > 70 years (OR 0.5) was also associated with a lower use of statins at hospital discharge. Patients with statins at discharge had a lower long-term mortality of 5.8% versus 12.9% in patients without statins. After adjustment to age and comorbidity, use of statins at discharge was associated with a borderline significant reduction of long-term mortality (multivariate OR 0.7, 95% CI 0.4-1.0). In a subgroup analysis of therapeutic benefit, measured by the "number needed to treat" (NNT), the number of patients to treat with statins to save one life, patients with cardiovascular risk factors, as heart failure (NNT 7.5), diabetes mellitus (NNT 7.8) and age > 70 years (NNT 13.8) had a larger therapeutic benefit as patients without these risk factors (NNT 345). However, these high-risk patients received less often statins than patients without risk factors (use of statins 11.8% versus 19.8%).

Background: Prognostic data on heart failure rely on epidemiological studies or large clinical trials. These data are not to transfer easily on everyday practice., Objective: To assess the prognosis of left ventricular dysfunction under the therapeutic conditions of the 1990s., Setting: Nonuniversity tertiary care hospital., Patients and Methods: Since January 1995 consecutive and complete registry of all inpatients presenting with a left ventricular dysfunction (EF < 45%). No exclusion criteria., Results: n = 512, mean age 64 years, 77% male, mean NYHA class 2.5, left ventricular EF 31%., Etiology: 58% coronary heart disease, 28% dilated cardiomyopathy. Medical treatment consisting of 91% ACE inhibitors, ACE inhibitor dosage 52% of the recommended dose, 42% beta-blockers, 70% diuretics, and 63% digitalis. Follow-up completeness 95.5%. One-year mortality 64/489 patients (13.9%). Determinants of mortality: NYHA III/IV, EF < 30%, malignant disease, age > 75 years., Conclusion: In spite of the aforementioned medical treatment and a proportion of 14.8% implanted defibrillators in 1998, the one-year mortality of ventricular dysfunction is as high as 13.9%. In everyday practice the prognostic effect of ACE inhibition and beta-blockade is not completely utilized.

Cardiopulmonary exercise testing (CPX) allows a non-invasive control of the cardiopulmonary exercise capacity. In this study, we wanted to investigate if the CPX can be securely, practicably, and accurately performed in patients with invasively documented coronary heart disease (CHD). Furthermore, we wanted to find out the clinical value of CPX in CHD diagnosis. The CPX measurements (symptom-limited; ramp program with 20 Watts increase/min; semi-supine position; continuous registration of the cardio-circulatory parameters (HR, RR, ECG), of the gas exchange parameters (O2, CO2) and of the ventilation) in 101 patients have shown that CPX is secure, accurate, and practicable. The day-to-day reproducibility is high (r > 0.8). The respiratory anaerobic threshold can be manually evaluated by means of the PET O2 criterion in 95% of the cases. The CCS-classification of angina pectoris could not accurately describe the cardiopulmonary exercise capacity as compared to the Weber-classification. The disadvantage of the Weber-classification is that it does not respect the age-, sex- and weight-dependent differences of the normal values. Our own data and results from the literature demonstrate that the anaerobic threshold, the maximum VO2 and the maximum O2-pulse are the more reduced the more coronary arteries are involved, the more reduced the left ventricular function is. But, nevertheless, the range of values shows large overlaps so that an exact differentiation, based upon these parameters, is not possible. Patients with similar functional results or degree of reduced exercise capacity have different morphological alterations. Most patients demonstrated typical ischemic cascade with anaerobic threshold, ST-segment alterations, angina pectoris and, finally, reduced max. VO2. In conclusion, CPX does not replace the traditional methods of non-invasive and invasive ischemia detection, but enables secure, practicable, and accurate measurements of the individual cardiopulmonary exercise capacity and the interaction between muscles, heart, circulation, and lungs. Possibly, CPX can be used in the near future for identifying CHD patients with low, medium or high risk.

In this study we wanted to investigate if noninvasive cardiopulmonary exercise testing can be securely, accurately applied in patients with acquired cardiac valve disease pre- and postoperatively with any convenience. Furthermore, we looked if the cardiopulmonary exercise capacity (anaerobic threshold, etc.) was improved postoperatively (3 and 6 months) in 15 patients suffering from severe mitral valve disease as compared to the preoperative condition. The symptom-limited cardiopulmonary exercise testing was performed on a bike in a semi-supine position using a ramp program (+20 W/min). The following parameters were continuously monitored, and the breath-by-breath gas exchange values documented: cardiocirculatory parameters (heart rate; blood pressure; surface ECG; exercise capacity in Watts); gas-exchange parameters (O2-uptake VO2; CO2-production VCO2; respiratory anaerobic threshold VO2 AT; gas-exchange ratio VCO2/VO2; O2-pulse VO2/HR; aerobic capacity delta VO2/delta WR) and ventilatory parameters (respiratory rate; tidal volume Vt; minute ventilation VE; equivalent for O2: VE/VO2 and CO2: VE/VCO2). The 155 cardio-pulmonary exercise tests in 115 patients were practicable, safe (no emergency case) and accurate. In 100 patients late postoperatively (68.3 +/- 53.0 -102.9 +/- 41.2 months) after aortic or mitral valve replacement or both without signs of significant hemolysis or prosthetic valve dysfunction the NYHA classification was too imprecise to characterize the actual exercise capacity of the patients (e.g., NYHA class II: Weber class B to E). Patients with aortic valve prosthesis had a significantly better anaerobic threshold (57.4 +/- 19.1% pred. value max. VO2) as compared to those with mitral valve replacement (mean: 35.9% pred. value max. VO2).(ABSTRACT TRUNCATED AT 250 WORDS)

We analyzed 128 cardiopulmonary exercise tests (CPX), performed in normal subjects (n = 31), in patients with coronary artery disease (n = 41), with chronic heart failure before (n = 14) and after (n = 14) application of oral PDE-inhibitors and in patients with HIV-infection on a bicycle-ergometer in semi-supine position using a ramp-program (dependent on study-population with 15, 20 or 35 Watt/min increases) with respect to the ability to determine the respiratory anaerobic threshold non-invasively, using the main criteria described by Wasserman et al.: the V-slope-method according to Beaver, the increase of the ventilatory equivalent for O2 (VE/VO2), the increase of the end-tidal PO2 (PETO2) and the increase of the respiratory quotient (RQ) during exercise. In the different study-populations we calculated the detection rates of the AT for each criteria separately. The typical changes in the end-tidal PO2 (124/128 = 96.9%) and the V-slope-method (119/128 = 92.9%) were the most reliable parameters to detect the anaerobic threshold. The characteristic changes of the ventilatory equivalent for O2 (VE/VO2) and of the respiratory quotient (RQ) we found in 100/128 (= 78.1%) and in 107/128 (= 83.6%) of the tests respectively. 86/128 tests (67.2%) showed typical changes in all four mentioned criteria. In another 24/128 tests (19.8%) three of four criteria were fulfilled. Therefore, our investigations showed that in 110/128 cases (85.9%) the AT could be determined by typical changes by means of at least three of the four described parameters. In 15/128 (11.7%) tests only two of four criteria were fulfilled.(ABSTRACT TRUNCATED AT 250 WORDS)

The cardiopulmonary exercise testing (CPX) is a non-invasive method for the evaluation of the cardiopulmonary exercise capacity. Based upon the recent technical progress in gas analysers and personal computers today it is possible to perform CPX with acceptable time consumption, high practicability and high reproducibility of the results in many clinical areas. CPX is realized on a bike or on a treadmill. In bicycle CPX a ramp program (increase of x watts per minute) or a constant workload test (p.e. with 75% of the watts at anaerobic threshold) are performed. Furthermore, an estimation of the cardiac output using CO2-rebreathing method can be realized during a ramp program or a constant workload test. In this paper, also the CPX parameters of the ramp program, the constant workload test and the CO2-rebreathing method are defined and explained. The normal values of CPX are dependent of age, sex, body weight and exercise program. This should be kept in mind in interpreting the measured CPX data. Additionally, the performance of a routine CPX will be reported. Furthermore, the accuracy of the CPX parameters and the potential influences on the data will be discussed. Finally, problems during measurements and their analysis will be clarified.

The clinician who uses cardio-pulmonary exercise testing (CPX) systems relies on the technical informations from the device producers. In this paper, the practicability, the accuracy and the safety of four different, available CPX systems are compared in the clinical area, using clinically orientated criteria. The exercise tests were performed in healthy subjects, in patients with cardiac and/or pulmonary disease as well as in young or old people. The comparison study showed, that there were partially large differences in device design and measurement accuracy. Furthermore, our investigation demonstrated that beneath repetitive calibrations of the CPX systems a frequent validation of the devices by means of a metabolic simulator is necessary. Problems in calibration can be caused by an inadequate performance or by unclean calibration gases. Problems in validation can be due to incompatibility of the CPX device and the validator. The comparison study of the four different systems showed that in the future standards for CPX testing should be defined.

Autologous blood donation is an established method for an effective reduction of the blood-transfusion-associated infectious diseases (hepatitis, HIV infections, etc.) in elective surgical procedures. The aim of the study was to investigate the effects of a blood donation of 450 ml on the cardiopulmonary exercise capacity in 16 apparently healthy young subjects. The 24 cardiopulmonary exercise tests were performed on a bicycle ergometer (Ergoline 900) in a semisupine position, using a ramp program (+20 watt/min) 1-7 days before and 2 days after blood donation. By means of continuous breath-by-breath measurements of the gas exchange (VO2, VCO2) and ventilation parameters (minute ventilation VE), as well as of the routine parameters (heart rate, blood pressure, work rate) during incremental exercise the respiratory anaerobic threshold VO2AT, the maximum VO2 (VO2max and the maximal working capacity (max. WR) were determined. Serum hemoglobin concentration was significantly (p < 0.0005) reduced from 14.5 +/- 1.0 to 13.0 +/- 1.4 g/dl after blood donation. The ventilatory anaerobic threshold (before: 68.5 +/- 17.0; after: 52.0 +/- 20.3% pred. max. VO2), the max. VO2 (before: 124.2 +/- 21.3; after: 110.2 +/- 23.2% pred. max. VO2) and max. WR (before: 287.1 +/- 75.6; after 265.5 +/- 76.2 watt) fell significantly (VO2AT: p < 0.0005; max. VO2: p < 0.0005; max. WR: p < 0.025). Heart rate and minute ventilation showed a steeper increase (dHR/dWR: before: 0.31 +/- 0.06; after: 0.34 +/- 0.05 beats/min/watt; dVE/dWR: before: 0.29 +/- 0.05; after: 0.31 +/- 0.05 l/watt) in relation to the increase in WR after blood donation as compared to the test before.(ABSTRACT TRUNCATED AT 250 WORDS)