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In patients admitted with acute myocardial infarction, cardiogenic shock remains the most common cause of death. Multidisciplinary care in a specialized center and guideline-compliant treatment of cardiogenic shock are crucial for the survival and prognosis of affected patients. Hemodynamic monitoring and stabilization by volume expansion, vasopressors and inotropes represent initial steps in the management of patients with cardiogenic shock. Nevertheless, early revascularization of the culprit-lesion is proved to be the most important treatment modality. Although the use of active mechanical circulatory support appears to be a promising therapeutic concept to improve clinical outcome in patients with infarct-related cardiogenic shock, in the few previous randomized trials mechanical circulatory support failed to show beneficial effects on short-term and long-term survival., Competing Interests: Die Autorinnen/Autoren geben an, dass kein Interessenkonflikt besteht., (© Georg Thieme Verlag KG Stuttgart · New York.)

Because of new surgical techniques, advanced monitoring modalities and improvements in perioperative care, perioperative mortality and morbidity have been significantly reduced in the last decades; however, patients still suffer from high perioperative mortality and morbidity, especially those with pre-existing cardiovascular diseases. Not only perioperative myocardial infarction but also myocardial injury after non-cardiac surgery, which presents without clinical symptoms, is associated with an adverse outcome. Patients at risk require particular interdisciplinary attention throughout the perioperative phase. The premedication visit is of particular importance. In addition to a thorough patient medical history and physical assessment, the perioperative handling of the patient's pre-existing medication and possible necessity for further preoperative tests should be verified. If necessary and where possible, optimization of the patient's state of health can be planned together with other disciplines. It is the anesthesiologist's responsibility to optimally guide and support patients with pre-existing cardiovascular diseases through the entire surgical procedure. This review summarizes perioperative interventions that have an influence on patient mortality and morbidity and evaluates the underlying evidence. This covers the perioperative handling of cardioprotective medication, choice of the anesthetic regimen, blood pressure management and transfusion regimens. Furthermore, this review highlights recent findings, e.g. perioperative reloading with statins and short-term preoperative initiation of beta blockers. The pros and cons of thoracic epidural anesthesia in patients with an elevated cardiovascular risk are discussed. Not only intraoperative hypotension should be of concern to anesthesiologists but also postoperative hypotension can have a deleterious impact on the outcome. This is relevant in the time period when a significant proportion of patients have already left the monitoring ward. The recently published recommendations by the World Health Organization concerning perioperative hyperoxia might not be beneficial for patients with an elevated cardiovascular risk. Finally, the treatment options for perioperative cardiovascular events are explained and an algorithm for handling of patients with perioperative myocardial injury without clinical ischemic symptoms is suggested (myocardial injury after non-cardiac surgery).

Exercise and Sports in the Therapy of Chronic Diseases - Coronary Heart Disease Abstract. Despite increasingly advanced diagnostic and therapeutic methods, coronary heart disease and myocardial infarction continue to be by far the leading cause of death worldwide. This makes it all the more important in this context to make full use of known but far from optimally used therapeutic measures. Adequate physical activity in everyday life and additional targeted training lead to an evidence-based improvement in quality of life, a reduction in morbidity and above all to a significant reduction in cardiac and overall mortality. However, an accurate risk assessment of the individual patient with consistent training recommendations and monitoring is crucial in medical training advice. Today's sports recommendations for coronary heart disease have become much more liberal than before and allow patients with a relatively low risk of sudden cardiac death to do virtually any kind of exercise. This progressive posture, according to optimal risk assessment, is important, as newer data also show a dose-dependent increase in the preventive effect in coronary heart disesase patients with an increase in the extent of weekly training.

Background:  In recent decades, guideline-based therapy of myocardial infarction has led to a considerable reduction in myocardial infarction mortality. However, there are relevant differences in acute care and the extent of infarction mortality. The objective of this survey was to analyze the current care situation of patients with acute myocardial infarction in the region of northeast Germany (Berlin, Brandenburg and Mecklenburg-Vorpommern)., Methods:  Based on pseudonymized data from a statutory health insurance of 1 387 084 persons, a total of 6733 patients with inpatient admission at MI were filtered using the ICD10 code I21 and I22 for 2012. Total inhospital mortality and 1-year mortality and prognostic parameters were evaluated and analyzed in country comparisons., Results:  Both the hospital mortality rate and the 1-year mortality rate of the individual countries (Berlin 13.6 resp. 27.5 %, respectively, BRB 13.9 and 27.9 %, MV 14.4 and 29.0 %, respectively) were comparable to the overall rate (13.9 % or 28.0 %) and in the country comparison. In the multiple analysis, the 1-year mortality was determined by the invasive strategy (OR 0.42, 95 % CI 0.35 - 0.51, p < 0.001) as well as by the implementation of the guidelines-based secondary prevention (OR 0.14, 95 % CI 0.12 - 0.17, p < 0.001). There were no statistical differences between the three federal states., Conclusion:  The investigated population of patients with acute MI in Berlin, Brandenburg and Mecklenburg-Vorpommern demonstrated a comparable inpatient and post-hospital care and 1-year prognosis regardless of the federal state assignment. Referral to coronary angiography and adequate implementation of evidence-based medication demonstrated a significant prognostic impact., Competing Interests: Disclosure The authors report no conflicts of interest in this work., (© Georg Thieme Verlag KG Stuttgart · New York.)

This CME article addresses the pathophysiology, incidence, current survival outcome and treatment options for patients with cardiogenic shock as a complication of acute myocardial infarction. The shock spiral of left heart failure due to cardiac infarction, subsequent vasoconstriction and paradoxical vasodilation due to the systemic inflammation response syndrome (SIRS) is a vicious circle which must be interrupted. Treatment focuses on the evidence from randomized clinical trials and the current guideline recommendations. With respect to interventional and surgical treatment the question of culprit lesion vs. complete revascularization is still unsolved. For medicinal treatment acetylsalicylic acid (ASA) and heparin are more often supplemented with prasugrel and ticagrelor. In the case of inotropes, dobutamine remains the first-line treatment option and for vasopressors norepinephrine. The calcium sensitizer levosimendan has not provided the hoped for superiority over conventional treatment in randomized trials. The use of intra-aortic balloon pumps (IABP) is no longer recommended as circulatory support in acute heart failure (reduced to class III). The use of percutaneous implantable mechanical circulatory support devices has not shown a survival benefit in the few randomized trials carried out so far even when compared with IABP, due to increased bleeding complications.

Recent advances in percutaneous coronary intervention and antiplatelet therapy as well as faster door-to-balloon times have markedly improved the therapy of patients with acute myocardial infarction. However, impaired myocardial perfusion despite revascularization of the infarcted vessel remains an ongoing problem with high prognostic relevance. In initial clinical trials thrombus aspiration in addition to conventional percutaneous coronary intervention demonstrated benefits regarding coronary flow and myocardial perfusion and was therefore recommended in practice guidelines. These improvements in surrogate endpoints did not translate into a favorable clinical outcome in recent large-scale multicenter randomized trials investigating the routine use of thrombus aspiration in patients with acute myocardial infarction. Furthermore, an increased risk of stroke after thrombus aspiration raises safety concerns. Therefore, thrombus aspiration has been downgraded in the recent guideline updates. The current article reviews the evidence from clinical trials and the recommendations in practice guidelines regarding thrombus aspiration in acute myocardial infarction.

Background: In contemporary practice with early catheterization in most patients with suspected acute myocardial infarction, the clinical utility of new or presumably new left bundle branch block (LBBB) as a diagnostic criterion equivalent to ST-segment elevation is not well established. This study therefore aimed to determine the predictive value of LBBB for the diagnosis of acute transmural myocardial infarction (or ST-segment elevation myocardial infarction, STEMI)., Patients and Methods: Between November 2006 and December 2011, 1,139 consecutive patients presenting to the heart center of the University of Cologne with suspected STEMI were examined. Of these patients, 935 presented with ST elevation, 72 with LBBB, and 132 had neither of these ECG changes. The diagnosis was confirmed with immediate coronary angiography., Results: Compared with ST-segment elevation, LBBB was associated with a higher prevalence of cardiovascular risk factors and end-organ damage, and more patients with LBBB presented with pulmonary edema or cardiogenic shock (Killip III/IV). STEMI was confirmed in 58.3 % of patients with LBBB and in 86.4 % with ST-segment elevation. The sensitivity (0.38 [0.29-0.46]; odds ratio: 1.24) and specificity (0.67 [0.58-0.77]) of LBBB for the prediction of STEMI were low. However, the additional assessment of troponin T (> 0.1 µg/l) increased the predictive value of LBBB significantly. After adjusting for age and gender, no difference in mortality was found between the groups., Conclusion: LBBB with acute chest pain characterizes a cohort of patients with high morbidity and mortality. For the triage of these patients at first contact, additional criteria should be evaluated, which could increase the specificity of LBBB for the diagnosis of STEMI.

Intra-aortic balloon pump (IABP) counterpulsation was for a long time considered to be an indispensable standard for support of drug therapy for all forms of acute left-sided cardiac failure and especially in cardiogenic shock due to infarction. The advantages of the system seemed to be obvious; however, many of the postulated effects on the hemodynamics, microcirculation and coronary perfusion could not be confirmed later in prospective studies. It was found that IABP had no influence on microcirculation disorders in cardiogenic shock due to infarction. In a meta-analysis on the application for acute myocardial infarction without shock, no effect was found on mortality. The benefit as adjunct therapy for percutaneous coronary interventions (PCI) in cardiogenic shock due to infarction places a question mark over both IABP-SHOCK studies; however, in constellations without PCI the additional benefit of IABP cannot be excluded which is why the procedure could be an option in this situation.

Background: Systemic thrombolysis was introduced as the sole prehospital treatment option in patients with cardiac arrest in the setting of acute myocardial ischemia or pulmonary embolism; however, it remains the subject of discussion., Patients and Methods: A total of 194 patients with sudden prehospital cardiac arrest were included in this retrospective case control study. Of these patients, 96 in whom circulatory arrest due to cardiac disease (pulmonary artery embolism or myocardial ischemia) was suspected underwent thrombolytic treatment and were compared to the remaining 98 patients that did not undergo thrombolytic therapy. In addition to the circumstances of circulatory arrest, the course and success of resuscitation, as well as in-hospital course (including bleeding complications), overall survival and neurological outcomes were compared., Results: There were no significant differences between patients with or without thrombolysis in terms of the circumstances of cardiac arrest. Patients that received thrombolytic treatment were significantly younger and were more frequently treated with anticoagulants, platelet aggregation inhibitors and amiodarone. They also received higher doses of epinephrine and arrived at hospital under ongoing resuscitation significantly more frequently. A trend toward more prehospital return of spontaneous circulation (ROSC) following thrombolytic treatment was seen in the entire cohort. However, patients pre-treated with acetylsalicylic acid and heparin did not show better prehospital ROSC rates as a result of additional thrombolytic therapy. Significant differences in terms of bleeding complications or the need for blood transfusion could not be seen due to the small number of patients., Discussion: The indication for systemic thrombolysis in the context of prehospital resuscitation should remain restricted to patients with clear symptoms of acute pulmonary embolism or recurrent episodes of ventricular fibrillation in the setting of acute myocardial infarction. Due to a lack of evidence, systemic thrombolysis should not be used as a treatment of last resort in younger patients with persistent ventricular fibrillation.

The present study analyses the information gain obtained by evaluating adverse events during follow-up compared to the sole analysis of events during the initial hospital stay for quality measurement purposes. The analysis is based on AOK administrative data from the years 2010 to 2012. The analyses were carried out for 10 quality indicators from the 4 QSR sectors knee replacement for osteoarthritis, appendectomy, prostate surgery for benign prostatic syndrome (BPS) and therapeutic cardiac catheterization (PCI) in patients with myocardial infarction. A total of 409,774 AOK cases were included. For almost all indicators considered, a relevant share of complications can be found to have occurred only after discharge from the initial hospitalization (7.7 %-92.6 %). Furthermore, there is only a weak connection between the findings from the first hospitalization and those from the follow-up period (0.0449 < r < 0.1935). 26-66 % of the hospitals will be classified differently based on Standardized Mortality/Morbidity Ratio (SMR) quartiles if follow-up events are included in the quality assessment (with the exception of "Other Complications after PCI" of 14 %). In summary, quality assessment is improved considerably by evaluating the follow-up period for almost all indicators considered. A quality measurement based solely on events in the initial hospital stay obscures relevant adverse events that have an impact on a comparative hospital quality assessment for these indicators., (Copyright © 2015. Published by Elsevier GmbH.)

Background: The introduction of clopidogrel was a milestone in the development of modern antiplatelet therapy. However, the shortcomings in the pharmacokinetics of clopidogrel have led to the development of alternative substances., Current Concept: The two new drugs prasugrel and ticagrelor were included in the current guidelines for the treatment of patients with acute coronary syndrome. These potent platelet inhibitors, however, are associated with an increased rate of bleeding events, which is of particular importance in critically ill patients. However, the new platelet inhibitors are less effective in patients with cardiogenic shock or patients treated with therapeutic hypothermia., Future: Recent studies underscore the assessment of the net clinical benefit in patient management. Since there is only a thin line between efficacy and safety in critically ill patients, future studies for risk stratification of antiplatelet therapy in terms of personalized medicine are mandatory.

The prevalence of a major depressive disorder in patients after myocardial infarction is 20%. Depression is a risk factor for incident coronary heart disease and poor prognosis after myocardial infarction. Poor lifestyle habits and adherence to cardiac therapy as well as metabolic and pathophysiologic changes may partially explain this link. The threatening experience of an acute coronary event and immune and inflammatory changes may be unique features contributing to incident depression after myocardial infarction. While psychotherapy, antidepressants, and physical exercise may alleviate depressive symptoms in patients with coronary heart disease, cardiac rehabilitation additionally reduces mortality risk. Attempts are being undertaken to identify the cardiotoxic characteristics of depression to develop even more effective therapies in the future.

Mortality is increased in acute coronary syndrome (ACS) related to the extent of myocardial injury even if percutaneous coronary intervention (PCI) was successful. The development of congestive heart failure (CHF) after PCI in ACS is of prognostic interest. Non-invasive imaging plays a major role for determination of structural myocardial damage and loss of function. Secondary prevention regarding pharmacologic and non-pharmacologic therapy is dependent on myocardial function and the presence or absence of CHF. Exercise training as part of the non-pharmacological therapy plays an important role in rehabilitation after ACS according to the severity of injury., (© Georg Thieme Verlag KG Stuttgart · New York.)

This review will address the pathophysiology, incidence, current outcome and treatment options of patients with cardiogenic shock complicating acute myocardial infarction. The major focus will be on the current evidence based on randomized clinical trials and the current guideline recommendations for the treatment of cardiogenic shock., (© Georg Thieme Verlag KG Stuttgart · New York.)

Background and Objective: The goal of treatment of patients with ST-segment elevation acute myocardial infarction (STEMI) is to restore perfusion as soon as possible, preferably by primary percutaneous coronary intervention (PCI). The aim of this study of the German Myocardial Infarction Registry (DHR) was to document acute care and in-hospital course of STEMI patients in Germany., Methods: Over three months patients with STEMI were consecutively included and their basic data, treatments and in-hospital complications were centrally recorded using an internet-based standardized questionnaire., Results: Included were 6,330 patients from 243 hospitals, in group 1 (primary admission in 136 hospitals with cath lab) 4,656 patients (74%) and in group 2 (primary admission in 107 hospitals without cath lab) 1,674 (26%). Reperfusion therapy was performed more frequently in patients of group 1 (91.1% PCI, 2.7% fibrinolysis) than in group 2 (80.7% PCI after transfer, 6.4% fibrinolysis). In-hospital mortality was 7.3% in all patients, 7.0% in group 1 and 8.3% in group 2., Conclusion: The DHR data show that about three quarters of patients with STEMI are primarily admitted to hospitals with cath labs. Primary PCI is the preferred treatment option both in hospitals with and without cath labs (in the latter after transfer); it is performed in about 85% of STEMI patients. In-hospital mortality is with over 7% higher in real-life than in randomized studies., (© Georg Thieme Verlag KG Stuttgart · New York.)

In the German Health Interview and Examination Survey for Adults (DEGS1), data on the prevalence of myocardial infarction and coronary heart disease were collected from 2008-2011 in a representative population-based sample of 5,901 adults aged 40-79 years. The results of DEGS1 were compared with the prevalence estimates from the German National Health Interview and Examination Survey 1998 (GNHIES98). The lifetime prevalence of myocardial infarction amongst 40-79 year olds in DEGS1 is 4.7 % (women 2.5 %; men 7 %). In comparison with GNHIES98 a small increase was observed in men, but not in women. The lifetime prevalence of coronary heart disease in adults aged 40-79 years in DEGS1 is 9.3 % (women 6.4 %; men 12.3 %). In comparison to GNHIES98 there is a slight reduction only in women. There is a significant inverse relationship between disease prevalence and socioeconomic status. The trend in prevalence of coronary heart disease is comparable with that in other high-income countries. Given a falling incidence of myocardial infarction and a decrease in the mortality rates due to coronary heart disease, the basically stable prevalence rates indicate a positive development in the field of cardiovascular prevention and therapy. An English full-text version of this article is available at SpringerLink as supplemental.

Background: Data on 1-year complication and follow-up intervention rates after coronary angiography (CA) and percutaneous coronary intervention (PCI) in German clinical routine are sparse. This analysis aims to determine these rates., Methods: The analysis uses 2009 AOK claims data. Patients were divided into 3 groups (CA, without cardiac surgery and without acute myocardial infarction (AMI) n=116.071; PCI with stenting, without AMI: n=36.685; PCI with stenting and with AMI: n=32.707). The frequency of the endpoints MACCE (mortality, AMI, stroke, TIA), CABG, PCI and CA was recorded for up to one year., Results: 1-year MACCE rates were 8.1 % (CA), 9.9 % (PCI without AMI) and 17.9 % (PCI with AMI). Quality-relevant follow-up intervention rates in the CA group were 2.5 % for CABG (after 31-365 days), 1.7 % for PCI within 90 days and 3.5 % for follow-up CA within 1 year. In the PCI groups, the frequencies were 1.6 % (without AMI) and 2.7 % (with AMI) for CABG (after 31-365 days), and 10.2 % (without AMI) and 10.1 % (with AMI) for PCI after 91-365 days., Conclusion: This is the first cross-sectoral routine analysis of cardiac catheters and sequential events up to one year in Germany. The actual medical care situation revealed information particularly with regard to the second and follow-up inventions, which cannot be derived directly from medical guidelines. Beyond clinical trials, knowledge can be gained which is important both for medicine as well as the politics of health services., (© Georg Thieme Verlag KG Stuttgart · New York.)

Cancer deaths contribute to more than 25% of the overall mortality in Germany, which is only superseded by death from cardiovascular diseases. Apart from improving cancer prevention, the development of effective therapies for advanced cancer is a key task in oncology. Here we compare the criteria of clinical effectiveness that are applied to medical cancer therapies with those that are applied to therapies for cardiovascular diseases. (As supplied by publisher)., (Copyright © 2013. Published by Elsevier GmbH.)

There is no doubt that a healthy diet and regular physical activity improve risk factors for cerebro-cardio-vascular disease and death. However, there is less evidence from prospective randomised controlled trials that they also reduce the actual risk of stroke, myocardial infarction and death. The only evidence from randomised controlled trials is, that a mediterranean diet with nuts and/or native olive oil considerably reduces stroke risk by 47% respectively 31%, however not the risk of myocardial infarction and death. A low-fat diet, a low-salt diet, and the addition of omega-3 fatty acids have no influence. In case of severe obesity with a BMI of > 34-38 kg/m2, weight reduction is the priority, if necessary by means of bariatric surgery. In longitudinal studies mortality (-29%), stroke (-34%), and myocardial infarction (-29%) could thus be reduced. Regular physical activity, whether endurance or more intense activity, leads to weight loss and improved vascular risk factors. An independent impact on stroke, myocardial infarction and mortality has not yet been demonstrated in prospective studies (double-blinding being impossible). Nevertheless, several epidemiological meta-analyses with observation durations of 4 to 28 years using data of up to 880 000 persons, indicate that there is a 2-3 fold risk reduction of cerebro-cardio-vascular death and global mortality in people with regular physical activity versus sedentary behaviour.

About 10 - 15% of all ischaemic strokes are caused by focal atherosclerosis and consecutive narrowing (stenosis) of the internal carotid artery (ICA). Carotid endarterectomy (CEA) - the standard treatment for carotid stenosis - substantially reduces the risk of recurrent stroke among patients who have had ischaemic symptoms such as stroke or transient ischaemic attack attributable to the stenosis. To a smaller extent, CEA also reduces the risk of first stroke in patients with hitherto asymptomatic carotid stenosis. Endovascular treatment techniques, including balloon angioplasty in the initial years and more recently, carotid artery stenting (CAS), have been developed as an alternative to CEA for treating carotid stenosis without necessitating surgery. The present review compares risks and benefits between CAS and CEA summarising the existing evidence derived from randomised controlled trials. Among patients with symptomatic carotid stenosis, CEA is associated with a lower risk of peri-procedural stroke or death than CAS. CAS reduces the risk of peri-procedural myocardial infarction, cranial nerve palsy and access site haematoma compared with CEA. The excess peri-procedural stroke risk associated with CAS appears to be limited to patients older than 70 years while in younger patients, CAS is as safe as CEA. Both treatments are equally effective in preventing recurrent stroke in the first few years following treatment. However, recurrent stenosis appears to be more common after CAS, and longer-term follow-up of ongoing trials should be awaited to investigate whether restenosis might be associated with recurrent stroke. The best treatment approach for patients with asymptomatic carotid stenosis remains to be determined in ongoing clinical trials.

The "acute coronary syndrome" (ACS) is a life threatening condition. In patients with ST-segment elevation myocardial infarction (STEMI) an immediate reperfusion therapy is indicated. Primary percutaneous coronary intervention (PCI) is the gold standard. In ACS without ST-segment elevation (NSTE-ACS) coronary angiography should be performed within 72 hours in patients with risk factors. Depending on the coronary anatomy treatment options are PCI, aorto-coronary bypass surgery or sole medical therapy. The antiplatelet therapy has a key role in ACS. In addition to acetylsalicylic acid (ASA) another platelet aggregation inhibitor should be given for 12 months. For the majority of patients ticagrelor and prasugrel are the agents of first choice, because both act faster and stronger than clopidogrel. In patients at high risk of bleeding clopidogrel remains the preferable antiplatelet agent. In addition to antiplatelet treatment anticoagulant therapy is necessary in ACS-patients., (© Georg Thieme Verlag KG Stuttgart · New York.)

The risk for myocardial infarction can be reduced by almost 50% solely by lowering LDL cholesterol. Despite success reducing LDL and cholesterol, atherosclerosis and myocardial infarction remain significant challenges. However, mechanisms of the reverse cholesterol transport system might be used more effectively in the foreseeable future. Although the benefit of high HDL cholesterol appears to be obvious, most clinical trials aimed at increasing HDL cholesterol failed to generate convincing results. Therefore, the question arises as to whether indeed only HDL level or perhaps rather more HDL function is of considerable therapeutic relevance. If function is the crucial issue drugs such as CETP (cholesteryl ester transfer protein) activators or SR-B1 (scavenger receptor type B-1) upregulators could be beneficial. These types of drugs could improve HDL metabolism and might have beneficial effects despite the fact that they lower HDL levels. Ongoing studies on next generation CETP inhibitors and nicotinic acid will clarify this question and might help in our struggle against atherosclerosis.

Reducing cardiac mortality and improving quality of life are the main objectives of cardiac rehabilitation. In recent years, outpatient rehabilitation within easy patient reach has achieved the same status as inpatient rehabilitation. Outpatient rehabilitation permits close involvement of the patient's family and social environment, thus easing reintegration into everyday life. However, the health care system is not yet utilizing outpatient rehabilitation to its full potential. This contribution illustrates the principles of rehabilitation following myocardial infarction or for heart failure in an outpatient setting, as well as its potential and future development.