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The vast majority of tricuspid valve regurgitations are of low degree without prognostic relevance in healthy individuals; however, morbidity and mortality increase with the degree of regurgitation, which can be secondary to either primary (structural) or secondary (functional) alterations of the valve. Due to the frequent lack of symptoms, echocardiographic examinations should be annually performed in patients with higher degree (at least moderate) tricuspid valve regurgitation, in particular in the presence of risk factors. Individual therapeutic management strategies should consider the etiology of the tricuspid valve regurgitation, the degree of regurgitation, the valve pathology and the risk-to-benefit ratio of the envisaged therapeutic procedure. Medicinal treatment options for tricuspid valve regurgitation are limited and generalized recommendations cannot be provided due to the lack of conclusive clinical trials. Symptomatic therapeutic measures encompass especially (loop) diuretics for the reduction of preload and afterload of the right ventricle. Pharmaceutical reduction of the heart rate should be avoided in patients with right heart insufficiency. While symptomatic therapeutic measures are often associated with only moderate effects, the most effective therapy of tricuspid valve regurgitation consists in the treatment of underlying illnesses, in most cases pulmonary hypertension due to pulmonary arterial hypertension (PAH), left heart disease or acute pulmonary embolism. Based on a number of published clinical studies and licensing of new drugs, treatment options for patients with PAH and heart failure with reduced ejection fraction (HFrEF) have substantially improved during the past years allowing for a differentiated, individualized management.

To analyse and evaluate the use of antihypertensive medication in elderly patients of nursing homes in Germany.Data from a large German health insurance company were collected in a cross sectional study. Included were all insured persons aged 65 years or older, who were residents of a nursing home between 1 April and 30 June 2007 throughout Germany. Antihypertensive drugs were those classified according to the current guidelines published by the German Hypertension Society.The study comprised 8,685 residents of nursing homes, 84 % women. The mean age was 84 years (range 65 - 106 years). Antihypertensive drug prescriptions accounted for 17 % of all drug prescriptions and about 70 % of all residents received at least one prescription for antihypertensive drugs. The most frequently prescribed antihypertensive drugs were diuretics, of which 70 % were loop diuretics. Potentially inappropriate combinations of antihypertensive drugs were noted in 5.2 % of patients receiving these drugs.Antihypertensive drugs account for a notable part (17 %) of all drug prescriptions in elderly residents of nursing homes throughout Germany. These results indicate that only a minority of all residents were treated with potentially inappropriate or potentially harmful drug combinations. However, the relatively high rate of prescriptions for loop diuretics is a matter of potential concern in this vulnerable group of patients.

Diuretics are commonly prescribed by physicians to contract the ECF volume. In two clinical situations combining different classes of diuretics make sense: First, if a loop diuretic at maximal dose alone does not lead to sufficient diuresis or second, if the side effect of a diuretic needs to be corrected by adding a diuretic of another class. The latter is clinically often used to counteract loop or thiazide diuretic-induced hypokalemia by the addition of a potassium sparing diuretic. Key to a reasonable combination of diuretics is understanding of the pharmaco-kinetics and knowledge of the molecular targets of the diuretics involved.

Vasopressin plays a physiological role in regulation of blood pressure, fluid volume, and serum osmolality. In heart failure inadequate release of vasopressin may result in excess fluid retention and hyponatremia. Vasopressin receptor antagonists are a new class of orally active drugs targeted to inhibit one or more of three distinct vasopressin receptors, namely V1a- (--vasoconstriction), V1b- (--release of ACTH) und V2-receptors (--inhibition of free water reabsorption in the kidney). In cardiac decompensation with fluid overload selective V2- (Lixivaptan, satavaptan and tolvaptan) and non-selective V1a/V2-receptor blockers (Conivaptan) have been shown to be superior to standard therapy, as they allow for a faster weight loss and a more rapid symptomatic improvement (i.e. reduction in dyspnea). Inhibiting free water reabsorption without affecting renal sodium excretion vasopressin receptor antagonists allow for a controlled normalisation of serum natrium in euvolemic and hypervolemic hyponatremia. Vasopressin antagonists are well tolerated and have--in contrast to diuretics--no negative influence on renal function and serum potassium. Heart rate and blood pressure are not affected by vasopressin receptor antagonists. However, despite its excellent acute clinical effects long-term treatment with tolvaptan did not result in a reduced mortality and morbidity in heart failure patients over a mean follow-up of 9.9 months in the EVEREST trial.

The death of a 17-year-old patient caused by hypokalemia-induced arrhythmia illustrates the tragic dangers of the current paranoid preoccupation, particularly of young women, with physical beauty and low body weight. This case also reminds the reader that modern textbooks are not always sufficiently reliable. An intellectual approach how to circumvent diagnostic misinterpretation even in the context of misleading textbook information is proposed.

A 45-year-old female presented with somnolence and convulsions after finishing her first ironman triathlon. Besides the neurological symptoms she had a swollen face and swollen ankles. Rales could be heard on pulmonary auscultation. The past medical history was unremarkable. Due to musculoskeletal pain the patient had taken ibuprofen until two days before the race.The laboratory tests showed severe hyponatremia ( 111 mmol/l ) and hypoosmolalitiy of the serum. The osmolality of the urine was high (314 mosm/kg). Radiological examination revealed pulmonary as well as cerebral edema.On admission the patient was treated with hypertonic saline which increased the serum sodium concentration. Nevertheless she developed respiratory and hemodynamic failure. She had to be intubated, mechanically ventilated and needed catecholamines. After treatment with furosemide recovery occurred. The patient was extubated and was transferred to a hospital near her home without any neurolgical deficits one week after admission. One year later the former patient was again participant of the ironman triathlon. She was advised not to drink excessively and received oral salt supplementation. This time the athlete finished the race with a serum sodium concentration of 141 mmol/l.Ultra-endurance exercise can lead to severe hyponatremia, pulmonary and cerebral edema. This is caused mainly by fluid overload due to excesssive drinking and a release of ADH induced by hypovolemia and stress which impairs the excretion of free water. Hence a moderate fluid intake during and after endurance exercise is very important.