Efficacy, usability and sequence of operations of a workflow-integrated algorithm for basal-bolus insulin therapy in hospitalized type 2 diabetes patients

AIMS

To evaluate glycaemic control and usability of a workflow-integrated algorithm for basal-bolus insulin therapy in a proof-of-concept study to develop a decision support system in hospitalized patients with type 2 diabetes.

METHODS

In this ward-controlled study, 74 type 2 diabetes patients (24 female, age 68 ± 11 years, HbA1c 8.7 ± 2.4% and body mass index 30 ± 7) were assigned to either algorithm-based treatment with a basal-bolus insulin therapy or to standard glycaemic management. Algorithm performance was assessed by continuous glucose monitoring and staff's adherence to algorithm-calculated insulin dose.

RESULTS

Average blood glucose levels (mmol/l) in the algorithm group were significantly reduced from 11.3 ± 3.6 (baseline) to 8.2 ± 1.8 (last 24 h) over a period of 7.5 ± 4.6 days (p < 0.001). The algorithm group had a significantly higher percentage of glucose levels in the ranges from 5.6 to 7.8 mmol/l (target range) and 3.9 to 10.0 mmol/l compared with the standard group (33 vs. 23% and 73 vs. 53%, both p < 0.001). Physicians' adherence to the algorithm-calculated total daily insulin dose was 95% and nurses' adherence to inject the algorithm-calculated basal and bolus insulin doses was high (98 and 93%, respectively). In the algorithm group, significantly more glucose values <3.9 mmol/l were detected in the afternoon relative to other times (p < 0.05), a finding mainly related to pronounced morning glucose excursions and requirements for corrective bolus insulin at lunch.

CONCLUSIONS

The workflow-integrated algorithm for basal-bolus therapy was effective in establishing glycaemic control and was well accepted by medical staff. Our findings support the implementation of the algorithm in an electronic decision support system.

Near Field Communication-based telemonitoring with integrated ECG recordings

OBJECTIVES

Telemonitoring of vital signs is an established option in treatment of patients with chronic heart failure (CHF). In order to allow for early detection of atrial fibrillation (AF) which is highly prevalent in the CHF population telemonitoring programs should include electrocardiogram (ECG) signals. It was therefore the aim to extend our current home monitoring system based on mobile phones and Near Field Communication technology (NFC) to enable patients acquiring their ECG signals autonomously in an easy-to-use way.

METHODS

We prototypically developed a sensing device for the concurrent acquisition of blood pressure and ECG signals. The design of the device equipped with NFC technology and Bluetooth allowed for intuitive interaction with a mobile phone based patient terminal. This ECG monitoring system was evaluated in the course of a clinical pilot trial to assess the system's technical feasibility, usability and patient's adherence to twice daily usage.

RESULTS

21 patients (4f, 54 ± 14 years) suffering from CHF were included in the study and were asked to transmit two ECG recordings per day via the telemonitoring system autonomously over a monitoring period of seven days. One patient dropped out from the study. 211 data sets were transmitted over a cumulative monitoring period of 140 days (overall adherence rate 82.2%). 55% and 8% of the transmitted ECG signals were sufficient for ventricular and atrial rhythm assessment, respectively.

CONCLUSIONS

Although ECG signal quality has to be improved for better AF detection the developed communication design of joining Bluetooth and NFC technology in our telemonitoring system allows for ambulatory ECG acquisition with high adherence rates and system usability in heart failure patients.

Mobile phone-based surveillance of cardiac patients at home

We tested the reliability, acceptability and feasibility of a home-monitoring system for cardiac patients. Each participant was equipped with a mobile phone, an automatic blood pressure device and a digital weight scale. In total, 20 patients (14 patients with chronic heart failure, six patients with hypertension; mean age 50 years, standard deviation [SD] 14) were monitored for 90 days each. They were asked to measure their blood pressure, pulse and body weight every day, and to transfer the data together with the dosage of medication to the telemonitoring server using wireless Internet technology in the mobile phone. The physician in charge received email alerts when reported data fell outside pre-defined limits. The patients' compliance with the system was high. During a cumulative monitoring period of 1,735 days, there were 2,040 data transfer sessions, a mean of 102 per patient (SD 43). The mean percentage of successful data transfers was 83% (SD 22). The stability of the telemonitoring system was 98%, meaning that patient data transfer was almost always possible. The accessibility of the secure web server for physicians was above 99%. The web-based home-monitoring system was reliable and easy to handle for both patients and health care professionals. It may be a useful tool for patients with heart failure as well as hypertensive patients.

Human paraoxonase 1 gene polymorphisms and the risk of coronary heart disease: a community-based study

Published data on the association between paraoxonase1 (PON1) polymorphisms and coronary heart disease (CHD) have yielded controversial results. The objective of this study was to determine the possible relationship between the two human PON1 amino acid variants, the Leu55Met and the Gln192Arg polymorphism, and the risk of CHD in a community-dwelling cohort of European ancestry. PON1 genotypes of 152 women and 151 men out of 1,998 randomly selected individuals aged 44-75 years were determined by polymerase chain reaction-based restriction enzyme digestion. Study participants underwent cardiological examination including a structured clinical interview, resting ECG, exercise testing and echocardiography. The diagnosis of CHD was based on history and/or appropriate findings during cardiac examination. Evidence for CHD was found in 43 (14.2%) study participants. The Leu/Leu (LL), Leu/Met (LM) and Met/Met (MM) genotypes at position 55 were noted in 131 (43.2%), 128 (42.2%) and 44 (14.5%) subjects; the Gln/Gln (QQ), Gln/Arg (QR) and Arg/Arg (RR) genotypes at codon 192 occurred in 167 (55.1%), 118 (38.9%) and 18 (5.9%) individuals, respectively. Homozygosity for the 55L-allele was significantly associated with CHD (p = 0.02), while the Gln192Arg polymorphism had no effect (p = 0.16). Logistic regression analysis demonstrated age (odds ratio 1.06/year), smoking (odds ratio 2.86), HDL cholesterol (odds ratio 0.94/mg/dl) and the paraoxonase LL genotype (odds ratio 2.25) to be significant predictors of CHD. These data suggest that the paraoxonase LL genotype at position 55 may present a risk factor for CHD.

Differing beta-blocking effects of carvedilol and metoprolol

BACKGROUND

Metoprolol is a beta(1)-selective beta-adrenergic antagonist while carvedilol is a non-selective beta-blocker with additional blockades of alpha(1)-adrenoceptors. Administration of metoprolol has been shown to cause up-regulation of beta-adrenoceptor density and to decrease nocturnal melatonin release, whereas carvedilol lacks these typical effects of beta-blocking drugs.

AIMS

To compare beta-blocking effects of metoprolol and carvedilol when applied orally in healthy subjects.

METHODS

We investigated the effects of single oral doses of clinically recommended amounts of metoprolol (50, 100 and 200 mg) and carvedilol (25, 50 and 100 mg) to those of a placebo in a randomised, double-blind, cross-over study in 12 healthy male volunteers. Two hours after oral administration of the drugs heart rate and blood pressure were measured at rest, after 10 min of exercise, and after 15 min of recovery.

RESULTS

Metoprolol tended to decrease heart rate during exercise (-21%, -25% and -24%) to a greater extent than carvedilol (-16%, -16% and -18%). At rest, increasing doses of metoprolol caused decreasing heart rates (62, 60 and 58 beats/min) whereas increasing doses of carvedilol caused increasing heart rates (62, 66 and 69 beats/min), 50 and 100 mg carvedilol failed to differ significantly from the placebo (71 beats/min).

CONCLUSIONS

We conclude that clinically recommended doses of carvedilol cause a clinically relevant beta-blockade in humans predominantly during exercise where it appears to be slightly (although not significantly) less effective than metoprolol. On the other hand, the effects of carvedilol on heart rate at rest appear rather weak, particularly in subjects with a low sympathetic tone. This might be caused by a reflex increase on sympathetic drive secondary to peripheral vasodilation resulting from the alpha-blocking effects of the drug. These results might be helpful in explaining why carvedilol, in contrast to metoprolol, may fail to cause up-regulation of beta-adrenoceptor density and does not decrease nocturnal melatonin release. This, in turn, may be a reason for the weak side-effects of carvedilol resulting from the beta-blockade. In addition, our data might be of interest in the interpretation of the forthcoming results of the COMET trial, although it has to be emphasised that they were derived from healthy subjects and, therefore, cannot be directly extrapolated to patients with heart failure.

[Angiotensin I receptor blockers for heart failure]

Angiotensin conversion enzyme inhibitors (ACE-inhibitors) have long been the only possibility to influence the renin angiotensin system (RAS) and its often fatal influences in heart failure. In the last few years specific blockers of the angiotensin 1 receptor (AT I blockers) offered a new possibility for this therapeutic target. In contrast to ACE inhibitors AT I blockers are relatively new and, therefore, few data on heart failure are available. The first head-to-head studies that compared AT I blockers and ACE-inhibitors and their effect on mortality did not show a reduced mortality in the AT I blocker groups. Based on the available data AT I blockers should be used in heart failure patients who are intolerant of ACE-inhibitors.

Change in left atrial and ventricular dimensions during and immediately after exercise

PURPOSE

The aim of this study was to evaluate differences in the left atrial (LAD), total ventricular end-diastolic (TEDD), end-systolic diameters (TESD), and left ventricular shortening fraction (SF) compared with heart rate (HR) and systolic blood pressure (SBP) during exercise and recovery.

METHODS

Healthy young male (N = 15) and female (N = 16) subjects performed an incremental cycle ergometer test in upright position, and three phases of energy supply were defined by means of blood lactate concentration (LA) and respiratory gas exchange variables (I: aerobic; II: aerobic-anaerobic transition; III: anaerobic). Subjects were required to rest their arms on a steering bar and to lean their upper body forward; two dimensional (2-D) echocardiograms were obtained over the left parasternal area at rest (R), at the end of each phase, immediately within 15 s post, and 6 min after exercise (6 min). By using VINGMED's "Anatomical M-Mode," it was possible to extract M-Mode Sweeps from stored 2-D-Loops and perform the M-Mode measurement.

RESULTS

In contrast to the significant decrease in TEDD and TESD from III to 15 s up to resting values and the significant increase in SF from III to 15 s, the moderate decrease in HR immediately post exercise (15 s) was not significant. The SBP showed a significantly decrease from III to 15 s; in contrast to TEDD, TESD, and SF, the values at 15 s were comparable with the values at II. For LAD, significant increase during exercise and a decrease during recovery were observed. Sex-specific differences of changes in measured variables could not be found.

CONCLUSION

We concluded that post exercise measurement of left ventricular and atrial dimensions or SF were not valid to describe heart function at maximal exercise although immediately post exercise HR was near maximal level.

Comparison of wrist blood pressure measurement with conventional sphygmomanometry at a cardiology outpatient clinic

OBJECTIVE

Oscillometric measurement of blood pressure at the wrist is becoming a widely used method for detection of hypertension and its control by treatment. The objective of the present study was to evaluate accuracy and suitability of wrist measurement in a clinical routine setting.

PATIENTS AND METHODS

A series of 333 consecutive patients admitted to our cardiology outpatient clinic were included. Blood pressure was measured at both upper arms according to World Health Organization-International Society of Hypertension guidelines. Oscillometric measurement was performed at the contralateral wrist simultaneously. Blood pressure readings were taken by an oscillometric device applied at the wrist ('Klock'; Industrielle Entwicklung Medizintechnik, Stolberg, Germany) and a conventional mercury sphygmomanometer applied at the upper arm.

RESULTS

Seventy-eight patients were excluded due to differences in blood pressure > 5 mmHg between both upper arms or due to 'error' messages of the wrist device. The data of the remaining 255 patients (149 males; mean age, 65 +/- 13 years; range, 18-95 years) are presented. Mean conventional blood pressure was significantly lower compared with the wrist device (137 +/- 20/80 +/- 11 mmHg versus 153 +/- 28/87 +/- 18 mmHg; P < 0.001 and P < 0.001). The mean difference was 16 +/- 25/6 +/- 17 mmHg. In clinical terms, differences in blood pressure exceeding +/-20/+/-10 mmHg reflecting classification of hypertension are considered important. Measurements of 101 (40%) patients were within these limits. Systolic readings of 110 (43%) and diastolic readings of 117 patients (46%) were beyond this scope.

CONCLUSION

Due to low reliability of wrist blood pressure measurement, it cannot compete with the upper arm standard procedure. If ever, it should only be used if test readings in an individual comparing wrist and upper arm measurement show differences within a range of +/-20/+/-10 mmHg.

N-terminal proatrial natriuretic peptide correlates with systolic dysfunction and left ventricular filling pattern in patients with idiopathic dilated cardiomyopathy

OBJECTIVE

To investigate the diastolic Doppler filling pattern in patients with idiopathic dilated cardiomyopathy and its relation to N-terminal pro-atrial natriuretic peptide (NT-pro-ANP).

METHODS

32 patients (26 male, six female) with idiopathic dilated cardiomyopathy were investigated. All were in sinus rhythm. Conventional M mode echocardiography and Doppler echocardiography was done in each patient. Pulsed wave Doppler inflow signals were obtained and the following variables were measured: maximum E wave, maximum A wave, E/A ratio, E wave deceleration time, A wave deceleration time. NT-pro-ANP was measured using radioimmunoassay.

RESULTS

Mean (SD) left ventricular ejection fraction was 34 (7)% and mean left ventricular end diastolic diameter on M mode echocardiography was 69 (7) mm. Left ventricular filling indices were as follows: maximum E wave velocity, 0.86 (0.22) m/s; maximum A wave velocity, 0.71 (0.24) m/s; E/A ratio, 1.41 (0.65). Mean E wave deceleration time was 140 (50) ms; mean A wave deceleration time was 100 (20) ms. In a stepwise forward regression model, NT-pro-ANP correlated significantly with left atrial diameter (r = 0.603; p < 0. 001), left ventricular ejection fraction (r = -0.758; p < 0.001), and Doppler derived E/A ratio (r = 0.740; p < 0.001).

CONCLUSIONS

In patients with idiopathic dilated cardiomyopathy there is a relation between NT-pro-ANP and both systolic and diastolic variables. In a multivariate model NT-pro-ANP correlated with left atrial diameter, left ventricular ejection fraction, and Doppler derived E/A ratio on transmitral inflow.

Natriuretic peptides in patients with diastolic dysfunction due to idiopathic dilated cardiomyopathy

AIMS

The degree of systolic dysfunction does not always correlate with functional impairment in patients with congestive heart failure. In contrast, diastolic dysfunction correlates well with functional impairment. In heart failure, both elevation of N-terminal proatrial natriuretic peptide and B-type natriuretic peptide are markers of a poor prognosis.

METHODS

We investigated 32 patients (26 male, 6 female; mean age 55+/-2 years) with dilated cardiomyopathy and sinus rhythm. M-mode echocardiography and 2D-echocardiography were carried out in each patient. Pulsed-wave Doppler inflow signals were obtained and the following parameters were measured: maximal E wave and maximal A wave velocity, E/A ratio, E wave deceleration time, A wave deceleration time. Immediately after echocardiography blood samples were collected from patients in the supine position. N-terminal proANP and brain natriuretic peptide were measured using a radioimmuno assay.

RESULTS

The left ventricular ejection fraction was 34+/-1%, the left ventricular end-diastolic diameter on M-mode echocardiography was 68+/-1 mm, while left atrial diameter was 45+/-1 mm. Univariate analysis revealed a significant correlation between both left atrial diameter and ejection fraction and N-terminal proANP and brain natriuretic peptide. All transmitral Doppler parameters showed a significant correlation with N-terminal proANP and brain natriuretic peptide. On forward stepwise regression analysis, left atrial diameter and ejection fraction were able to predict both N-terminal proANP and brain natriuretic peptide. However, of the diastolic parameters only the E/A ratio remained significant. Mildly symptomatic patients differed significantly from severely symptomatic patients in all Doppler parameters. Mildly symptomatic patients had significantly lower levels of N-terminal proANP (0.571+/-0.079 vs 2.282+/-0.340 nmol. l(-1);P<0.001) and brain natriuretic peptide (51+/-14.8 vs 474.2+/- 86.8 pg. ml(-1);P<0. 001).

CONCLUSION

There is a close relationship between natriuretic peptides and diastolic Doppler parameters of left ventricular filling in patients with dilated cardiomyopathy. There is also a significant difference between patients with mild and severe functional impairment regarding both natriuretic peptides and transmitral Doppler parameters.

[Results of efficacy study with diclofenac/orphenadrine infusions in patients with musculoskeletal diseases and functional disorders]

During a post-marketing surveillance study, 641 patients (age range 18 to 86 years) with painful rheumatic diseases, mostly of vertebral etiology, were given ready-for-use infusions containing a combination of the non-steroid antiphlogistic agent diclofenac (75 mg) and the muscle relaxing agent orphenadrine (30 mg) parenterally for 7 days. The goal of the study was to investigate efficacy, tolerability, and acceptance of this intravenous therapy in wide use in physicians' practices. At the end of treatment, the global evaluation resulted in a score of 1.6 on a scale of 1 (very good) to 4 (insufficient). The tolerability score was 1.3 and the acceptability score was 1.5. Only 20 patients (3.1%) had adverse effects, most of which were of gastrointestinal nature. The medication proved appropriate for use in the treatment of painful spine syndromes, inflammatory osteoarthritis, painful osteoporosis, post-operative conditions, and extra-articular rheumatism and could represent a first step towards multi-factorial therapeutic management of these diseases.

[Drug therapy of chronic heart failure]

Prevention of disease leading to cardiac dysfunction, improvement of quality of life and reduction of mortality are the primary objectives in the treatment of chronic heart failure. The therapeutic possibilities are various, including general advices, pharmacological therapy and surgical interventions. Standard medical treatment of systolic cardiac dysfunction contains ACE inhibitors, diuretics and cardiac glycosides. Beta-blocking agents, oral anticoagulation and antiarhythmic drugs can be used in addition. A therapeutic management of chronic heart failure tailored to the individual patient has nowadays become available due to multiple treatment options.

[Diagnosis of heart failure]

Heart failure is a clinical syndrome caused by various etiologic factors. The physician should undertake every effort to identify potentially reversible causes that lead to heart failure. Therefore one should go through various non-invasive as well as invasive diagnostic procedures. The diagnostic tests can be helpful in identifying patients with a poor prognosis.

Parasympathetic receptor blockade and the heart rate performance curve

Parasympathetic receptor blockade and the heart rate performance curve. Med. Sci Sports Sci., Vol. 30. No. 2, pp. 229-233, 1998. The aim of the present study was to investigate the influence of parasympathetic receptor blockade on the heart rate performance curve (HRPC). Twenty healthy male subjects performed a first cycle ergometer test (F), showing a HRPC deflection of varying degree and direction. Subjects then in random order performed two additional cycle ergometer tests, one with atropine (A) and the other with placebo (P). Two lactate turn points (LTP1, and LTP2) were determined by means of linear regression turn point analysis. The degree and direction of the deflection of the HRPC was calculated mathematically as factor kHR (kHR>0 = downsloping of HPRC; kHR<0 = upsloping of HRPC). In comparison with that in F and P, HR in A was significantly higher at rest, LTP1, LTP2, and during recovery, but not at Power(max). An upsloping deflection of the HRPC was seen in only five cases in F and P, whereas in A 10 cases were observed (P < 0.05). In A, kHR was significantly lower than in F and P. A significant correlation for kHR was found among F, P, and A. Independent from parasympathetic receptor blockade and the HR at Power(max), the HR at LTP2 was lower in cases with negative kHR (upsloping). In A as well as in P a significant correlation was observed between kHR and HR at LTP2. The individual time course of HRPC is reproducible and may be independent of parasympathetic activity.

Bradydysrhythmia-related presyncope secondary to pheochromocytoma

Pheochromocytoma endures as a life-threatening disorder. In the absence of systemic hypertension, diagnosis may be difficult. We present a 46-year-old normotensive male with a history of presyncope. One of these episodes could be documented, and revealed symptomatic bradycardia suspicious of sinus node arrest. Due to hints of an elevated sympathetic tone (Schellong test, circadian blood pressure pattern without diurnal rhythm) 24-h urinary catecholamine concentrations were measured and found increased. MIBG-scintigraphy and abdominal-computed tomography indicated the location of the pheochromocytoma. After removal of the tumour, no further episodes of presyncopes or bradydysrhythmias were observed.

Increased neopterin in patients with chronic and acute coronary syndromes

OBJECTIVES

The aim of our study was to determine neopterin levels in patients with chronic and acute coronary syndromes.

BACKGROUND

In chronic and acute coronary syndromes the release of different cytokines activates cellular defense. Infiltration of neutrophils and monocytes/macrophages is detected in the vessel wall as well as in the myocardium. Neopterin, which is a by-product of the guanosine triphosphate-biopterin pathway, is a marker for those activated macrophages.

METHODS

We studied 123 subjects: 1) 21 consecutive patients (17 men, 4 women; mean age +/- SD 66 +/- 15 years, range 31 to 87) with acute myocardial infarction (AMI); 2) 62 consecutive patients (50 men, 12 women; mean age 61 +/- 8 years, range 43 to 81) with signs and symptoms of clinically stable coronary artery disease (CAD); and 3) 40 healthy blood donors (28 men, 12 women; mean age 35 +/- 13 years). Neopterin levels were determined with a commercially available enzyme-linked immunosorbent assay method.

RESULTS

In patients with AMI before thrombolytic therapy, neopterin levels were significantly higher than levels in patients with CAD and control subjects (13.7 vs. 8.6 and vs. 6.8 nmol/liter, p < 0.0001). Values also differed significantly between patients with CAD and control subjects (p < 0.0001). Neopterin levels in patients with AMI were measured seven times during a 72-h period. Within-group comparison showed significant differences over this period (p < 0.00001). The lowest value (11.4 nmol/liter) was observed after 4 h and differed significantly from the initial value and values after 24 and 72 h (p < 0.05). After 72 h, neopterin increased to 14.9 nmol/liter, a value significantly different from all values other than the initial one. There was no correlation between neopterin and creatine kinase (CK); CK, MB isoenzyme; or lactate dehydrogenase as markers for the extent of the myocardial infarction during the observation period.

CONCLUSIONS

Our data support the hypothesis of an activation of monocytes and macrophages in patients with an acute or chronic coronary syndrome. Neopterin as a marker for macrophage activation is significantly increased in patients with chronic CAD and more pronounced in patients with AMI shortly after the onset of symptoms.

Left ventricular function in response to the transition from aerobic to anaerobic metabolism

The purpose of this investigation was to study myocardial function at rest, during three phases of energy supply, and during recovery. Radionuclide angiography was performed during the aerobic phase (phase I, rest-first lactate increase), the aerobic-anaerobic transition phase (phase II, first lactate increase-second lactate increase), the anaerobic phase (phase III, second lactate increase-maximal work performance (Pmax)), and during recovery. Thirty-eight male patients (59 +/- 7 d after myocardial infarction) were compared with 19 healthy control subjects and 21 sport students of comparable age. Left ventricular ejection fraction (LVEF) increased from rest to phase I and from phase I to phase II in sports students and control subjects. During phase III, LVEF did not change significantly in sports students, but it decreased significantly in control subjects. This is in contrast to the patients, who showed an increase of LVEF from resting values (47 +/- 3%) to phase I (50 +/- 1%), no change during phase II (51 +/- 2%), and a decrease to resting values (45 +/- 2) during phase III. All subjects showed an increase in stroke volume (SV) during phase I and II, reaching a maximum at phase II. This was evidenced by an improvement of the systolic function with a constant left ventricular end-diastolic volume (EDV) in control subjects and sports students. In contrast, an improved SV in patients was achieved through an increase in EDV and a less distinct increase in the left ventricular end-systolic volume (ESV). Maximal LVEF values were measured during the first 90 s of recovery in all subjects. Values during recovery are not representative of load dependent myocardial function. This increase in LVEF does not cause an increase in cardiac output but is a consequence of changes in the EDV and ESV, which decrease again immediately after the end of exercise performance.

[The extent of diastolic dysfunction and its correlation with subjective impairment of physical capacity in dilated cardiomyopathy]

OBJECTIVE

To find out whether in patients with dilated cardiomyopathy (DCM) there is a correlation between subjective reduction in physical capacity and the transmitral Doppler profile as a measure of left ventricular (LV) filling.

PATIENTS AND METHODS

30 consecutive patients (24 men, six women; average age 55 +/- 2 years) with chronic primary DCM were examined by Doppler echocardiography to determine possible differences in LV filling pattern, in correlation with subjective impairment of physical capacity graded according to the New York Heart Association (NYHA) classification.

RESULTS

Mean LV ejection fraction was 34 +/- 1%. All patients were in sinus rhythm. Eight patients, in NYHA class I had nearly normal LV filling (E wave 79 m/s, A wave 0.76 m/s); 11 patients in class II had impaired relaxation (E wave 0.77 m/s. A wave 0.82 m/s) and 11 in class III/V had a restricted filling pattern (E wave 0.98 m/s. A wave 0.57 m/s). There was a significant difference between class II and class III/IV patients with regard to E wave deceleration time (0.15 and 0.11 s, respectively; P < 0.05), as well as between class I and class III/IV patients (0.18 and 0.11 s, respectively; P < 0.05). The A wave deceleration time was clearly shorter in class III/IV than class II (0.08 s and 0.11 s; P < 0.05) and class I patients (0.08 s and 0.10 s; P < 0.05).

CONCLUSIONS

The extent of LV diastolic dysfunction correlated with subjective physical capacity. The more the LV filling pattern had changed from normal towards restricted, the greater the patient's symptoms.

Subclinical thyroid disorders in patients with dilated cardiomyopathy

Severe thyrotoxicosis can cause irreversible congestive heart failure. To investigate the coincidence of subclinical thyroid disorders and idiopathic dilated cardiomyopathy (IDC) we investigated these patients with respect to their morphological and functional thyroid status. Thyroid sonography as well as thyroid hormone levels were measured in all patients.

RESULTS

Sixty-one patients (50 male, 11 female) with chronic stable IDC were included. Two out of 61 patients showed completely normal thyroid morphology and function. The other 59 patients showed either morphological or functional abnormalities or both. Of the 53 patients with morphological abnormalities 23 patients (all male) showed diffuse goiter as opposed to 29 nodular enlarged organs (24 male, 5 female). No clinically significant hypothyroidism or thyrotoxicosis was seen. A good correlation was found between the duration of IDC and thyroid volume (r = 0.44; p < 0.001). Two patients died during the study period, 1 from sudden death and 1 from progressive heart failure.

CONCLUSION

Subclinical thyroid disorders are frequently seen in patients with long-standing IDC when they live in an area of chronic iodine deficiency. This can be explained by chronic salt restriction as basic treatment for congestive heart failure. Therefore we conclude that examination of the thyroid gland should be done routinely in patients with IDC, especially when restriction of salt intake is recommended by the treating physician.

Syncope in dilated cardiomyopathy is a predictor of sudden cardiac death

Fifty percent of patients with dilated cardiomyopathy die within 5 years of diagnosis. Syncope is known to be a predictor of poor outcome in patients with advanced heart failure. To assess the risk of patients with dilated cardiomyopathy with a history of syncope during standard medical treatment we compared this group to similar patients without syncope. Twenty-three patients with angiographically proven dilated cardiomyopathy and syncope were followed prospectively and compared to 201 patients without history of syncope. All patients showed a left-ventricular ejection fraction of less than 45%. Both groups did not differ in left-ventricular ejection fraction at baseline (30 +/- 7% in the syncope group, 30 +/- 8% in the no syncope group). Mean follow-up was 2.6 years in the syncope group and 2.4 years in the no syncope group. At baseline, syncope patients used more often amiodarone (p < 0.04), while there was no statistically significant difference between the two groups regarding the intake of digitalis, diuretics and angiotensin-converting enzyme inhibitors. Twenty-six percent of patients in the syncope group and 20% in the no syncope group died during follow-up (non significant). The striking difference, however, was the type of death: 5 out of 6 patients in the syncope group died suddenly compared to 13 of 41 patients in the no syncope group (p < 0.025). Patients with dilated cardiomyopathy and a history of syncope are at high risk of sudden death.

[Coronary aneurysm in a 69-year-old patient. Transthoracic echocardiography]

This case report is on a 69-year old male patient treated with cephalosporins because of suspected myocarditis due to borreliosis. Using transthoracic echocardiography a big aneurysm of the proximal part of the left coronary artery was detected. Coronary angiography revealed an aneurysm 1.2 cm in diameter at the origin of the left anterior descending branch and confirmed the initial diagnosis. In addition, coronary three-vessel disease with reduced left ventricular function was found. Coronaritis due to Lyme borreliosis could not be ruled out with certainty. The patient was relatively asymptomatic, and hence conservative therapy was recommended. The case described here serves as a basis for a discussion on the aetiology, clinical manifestation, diagnosis and therapeutic management of coronary aneurysms.

[Thrombosis of a prosthetic mitral valve in the anticardiolipin syndrome]

A 40-year-old woman in whom the mitral valve had to be replaced with a prosthetic one (St. Jude's) had to be reoperated 8 months later because of endocarditis on the second prosthetic valve (Carbo-Medics). Four months later her general condition deteriorated progressively with cough and dyspnoea, requiring hospitalization. Auscultation revealed moist rales over both lung bases; heart sounds were distant but otherwise normal. The "international normalized ratio" was 2.5, while erythrocyte sedimentation rate, white cell count and C-reactive protein were normal. Transthoracic echocardiography demonstrated a hardly moving mitral valve prosthesis with an opening area of 0.8 cm. Subsequently this decreased further and measurement of the anticardiolipin antibody titre revealed an IgG fraction of 37.9 U/ml (normal up to 12 U/ml). Within 48 hours thrombolysis with streptokinase had increased the valve's opening area to 1.8 cm. The patient made an uneventful recovery under strict anticoagulation. This case illustrates that the anticardiolipin syndrome can be a cause of an otherwise unclear genesis.

Transient reduction of autoantibodies against oxidized LDL in patients with acute myocardial infarction

Fifteen consecutive patients (mean age 66 +/- 14, range 31-82) with an acute myocardial infarction (MI) suitable for thrombolytic therapy were included in this study. Autoantibodies against oxidized low-density lipoprotein (LDL) were determined by enzyme-linked immunosorbent assay (ELISA). Patients (n = 10) with marked elevation of the MB isoenzyme of creatinine kinase (CK-MB)-mass had significant decreases of oLDL-Ab during the acute phase, with a minimum after 8 h following the onset of thrombolytic therapy (within-group significance: p < .001; between groups: p = .01). Patients (n = 5) with CK-MB-mass values less than 70 ng/ml did not show this phenomenon. Furthermore, significant correlations existed between CK-MB-mass and oLDL-Ab after 6 and 8 h (n = 15; r = .72; p = .003) and the time of the highest CK-MB-mass values (after 12 h) and the time of the maximal decrease of oLDL-Ab (after 8 h) (r = .74; p = .003). Our observations provide further evidence for the release of free radicals and for increased lipid peroxidation during reperfusion after prolonged ischemia. The decrease of oLDL-Ab appears to be a marker for the severity of MI.

Effects of treadmill exercise protocol with constant and ascending grade on levelling-off O2 uptake and VO2 max

In order to investigate the effect of an exercise protocol on the levelling-off O2 uptake and VO2 max values, ten male subjects aged 28 +/- 5 yrs, height 1.8 +/- 0.05 m, body mass 76 +/- 6 kg performed two treadmill exercise protocols: 1) constant grade (CG) of 5%, with increasing running speed starting at 6 km.h-1 and increments of 2 km.h-1 every 3 minutes. 2) ascending grade (AG) starting at 0% and increments of 5% every 3 minutes, with constant running speed of 5 km.h-1. During each protocol oxygen uptake (VO2), pulmonary ventilation (VE), tidal volume (Vt), and breathing rate (BR) as well as blood lactate concentration (La) and heart rate (HR) were measured. In CG a levelling-off phenomenon of VO2 in all cases was observed. Aerobic capacity expressed as VO2 max in CG was 46.2 +/- 6.0 ml.min-1.kg-1. In contrast, VO2 max was 35% higher in AG (62.6 +/- 7.2 ml.min-1.kg-1). The behaviour of VO2 indicates a lower efficiency with increasing work load in AG as compared to CG. Regarding maximum performance it can be concluded that VO2 in CG seems to be limited by a mechanical or neuromuscular constraint on the depth of breathing, which is confirmed by a distinct flattening of Vt. The levelling-off of the VO2 in CG, something which is not observed in AG, can be explained plausibly this way.

Changes in thyroid hormone parameters after acute myocardial infarction

Abnormalities in circulating thyroid hormone levels are very common in systemic nonthyroidal illnesses, such as acute myocardial infarction. In this study, thyroid parameters were determined in a series of 16 consecutive infarction patients treated by thrombolysis. Blood samples were taken before therapy as well as 2, 4, 6, 8, 12 and 72 h following admission. Total and free serum thyroxin and triiodothyronine decreased and reverse T3 increased significantly showing no major variations up to 72 h, whereas thyroid-stimulating hormone values remained almost unchanged during the observation period. Subjects with CK-MB levels of more than 150 ng/ml (n = 10) revealed similar changes in thyroid parameters in comparison to those with lower values (n = 6; NS). Thus, although hormone modifications very often occur following acute infarction, thyroid status may not serve as a marker for the extent of left ventricular dysfunction in the early phase of myocardial infarction.

Long-term outcome and prognostic factors in dilated cardiomyopathy. Preliminary results

To investigate long-term follow-up and identify prognostic factors in patients with dilated cardiomyopathy (DCM) the authors investigated 167 consecutive patients on an outpatient basis. All patients underwent left- and right-heart catheterization; follow-up comprised clinical and echocardiographic investigations.

RESULTS

After a mean follow-up period of ninety-three +/- thirty-six months 82 patients (49%; 71 men, 11 women, mean age fifty-five +/- eleven years) were alive. 29 of them (27 men, 2 women, mean age fifty-two +/- nine) showed normal left ventricular ejection fraction (LVEF) after a mean follow-up period of one hundred four +/- forty months. The remaining 53 patients (44 men, 9 women, mean age fifty-six +/- eleven) revealed LVEF similar to that of the first examination. Eighty-five patients died (51%; 73 men, 12 women). Causes of death were the following: progressive heart failure, 24; sudden death, 23; stroke, 3; pulmonary embolism, 2; noncardiac death, 4; unknown causes, 29. The median period from the onset of first symptoms until definite diagnosis was two months in patients with stable conditions, three months in those with normalization of LVEF and twenty-four months in those who died, respectively (P < 0.01). At the time of diagnosis, patients with stable outcome had a mean LVEF (LVEF 1) of 37%, those who returned to normal had 40% (ns). Patients who died had a mean LVEF 1 of 32% and therefore differed significantly from both groups of survivors (P < 0.001). Left ventricular end-diastolic pressure (LVEDP) at the time of diagnosis was highest in patients who died (22 mmHg) and therefore differed significantly from both groups of survivors (normalization: 16 mmHg, stable patients: 18 mmHg, P < 0.001).

CONCLUSIONS

According to their results, time until diagnosis, LVEF, and LVEDP are prognostic indicators. No difference was noted between the groups concerning etiology, medical treatment, or functional classification according to the New York Heart Association.

[Toxoplasmosis peri-myocarditis as initial manifestation of highly malignant non-Hodgkin's lymphoma]

A case report of a 28-year-old mother of two children with FUO is presented. Physical examination revealed an anemic and febrile woman, who lost 10 kg of weight during the past 3 months. Furthermore, two lymphatic nodes with diameters below 1 cm were detected at the neck and inguinal region. A search for origin of fever including evaluation of foci, malignancies and laboratory investigations was primarily unsuccessful. At day 7 after admission a pericardial murmur could be heard. Echocardiography revealed a pericardial effusion, which increased up to 4 cm during the following days, leading to hemodynamic impairment and asystole. Immediate CR was successful, pericardial effusion was aspirated. Looking for etiology of fever the presence of IgM-antibodies against toxoplasma gondii by an ELISA test was possible. Therefore, toxoplasmosis was diagnosed and a treatment-regimen comprising pyrimethamin and sulfadiazin was initiated. Because of the threat to life and very high titers of C-reactive protein, antibiotic therapy (imipenem) was given additionally. An immunologic impairment was excluded by normal ratio of CD4:CD8 of lymphocytes, normal HIV-test and a nonsuspicious Jamshidi-biopsy of the bone marrow. However, in week 9 after admission lymphatic node-tumors suddenly appeared at the neck and pulmonary hilus. After diagnostic exstirpation a malignant non-Hodgkin-lymphoma (T-cell-type) was diagnosed. It is concluded that in obscure pericardial effusion toxoplasmosis should be considered and that this manifestation may be a precursor of malignant non-Hodgkin-lymphoma.

A physiological oral magnesium supplement does not influence total serum magnesium, left ventricular ejection fraction and prognosis in patients with dilated cardiomyopathy

It has been postulated that patients with congestive heart failure (CHF) benefit from physiological oral magnesium supplements. In order to study the effect of such supplements upon patients with idiopathic dilated cardiomyopathy (IDC) we studied a group of 23 patients with the salient characteristics of IDC (18 male, 5 female; mean age 51 +/- 13 years [range: 23-72]; Mg group), who received oral magnesium supplements (15 mmol/day). All patients received oral ACE inhibitors and 22 were receiving digitalis and diuretics. A control group of 27 patients, matched for age, sex, symptoms, and additional treatment (22 male, 5 female; mean age 52 +/- 13 years [range 22-71]) were not given oral magnesium supplements. All these patients also received oral ACE inhibitors, 25 were receiving digitalis, and 23 were receiving diuretics. Mean serum magnesium concentration (total serum Mg) in the Mg group was 0.83 +/- 0.06 mmol/litre [mean +/- SD, range 0.69-0.99], while in the control group it was 0.83 +/- 0.07 mmol/litre [range 0.70-0.96], P = NS. Left ventricular ejection fraction (LV-EF) improved from 32 +/- 11 per cent [range 13-51] to 42 +/- 14 per cent [range 15-66] in the Mg group and from 30 +/- 13 per cent [range 10-52] to 42 +/- 11 per cent [range: 25-64] in the control group. We found that physiological oral Mg supplements did not influence serum magnesium, LV-EF, or prognosis. Furthermore, we found that 56 per cent of all patients improved when subjected to strict guidance and therapy with ACE inhibitors, digitalis, and diuretics.