Background Heart failure with normal left ventricular ejection fraction (HFNEF) accounts for about one third of all heart failure patients with considerable mortality. The metabolic syndrome (MS) is a risk factor for diastolic dysfunction and HFNEF. We hypothesized that modifying metabolic burden by exercise training and weight loss might improve left ventricular diastolic function, heart failure symptoms and rehospitalization rate.Methods and results Forty patients with HFNEF, MS and prediabetes were enrolled in this prospective study. Echocardiography and cardiopulmonary exercise testing (CPET) were done at baseline and after 3 months lifestyle modification (LSM). NT-pro BNP and adiponectin were determined at baseline as both peptidehormones play a crucial role in MS and heart failure. After discharge a 3-month LSM program with the aim of weight reduction by diet and exercise was started. After the intervention period a weight reduction of >= 2% was defined as successful LSM (group A=23 patients), while a weight reduction <2% was classified as unsuccessful LSM (group B=17 patients). At baseline NT-pro BNP (424 +/- 381 versus 121 +/- 99 pg/ml, P < 0.01) and adiponectin (10.1 +/- 6.2 versus 4.6 +/- 2.0 mu g/ml, P < 0.01) were higher in group A than in group B. After 3 months of LSM, CPET showed a significant improvement of VO2 peak (P < 0.01), EqCO(2) (P < 0.01), 02-pulse (P = 0.02) and VE/VCO2 slope (P = 0.01) in group A. After one year of follow-up a modest but significant reduction of left atrial size and mitral flow to mitral annulus velocity ratio E/E' was seen in group A. LSM resulted in significant improvement of NYHA status (P = 0.03) and higher freedom of rehospitalization (P = 0.04) in group A.Conclusion Successful lifestyle modification in obese, prediabetic patients with HFNEF improves diastolic left ventricular function and cardiopulmonary exercise capacity. As these measures result in improved NYHA status and less hospitalization, LSM might be a promising approach to prevent chronic diastolic heart failure.

Background/Objectives: Non-ST segment elevation myocardial infarction (MI) poses similar detrimental long-term prognosis as ST-segment elevation MI. No marker on ECG is established to predict successful reperfusion in NSTEMI. QT dispersion is increased by myocardial ischemia and reduced by successful restoration of epicardial blood flow by PCI. Whether QT dispersion reduction translates to smaller infarcts and thus indicates successful reperfusion is unknown. We hypothesized that the relative reduction of QT dispersion (QTD-Rrel ) on a standard ECG in acutely reperfused NSTEMI is related to infarct size and infarct transmurality as assessed by delayed enhancement CMR (DE-CMR). Methods and Results: 69 patients with a first acute NSTEMI were included. QTD-Rrel was stratified according to LV function and volumes, infarct transmurality and size as assessed by DE-CMR. Extensive myocardial infarction was defined as above median infarct size. LV function and end-systolic volume were only mildly related to QTD-Rrel . QTD-Rrel was inversely related to infarct size (r=-0.506,p=0.001) and infarct transmurality (r=-0.415, p=0.001). QTD-Rrel was associated with extensive myocardial infarction in univariate analysis (odds ratio (OR) 0.958, CI 0.935-0.982; p=0.001). Compared to clinical and angiographic data QTD-Rrel remained the only independent predictor of non-transmural infarcts (OR 1.110, CI 1.055-1.167; p=0.049). Conclusion: In patients with acute Non-ST-Segment Myocardial infarction QTd-Rrel calculated on a surface ECG prior and post PCI for restoration of epicardial blood flow detects small, non-transmural infarcts as assessed by delayed enhancement CMR. Thus, QTd-Rrel can indicate successful reperfusion therapy.

CMR is a safe procedure, with high image quality, relevant clinical indications, and a strong impact on patient management. Recommendations for training in cardiovascular magnetic resonance encompass three levels: one month for level 1, three months for level 2, and twelve months for professional expertise at level 3. Interdisciplinary approaches and accreditation programs are needed to further optimize training in cardiovascular magnetic resonance.

Background The EuroCMR registry sought to evaluate indications, image quality, safety and impact on patient management of clinical routine CMR in a multi-national European setting. Furthermore, interim analysis of the specific protocols should underscore the prognostic potential of CMR. Methods Multi-center registry with consecutive enrolment of patients in 57 centers in 15 countries. More than 27000 consecutive patients were enrolled. Results The most important indications were risk stratification in suspected CAD/Ischemia (34.2%), workup of myocarditis/cardiomyopathies (32.2%), as well as assessment of viability (14.6%). Image quality was diagnostic in more than 98% of cases. Severe complications occurred in 0.026%, always associated with stress testing. No patient died during or due to CMR. In 61.8% CMR findings impacted on patient management. Importantly, in nearly 8.7% the final diagnosis based on CMR was different to the diagnosis before CMR, leading to a complete change in management. Interim analysis of suspected CAD and risk stratification in HCM specific protocols revealed a low rate of adverse events for suspected CAD patients with normal stress CMR (1.0% per year), and for HCM patients without LGE (2.7% per year). Conclusion The most important indications in Europe are risk stratification in suspected CAD/Ischemia, work-up of myocarditis and cardiomyopathies, as well as assessment of viability. CMR imaging is a safe procedure, has diagnostic image quality in more than 98% of cases, and its results have strong impact on patient management. Interim analyses of the specific protocols underscore the prognostic value of clinical routine CMR in CAD and HCM. Condensed abstract The EuroCMR registry sought to evaluate indications, image quality, safety and impact on patient management of clinical routine CMR in a multi-national European setting in a large number of cases (n > 27000). Based on our data CMR is frequently performed in European daily clinical routine. The most important indications in Europe are risk stratification in suspected CAD/Ischemia, work-up of myocarditis and cardiomyopathies, as well as assessment of viability. CMR imaging is a safe procedure, has diagnostic image quality in more than 98% of cases, and its results have strong impact on patient management. Interim analyses of the specific protocols underscore the prognostic value of clinical routine CMR in CAD and HCM.

Myocarditis is an inflammatory condition affecting the myocardium. The presentation and clinical course of myocarditis can be highly variable which makes it difficult to diagnose the disease. EMB can ascertain the diagnosis by (immuno-) histologic methods, PCR may in addition detect the presence of viral genomes which often play a pathogenic role in myocarditis. However, EMB is not often performed.CMR is a non-invasive technique that offers the possibility to analyze left ventricular function with great precision. Myocardial scars or necroses can be visualized by LGE. In myocarditis the typical pattern of LGE is epicardial or intramural. LGE in patients with myocarditis is associated with an unfavourable prognosis and an increased rate of cardiac events. In acute myocarditis T2-weighted images performed before administration of contrast agents may show myocardial oedema.

Predictors of long-term mortality after discharge after acute myocardial infarction (AMI) are well characterized. However, these established risk factors are based on data almost exclusively derived from older studies without consistent use of revascularization therapy and adjunctive therapy with statins, platelet inhibitors, beta-blockers and ACE inhibitors/ARBs. We therefore sought to investigate predictors of 1-year mortality in survivors of AMI treated with contemporary guideline-adherent therapy.

Die kardiale Magnetresonanztomografie ist ein sicheres bildgebendes Verfahren mit hoher Bildqualität und klinisch bedeutsamen Indikationen und Befunden, die das Patientenmanagement stark beeinflussen. Aktuelle Weiterbildungscurricula enthalten 3 Stufen von Expertise: 1 Monat in der Basisstufe 1 (Kennenlernen von typischen Indikationen und Befunden), 3 Monate in der Stufe 2, die zum eigenverantwortlichen Untersucher, und 12 Monate und mehr als 300 Untersuchungen auf der Stufe 3, die zum Weiterbilder berechtigt. Interdisziplinäre Programme unter Beteiligung von Kardiologen und Radiologen sind geeignet, die Weiterbildung in der kardialen Magnetresonanztomografie weiter zu verbessern.

Die Myokarditis stellt eine entzündliche Erkrankung des Herzmuskels dar, die verschiedenste Verläufe zeigen kann und klinisch oft schwierig zu diagnostizieren ist. Mittels endomyokardialer Biopsie (EMB) lässt sich die Diagnose (immun-)histologisch sichern, in der PCR ist auch der Nachweis von Virusgenomen, die als Auslöser vermutet werden, möglich. Allerdings wird die EMB oft aus verschiedenen Gründen nicht durchgeführt. Die kardiale MRT bietet als nicht invasive Methode zunächst die Möglichkeit, die linksventrikuläre Funktion präzise zu bestimmen. Mittels LGE lassen sich auch Narben oder Nekrosen, vornehmlich als intramurale und epikardiale Kontrastmittelanreicherungen nachweisen. Ein in der MRT nachweisbares LGE ist dabei nachweislich mit einer ungünstigeren Prognose und einer erhöhten Rate kardialer Ereignisse assoziiert. Bei akuten Verlaufsformen kann optional auch mit T2-gewichteten Bildern (vor Gabe von KM) das akute Ödem dargestellt werden.

BACKGROUND:Controversy exists about the impact of treating bifurcations on overall outcome of coronary interventions using drug-eluting stents (DES). We sought to investigate 1-year outcome of the treatment of bifurcation lesions using DES in a large "real-world" cohort.METHODS AND RESULTS:Among 5,126 patients enrolled in phase I of the multicenter German Drug-Eluting Stent Registry, 814 (16%) were treated for a bifurcation lesion. Patients with bifurcations were compared to those without bifurcations in terms of baseline characteristics, major adverse cardiac and cerebrovascular events (MACCE) and target vessel revascularization (TVR) at 1 year. Usage of sirolimus-eluting stents (SES) versus paclitaxel-eluting stents (PES) was also evaluated. In total, 1,021 and 5,189 stents were implanted in the bifurcation (1.25 stents/patient) and nonbifurcation (1.2 stents/patient) group, respectively, but 64.5% of bifurcation lesions were treated with a single stent. More complex lesion and procedural characteristics were observed in the bifurcation group. However, there was no difference in 1-year MACCE rates (a composite of death, myocardial infarction, and stroke) between the bifurcation group and nonbifurcation group (8.1% vs. 8.3%, P = 0.85). Rates of TVR (11.2% vs. 10.8%, P = 0.75) and Academic Research Consoritum-defined definite stent thrombosis (0.9% vs. 0.8%, P = 0.67) were also comparable. MACCE and TVR rates remained similar after adjustment for differences in baseline characteristics. MACCE and TVR in SES patients were 7.2% and 12.6% versus 8.7% and 10.2% in PES patients (P = 0.46 and P = 0.30, respectively).CONCLUSION:In this large multicenter registry, treatment of bifurcation lesions with DES appears effective and safe. The presence of bifurcations did not affect 1-year outcomes after DES implantation. The outcomes for SES and PES were similar.

In the setting of acute myocardial infarction and sinus rhythm, the heart rate (HR) has been demonstrated to correlate closely with mortality. In patients presenting with acute myocardial infarction and atrial fibrillation (AF) on admission, however, the prognostic relevance of the HR has not yet been systematically addressed. A post hoc subgroup analysis of the data from the OMEGA trial was conducted to analyze whether the admission HR determines the 1-year mortality in patients presenting with AF in the setting of acute myocardial infarction. Of 3,851 patients enrolled in the OMEGA study, 211 (6%) presented with AF on admission. This subgroup was dichotomized according to the admission HR (cutoff 95 beats/min). Multiple regression analysis revealed that an admission HR of ≥95 beats/min independently determined the 1-year mortality in patients with AF (odds ratio 4.69, 95% confidence interval 1.47 to 15.01; p = 0.01). In conclusion, this is the first study demonstrating that a high HR (≥95 beats/min) on admission in patients with AF and acute myocardial infarction is associated with an almost fivefold mortality risk.

AIMS Drug-eluting coronary stents (DES) have gained widespread use for the treatment of coronary artery disease. However, because of safety concerns and frequent "off-label" use data from "real life," registries are necessary to monitor indications and outcome of DES in daily clinical practice. METHODS AND RESULTS We evaluated data from the German Cypher Stent Registry. A total of 10,894 patients treated with at least one sirolimus-eluting stent (SES) at 152 hospitals were included. Follow-up at a median of 6.4 months was available in 10,006 patients (92%). Median age was 64.8 years and 75.5% were male. Per lesion a mean of 1.09 +/- 0.41 SES were implanted with a mean length of 21.1 +/- 11.5mm. During follow-up, death rate was 1.8% and the rates of myocardial infarction or stroke were 2.1% and 0.5%. Any target vessel revascularization (TVR) was performed in 8.0% of patients. Independent predictors for death, myocardial infarction, or stroke were: cardiogenic shock, acute coronary syndromes, reduced left ventricular function, renal insufficiency, diabetes mellitus, advanced age, three-vessel disease, degree of stenosis, and prior myocardial infarction. Predictors for a TVR were: two- or three-vessel disease, target vessel = coronary bypass, advanced age, stent diameter, ostial lesions, indication in-stent restenosis, renal failure, and target vessel = left anterior descended artery. CONCLUSIONS These results demonstrate that SES use in clinical practice is safe and effective. The main predictors of clinical events during follow-up are clinical parameters whereas as predictors of TVR mainly are angiographic parameters.

BACKGROUND:There is no randomized, double-blind trial testing the prognostic effect of highly purified omega-3 fatty acids in addition to current guideline-adjusted treatment of acute myocardial infarction.METHODS AND RESULTS:OMEGA is a randomized, placebo-controlled, double-blind, multicenter trial testing the effects of omega-3-acid ethyl esters-90 (1 g/d for 1 year) on the rate of sudden cardiac death in survivors of acute myocardial infarction, if given in addition to current guideline-adjusted treatment. Secondary end points were total mortality and nonfatal clinical events. Patients (n=3851; female, 25.6%; mean age, 64.0 years) were randomized in 104 German centers 3 to 14 days after acute myocardial infarction from October 2003 until June 2007. Acute coronary angiography was performed in 93.8% and acute percutaneous coronary intervention in 77.8% of all patients. During a follow-up of 365 days, the event rates were (omega and control groups) as follows: sudden cardiac death, 1.5% and 1.5% (P=0.84); total mortality, 4.6% and 3.7% (P=0.18); major adverse cerebrovascular and cardiovascular events, 10.4% and 8.8% (P=0.1); and revascularization in survivors, 27.6% and 29.1% (P=0.34).CONCLUSIONS:Guideline-adjusted treatment of acute myocardial infarction results in a low rate of sudden cardiac death and other clinical events within 1 year of follow-up, which could not be shown to be further reduced by the application of omega-3 fatty acids.CLINICAL TRIAL REGISTRATION:URL: http://www.clinicaltrials.gov. Unique identifier: NCT00251134.

Blood glucose level at admission in ST-segment elevation myocardial infarction (STEMI) is a predictor of heart failure and mortality. This study was performed to investigate the impact of hyperglycemia at admission in non-diabetic patients on infarct size, microvascular obstruction, and long-term outcome using contrast-enhanced magnetic resonance imaging (CMR) in patients with acute STEMI.

Left ventricular hypertrophy (LVH) is an important prognosticator for cardiovascular (CV) risk in persons with and without arterial hypertension. Given the high prevalence of these conditions, LVH screening is mandatory for CV prevention. Although not evaluated in a middle aged preventive medicine population, Electrocardiography (ECG) is widely used for LVH screening. Although not widely accessible as a screening technique, cardiovascular magnetic resonance (CMR) offers a unique opportunity to calculate LV mass index (LVMI) as the gold standard for other diagnostic tests.

High sensitive troponin T (hsTnT) is a highly specific marker of myocardial injury and one of the keystones in the diagnosis of acute coronary syndrome. Although hsTnT is thought to be released by myocardial cell damage, recent studies reported elevated levels after exercise testing and endurance sports. The exact mechanism of this phenomenon is discussed controversially. CMR stress testing is widely used for detection of myocardial ischemia. The kinetic of troponin release after CMR stress testing has not been studied previously.

Observational studies from the USA have demonstrated that off-label use of drug-eluting stents (DES) is common. Data on off-label use in Western Europe are limited.

The purpose of this study was to assess the frequency, manifestation, and severity of acute adverse reactions associated with administration of several gadolinium-based contrast agents to patients who underwent cardiac magnetic resonance (CMR) imaging in the EuroCMR (European Cardiovascular Magnetic Resonance) Registry multinational and multicenter setting.The frequency, manifestations, and severity of acute adverse reactions associated with gadolinium-based contrast agents in the specific setting of cardiovascular magnetic resonance have not been systematically evaluated yet.This is a multicenter and multinational registry with consecutive enrollment of patients in 45 European centers. During the current observation, 17,767 doses of gadolinium-based contrast agent were administered to 17,767 patients. The mean dose was 25.6 ml (range 5 to 80 ml), which is equivalent to 0.128 mmol/kg (range 0.012 to 0.3 mmol/kg).Thirty acute adverse reactions due to contrast administration occurred (0.17%). All reactions were classified as mild according to the American College of Radiology definition. The most frequent complaints following contrast administration were rashes and hives (9 of 30), followed by nausea (7 of 30), and anxiety (6 of 30). The event rate ranged from 0.06% (linear nonionic agent gadodiamide) to 0.47% (linear ionic agent gadobenate dimeglumine). Interestingly, we also found different event rates between the three main indications for CMR imaging, ranging from 0.1% (risk stratification in suspected coronary artery disease) to 0.42% (viability in known coronary artery disease).The incidence of acute adverse reactions after administration of gadolinium-based contrast in the "off-label" setting of CMR in our population was not different from the incidence in the U.S. Food and Drug Administration-approved general radiology setting. Thus, the off-label use of gadolinium-based contrast in CMR should be regarded as safe concerning the frequency, manifestation, and severity of acute events.

Background: The Myocardial Infarction Network Essen was initiated in order to establish a standardized procedure with immediate reopening of the infarcted vessel for patients with ST-elevation myocardial infarction (STEMI) in the city of Essen, Germany. The present study aims to evaluate gender-related differences in presentation of disease and clinical outcome.Hypothesis: Gender is associated with differences in presentation and outcome of STEMI.Methods: All patients with STEMI were included without exception. Parameters such as risk profile, mortality, and relevant time intervals were documented. The follow-up period was 1 year.Results: For this study, 1365 patients (72.1% male) were recruited. Women were significantly older, with higher prevalence of diabetes (28.1% vs 20.3%, P = 0.004) and hypertension (76.5% vs 64.8%, P < 0.0005). Analysis of time intervals between symptoms to actions showed no significant differences. However, women tended to wait longer before calling for medical assistance (358 vs 331 min, P = 0.091). In-hospital mortality was comparable with respect to gender, whereas women had higher 1-year mortality (18.6% vs 13.2%). Age and diabetes were associated with a higher mortality. Adjusted for age, gender is no longer an independent risk factor. In the follow-up period, significantly more women were readmitted to the hospital without a difference in the frequency of reangiography, surgery, or target-vessel revascularization.Conclusions: The present data display a successful implementation of a standardized procedure in patients with STEMI. Although differences between genders are not as obvious as expected, efforts should be taken to perform a gender-specific risk analysis as well as to promote education about proper behavior in case of new onset of angina.