Drug Prescribing for Patients with Chronic Kidney Disease in General Practice: a Cross-Sectional Study

Results of studies concerning prevention of cardiovascular disease by treatment with macrolide antibiotics targeting C. pneumoniae infection are still controversial. This study describes the results of different tests for infection with C. pneumoniae as well as the effect of treatment with roxithromycin in patients with acute myocardial infarction (AMI) in relation to their serostatus against C. pneumoniae.

Drug Prescribing for Patients with Chronic Kidney Disease in General Practice: a Cross-Sectional Study

Dtsch. Med. Wschr. 0120472 001; 126: 1245–1248 © Georg Thieme Verlag Stuttgart · New York A k t u e l l e D i a In Anbetracht der Überlegenheit implantierbarer Defibrillatoren (3, 11) wird man sich bei der Behandlung maligner ventrikulärer Arrhythmien kaum auf Antiarrhythmika verlassen wollen, zumal ein Nachweis für deren Wirkung auf die Prognose bislang aussteht. Als maligne Arrhythmien gelten anhaltende ventrikuläre Tachykardien und Kammerflimmern. Letzteres wird häufig, oft auch fälschlich, mit einer stattgehabten Reanimation gleichgesetzt. Maligne Arrhythmien ohne reversible Ursache (akute Ischämie, Hypoxie, Elektrolytentgleisung, Proarrhythmie) weisen ein hohes Rezidivrisiko auf. Deren Behandlung dient daher der Sekundärprophylaxe. Ventrikuläre, ggf. salvenartige Extrasystolen bei Patienten mit Herzinsuffizienz und koronarer Herzerkrankung gehen mit einem erhöhten Risiko für maligne Rhythmusereignisse (5) einher. Eine antiarrhythmische Therapie soll dieses Risiko reduzieren (Primärprophylaxe). Plazebokontrollierte Studien zur Sekundärprophylaxe mit Antiarrhythmika fehlen, die Ergebnisse von Studien zur Primärprophylaxe waren bestenfalls neutral (2, 6). Der Nutzen der Pharmakotherapie ventrikulärer Arrhythmien aus prognostischer Indikation ist daher wissenschaftlich nicht bewiesen. Allerdings wird man nicht selten auch durch die klinische Symptomatik des Patienten vor die Frage nach einer effektiven und risikoarmen Behandlungsmöglichkeit gestellt. Daher sollen in der vorliegenden Übersicht Empfehlungen für den differenzierten, symptomgerichteten Einsatz von Antiarrhythmika gegeben werden. Da die Entscheidung für eine symptomatische Therapie eine prognostische Bewertung voraussetzt, werden auch Grundzüge der Risikostratifizierung in der Praxis erörtert.

Drug Prescribing for Patients with Chronic Kidney Disease in General Practice: a Cross-Sectional Study

Patienten mit einem implantierbaren Cardioverter-Defibrillator (ICD) benötigen häufig zusätzlich ein antibradykardes Schrittmachersystem (SM). Die simultane Therapie führte in der Vergangenheit wiederholt zu Interaktionen zwischen den Systemen mit Therapieversagen auf beiden Seiten.

A 62year old patient with an aneurysm of the inferior wall due to previous myocardial infarction presented in hospital with dyspnoe and intermittent tachycardia, but no evidence of syncope. The subsequent diagnostic procedures revealed several risk factors which could be associated with high risk of malignant ventricular arrhythmias. The coronary angiography did not show a hemodynamically relevant stenosis, therefore revascularisation as antiischemic therapy was not indicated. The left ventricular function was slightly depressed and there was a positive signal-averaged electrocardiogram. The electrophysiological study revealed that a sustained monomorphic ventricular tachycardia could be induced, degenerating into ventricular fibrillation. This ventricular tachycardia could also be induced during treatment with sotalol. We decided to implant an ICD prophylactically. One year after implantation an episode of syncope occurred, caused by a fast ventricular tachycardia which was terminated by defibrillation with 34 J. This first spontaneous episode of malignant arrhythmia would have proven fatal without the described preventive therapy.

Patients who need an implantable Cardioverter/Defibrillator (ICD) often require a cardiac pacemaker (PM) to treat underlying symptomatic bradycardia. In some cases the simultaneous therapy has caused interactions between the systems with defaults on both sides.Four patients with an ICD of the newer generation received a single or dual chamber pacemaker system. In all cases bipolar pacemaker electrodes were used. They were positioned together with the ICD-electrode in the right ventricular apex without regard to the distance between them. In order to exclude possible interference between systems special tests were performed during the operative procedure with respect to the system implanted first. In a follow-up period of 4-14 months all patients had episodes of ventricular tachycardia or ventricular fibrillation that were terminated successfully. Two patients with a bradycardia related arrhythmia after shock delivery showed a correct pacemaker stimulation. Subsequent to the start of pacemaker therapy improvement in stress capacity could be documented, partly on the basis of echocardiography.Combined ICD and PM therapy can thus be generally regarded as compatible. For AV-sequential pacing at least three electrodes and two aggregates are necessary. The development of an ICD with the option for a dual-chamber stimulation would simplify the therapy, along with a greater acceptance on part of the patients.

QT dispersion (QTd) describes the heterogeneity of ventricular repolarization on the basis of the temporal range of QT intervals as measured in the 12‐lead ECG. We examined the spatial distribution of QTd using multichannel magnetocardiograms (MCGs), which noninvasivety register changes in magnetic field strength at 37 sites over the heart. As in ECG, the MCG signal in each channel may be used to measure QT interval. By calculating QT deviation from QTmin at each site, one can reconstruct the spatial distribution of QTd. Analysis of spatial QTd in ten healthy subjects and ten patients after acute myocardial infarction (MI) showed clear differences in spatial distribution. The healthy subjects generally displayed shorter QT intervals along a line corresponding to the approximate position of the septum with longer intervals in plateaus in the upper right and lower left. Spatial QTd of the post‐MI patients deviated from this pattern, often displaying a sharp rise in QT duration over specific areas, which could be related to functional and morphological disturbances. The quantification of local irregularities as well as the overall pattern on the basis of a smoothness index allowed better discrimination between healthy subjects and post‐ MI patients than QTd. Distribution patterns of QTd which reflect local repolarization alterations may thus represent a more differentiated marker for pathology and risk.

A retrospective study of 798 patients from Essen University Medical Hospital during the period 1960-1987 with operation performed due to valvular heart disease was undertaken. Among them were 324 suffering from mitral stenosis, 12 from mitral regurgitation, 462 from mixed mitral valvular diseases. The surgical treatment consisted of commissurotomy in 611 patients, and prosthetic valve replacement in 187 patients. Follow-up studies showed: Before and after operation, occurrence of embolism was 16.5 vs 8.7%; status of class of cardiac function (NYHA) from group with commissurotomy was 3.1 vs 2.0; NYHA classification in group of prosthetic replacement was 3.1 vs 1.9; 10 years survival rate after commissurotomy was 95.2%; after valve replacement it was 80.2%; early letality rate after operation (at or within 2 months after operation) depended on 1) the type of operation: commissurotomy 2.8%, valve replacement 10.2%; 2) the state of cardiac function: in class IV it was 12.9%, in class III 4.6%; 3) the number of operations: in only operation it was 4.8%, in reoperations 19.5%. Thus the following fact will lead to false judgement: though the area is the same, the regurgitant volume may vary with the brightness of coloration. Furthermore the left auricle will be enlarged consequently following the increase of regurgitant volume, also causing misinterpretation. It is of practical importance to consider some other factors in quantifying the regurgitant volume.

In unserer Studie wurden 798 Fälle mit Mitralklappenfehlern analysiert. Die Beziehungen zwischen verschiedenen Parametern und den NYHA-Klassen, der Erfolg der Operation, die Operationsletalität, die Lebensqualität und die 10-Jahres-Überlebenswahrscheinlichkeit wurden diskutiert. Es wird empfohlen, bei Patienten mit Indikation zur Mitralkommissurotomie (bei reiner Mitralstenose ohne Verkalkung an der Klappe, und bei kombinierten Mitralvitien mit überwiegender Stenose, aber ohne erhebliche Vergrößerung des linken Ventrikels) die Operation frühzeitig anzustreben. Bei Patienten, bei denen Kommissurotomie nicht mehr indiziert ist, ist der Mitralklappenersatz baldigst durchzuführen.

A 26-year-old female patient was admitted 30 minutes after suicidal poisoning with 750 mg amitriptyline (Saroten), 4800 mg dibenzepine (Noveril retard) and 2100 mg thioridazine (Melleril). Life threatening disturbances of cardiac rhythm occurred in addition to coma, pulmonary insufficiency requiring assisted ventilation, and hypotension. Physostigmine only caused temporary improvement and the arrhythmias only resolved completely after additional administration of NaCl.

In a 38-year-old patient with alcoholic liver cirrhosis and haemorrhage from a gastric ulcer, granulocytopenia occurred during cimetidine treatment. It was reversible after therapy was stopped. The platelet count also fell during cimetidine and a reduction of megakaryocytes was found in the bone marrow.

The absorption of helium excited at low voltages for its own lines, the $2^{3}S\ensuremath{-}2^{3}P$ at 10830A and the $2^{1}S\ensuremath{-}2^{1}P$ at 20582A, is determined. The percentage absorption of the $2^{3}S\ensuremath{-}2^{3}P$ line increases when either the exciting current or the pressure in the absorbing tube is increased, and also when either the current or the pressure in the source tube is decreased. When the light to be absorbed is taken end on from a Geissler tube source, the percentage absorption is much less than when the light is taken off at right angles to the capillary. The changes with source tube conditions are ascribed to the corresponding variations of the shape and width of the emission line. Observable absorption begins when the exciting voltage is 25 volts. No absorption is detected at 19.8 volts, the excitation potential of the $2^{3}S$ state. The 10830A line shows strong resonance which is directly proportional to the percentage absorption. The absorption for the 20582A line is very small. It shows no detectable resonance.