The most important cardiovascular risk factors (hypercholesterolemia , hypertension, diabetes, chronic stress, physical inactivity, smoking, adipositas) were evaluated in the second half of the last century using placebo controlled trials. The mechanismen of action was not fully understood or remained unclear. In some studies not only the risk of atherosclerosis was reduced but life expectancy was improved. The length of telomeres is influenced by many of the cardiovascular risk factors and is a biomarker of age. Reduced telomere length are found in higher age, atherosclerosis, hypertension, adipositas, diabetes, smoking, physical inactivity, heart failure, maltreatment in childhood, exposure to traffic pollution, chronic infection, single life and dementia. A positive effect on telomerase and telomere length is found with increased physical activity, statins for treatment of hypercholesterolemia, and higher blood levels of omega-3 fatty acids. The probable mechanismen for this is an activation of telomerase activity. Many of the cardiovascular risk factors influence the cellular DNA by telomere shortening. These effects could be reduced by life style measures with prudent diet and drugs for good somatic fitness and healthy aging. By this mechanism cardiovascular prevention not only reduces the risk of atherosclerosis but also improves life exspectancy by anti-aging effects.

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

In addition to medication with negative inotropic drugs, surgical myectomy and DDD pacemaker implantation are standard procedures in the treatment of hypertrophic obstructive cardiomyopathy (HOCM). In a preliminary series the results obtained with a recently described method, consisting of transcatheter myocardial reduction, are evaluated.Six patients (two women, four men; mean age 52.7 [44-68] years), who remained in moderate heart failure despite medical treatment, underwent the procedure. After atrial transseptal puncture (via a catheter introduced percutaneously into the femoral vein) the left ventricular outflow tract (LVOT) gradient was measured at rest and after 5-minute balloon occlusion of the first septal branch of the left coronary artery. After demonstration of significant reduction of the gradient by the occlusion, one (n = 3) or two (n = 3) septal branches were occluded by the injection of 2-5 ml of 96% alcohol.The LVOT gradient was reduced from 57.8 +/- 22.4 (38-97) mm Hg to 11.3 +/- 8.6 (0-21) mm Hg and postextrasystolic from 131.0 +/- 40.7 (78-198) mm Hg to 44.0 +/- 35.6 (19-69) mm Hg. All patients had angina for 24 hours after the procedure. Maximal rise in creatine kinase activity was 982 +/- 589 (392-1729) U/l after 8.0 +/- 3.9 (4-15) hours. In three patients transitory complete atrioventricular block developed 10 min to 5 days later, requiring temporary pacemaker implantation. The further course was without complication in all patients and they were discharged after 7.5 +/- 1.8 (6-11) days.The described catheter method provides a nonsurgical means of reducing the amount of septal myocardium with subsequent reduction of the LVOT gradient in HOCM. Long-term observation in a larger group of patients and comparison with conventional forms of treatment are required to determined the method's ultimate place in the treatment of HOCM.

A 30-year-old woman with severe mitral stenosis was admitted to hospital in cardiogenic shock (tachycardia, hypotension, low cardiac output) requiring artificial ventilation. As the cardiovascular state failed to respond to drug treatment, percutaneous mitral valvoplasty (MVP) was performed as an emergency with the Inoue balloon catheter. This brought about immediate improvement in the clinical and haemodynamic condition. As later seen at open-heart surgery, the MVP had produced a tear in the anterior mitral leaflet with considerable regurgitation. Mitral valve replacement was performed as an elective procedure 4 weeks after the MVP, at a time when the patient was mobile. MVP with the Inoue catheter system can achieve a stable clinical and haemodynamic state when there is cardiogenic shock due to severe mitral stenosis and conservative measures have failed.

To assess a new transvenous transcatheter method of closing a persistent ductus arteriosus, combining advantages of the Porstmann and Rashkind techniques.Five patients (three men, two women, mean age 36.2 [19-56] years) underwent the procedure. The diameter of the duct was 3-6 mm. A compressed ivalon (poly-vinyl-alcohol) foam plug, introduced and held by a modified biopsy forceps, was placed into the duct via a percutaneously and transvenously placed catheter sheath. Small titanium legs attached to the plug at the aortic and pulmonary ends unfolded once the plug was correctly placed, ensuring safe fixation.Closure was achieved in all five patients and no shunt demonstrated immediately afterwards in four. In one patient a small shunt briefly persisted but was not longer present the day after. One patient had a fever of up to 39 degrees C for several weeks that required no treatment and was thought to have been a foreign body reaction. Follow-up examination after 5-19 months confirmed complete closure.The described method appears to be safe and superior to the Porstmann and Rashkind techniques, but the results must be tested on a larger number of patients with longer follow-up.

The chest roentgenogram in a 46-year-old woman with dyspnoea for several months revealed global cardiac enlargement. Echocardiography demonstrated a tumour in the right atrium, about 4 x 5 cm, as well as circular pericardial effusion. Septic temperatures occurred in the further course, and blood cultures grew Staphylococcus aureus. Recurrent pulmonary emboli and cerebral emboli with hemiparesis, especially of the brachiofacial region, occurred despite heparinization. Shortly after hospitalization a chest roentgenogram revealed a round shadow, about 1 cm in diameter, in the left upper lobe. The patient died in cardiogenic shock on the 16th hospital day. Autopsy showed the tumour to be a poorly differentiated round-cell sarcoma, originating from the wall of the right atrium, infiltrating the myocardium through to the epicardium and extending to the tricuspid orifice. The foramen ovale was open, making paradoxical emboli at atrial level possible.

Recanalization procedures with the "Magnum" system were undertaken in 137 patients (113 men, 24 women; mean age 57.1 +/- 8.1 years) with complete occlusion of a coronary artery. The system consists of a 0.021 inch guidewire with a flexible 1 mm diameter olive tip, a double-lumen probing catheter and a Magnarail balloon catheter. Chronic coronary artery occlusion of maximally 3 months was present in 51 patients (37%), for over 3 months in 52 (38%), while the duration of occlusion was unknown in 18 (13%). An acute coronary occlusion was successfully recanalized in 7 patients (5%), while in 9 (7%) it was accomplished when it had occurred during or shortly after a percutaneous coronary artery angioplasty (PCTA). The occlusion was successfully passed in 87 patients (64%); in 15 of them recanalization with another system had failed. The highest success rates were obtained with an acute occlusion (5 of 7; 71%), occlusion of 3 months' duration or less (39 of 51; 76%), and occlusion during PTCA (8 of 9; 89%). The success rates were lower for occlusions over 3 months' duration (25 of 52; 48%; P < 0.05) and of unknown duration (10 of 18; 56%; n.s.). Recanalization after failed recanalization was successfully accomplished by rotation-angioplasty (n = 2) or a standard system (n = 4).--These results indicate that the Magnum system is suitable for recanalizing chronic or acute coronary occlusion. But cardiologists should be capable of using several systems to increase the chances of successful recanalization.

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

A ventriculoatrial shunt had been placed 3 years previously in a now 17-year-old boy because of obstructive hydrocephalus of unknown cause. He presented with symptoms of elevated cerebrospinal fluid pressure and computed tomography demonstrated a dilated ventricular system. The chest X-ray film revealed a break in the shunt catheter at the level of the right clavicle with embolization of its 13 cm long distal part into the main stem and right branch of the pulmonary artery. The fragment was retrieved without complication with a percutaneously and transvenously introduced basket catheter. Centrally embolized catheter fragments should be removed as soon as possible. The percutaneous route is well tolerated by and of low risk for the patient. It should always be attempted before any surgical intervention.

: Out-patient groups of hypertensives were organized in an effort to improve long-term treatment results with greater attention to general measures and to increase compliance. Under supervision of a doctor and a physiotherapist 45 patients (aged 54 +/- 10 years) with mild or moderately severe hypertension were enrolled in a sports training programme after thorough examination. At the same time they were given advice and instructions on self-measurement of blood pressure, diet, medication, general life style and relaxation techniques. In the first 20 patients (observation period of more than one year) a significant reduction in both resting (systolic of -9%) and exercise (systolic of -12%) blood pressures was noted. At the same time exercise tolerance was raised (+18%), while body-weight and total cholesterol concentrations were lowered. It was possible to reduce drug dosage in seven patients, in three more it was discontinued. Left-ventricular wall thickness fell slightly but not significantly. There were no complications. It is concluded that group therapy with sport as a vehicle and advice on general life style are satisfactory means for controlling hypertension and achieve better compliance.

AIMS:To analyze the impact of intra-procedural echocardiographic imaging on the interventional strategy in ethanol-induced septal ablation (PTSMA) for symptomatic hypertrophic obstructive cardiomyopathy (HOCM), based on a single-center experience of 7 years.METHODS AND RESULTS:PTSMA was intended for refractory symptoms in 337 patients (pts.) with HOCM (mean age: 54 +/- 15 years), with 312 procedures completed by injection of 2.8 +/- 1.2 ml ethanol. In 25 pts. (8%) the intervention was aborted without ethanol injection, mostly because of echocardiographic findings (n = 18/6%). An echocardiography-driven target vessel change was necessary in 33 pts. (11%). In the 312 pts. who received ethanol, permanent pacing was necessary in 22 cases (7%). In-hospital mortality was 1.3% (4 pts.). After 3 months, mean NYHA functional class was reduced from 2.9 +/- 0.5 to 1.5 +/- 0.6 (p < 0.0001) along with a gradient reduction from 60 +/- 33 to 13 +/- 18 mmHg at rest, and from 120 +/- 43 to 38 +/- 35 mmHg with provocation (p < 0.0001 each). Exercise capacity improved from 94 +/- 51 to 115 +/- 43 W, peak oxygen consumption from 18 +/- 4 to 21 +/- 6 ml/kg/min (p < 0.01 each). There was no significant difference regarding residual gradients in pts. with different levels of immediate gradient reduction during probatory balloon occlusion.CONCLUSIONS:Catheter-based septal ablation is an effective non-surgical technique for reducing symptoms and outflow gradients in HOCM. Intra-procedural echocardiographic guidance has a cumulative impact on the interventional strategy in about 15-20%, and clearly identifies pts. who should not receive ethanol but undergo a surgical myectomy.

Aims of present study were: a) to demonstrate whether Quantitative Myocardial Contrast Echocardiography (QMCE) could detect coronary flow reserve through the analysis of "refilling curves" generated by micro bubbles transit into myocardium both at rest and after vasodilatation induced by dipyridamole; b) to explore with this method coronary microcirculatory function in two different models: essential hypertension and healthy controls.Methods and Results: Two groups of strictly age-matched males were studied (case-control study): twelve, young, a symptomatic and never treated essential hypertensive patients with a mild degree of left ventricular hypertrophy with a normal left ventricular function and eleven healthy controls.QMCE was performed in all study subjects.We used as echocardiography contrast agent the SonoVue TM, a second generation ultrasound micro bubbles.Real-time Color-coded Power Modulation was performed with a phased-array system interfaced to a S3 transducer (1.3 -3.6 MHz).In healthy subjects there was a little increase in Myocardial Blood Volume (30%) between basal and hyperemic status (p<0.05);so in hypertensives this parameter increases of 22% (p<0.05).Coronary blood velocity (ß) increased after dipyridamole of 270% in healthy (p<0.01),while in hypertensive this parameter increased only of 150% (p<0.02).Coronary Blood Flow Reserve was significantly lower in hypertensive (C: 4.4±0.3;H: 3.3 ±0.3; p<0.01). Conclusion:Results of our study documented that coronary microcirculation in young adult hypertensive patients, showed an early impairment both in the vasodilatation capacity of the resistance arterioles under dipyridamole induced hyperemia, as demonstrated by a reduction of Coronary Reserve.