Der Internist
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Cerebral lesions may contribute to a transient left ventricular ballooning syndrome that can mimic acute myocardial infarction. Fibrinolytic therapy or GP IIb/IIIa antagonists should be withheld in cases of neurologic disorder or unconsciousness even in the presence of ST-elevation. ECG transmission by telemetry and myocardial infarction alarm networks allow correct diagnosis and catheter treatment within required time limits.
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Inadequate oral food intake and impending or manifest malnutrition are an indication for artificial nutrition. Regarding the course of the disease and quality of life this can improve the prognosis and also prolong the life span. ⋯ Prerequisites for any nutritional concept are careful evaluation of the nutritional status and specification of the nutritional concept adapted to any disease-specific changes in digestive capacity and metabolism. Enteral nutrition, if possible as volitional nutritional support, should be preferred to parenteral nutrition.
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Whereas the right ventricle tolerates volume loads without any substantial increase of the pressure in the pulmonary circulation by recruiting capacitance vessels and capillaries, it possesses only small contractile reserves and reacts unadapted with right ventricular dysfunction. Its size and pressure load are relevant factors for prognosis of all forms of pulmonary hypertension, in particular if linked to left-sided heart failure. Differentiation of pulmonary hypertension according to the Venice classification is highly important. ⋯ The most important noninvasive diagnostic method is transthoracic echocardiography with determination of the Tei index and Doppler echocardiographic estimation of pulmonary artery pressure. Chronic obstructive pulmonary disease is the most frequent cause of cor pulmonale. While long-term oxygen therapy in patients with COPD and cor pulmonale and for example the administration of endothelin receptor antagonists in patients with idiopathic pulmonary hypertension is beneficial, the therapeutic use of drugs effective for left-sided heart failure is very limited in patients with right ventricular dysfunction.
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Intracardiac conduction disturbances, mostly manifested as a left bundle branch block (LBBB), are common findings in cardiac failure and associated with a poor prognosis. LBBB is a marker of disease progression and also leads to worsened cardiac hemodynamics by dyssynchronous contraction that can accelerate progression of the underlying disease. Cardiac resynchronization therapy (CRT) can reduce the negative effects of these disturbances leading to improvement in hemodynamics and long-term improvement in cardiopulmonary exercise tolerance, reduction of left ventricular volumes and functional mitral regurgitation. ⋯ Thus, CRT has been adopted in the current guidelines of cardiology societies. Nevertheless, there are a number of open issues with CRT, such as the high number of non-responders or the value of CRT in patients with atrial fibrillation, narrow QRS complex and mild cardiac failure or asymptomatic left ventricular dysfunction. In addition, the question whether every CRT patient needs a device with defibrillating capabilities is not fully resolved, at least for patients with dilative cardiomyopathy.