Herz
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Practice Guideline
[Diagnosis and management of acute pulmonary embolism. ESC guidelines 2014].
Acute pulmonary embolism (PE) still represents a challenge regarding a rapid diagnosis and a risk-adapted therapy. In the 2014 guidelines of the European Society of Cardiology (ESC) on the diagnosis and management of acute PE, several new recommendations have been issued based on new study data. Some established scores for risk stratification were developed further and there is now good evidence for the use of age-adjusted D-dimer cut-off levels. ⋯ For the treatment of patients with venous thromboembolism with or without PE, the non-vitamin K-dependent oral anticoagulants (NOACs) are a safe alternative to the standard anticoagulation regimen with heparin and vitamin K antagonists. Systemic thrombolytic therapy should be restricted to patients with high risk or intermediate high risk with hemodynamic instability. Finally, new recommendations for the diagnosis and therapy of patients with chronic thromboembolic pulmonary hypertension (CTEPH), with cancer or during pregnancy are given.
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In contemporary practice with early catheterization in most patients with suspected acute myocardial infarction, the clinical utility of new or presumably new left bundle branch block (LBBB) as a diagnostic criterion equivalent to ST-segment elevation is not well established. This study therefore aimed to determine the predictive value of LBBB for the diagnosis of acute transmural myocardial infarction (or ST-segment elevation myocardial infarction, STEMI). ⋯ LBBB with acute chest pain characterizes a cohort of patients with high morbidity and mortality. For the triage of these patients at first contact, additional criteria should be evaluated, which could increase the specificity of LBBB for the diagnosis of STEMI.
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Review
[Rise of the machines? : Left ventricular assist devices for treatment of severe heart failure].
The use of left ventricular assist devices (LVAD) as a treatment for severe heart failure has gained momentum in recent years. Even at this stage the number of worldwide LVAD implantations far exceeds the volume of heart transplantations in view of the chronic shortage of donor organs. Third generation continuous flow assist devices have helped to improve survival, quality of life and symptom burden of heart failure patients in comparison to a regimen of optimal medication management. ⋯ A careful patient selection process is crucial for a good clinical outcome after device implantation and risk assessment for postoperative right ventricular failure is of particular importance in this context. The rate of hospitalization during LVAD support is still high, despite the step-wise attempts to widen the indications to less severely ill heart failure patients. An effective perioperative and postoperative management will help to lower the incidence of complications (e.g. bleeding, infections, thromboembolic events and right ventricular failure) and to improve the encouraging results of mechanical circulatory support.
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Controlled Clinical Trial
Serum NT-proBNP on admission can predict ST-segment resolution in patients with acute myocardial infarction after primary percutaneous coronary intervention.
The aim of this study was to investigate the value of initial serum N-terminal pro-brain natriuretic peptide (NT-proBNP) concentrations in ST-segment elevation myocardial infarction (STEMI) patients for predicting ST-segment resolution (STR) after primary percutaneous coronary intervention (pPCI). ⋯ Serum NT-proBNP concentrations in STEMI patients on hospital admission were useful in predicting non-STR after pPCI.
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Treatment of patients in cardiogenic shock (CS) presenting with acute myocardial infarction (AMI) is still a challenge and mortality rates remain high, approaching 50 %. Hemodynamic stabilization before and/or after early revascularization remains the primary goal in these patients. In addition to hemodynamic support by inotropes and vasopressors, support with mechanical devices such as intra-aortic balloon pumping (IABP), percutaneous left ventricular assist devices (LVAD) and complete extracorporeal life support (ECLS) with extracorporeal membrane oxygenation (ECMO) may be considered. ⋯ Another important open question to be answered is which subgroups of patients may have a benefit from LVAD therapy. Guidelines discourage the routine use of mechanical support as a first-line treatment in CS patients and emphasize that the application should be restricted to those patients with refractory shock. This article gives an overview of the different devices for percutaneous mechanical support in CS and describes the available evidence and guideline recommendations.