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The effect of respiratory infectious diseases on STEMI incidence, but also STEMI care is not well understood. The Influenza 2017/2018 epidemic and the COVID-19 pandemic were chosen as observational periods to investigate the effect of respiratory virus diseases on these outcomes in a metropolitan area with an established STEMI network. We analyzed data on incidence and care during the COVID-19 pandemic, Influenza 2017/2018 epidemic and corresponding seasonal control periods. Three comparisons were performed: (1) COVID-19 pandemic group versus pandemic control group, (2) COVID-19 pandemic group versus Influenza 2017/2018 epidemic group and (3) Influenza 2017/2018 epidemic group versus epidemic control group. We used Student's t-test, Fisher's exact test and Chi square test for statistical analysis. 1455 patients were eligible. The daily STEMI incidence was 1.49 during the COVID-19 pandemic, 1.40 for the pandemic season control period, 1.22 during the Influenza 2017/2018 epidemic and 1.28 during the epidemic season control group. Median symptom-to-contact time was 180 min during the COVID-19 pandemic. In the pandemic season control group it was 90 min (p = 0.183), and in the Influenza 2017/2018 cohort it was 90 min, too (p = 0.216). Interval in the epidemic control group was 79 min (p = 0.733). The COVID-19 group had a door-to-balloon time of 49 min, corresponding intervals were 39 min for the pandemic season group (p = 0.038), 37 min for the Influenza 2017/2018 group (p = 0.421), and 38 min for the epidemic season control group (p = 0.429). In-hospital mortality was 6.1% for the COVID-19 group, 5.9% for the Influenza 2017/2018 group (p = 1.0), 11% and 11.2% for the season control groups. The respiratory virus diseases neither resulted in an overall treatment delay, nor did they cause an increase in STEMI mortality or incidence. The registry analysis demonstrated a prolonged door-to-balloon time during the COVID-19 pandemic.

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The stress-ECG is the most often adopted and most cost effective initial diagnostic test for the assessment of myocardial ischemia in patients with suspected coronary artery disease (CAD). Prerequisites for the diagnostic usefullness of stress-ECG are a clearly interpretable ST-segment, ability to reach the predicted work load, an intermediate pretest probability for CAD ranging between 10% and 90% and the absence of any contraindications for dynamic exercise. Because of the limited diagnostic sensitivity of about 70%, and a high percentage of patients, who are unable to exercise, a negative stress ECG can definitely not exclude hemodynamically significant CAD. Therefore, stress imaging techniques like myocardial scintigraphy, stress-echocardiography and stress magnetic resonance imaging play a major role in the stepwise diagnostic work-up of patients with suspected CAD. These stress imaging techniques are basically interchangeable since no method is definitely superior to one of the others. However, each method has its specific pros and cons and inherent contraindications. Therefore the choice of the stress imaging method and the form of stress applied should be based on the individual patients characteristics to gain optimal image quality and diagnostic accuracy. Moreover, the decision for one method should take the local availability and institutional expertise of diagnostic centers into account. Although partly substituted by stress imaging techniques the stress-ECG still remains the workhorse for a stepwise diagnostic work-up of patients with suspected CAD.

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Dual platelet inhibition (ASA and clopidogrel) is the generally accepted standard therapy to avoid stent thrombosis although clopidogrel is not approved for this indication in Germany. The duration of dual platelet inhibition depends on the complexity of the stenosis, plaque activity and the type of stent implanted. Recent analyses suggested that implantation of drug eluting stents is associated with a substantially higher rate of stent thrombosis when compared with bare metal stents. This in turn fueled an ongoing debate about the optimal duration of dual platelet inhibition after implantation drug eluting stents. Guideline rcommendations vary between between 3 months and lifelong therapy with updates and additional statements published on a monthly basis leaving cardiologists and primary care providers in a state of therapeutic uncertainty. Taking the most recent guidelines and professional statements into account the following duration of dual platelet inhibition can be recommended: dual platelet inhibition for 1 month after implantation of bare metal stents, dual platelet inhibition for 9-12 months after an acute coronary syndrome; dual platelet inhibition for at least 12 months after implantation of drug eluting stents and brachytherapy in patients who are not at high risk for bleeding. Patients with previously implanted drug eluting stents who are currently taking dual antiplatelet therapy are at high risk for developing stent thrombosis when a situation arises that requires cessation or interruption of dual platelet inhibition. Therefore, the interventionalist is advised to carefully discuss risks and benefits of the selected stent and clearly document the decision process in an accepted consent form. When elective or urgent surgery is required the surgeon and practitioner must decide whether the procedure can be performed with reasonable safety without discontinuation of antiplatelet therapy posing a higher bleeding risk to the patient. Patients on chronic oral anticoaglation should be additionally treated with clopidogrel for 1 month after implantation of bare metal or 12 months after drug-eluting stents. Additional treatment with ASS is not generally recommended since the bleeding risk of this triple medication may overweigh the benefits of dual antiplatelet inhibition.

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In cases of stable or to a large extent symptom-free coronary heart disease (CHD) and atypical symptomatology, the indication for diagnostic cardiac catheterization is first confirmed by noninvasive diagnostics of ischemia. This can be carried out either with ergometric stress tests or imaging procedures in combination with ergometric or pharmacological stress. Myocardial scintigraphy and stress echocardiography are established techniques and to an increasing extent stress magnetic resonance imaging (MRI). In addition to sensitivity in providing evidence for ischemia, technical improvements in computed tomography (CT) and MRI have opened up new possibilities for visualizing coronary vessels and vascular wall morphology. While CT coronary angiography with its high spatial resolution is on the threshold of clinical application for selected patients, MRI has the potential for furnishing information on wall movement analysis, perfusion, coronary flow measurement, and plaque characterization to become the future cardiovascular "all-round examination".

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Endothelial dysfunction is a "systemic disease" and a predictor of preclinical atherosclerosis. A relatively simple-to-perform and reliable diagnostic method of evaluating endothelial function is the measurement of the forearm blood flow (FBF). Unremarkable vasoreactivity of the brachial artery on performing FBF measurement is a prognostically favorable sign. This applies equally to patients with cardiovascular risk factors such as hypertension, hyperlipidemia or diabetes mellitus, and to patients with angina pectoris. A number of investigations suggest that cardiovascular endpoints can be significantly diminished by reducing the risk factors.

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Postoperative surgical site infections remain frequent despite intensive control programs. With rising numbers of operations and invasive procedures in the outpatient setting and in immunocompromised patients, the prevention of wound infections presents a rapidly growing challenge to the medical community. Barrier measures including drapes and surgical gowns to prevent wound contamination, have clearly reduced the rate of wound infections. The optimal material characteristics for operating gowns and drapes are well defined, but there is still a long running controversy on the use of single-use versus reusable materials. We review the efficacy and ecological impacts of these different approaches. Currently no superiority of any of these approaches with regard to either efficacy or ecological impact can be found. The European Union has recently published a series of mandatory standards to specify material characteristics of barrier materials used in operating theatres (EN 13795). Their scope include production standards of these materials as well as specific processes in auditing their characteristics. The implementation of these norms will clearly present a challenge to European hospitals but will lead to better material characteristics in the end.

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AIM: Recently minimally invasive direct coronary artery bypass grafting (MIDCAB) has become an interesting alternative to conventional coronary artery bypass grafting, especially in patients with a high-grade left anterior descending coronary artery (LAD) stenosis unsuitable for balloon angioplasty. Although MIDCAB offers several advantages such as the avoidance of sternotomy and cardiopulmonary bypass, concerns have been raised about the technical accuracy of the anastomoses that can be performed on a beating heart. Therefore, clinical and angiographic outcomes after MIDCAB are the subject of current controversy. METHODS: A literature search for all published outcome studies of MIDCAB grafting was performed for the period from January 1995 through April 2003. Sixteen articles were enrolled in this review. The data presented in the studies was analysed with regard to clinical outcome and angiographic results. RESULTS: Early mortality ranged from 0% to 4.9% and late mortality (>30 days after MIDCAB) ranged from 0.3% to 12.6%. Infarct rates (non-fatal myocardial infarction) ranged between 0% and 3.1%. Intra- and postoperative complications (wound infections, reoperation for management of bleeding, arrhythmias, stroke, etc.) occurred in 1.6-40%. The conversion rate to sternotomy/cardiopulmonary bypass ranged between 0% and 6.2%. Reinterventions due to graft failure were necessary in up to 8.9% of patients (surgical revision or percutaneous transluminal coronary angioplasty, PTCA). Short-term and mid-term angiographic outcomes are given in Table I. CONCLUSION: Clinical outcomes and immediate graft patency after MIDCAB are acceptable. However, long-term follow-up results and further randomized prospective clinical trials comparing this new technique with standard revascularization procedures are needed.

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Acute aortic arch syndrome is a medical emergency associated with a high mortality rate. In view of the great variation in symptomatology, this condition can readily be overlooked. A carefully obtained history (pain!), a thorough physical examination (differences in pulse and blood pressure) may be suspicious for acute aortic arch syndrome, which today can be reliably and rapidly diagnosed by noninvasive imaging (CT, TEE). Confirmation of the suspected diagnosis must be followed by further intensive medical surveillance (Stanford B) or, in the event of involvement of the ascending aorta or aortic arch (Stanford A), referral without delay to a cardiosurgical center. Apart from a further shortening of the time lapse between diagnosis establishment and emergency surgery, new therapeutic (e.g. stenting) and surgical procedures may improve the prognosis of the syndrome. Maybe new diagnostic tools (monoclonal antibodies against aortic myosin and radio-immunoscintigraphy) will help to recognize the aortic syndrome more rapidly.

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The tumour-suppressor protein BRCA1 mediates its biological functions by interacting with cellular factors such as the CtIP polypeptide, a substrate for the ATM (for 'ataxia telangiectasia mutated') protein kinase. Li et al. report that the BRCA1-CtIP interaction is disrupted by ionizing radiation and by other genotoxic stresses that induce phosphorylation of CtIP by ATM kinase, and that this dissociation of the BRCA1-CtIP complex in turn modulates the transcription of DNA-damage-response genes. We have shown that the BRCA1-binding domain of CtIP (amino-acid residues 133-369) is distal to the sites that are phosphorylated by ATM kinase (residues S664 and S745). We now show that the BRCA1-CtIP complex is stable in irradiated cells, and that the phosphorylated isoforms of CtIP that are induced by ionizing radiation still interact in vivo with BRCA1. We conclude that disruption of the BRCA1-CtIP complex cannot account for induction of DNA-damage-response genes in the way proposed by Li et al.

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Reduced regional technetium-99m methoxyisobutylisonitrile (99mTc-MIBI) accumulation in patients with chronic non-Q-wave infarction (NQWI) but without significant coronary artery stenosis indicates non-transmural damage of the myocardial wall. The aim of this study was to characterise cardiac energy metabolism after NQWI using phosphorus-31 magnetic resonance spectroscopy (31P-MRS) and to compare the biochemical remodelling with changes in regional 99mTc-MIBI uptake and with morphological and functional parameters assessed by magnetic resonance imaging (MRI). Fifteen patients with a history of NQWI, exclusion of significant coronary artery stenosis (<50% diameter stenosis) and hypokinesia of the anterior wall (group A) were examined with 31P-MRS to study the effects of NQWI on myocardial energy metabolism. Spectroscopic measurements were performed in the infarct-related myocardial region. Corresponding gradient-echo MR images and myocardial 99mTc-MIBI single-photon emission tomography images were acquired for exact localisation of the infarct region. All examinations were performed at rest under anti-ischaemic medication. Data were compared with those of patients in whom coronary artery disease had been excluded by angiography (group B, n=10). All patients of group A displayed anterior wall hypokinesia in the infarcted area on both ventriculography and MRI, with a reduced myocardial accumulation of 99mTc-MIBI (66.3%+/-11.8% vs 95.6%+/-2.2% in group B). The mean wall thickness during the complete cardiac cycle (9.5+/-1.8 mm vs 13.1+/-1.1 mm in group B, P<0.001), the systolic wall thickening (2.6+/-1.4 mm vs 5.8+/-1.5 mm in group B, P<0.01) and the phosphocreatine/adenosine triphosphate ratio (1.12+/-0.22 vs 1.74+/-0.23 in group B, P<0.01) in the hypokinetic area were all significantly reduced. It is concluded that persisting hypokinetic myocardium after NQWI combined with reduced myocellular uptake of 99mTc-MIBI displays a reduced PCr/ATP ratio. Our results indicate that morphological remodelling after NQWI is accompanied by fundamental changes in cardiac energy metabolism.

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BACKGROUND: Narrowing of lumen in atherosclerotic lesions is determined not solely by accumulation of plaque but also by constrictive or expansive vascular remodeling. Underlying mechanisms and determinants of these bidirectional processes are not known. OBJECTIVES: To elucidate the response of vascular remodeling to progressive atherosclerosis by analyzing its potential association with composition of plaque. METHODS: Seventy patients with 77 de-novo coronary artery lesions underwent intravascular ultrasound imaging before coronary intervention. Target lesions were defined as soft, fibrous/mixed, and calcified plaques. Quantitative measurements of area of lumen (A(L)), total area of vessel (A(TV)) and area of plaque (A(P) = A(TV)-A(L)) were performed at the lesion site and at the proximal and distal reference sites. Remodeling was determined by using a remodeling index [I(R) = (stenosis of A(TV)/mean reference A(TV)) x 100]. RESULTS: Overall vascular remodeling was balanced with a mean remodeling index of 100.2+/-19.3% and a high interlesion range (60.2-152.4%). The remodeling index for soft lesions was significantly higher than those for fibrous/mixed and calcified lesions (110+/-18.8 versus 96.2+/-14.4 and 85.9+/-15.1%, P < 0.01). Calcified lesions exhibited lower remodeling indexes than did uncalcified lesions (85.9+/-15.1 versus 104.6+/-18.4%, P < 0.01). CONCLUSIONS: Processes involved in vascular remodeling are affected by composition of plaque insofar as there is a higher prevalence of constrictive remodeling among calcified plaques and a higher prevalence of expansive remodeling among soft lesions. These findings indicate that constrictive remodeling is a late manifestation in atherogenesis. Future studies are warranted in order to enhance the understanding of progression of atherosclerosis, and of mechanisms of vascular remodeling and their impacts on interventional therapy.

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HISTORY AND ADMISSION FINDINGS: For seven weeks a 57-year-old man had been complaining of recurrent non-radiating retrosternal pain and pressure on slightest exertion. Admission physical examination was unremarkable except for evidence of peripheral vascular disease. Cardiovascular risk factors were hypertension, hyperlipoproteinaemia and obesity. INVESTIGATIONS: The resting ECG was unremarkable. Objective signs of myocardial ischaemia were produced in the exercise ECG (angina at 100 Watt, negative T waves in V2 to V6 and borderline S-T depression in V4). Myocardial scintigraphy showed reversible reduced perfusion of the anterior wall near the apex and also of the apex and septum. Left ventricular (LV) angiography demonstrated a normally contracting LV, while selective coronary angiogram revealed a 20% reduction in caliber of the proximal branch of the anterior interventricular branch (AIVB), with otherwise normal coronary arteries. Subsequent intravascular ultrasound (IVUS) showed a circular echo-poor 80% stenosis at the origin of the AIVB with extension to the main stem. TREATMENT AND COURSE: A bypass from the internal mammary artery to the AIVB and an aortocoronary venous bypass to the intermediate branch were performed. The patient was free of symptoms postoperatively. CONCLUSION: If cases where there is a discrepancy between clinical and coronary angiographic findings--the latter being unclear or inconsistent, especially in the area of the left main stem, bifurcations or vessel origin--IVUS may contribute decisively to demonstrating coronary anatomy or pathology, and to indicating the type of revascularizing measures.

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AIM: During the past decade stress-echocardiography has gained increasing popularity for detection of myocardial ischemia in patients with coronary artery disease. However, about 10% to 15% of the patients submitted for stress-echocardiography do not have an adequate acoustic window. The purpose of this study was to compare high-dose dobutamine-stress magnetic resonance imaging (dobutamine-MRI) with dipyridamole-Tl-201-SPECT (dipyridamole-SPECT) as alternative strategies for detection of myocardial ischemia in patients with inadequate image quality by stress-echocardiography. PATIENTS AND METHODS: Of 296 patients which were consecutively submitted to stress-echocardiography 45 patients (15%) had two or more segments that could not be evaluated according to the 16-segment-model of the American Society of Echocardiography. They underwent dobutamine-MRI and dipyridamole-SPECT studies, which were evaluated using a 28-segment modell. Myocardial segments were attributed to perfusion territories of the coronary arteries. The results of ischemia detection were compared to the results of coronary angiography (stenosis > or = 50%). RESULTS: In comparison to coronary angiography dobutamine-MRI yielded a sensitivity of 87%, a specificity of 86%, a positive predictive value of 93%, a negative predictive value of 75% and a diagnostic accuracy of 86%. For dipyridamole-SPECT results were 90%, 86%, 93%, 80% and 89%, respectively. These values were not significantly different. CONCLUSIONS: In patients not suitable for stress-echocardiography, both dobutamine-MRI and dipyridamole-SPECT are reliable strategies for detection of myocardial ischemia. Selection is dependent on the patient criteria, technical considerations, local logistics and experience of the observer.

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