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Biomedical subjects

H Völler

Publications and source records attributed to H Völler.

At least 19 recordsLinked to original sources
PubMed2006

Implementation of evidence-based therapy in patients with systolic heart failure from 1998-2000.

BACKGROUND: In recent years, the incidence of systolic heart failure has increased. Besides a complete revascularization, guideline-based medication represents the most effective therapeutic approach. AIM: Analysis of adherence of guideline-recommended and actual medication during inpatient cardiac rehabilitation as well as under subsequent outpatient conditions. METHODS: From 01/1998 to 12/ 2000, 1346 consecutive patients (64 +/- 10 years, 73% male, LVEF 36.3 +/- 8%, 88% ischemic, 6.7% valvular cardiomyopathy, 5.3% other causes, 11.8% atrial fibrillation) were included in a singlecenter prospective register. Medication was recorded at discharge and after the follow-up period of 731 +/- 215 days. Trends in prescription rates were analyzed based on nonparametric correlations (Spearman's-Rho). Changes in medication from in- to outpatient settings were analyzed using exact McNemar test. RESULTS: At discharge 75.3% (67.9%/68.9%/ 86.6% in 1998/1999/2000, p <0.001) of the patients were treated as recommended. This rate dropped to 68.3% at followup (p <0.0001). Mortality within the follow-up period was low (12.6%). CONCLUSION: It could be shown that from 1998 to 2000 inpatient guideline conformity was implementable adequately. Outpatient conformity was significantly lower. Although a high proportion of correctly prescribed CHF medication could be demonstrated, a further effort to improve guideline adherence in the management of heart failure patients is desirable.

Aged↗
PubMed2006

[Significance of changes in habits followed by risk reduction].

Cardiovascular risk is substantially influenced by changes in habits. In this context the INTERHEART study showed that a healthy vitamin-packed nutrition and regular workout reduced the cardiovascular risk up to 79%. In this case people older than 50 years would benefit most from change. Patients suffering from obesity should combine a low-calory diet with physical training in order to reduce weight. Here optimal results can be achieved by considering intensity as well as quantity for each patient.

Aged↗
PubMed2005

Self-management of oral anticoagulation in nonvalvular atrial fibrillation (SMAAF study).

UNLABELLED: Most patients with atrial fibrillation are at risk of suffering thromboembolic events. This risk can be reduced by twothirds by efficient anticoagulation. This prospective multi-center trial investigated whether the quality of treatment can be improved by self-management in patients with atrial fibrillations (SMAAF Study) compared to conventional patient management by the family doctor. METHODS: Two thousand patients suitable for self-management were to be randomized into the two arms of the study. In the period of investigation from December 1999 to July 2001, only 202 patients (64.3+/-9.2 years, 69.3% men) consented to participate. The study was discontinued prematurely since the number of patients was too low. As a consequence, the group comparison is confined to the evaluation of the INR values measured using the two-tailed t test. RESULTS: Of the 202 patients included, 101 were assigned to the self-management group (64.6+/-9.6 years, 71.4% men) and 101 (64.1+/-8.9 years, 61.4% men, n.s.) were assigned to the group managed by the family doctor. The total number of INR measurements was 2 865. This comprised 2 072 measurements in patients under self-management and 793 in the family doctor group. The values were within the target range significantly more frequently (p=0.0061) in patients under self-management (67.8%) as compared to the family doctor group (58.5%). There was a trend with regard to the time within target range, but the difference was not significant (178.8+/-126 days as compared to 155.9+/-118.4 days). In the self-management group, there were two severe hemorrhages, and there was one thromboembolic event in the family doctor group. CONCLUSION: Management of oral anticoagulation by INR self-management in patients with atrial fibrillation is not inferior to conventional care.

Administration, Oral↗
PubMed2004

[Acceptance of a patient passport in secondary prevention of coronary heart disease].

BACKGROUND AND OBJECTIVE: Over the long term a large percentage of patients exhibit inadequately managed cardiovascular risk factors following an acute cardiac event. It remains unclear whether the patients would accept a health pass and which sociodemographic variables have an effect on the number of its users. PATIENTS AND METHODS: 437 patients (25% women, 69 +/- 10 years; 75% men 63 +/- 10 years) with diagnosed coronary heart disease were issued a health pass before being discharged from in-patient rehabilitation care. Besides their medical history, the passes contained the patients' latest values for hypertension, glucose, lipids, body mass index (kg/m(2)), and smoking. How many patients actually use the health pass was checked by the patients' physicians after 3, 6, and 12 months. In addition, cardioprotective drugs and cardiac events were logged. RESULTS: 185 (44%) of the patients used the pass continually over the course of one year. These patients tended to be older (> or = 60 years vs. < 60 years, p = 0.023), to be white-collar workers (white-collar vs. blue-collar, p = 0.043), and to have a higher level of education (> 10th class vs. < or = 10th class, p = 0.039) compared to "non-users". CONCLUSION: The acceptance of a passport is low, because fewer than half the patients used it in connection with the secondary prevention of coronary heart disease. Therefore the health pass in its present form did not show up as a useful device in patient care, particularly in single persons and those of a low sociodemographic status.

Age Factors↗
PubMed2004

[Obesity and cardiovascular diseases-theoretical background and therapeutic consequences].

In the normal population, the prevalence of obesity is almost 20%. It is a condition influenced by genetic factors, so that individual behavior cannot be regarded as its sole cause. The amount of food is essentially determined by the hormone leptin, the feedback regulation of which can be disturbed by a modification of the molecule or a mutation of the receptor. A further important determinant is energy consumption, which is subject to large individual variations, which partly result from thermogenesis. With regard to the fat distribution, it is concentrated on the trunk in the android form as compared to the hips in the gynecoid form. The android form is subject to a higher incidence of cardiovascular morbidity and mortality. The indirect determination of body fat by measuring the body mass index (weight [kg]/body weight [m(2)]) is hence less reliable than measuring the waist (women > 80 cm, men > 94 cm). The effects of generalized obesity on cardiovascular function are chiefly an increase of blood volume and an eccentric left ventricular hypertrophy. This first of all results in diastolic dysfunction, which can give rise to a disturbance of systolic function in left ventricular dilatation. Concentric hypertrophy develops in the presence of arterial hypertension. This is twice as frequent in obese patients than in the normal population, which is due to increased activity of the sympathetic nervous system and stimulation of the renin-angiotensin system. A disturbance of lipid metabolism is observed four to six times more frequently. The qualitative change in LDL fraction with a raised concentration of low density LDL particles appears to be of crucial importance. With increasing fat mass, the sensitivity to insulin is lowered, so that in obesity the risk of developing diabetes mellitus type 2 is tripled. Since there has been a dramatic increase in the numbers of overweight children and adolescents (from 10.5% to 15.5% within the past five years), prevention programs should be started in good time. A reduction in calorie intake and an altered dietary composition (55% complex carbohydrates, 30% fat and 15% to 20% protein) on the one hand, and increased physical activity on the other hand continue to be the central components. The latter is especially effective when it regularly gives rise to an increased turnover of fatty acids as a result of an increased energy metabolism at moderate intensity. This leads to adaptation, i. e. an increase in the activity of lipoprotein lipase. If prevention programs and/or changes in lifestyle do not give rise to the desired weight reduction, medication is indicated in some adults. Sibutramine (Reductil and orlistate (Xenical) lead to an additional weight loss of up to 10%. However, consistent treatment of any cardiovascular risk factors present is more important. Treatment of arterial hypertension is of greatest prognostic significance, especially in concomitant diabetes mellitus. In individual cases and after thorough discussion of indication surgical options should be considered.

Adolescent↗
PubMed2004

[Risk-adjusted prevention post-MI].

A recent clinical registry with 96 participating hospitals specialized in cardiological rehabilitation provided data from 47,324 patients. Registry data showed a significant reduction of risk factors over time. The incidence of systolic hypertension, for example, was reduced from 44.6 to 16.9%. In addition, clinical rehabilitation raised awareness of AMI survivors for individual risk factors, thus providing the basis for a lifestyle change that allows an improved long-term outcome.

Follow-Up Studies↗
PubMed2004

Change in quality of life in the year following cardiac rehabilitation.

The aim of the present study was to assess change in health-related quality of life (HRQoL) after cardiac rehabilitation in the usual care setting, and to determine predictors for change. In the Post Infarction Care Study, 2441 patients were consecutively included at admission to 18 inpatient cardiac rehabilitation centres following coronary events. HRQoL was assessed with the SF-36 questionnaire at baseline as well as 6 and 12 months after discharge. HRQoL improved significantly in patients after coronary artery bypass grafting (CABG) but not in patients after myocardial infarction. Significant baseline predictors for change of the SF-36 physical component summary (PCS) score were the exercise ECG result at admission (0.59 absolute change/10-watt increase; 95% CI: 0.39, 0.79), an income > or = 1750 euros (1.64; 95% CI: 0.35, 2.93), baseline PCS score (-0.63; 95% CI: -0.69, -0.57), and CABG as indication for admission (3.65; 95% CI: 2.27, 5.04). Significant predictors for change of the mental component summary (MCS) score were age (1.28/10-year increase; 95% CI: 0.62, 1.94), East Germany as area of residence (2.62; 95% CI: 1.32, 3.91), baseline MCS score (-0.58; 95% CI: -0.63, -0.52), and CABG as indication for admission (1.68; 95% CI: 0.36, 3.01). The identification of predictors of HRQoL in the present study may aid in the further development and evaluation of cardiac rehabilitation programmes.

Aged↗
PubMed2003

Cardiac rehabilitation in patients with implantable defibrillators. Feasibility and complications.

OBJECTIVE: We examined patients with implantable cardioverter defibrillators (ICD) in order to demonstrate their safe participation in a standard rehabilitation program. DESIGN: Prospective cohort study of a consecutive series of patients after ICD implantation. Setting Inpatient rehabilitation center. PATIENTS AND METHODS: A total of 118 patients (73.7% male, mean age 60+/-11 years) took part for 23 +/- 4 days in a standard inpatient rehabilitation program including physical activity, psychological care, heart function seminars, and resuscitation exercises with family members. The following noninvasive tests were performed: symptomlimited exercise testing, two-dimensional echocardiography, Holter monitoring, telemetric ICD interrogation, optional fluoroscopy or X-ray examination of the thorax, and (in some patients) defibrillation threshold testing. RESULTS: Out of 118 patients 101 patients (85.6%) participated in regular ergometer training during which the initial workload of 23 +/- 11 Watts could be increased to 45 +/- 18 Watts. An individual conditioning program was assigned to 15% (n = 17) patients, thereby enabling the inclusion of all patients in the rehabilitation process. Under these conditions 12 patients (10%) experienced ICD malfunctions requiring therapy. As a consequence of all cardiac function tests, ICD reprogramming was necessary in 26 patients (22.1%). CONCLUSION: Following ICD implantation, patients may participate in a standard rehabilitation program without serious complications and with a significant increase in physical capacity. However, ICD malfunction occurs in approximately 10% of patients. Additional tests performed by skilled medical staff and appropriate technical equipment allows the ICD program to be optimized.

Aged↗
PubMed2002

Peripheral arterial disease (PAD): secondary prevention.

SUMMARY: The prevalence of PAD rises as the population becomes increasingly older. At present, about 4.5 million citizens in Germany are estimated to be affected. In only one third of the patients intermittent claudication is found as a classical PAD marker. The course is thus predominantly asymptomatic. Consequently, careful evaluation of patients, including case history and pulse status as well as detailed recording of risk factors of atherosclerosis (chiefly smoking and diabetes mellitus), are important. When noninvasive methods of investigation is taken into account, the prevalence rises two- to three-fold. Duplex sonography with measurement of the ankle-brachial index (ABI) is a method which has so far not been used widely although it is highly accurate. Life expectancy of patients with PAD is shortened by about ten years. The prognosis is determined by the natural course of the disease in only a few patients (ischemia syndrome and/or ABI < 0.4). Patients are at much greater risk for cardiovascular and cerebrovascular incidents than of a systemic disease. Mortality is raised up to six fold by concomitant coronary heart disease. Therapy should therefore not only be designed to treat the peripheral, as well as the atherosclerosis. Like walk training under supervision, no smoking, optimal glycemic control in diabetic patients and restoration of the lipid status to normal are treatment measures that have proved to be effective. As for pharmacotherapy, the efficacy of thrombocyte aggregation inhibitors is regarded as proved, whereas many drugs targeting symptoms have yielded disappointing results in patients with intermittent claudication.

Adult↗
PubMed2002

[Thrombophilia--diagnostic steps and therapeutic consequences after deep vein thrombosis].

SUMMARY: In developed countries there is an age dependent increasing incidence of deep vein thrombosis. Hereditary thrombophilia is usually suspected by the clinical constellation and anamnestic informations. For economical reasons usually laboratory testing should be avoided if the results will not change directly the therapeutic process. But for hereditary defects consequences for the patient in future and for relatives should be taken into account especially as more selective strategies for prophylaxis and treatment have to be expected by increasing information in that field of research. As deficiencies of anticoagulant proteins (PC, PS, AT) have an impact on anticoagulant treatment, the indication for testing should not be held too strict. Time point for diagnostic procedures should be early after a thromboembolic event as negative results exclude hereditary defects definitely which allows the planning of the aimed treatment duration. After first onset of deep vein thrombosis, even in presence of hereditary coagulation defects the duration of anticoagulation usually depends on the clinical and anamnestic signs for a thrombophilic tendency of the individual patient. First publications suggest the need for prolonged anticoagulation of carriers with combined defects, showing an elevated rate of re-thrombosis after the first thromboembolic event, when anticoagulation is stopped. Every ongoing anticoagulation should be checked repeatedly in the sense of a risk -benefit evaluation even for patients with a thrombophilic tendency and should be adapted to actual publications.

Humans↗
PubMed2001

Cardiogenic embolism as the main cause of ischemic stroke in a city hospital: an interdisciplinary study.

BACKGROUND: It is essential to understand the pathogenesis of ischemic stroke to ensure rational acute therapy and secondary prevention. We wanted to know the distribution of pathogenesis in patients of a city hospital and the differences in risk factors, neurologic deficits, disability, and delay in clinical admittance. PATIENTS AND METHODS: During a period of one year, 222 patients (mean age 76.6 years; 59% women) with complete acute ischemic stroke were admitted and underwent complete clinical and diagnostic procedures: CCT/MRI; Doppler- and color-coded duplex and transcranial sonography; echocardiography; use of the NINCDS stroke scale and the Oxford disability scale; study of risk factors, and exploration of delay in admittance. RESULTS: The following percentages of etiologies were evident: 31% cardiogenic embolism (60% with atrial fibrillation), 13% microangiopathy, 9% macroangiopathy, 11% cerebellar or brain stem infarction, 18% more than one cause and 18% no cause found. The patients with cardiogenic embolism showed significantly the highest scores on the stroke scale and the disability scale and had the shortest delay in admittance (57% were admitted within 3 hours). CONCLUSIONS: In a city hospital, cardiogenic embolism is the main cause of ischemic stroke. These patients suffer significantly the most severe neurologic deficits, dependence, and requirement of daily nursing care. These patients have the shortest delay in clinical admittance and the best chance of benefitting from acute therapy and early secondary prevention.

Aged↗
PubMed2001

Cardiac risk factors, medication, and recurrent clinical events after acute coronary disease; a prospective cohort study.

AIMS: Systematic data are sparse on clinical outcome after acute coronary disease followed by cardiac rehabilitation therapy. Therefore, our objective was to determine the long-term development of cardiac risk factors, recurrent clinical events, and cardiac medication in patients undergoing routine in hospital cardiac rehabilitation therapy. METHODS AND RESULTS: In the prospective PIN Study (Post Infarct Care), 2441 consecutive patients (78% men, 60+/-10 years, 22% women, 65+/-10 years) were enrolled in 18 inpatient rehabilitation centres in Germany following myocardial infarction (56%), coronary artery bypass graft (38%) or percutaneous transluminal coronary angioplasty (6%). Cardiac risk factors, pre-specified clinical end-points, and the prescription of cardiac medication were prospectively documented on admission to and at discharge from rehabilitation therapy, and 3, 6 and 12 months later by obtaining information with standardized questionnaires from the patients and their physicians. The cardiac risk factors improved initially during cardiac rehabilitation therapy, but deteriorated within the following 12 months: 39% patients smoked at the beginning vs 5% at the end of in hospital rehabilitation vs 10% at 12 months follow-up (P<0.001). The respective numbers for patients with blood pressure >140 and/or 90 mmHg were 24 vs 8 vs 25% (P<0.01) and with plasma cholesterol >200 mg. dl(-1)57 vs 29 vs 51% (P<0.01). A total of 886 patients experienced one or more recurrent clinical events during the first year, 69% of those within the initial 6 months. At 12 months follow-up, 77% of patients received aspirin, 70% beta-blockers, 62% lipid lowering medication, and 53% angiotensin converting enzyme inhibitors. CONCLUSION: The present results indicate that the benefit of cardiac rehabilitation therapy following acute coronary events is only partially maintained during the following year. Continuous strategies of medical care need to be developed to improve the long-term outcome in coronary patients.

Aged↗
PubMed2000

[Secondary prevention in coronary patients after inpation rehabilitation].

BACKGROUND AND OBJECTIVE: [corrected] Data on impressive improvements in the prognosis and clinical progress of patients with coronary heart disease (CHD) through consistent reduction of risk factors and administration of cardioprotective drugs have led to the formulation of guidelines by professional associations. The aim of this prospective, multicenter cohort study (PIN: Post-Infarkt-Nachsorge = Postinfarction Aftercare) was to determine the extent to which these recommendations are implemented in the long term in patients who have had an acute coronary event and are undergoing rehabilitation therapy. PATIENTS AND METHODS: From January to May 1997, 2441 patients at 18 rehabilitation centers (22% women, 65 +/- 10 years; 78% men, 60 +/- 10 years) with diagnosed CHD following an acute cardiac event were enrolled in the study. Risk factors and pharmacologic therapy were recorded by the patients' GPs on a standardized questionnaire on admission to and discharge from rehabilitation therapy (RT) as well as after 3, 6, and 12 months. New clinical events were documented by questioning the patients and their attending physicians. RESULTS: After an impressive reduction of cardiovascular risk factors during RT, the percentage of patients with blood pressure values > 140/90 mmHg rose from 8% to 25% after 12 months (p < 0.001). 11% vs 17% of the patients had glucose levels > 140 mg/dl and 29% vs 51% had total cholesterol levels > 200 mg/dl (p < 0.001). 5% of the patients smoked at the time of discharge, 10% after one year. Compared to the time of discharge, significantly fewer beta-receptorblockers, lipid-lowering drugs, angiotensin converting-enzyme (ACE) inhibitors, and acetylsalicylic acid were prescribed. During follow-up observation, 886 patients suffered one or more clinical events, of which 69% occurred in the first six months. CONCLUSION: The interventional success of in-patient rehabilitation therapy is not sustained in the long term. This could be due to deficient implementation of guidelines for the secondary prevention of CHD, as the cardiovascular risk factors exceed pathological limits in a large proportion of patients and the prescription of cardioprotective medications is less than optimal.

Aftercare↗
PubMed2000

[Background and evaluation plan of a study on self-management of anticoagulation in patients with non-valvular atrial fibrillation (SMAAF Study)].

The objective of this open, randomized, multicenter study is to investigate the benefits and economic efficiency of self-management of oral anticoagulation in patients with atrial fibrillation (SMAAF study) in comparison with a group of patients given conventional care by a general practitioner or specialist. Two thousand patients suitable for self-management will be assigned at random to either the self-management group or the control group. The numbers of thromboembolic and hemorrhagic complications requiring treatment during the 2-year follow-up period will be recorded as the primary end point. The secondary endpoint variables will be maintenance of the INR value in the individual target range, INR variance, the course of complications over time, and the cost efficiency of self-management compared with the routine procedures. The last of these parameters will include the diagnostic and/or therapeutic measures carried out, the duration of inpatient hospital treatment, and the social consequences (subsequent rehabilitation treatment, inability to work, forced retirement). The estimate of the required number of patients was based on the assumption that during long-term anticoagulant therapy within the framework of primary and secondary prevention 4% of patients with chronic non-valvular atrial fibrillation would have severe thromboembolic of hemorrhagic complications each year. Since this rate can be halved by self-management, a one-tailed chi 2-test of 80% power and a 5% significance threshold would require n = 997 patients per group. The results of the SMAAF study will establish the socioeconomic benefits of self-management in patients with non-valvular atrial fibrillation.

Administration, Oral↗
PubMed2000

[Assessment of myocardial vitality with dobutamine echocardiography: current review].

Myocardial stunning (contractile dysfunction in the presence of normalized perfusion) and myocardial hibernation (contractile dysfunction matching reduced perfusion) have represented separate concepts of viable, but dyssynergic myocardium in the past. However, in vivo experimental and clinical work suggests that repetitive ischemia due to coronary artery disease may induce a gradual transition between stunned and hibernating myocardium. Myocardial hibernation itself can result from a spectrum of ischemic conditions ranging from impaired myocardial blood flow reserve to frank hypoperfusion. With increasing severity and duration of ischemia, degeneration of cardiac myocytes, accumulation of glycogen and cell death ensue. Additionally, there is an increase of extracellular matrix protein content leading to reparative fibrosis, which in turn limits functional recovery. In the light of these structural features, the available methods for detection of viable myocardium, in particular dobutamine echocardiography and nuclear imaging techniques, offer complementary rather than contradictory information. Dobutamine echo has satisfactory sensitivity, excellent specificity, and high diagnostic accuracy for the detection of viable dyssynergic myocardium. While in the past only its predictive accuracy for segmental recovery has been validated, newer data show an improved survival after revascularization if at least four viable dyssynergic left ventricular segments in a 16 segment model can be identified by dobutamine echocardiography. The complete (low and high dose) dobutamine protocol can elicit several types of contractile responses (sustained improvement in contraction or monophasic response, biphasic response, new wall motion abnormality) which should be interpreted in view of other clinical data including a previous infarction. The test protocol can be used safely at the end of the first week after myocardial infarction. If ischemia or viability is documented, revascularization should be performed promptly. A similar strategy should be followed in the setting of chronic coronary heart disease with left ventricular dysfunction. Since the structural changes of hibernating myocardium are progressive, time to revascularization is critical. On the other hand, responsible therapeutic planning requires proof of ischemia or viability before initiating a potentially hazardous revascularization procedure.

Cardiotonic Agents↗
PubMed1999

[Effects of inpatient rehabilitation on cardiovascular risk factors in patients with coronary heart disease. PIN-Study Group].

BACKGROUND AND OBJECTIVE: The prognostically favourable effect of secondary prevention in patients with proven coronary heart disease (CHD: documented myocardial infarction, angiographically proven coronary artery stenosis > 60% and/[or] status after coronary artery surgery) has been demonstrated. But it has not been adequately shown to what extent the guidelines laid down by specialist societies is being followed in routine clinical practice. Nor have there been any large-size standardized investigations of whether in-hospital rehabilitation decreases cardiovascular risk factors. It was the aim of this study to investigate the acute effects on cardiovascular risk factors of in-hospital post-infarction rehabilitation. PATIENTS AND METHODS: From January to May 1997, at 18 rehabilitation clinics, 2441 consecutive patients (22% women, aged 65 +/- 10 years, 78% men, aged 60 +/- 10 years) with proven CHD were included in this post-infarction after-care (PIN) study. During their hospital stay (26 +/- 5 days) they undertook physical training appropriate for cardiological follow-up treatment, as well as various other modes of treatment to affect risk factors. Diagnosis, treatment and standardized data were prospectively recorded on admission and discharge. RESULTS: At discharge the proportions of patients with conventionally defined risk factors were significantly lower than on admission (P < 0.001). The proportion was 8% in patients with arterial blood pressure > 140/90 mm Hg (vs. 24% on admission), 5% in smokers (vs. 39% on admission), 30% vs. 60% in patients with cholesterol levels > 200 mg/dl, 67% vs. 87% in those with low density lipids > 100 mg/dl, 15% vs. 22%, in those with serum triglyceride levels > 200 mg/dl, 11% vs. 14% in those with glucose levels > 140 mg/dl, and 15% vs. 18% in patient with a body/mass index > 30 kg/m2. There was an increase in the proportion of patients who during their hospital stay were prescribed additional drugs: from 85% to 86% for acetylsalicylic acid (P < 0.05), 61% to 77% for beta-adrenergic receptor blockers, 33% to 67% for cholesterol synthesis enzyme (CSE) inhibitors, and 51% to 57% for angiotensin converting enzyme (ACE) inhibitors. CONCLUSION: Modifiable cardiovascular risk factors can be reduced by various methods of rehabilitation and more intensive drug treatment during hospitalization. By taking account of evidence-based medicine favourable conditions can be created for longterm ambulant after-care.

Aftercare↗