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Inotropic stimulation of the myocardium, as well as vasodilation
and diuresis as essential principles in the treatment of congestive
heart failure have recently met with considerable criticism and
reevaluation. It is generally agreed that unloading of the heart,
either through vasodilation and/or diuresis, improves the working
conditions of the dilated, failing heart. It reduces myocar dial
oxygen consumption through reduction of chamber radius and,
thereby, wall tension as the major determinants of myocardial
oxygen consumption. Inotropic stimulation, quite in contrast, does
not conserve oxygen. It rather consumes energy and that may be
disadvantageous in situations of compromised oxygen supply and
energy metabolism of the working myocardium. However, under
conditions of suf ficient oxygen supply and metabolic support
inotropic stimulation may bring about in creased pumping and
subsequent improvement of myocardial failure. In recent years it
could convincingly be demonstrated that vasodilation leads to symp
tomatic improvement of congestive heart failure, improvement of
exercise tolerance, and it prolongs life - especially in the case
of ACE-inhibitors and the combination of hydra lazine with
long-acting nitrates. Quite in contrast, equally beneficial effects
could not be demonstrated for inotropic agents in congestive heart
failure. Only for the cardiac glyco sides has it been shown that
beneficial effects can be achieved, especially if atrial fibril
lation with absolute arrhythmia is present. The influence of the
cardiac glycosides on the latter represents an effect which is
independent of the inotropic action."
From molecule to man: Medical research has indeed taken this
direction, and major improvements of our understanding of the
pathophysiology and epidemiology of disease have been achieved. The
molecular basis of the congenital cardiovascular disorders has been
extended from relatively few congenital malformations into everyday
illnesses such as diabetes mellitus, hyperlipoproteinaemea, and
arterial hypertension. The monogenic and, more difficult, polygenic
basis for a vast majority of cardiovascular disorders are being
defined more precisely from year to year. This book gives an
overview of what has been achieved so far and defines the current
position.
Angiocardiography has undergone tremendous development. It
currently repre- sents the imaging system offering the highest
resolution and greatest detail information. A widely applicable,
complex technique able to meet high standards was required by the
increasing number of coronary bypass interventions as well as by
the advent of interventional catheter techniques, such as
transluminal per- cutaneous catheter balloon dilatation,
recanalization techniques, and intracoro- nary thrombolytic
procedures. At the same time, improved image resolution began to
furnish information on intracoronary flow dynamics and anatomy,
thereby opening a new avenue of acquiring prognostically and
therapeutically important pathophysiologic information. In spite of
rapid improvements in the equipment, there are still demands for
improved resolution, image quality, and methods of image
processing. In this situation, the need was felt to describe the
current status of equipment, angiocardiographic systems, image
intensifiers, photographic materials, and processing techniques.
Furthermore, the attempt was made to describe evalua- tion
techniques using manual or computer-assisted semi- or fully
automated procedures to estimate left ventricular volumes,
ventricular mass, cardiac func- tion, anatomy, and flow dynamics of
the coronary arterial system. This book assembles original work
presented at a symposium held by the European Soci- ety of
Cardiology, the Deutsche Gesellschaft fur Herz-und
Kreisiaufforschung, and the Deutsche Gesellschaft fUr
Biomedizinische Technik. It was the aim of the symposium to outline
the current state of the art and to define a process for further
improvement.
In a variety of cardiac diseases the influence of heart rate on
cardiac function is altered and both heart rate and heart rate
variability are of great relevance for the prognosis of cardiac
patients. This book provides a summary of the current knowledge on
the influence of heart rate on myocardial function and hemodynamics
in non-failing and failing animal and human hearts. The subcellular
and molecular alterations underlying the altered heart rate
response in heart failure are discussed in detail. In addition,
studies related to the impact of heart rate and heart rate
variability on arrhythmogenesis and prognosis in patients with
cardiac diseases are critically reviewed. Finally, the relevance of
heart rate control by therapeutic interventions is also discussed.
The book contains 19 different chapters written by well-known
experts in this novel and clinically important field.
In recent years, we have witnessed a rapid expansion of our
knowledge regarding the role of the endothelium in the control of
vascular tone (and organ perfusion) in health and disease.
Physiology, pharmacology, and molecular biology have uncovered a
wealth of information on structure and function of this heretofore
largely neglected "organ". Clinical medicine is now called upon to
define the clinical significance of these observa tions that imply
the mechanisms of blood coagulation, e.g., the interaction of throm
bocytes with the endothelium, vasomotor control, and specifically,
the regulation of smooth muscle tone with consequences for vascular
resistance and conductance and organ blood flow. Finally,
metabolism of lipids with the everlasting problem of athero
sclerosis is an important aspect. In a second step, implications
regarding the improvement of current therapeutic con cepts, as well
as the development of new modalities of pharmacotherapy will have
to be discussed. The topic addressed by the 1990 Gargellen
Conference: Endothelial Mechanisms of Vasomotor Control, clearly is
of interest for both basic scientists and clinicians. It has been
the aim of the organizers, the Society for Cooperation in Medical
Science (SCMS) with this and the previous symposia to foster and
support both basic science and clinical research. Research in
medicine today shows two major directions of development: on the
one hand, increasing involvement of the basic sciences and their
methodology. On the other hand, statistical validation of concepts
and therapeutic strategies in large scale population-and
multicenter-studies.
A vast literature has been concerned with arteriosclerosis and yet,
many aspects of pathogenesis and of the mechanism of development of
the arteriosclerotic vascular lesion remain only poorly understood.
In recent years, our knowledge of the earliest stages of
arteriosclerosis have greatly improved. By now, we have learned to
relate morphologic changes to disturbances in function. It has been
of particular impor tance that components of the arterial wall
could be analyzed in regard to dysfunction, for example, in the
endothelium or the vascular smooth muscle. The interaction of the
different morphological components of the vascular wall could thus
be much bet ter understood. Likewise, the interaction between the
arterial wall and the flowing blood could be much better described,
including the intimate relationship between platelets and the
endothelium, the coagulation system and the endothelium, the
granulocytes and the endothelial cell layer, as well as processes
of migration of blood cells into the subendothelial space. The
recognition of functional and morphological disturbance has
attained clinical significance not only because the
arteriosclerotic diseases have quantitatively reached the
dimensions of an epidemic, that is, of a magnitude never been
witnessed. It is also because of the development of new drugs that
interfere with the atherogenic process and thereby prevent the
development of the disease or halt its progression. It is also
becoming increasingly possible to inhibit the occurrence of
complications in existing arteriosclerotic lesions in manifest
disease, i. e.
During recent years, it has become evident that ventricular
arrhythmias may arise from myocardial ischemia and that they may be
harbingers of sudden cardiac death. On the other hand, ventricular
arrhythmias may occur without any prognostic significance and
sudden cardiac arrhythmic death may strike without any warning
arrhythmia. The role of ischemia in the genesis of ventricular
arrhythmias and of sudden cardiac death has been observed beyond
doubt. However, the mechanism by which ischemia leads to the
appearance of ventricular arrhythmias and/or sudden cardiac death
has remained rather poorly understood, inspite of rather remarkable
research efforts on the one hand, and the magnitude of the problem
on the other hand. We have therefore set out to assemble scientists
from around the world in order to define the current state of our
knowledge on myocardial ischemia and arrhythmia. Well in line with
the tradition of the Gargellen Conferences, we assembled clinicians
and basic scientists for the 7th Gargellen Conference. This book
presents the proceed- ings of the Symposium in the attempt to
define the current status of our understand- ing of this
significant problem. The Symposium was organized by the Society for
Cooperation in Medicine and Science (SCMS) and was generously
sponsored by Astra Chemicals, Wedel; Bayer AG, Leverkusen;
Boehringer-Mannheim; CPI-Lilly, Giessen; Janssen GmbH, Neuss;
Minden Pharma, Minden; Rahm Pharma, Weiter- stadt; Schering AG,
Berlin, and Siemens AG, Erlangen.
The therapeutic principle of pharmacological vasodilation in
congestive heart failure is based upon established physiological
and pathophysiological mechanisms and has been proved to be
effective and useful. In acute heart failure this method of
treatment has assumed importance as the first measure to be taken.
In chronic heart failure a sizeable increase in cardiac output can
be achieved with a number of vasodilating drugs. This effect can be
maintained over several weeks or months. The adjustments of the
heart and the circulation to the arteriolar and/or venous unloading
effect of vasodilatation in the situation of acute and chronic
heart failure are well understood. However, long-term adaptations
of the organism to the vasodilat- ing intervention have not yet
fully been described. In many instances of chronic ad- ministration
of vasodilators, attenuation of the response has been observed. The
mech- anisms responsible have not been fully elucidated, nor has
there been a satisfactory demonstration of improved exercise
performance or of life expectancy under this mode of treatment in
the patient with chronic heart failure. In an attempt better to
understand the pathophysiological mechanisms of chronic congestive
heart failure as they apply to long-term treatment with
vasodilators, the working group on vasodilator therapy of the
Deutsche Gesellschaft fUr Herz- und Kreis- laufforschung has
assembled a group of physiologists, pharmacologists, and
clinicians. The Proceedings of their Symposium held in Hinterzarten
in June 1981 are presented here.
From molecule to man: Medical research has indeed taken this
direction, and major improvements of our understanding of the
pathophysiology and epidemiology of disease have been achieved. The
molecular basis of the congenital cardiovascular disorders has been
extended from relatively few congenital malformations into everyday
illnesses such as diabetes mellitus, hyperlipoproteinaemea, and
arterial hypertension. The monogenic and, more difficult, polygenic
basis for a vast majority of cardiovascular disorders are being
defined more precisely from year to year. This book gives an
overview of what has been achieved so far and defines the current
position.
Die Pharmakotherapie des HerzversageI). s gleich welcher Ursache
wird heute in immer weite- rem M~e den pathophysiologischen
Mechanismen der zugrunde liegenden FunktionsstOrun- gen des Herzens
angep~t. Drei Einflu~gro~en sind bekannt, tiber die die
Kontraktions- und Fi:irderleistung des Herzens beeinflu~t werden
kann: 1. der inotrope Zustand des Myokards oder die Kontraktilitat,
2. die prasystolische Faserspannung oder die Vorbelastung
(Frank-Straub-Starling-Mechan- mus) und 3. die Nachbelastung. In
der Pharmakotherapie der HerzinsuffIzienz und des Schocks werden
aIle 3 Mechanismen therapeutisch genutzt. Hierbei hat sich das
Konzept der adrenergen Receptoren als besonders fruchtbar erwiesen.
1st doch hierdurch eine bedeutsame Entwicklung im Verstandnis der
phar- makologischen Wirkungen am Herzen und an der
Kreislaufperipherie eingeleitet worden. 1m- mer mehr spezifisch
wirkende, stimulierende oder blockierende Substanzen wurden
entwickelt und therapeutisch eingesetzt. Hierbei ist sehr deutlich
eine Tendenz zur Entwicklung solcher Substanzen zu erkennen, die
mi:iglichst isolierte kardiale oder peripher vasculare Wirkungen
be- sitzen, die sich auf einen oder wenige Receptortypen richten
lassen, so da~ eine gezielte Beein- flussung von kardiovascularen
FunktionsstOrungen mi:iglich wird. Dabei werden heute zuneh- mend
positiv-inotrope, d. h. ~l-Receptorenstimulierende Substanzen in
Kombination mit peri- pher gefaf~erweiternden, also Q-blockierenden
Medikamenten in Kombination verwendet. FUr die Steuerung des
veni:isen Zustroms zum Herzen werden venendilatierende oder den
Venen- tonus beeinflussende Medikamente verwendet. Unter bestimmten
Bedingungen werden auch a-Receptoren-stimulierende, also den
Arteriolentonus erhi:ihende Medikamente zusammen mit
positiv-inotrop wirkenden Substanzen benutzt, je nach Ausgangslage
der kardiovascuHiren Funktionssti:irung.
Im vorliegenden Band wird die vielschichtige klinische Problematik
von Herzmuskel- und Perikarderkrankungen sowie der Herz- und
Perikardtumoren ausfuhrlich dargestellt. Die Klassifizierung der
Myokarderkrankungen folgt der derzeitigen Einteilung in (primare)
Kardiomyopathien und (sekundare) spezifische
Herzmuskelerkrankungen. Besondere Schwerpunkte liegen in der
Darstellung der Immunpathogenese myokardialer Erkrankungen und der
Anwendung neuer diagnostischer Verfahren wie Myokardbiopsie und
bildgebender Verfahren. Breiter Raum ist in der Therapie neben den
klassischen Methoden der Anwendung von Vasodilatantien,
Betablockern, Kalziumantagonisten und Immunsuppressiva gewidmet.
Erstmalig werden Myokardalterationen bei genetischen Erkrankungen
und neurologischen Systemkrankheiten zusammenfassend dargestellt.
Von besonderer Aktualitat sind toxische Einwirkungen auf das
Myokard sowie Strahlenschaden. Internisten und allen kardiologisch
interessierten Arzten vermittelt dieser Band umfassende
Basisinformationen uber die diagnostischen und therapeutischen
Fortschritte unter Einschluss der jeweils aktuellen Probleme in
Pathogenese und Therapie."
Perioperative Gerinnungsstorungen stellen den Kliniker oft vor
unlosbare Probleme. Vom Anasthesisten und Intensivmediziner wird
aufgrund der Dringlichkeit eine schnelle therapeutische
Entscheidung verlangt. In diesem Buch werden die
hamostaseologischen Storungen in der operativen Medizin und
Intensivtherapie in ubersichtlicher und praxisorientierter Form fur
den klinisch tatigen Anasthesisten und Intensivmediziner dargelegt.
Besonderes Gewicht wird auf eine praxisnahe Darstellung von
Gerinnungsstorungen in bestimmten klinischen Situationen und bei
bestimmten Patientengruppen gelegt. Eine neue Methode der
intraoperativen Uberwachung der Gerinnung wird vorgestellt.
Spezielle Probleme in der Geburtshilfe und in der
Transplantationschirurgie sowie das Problem der autologen
Bluttransfusion und der Sicherheit bei der Transfusion von Blut und
Blutbestandteilen werden in eigenen Kapiteln behandelt.
Schliesslich werden die alternativen Wege in der
Transfusionsmedizin in einer Ubersicht dargestellt. Die
medikolegalen Aspekte der Transfusion werden gesondert
berucksichtigt.
Sympathikomimetika werden dank ihrer rasch einsetzenden und sehr
starken Wirkung oft bei bedrohlichen Krankheitsbildern in der
Notfall- und in der Intensivmedizin eingesetzt. Sowohl die Schwere
der so zu behandelnden Krankheitsbilder wie auch die starke
Wirksamkeit und schmale therapeutische Breite dieser Substanzen
erfordern ein ganz besonders gutes Verstandnis der
Wirkungsgrundlage einerseits und der Pathophysiologie des
jeweiligen Krankheitszustandes andererseits. Das Buch vermittelt
dem Arzt ein besserers Verstandis fur die Wirkung dieser
hochpotenten Pharmaka und gibt ihm die Moglichkeit einer besseren
Differentialtherapie besonders bei schweren und schwersten
Krankheitsbildern.
Von einem Taschenbuch erwartet der Leser meist, daB es ihn auf
knappem Raum iiber ein umfangreiches Wissensgebiet infor miert.
Dieses Biichlein behandelt dagegen ausfiihrlicher als ein Lehrbuch
die Grundlagen eines einzigen Krankheitsbildes. Die erschreckende
Haufigkeit des Herzinfarktes hat uns zu dieser ein gehenden
Darstellung bewogen. Wir hO'ffen, daB die Schilderung der
Morphologie, Physiologie und Epidemiologie beim behandeln den und
beim angehenden Arzt das Verstandnis fur die Entste hung und den
Ablauf eines Herzinfarktes vertiefen und zum Nachdenken uber seine
Verhutung und rationelle Therapie bei tragen mogen. An geeigneten
Stellen haben wir O'ffene Fragen nicht ver schwiegen. Vielleicht
werden dadurch weitere Untersuchungen angeregt, die mithelfen
konnen, Lucken im Gebaude unseres Grundlagenwissens uber den
Herzinfarkt zu schlieBen. Gottingen, Mai 1969 W. HORT
Mitarbeiterverzeidtnis HEYDEN, S., Associate Prof., M. D.,
Department of Community Health Sciences, Duke University Medical
Center, Durham N. C. 27706 / U. S. A. HORT, HEDWIG, Dr. med., 3400
Gottingen, Humboldtallee 20 HORT, W., Prof. Dr. med.,
Pathologisches Institut der Universitat, 3400 Gottingen,
GosslerstraBe 10 JUST, H., Dr. med., II. Medizinische
Universitatsklinik und Poliklinik (Kreislaufabteilung), 6500 Mainz,
LangenbeckstraBe 1 MEESMANN, W., Prof. Dr. med., Direktor des
Instituts fUr Pathologische Physiologie am Klinikum Essen der
Ruhr-Universitat, 4300 Essen, HufelandstraBe 55 SCHULZ, F. -W., Dr.
med., Institut fur Pathologische Physiologie des Klinikum Essen der
Ruhr-Universitat, 4300 Essen, HufelandstraBe 55 SINAPIUS, D., Prof.
Dr. med."
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