Was ist neu in der Kardiologie 2019? - Stephan Baldus Klinik III für Innere Medizin

 
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Was ist neu in der Kardiologie 2019? - Stephan Baldus Klinik III für Innere Medizin
Was ist neu in der Kardiologie 2019?
Stephan Baldus
Klinik III für Innere Medizin
12.01.2019
Was ist neu in der Kardiologie 2019? - Stephan Baldus Klinik III für Innere Medizin
of this. By contrast, STEMI usually presents with

                                                                                                                                                                      www.bmj.com/ on 19 December 2018 by guest. Protected by copyright.
         would expect this to result in lower rates of myocardial                                       more pronounced symptoms and is usually treated
         infarction before Christmas than afterwards. However,                                          with minimal delay. Previous studies have shown a
         the absence of any decline preceding or following
         Risikotage liegen hinter uns...
         Christmas indicates that these behavioural aspects
                                                                                                        higher risk of myocardial infarction in the working
                                                                                                        population.29 By contrast, we found the pattern to be
         are not the main contributing factors to the Christmas                                         similar in both retired (≥75 years) and younger patients
         peak in myocardial infarction.                                                                 (
Was ist neu in der Kardiologie 2019? - Stephan Baldus Klinik III für Innere Medizin
of this. By contrast, STEMI usually presents with

                                                                                                                                                                             www.bmj.com/ on 19 December 2018 by guest. Protected by copyright.
         would expect this to result in lower rates of myocardial                                       more pronounced symptoms and is usually treated
         infarction before Christmas than afterwards. However,                                          with minimal delay. Previous studies have shown a
         the absence of any decline preceding or following
         Risikotage liegen hinter uns...
         Christmas indicates that these behavioural aspects
                                                                                                        higher risk of myocardial infarction in the working
                                                                                                        population.29 By contrast, we found the pattern to be
         are not the main contributing factors to the Christmas                                         similar in both retired (≥75 years) and younger patients
         peak in myocardial infarction.                                                                 (
Was ist neu in der Kardiologie 2019? - Stephan Baldus Klinik III für Innere Medizin
Mentaler Stress - Myokardischämie

Hämodynamik                  Myocardial ischemia
                                                          Women                    Men
Herzfrequenz     + 25/min    Conventional stress
                             (n=300)
                             Myocardial ischemia          31%                      16%
Blutdruck
                             Mental stress
systolisch       + 41mmHg
                             (n=306)
diastolisch      + 28mmHg
                             Myocardial ischemia          22%                      11%

                                                                  Vaccarino
                            Sex and Age Specific Inflammatory ResponsesSullivan et alet al. Circulation 2018

4   12.01.2019
                                                     Sullivan et al. JAHA 2018
Was ist neu in der Kardiologie 2019? - Stephan Baldus Klinik III für Innere Medizin
Was erwarten wir dieses Jahr?

    ESC Leitlinien 2019
    •    Chronisches Koronarsyndrom
    •    Diabetes und KHK
    •    Dyslipidämie
    •    Lungenembolie

5   12.01.2019
Was ist neu in der Kardiologie 2019? - Stephan Baldus Klinik III für Innere Medizin
Primärprävention venöser Thrombembolien bei Krebspatienten
      durch NOACs

       N=574, ambulant
mind. 3 Monate Chemotherapie
 gynäkologisch/Lymphom/BC
             1:1

      Placebo         Apixaban
                      2x2.5mg/d

                   Carrier, NEJM 2018
  6   12.01.2019
Primärprävention venöser Thrombembolien bei Krebspatienten
      durch Faktor Xa Inhibition
                                        Khorana Risiko Score
                                         Patientencharakteristika         Risiko Score
       N=574, ambulant
mind. 3 Monate Chemotherapie             Tumor-Entität
 gynäkologisch/Lymphom/BC                Magen/Pankreas                   2
             1:1                         Lunge, Lymphom, gynäkolog.       1
                                         Prä-Chemo Thrombozytenzahl >     1
                                         350 MRD/l
      Placebo      Apixaban              Hb < 10g/dl                      1
                   2x2.5mg/d             Prä-Chemo Leukozytenzahl > 11    1
                                         MRD/l
                                         BMI < 35kg/m2                    1

                                         Niedriges Risiko:          0

                                         Intermediäres Risiko:      1-2
  7   12.01.2019
                   Carrier, NEJM 2018
                                         Hohes Risiko:              >3
NOAC zur Verhinderung von Thrombembolien bei Krebspatienten
           Apixaban to Prevent Venous Thromboembolism

              N=574, ambulant                                                                                                                                   .001
                                                                                                                                                               0
 istent with rates reported in previous
     mind. 3 Monate Chemotherapie                                                                                                                           p<
ving patients with cancer with a Kho-                                              100
                                                                                                                                           .2%
 f 2 orgynäkologisch/Lymphom/BC
        higher.7 Our analysis of out-                                                                                                    10
                                                                                                                                      vs

                                                   Patients Alive without Venous
g the treatment period1:1
                                                                                                  100
                        showed a more                                              80
                                                                                                                                   .2
                                                                                                                                 :4

                                                      Thromboembolism (%)
 nefit (hazard ratio, 0.14; 95% CI,
                                                                                                                            te
                                                                                                      95
                                                                                                                           a                     Apixaban
 than previous studies that assessed                                               60
                                                                                                      90
                                                                                                                    M    on
hromboprophylaxis.20,21 The reasons                                                                               6                                Placebo
 epancy are unclear, but the use of a                                                                 85
                                                                                                      n         /
 nt andPlacebo           Apixaban
                                                                                   40
                                                                                                  lie
         a twice-daily dosing regimen                                                          bo
                                                                                                80
                         2x2.5mg/d                                                           m
  for some of the difference.                                                      20
                                                                                           be          0
of major bleeding was significantly                                                      m
                                                       hr0o
                                                                                                           0        30   60     90         120   150   180

 apixaban than with placebo in the                    T
 ention-to-treat analysis (3.5% and               ö se 0                                        30             60         90         120         150        180
                                                 n
ctively; hazard ratio, 2.00; 95% CI,          Ve                                                                         Days

   number needed to harm, 59), but         No. at Risk
                                                Major bleeding:
                                           Apixaban      288    1.1% vs
                                                               276   2652.1%256p=0.046
                                                                                   249                                                           244        229
 not significantly higher with apixa-      Placebo                                   275        268            259       244         237         228        215
h placebo in the analysis of outcomes                                                                                                 Carrier, NEJM 2018
 eatment period (2.1% and 1.1%, re-       Figure 2. Kaplan–Meier Cumulative Event Rates of Venous Thromboembolism.
 azard ratio, 1.89; 95% CI, 0.39 to       The inset shows the same data on an enlarged y axis.
      8 12.01.2019
  needed to harm, 100). The between-
Rekurrenz von Thrombembolien nach Absetzen einer
    Antikoagulation

                 Symptomatische rezidivierende VTE

                                                     EINSTEIN Investigators, N Engl J Med 2010

9   12.01.2019
Arterielle thrombembolische Ereignisse vor der Diagnose Krebs

     N=748.000 pts.
     >67 Jahre
     Krebs-Erstdiagnose

     2005-2013

10   12.01.2019                     Navi et al. Blood 2019, in press
Arterielle thrombembolische Ereignisse vor der Diagnose Krebs

     N=748.000 pts.
                                     From www.bloodjournal.org by guest on January 3, 2019. For personal use only.

     >67 Jahre
     Krebs-Erstdiagnose
                                                                                                                     + 70%
     2005-2013
                  Relative Odds of
                    Stroke /AMI

11   12.01.2019                                                                         Navi et al. Blood 2019, in press
12

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     12   12.01.2019
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