RESUMO
The recognizing of the EP is still not satisfied because specifity and sensitivity of clinical symptoms is relatively low. SCT is an important examination in the diagnostic of pulmonary embolism and is the alternative to often nonconclusive scintigraphy and conclusive but invasive pulmonary angiography. The authors describe the role of SCT in the diagnostic algorithm of the suspected pulmonary embolism of the high and not high risk, discuss the interpretation of result of SCT due to the sort of SCT (SDCT or MDCT) and to clinical probability of PE and they discuss the problem of subsegmental PE.
Assuntos
Algoritmos , Embolia Pulmonar/diagnóstico por imagem , Tomografia Computadorizada Espiral , HumanosRESUMO
BACKGROUND: Pulmonary endarterectomy is the treatment of choice for a majority of patients with chronic thromboembolic pulmonary hypertension (CTEPH), however, haemodynamic criteria for the surgery have not been established. It is still unknown whether patients with mild CTEPH should be operated on and what is the clinical course of unoperated, anticoagulated mild CTEPH. AIM: To determine the clinical course in chronically anticoagulated, unoperated patients with mild CTEPH. METHODS: A single-centre, non-randomised, follow-up study involved 10 anticoagulated, unoperated patients (3 males and 7 females aged 46 to 77 years) with mild CTEPH (mean pulmonary artery pressure [MPAP] £ 30 mm Hg and pulmonary vascular resistance £ 300 dynes x s x cm(-5), ≥ 2 METs achieved during symptom limited treadmill exercise test) selected from 73 consecutive patients with CTEPH. The 3-year follow up included yearly echocardiographic evaluation of pulmonary artery systolic pressure (PASP), right ventricular end-diastolic diameter (RVEDD) and acceleration time (AcT) as well as NYHA functional class and symptom-limited treadmill exercise test. RESULTS: All the patients survived the 3-year follow-up. The PASP, RVEDD and AcT (mean ± SD) at baseline and at the end of follow-up were 43.9 ± 6.1 mm Hg and 25.6 ± 8.0 mm Hg, p = 0.0017, 25.4 ± 4.9 mm and 17.8 ± 3.82 mm, p = 0.00006, 68.3 ± 10.0 ms and 104.4 ± 16.48 ms, p = 0.0004, respectively. The NYHA functional class improved from 2.1 ± 0.32 to 1.3 ± 0.48, p = 0.002 and was accompanied by the trend to improve results of exercise test. CONCLUSIONS: The results of the study suggest that patients with mild CTEPH can be treated successfully by anticoagulation alone with excellent 3-year survival rate, improved functional status and with gradual decrease of pulmonary pressure and right ventricular overload.
Assuntos
Endarterectomia , Hipertensão Pulmonar/etiologia , Hipertensão Pulmonar/cirurgia , Embolia Pulmonar/complicações , Embolia Pulmonar/cirurgia , Idoso , Doença Crônica , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Embolia Pulmonar/diagnóstico por imagem , Radiografia , Recidiva , Índice de Gravidade de Doença , Resultado do TratamentoRESUMO
Chronic thromboembolic pulmonary embolism not preceded by clinical thromboembolic event(s) in a 50 year-old male with a history of three-year dyspnea on exertion was detected. Proximal chronic pulmonary embolism, mean pulmonary artery pressure 32 mm Hg, and pulmonary vascular resistance of 444 dyn x s(-1) x cm(-5) were found. We describe a 11-year clinical course of anticoagulated patient with monitoring of functional status and echocardiography and with control of pulmonary haemodynamics at the end of follow-up.
Assuntos
Anticoagulantes/uso terapêutico , Hemodinâmica/efeitos dos fármacos , Embolia Pulmonar/diagnóstico por imagem , Embolia Pulmonar/fisiopatologia , Doença Crônica , Dispneia/tratamento farmacológico , Dispneia/fisiopatologia , Ecocardiografia/métodos , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Artéria Pulmonar/fisiopatologia , Embolia Pulmonar/tratamento farmacológico , Fatores de Tempo , Resultado do Tratamento , Resistência Vascular/fisiologiaRESUMO
In the guidelines for patients with acute coronary syndrome (ACS), reperfusion, antiplatelet treatment, completed with parenteral anticoagulant are the standard therapy. It is because ACS is the result of occlusion of related artery by thrombus compound mostly of platelets, with processes of aggregation and adhesion in its pathogenesis. However, many patients after ACS experience major adverse cardiovascular events (MACE) despite optimal long term antiplatelet therapy. The possible reasons seem to be not only the resistance to this drugs but also underestimated coagulation processes. This review describes the dysfunction of particular coagulation parameters in patients with coronary artery disease and their relationship with MACE after ACS.
Assuntos
Síndrome Coronariana Aguda/complicações , Transtornos da Coagulação Sanguínea/etiologia , Síndrome Coronariana Aguda/tratamento farmacológico , Anticoagulantes/uso terapêutico , Antitrombinas/metabolismo , Fibrinogênio/metabolismo , Fibrinopeptídeo A/metabolismo , Humanos , Fragmentos de Peptídeos/metabolismo , Inibidores da Agregação Plaquetária/uso terapêutico , Precursores de Proteínas/metabolismo , Protrombina/metabolismo , Tromboplastina/metabolismo , Fator de von Willebrand/imunologia , Fator de von Willebrand/metabolismoRESUMO
We present a case of a 77-year-old female with distal chronic thromboembolic pulmonary hypertension. Diagnostic and therapeutic difficulties are discussed. Clinical and haemodynamic benefits resulting from treprostinil therapy added to continuous anticoagulation are shown.
Assuntos
Anti-Hipertensivos/uso terapêutico , Epoprostenol/análogos & derivados , Hipertensão Pulmonar/tratamento farmacológico , Embolia Pulmonar/tratamento farmacológico , Idoso , Doença Crônica , Epoprostenol/uso terapêutico , Feminino , Humanos , Resultado do TratamentoRESUMO
UNLABELLED: Little is known on oxygen saturation in patients with chronic pulmonary embolism. AIM OF THE STUDY WAS: Tto assess the occurrence and importance of oxygen desaturations (D) in these patients. MATERIAL AND METHODS: The study involved 58 normotensive patients with chronic pulmonary embolism (18 males, 40 females, mean age 60 years, range 22-87 years) and was carried out 6 weeks to 2 years after an acute pulmonary embolic event. During 24-hour pulse oximetry mean oxygen saturation (SpO2), and number and duration of desaturations (D), defined as at least a 6% drop of pSO2, below 88%, lasting a minimum of 8 s, were recorded. Simultaneously echocardiographic study and blood gases analysis was performed. RESULTS: Desaturations were found in 39 (67.2%) patients, whereas 79% patients had pSO2 <95% in gasometry. 27 patients had both diurnal (06(00)-22(00)) and nocturnal (22(00)-06(00)) D, 9 patients only nocturnal D, and 3 patients only diurnal D. The number (14.7 vs 36.1) and duration (733.9 vs 1528 s) of D episodes were approximately 2 times greater at night than day. There were 18 (75%) desaturators among patients with pulmonary hypertension (defined as an echocardiographic tricuspid gradient >30 mmHg), and 21 (61.8%) desaturators among patients with chronic pulmonary embolism and without pulmonary hypertension. The patients with pulmonary hypertension had a lower mean SpO2 (p=0.005) and a lower number and duration of nocturnal (p=0.008, 0.03) and diurnal (p=0.008, 0.035) D. CONCLUSION: A large number of D episodes were found in the patients with chronic pulmonary embolism, mostly at night and in the patients with pulmonary hypertension. It is unclear whether D merely reflects pulmonary vasculature embolization or whether they are capable of impacting development of chronic thromboembolic pulmonary hypertension on the basis of vicious circle. In the latter case the need for a long term oxygen therapy, or at least nighttime oxygenation, should be taken into account to slow down progression of the disease.
Assuntos
Ritmo Circadiano , Hipóxia , Oxigênio/sangue , Embolia Pulmonar/sangue , Embolia Pulmonar/diagnóstico , Adulto , Idoso , Idoso de 80 Anos ou mais , Gasometria , Doença Crônica , Progressão da Doença , Ecocardiografia , Feminino , Humanos , Hipóxia/sangue , Hipóxia/diagnóstico , Masculino , Pessoa de Meia-Idade , Oximetria , Embolia Pulmonar/fisiopatologiaRESUMO
BACKGROUND: Little is known about the incidence and diagnosis of pulmonary thromboembolism (PE) in patients with chronic permanent atrial fibrillation (CAF). Also it has not been established if echocardiography, a diagnostic tool useful in clinical evaluation of both diseases, is of value in diagnosis of PE in CAF patients. AIM: To establish the prevalence of PE among patients suffering from CAF without or with poorly controlled anticoagulation as well as to evaluate the possibility to detect PE and to assess the diagnostic role of echocardiography. METHODS: Prevalence of PE in a population of 102 patients (52 males and 50 females at the mean age of 68 years, range 32-88 years) admitted to hospital between January and December 2004 with diagnosis of CAF was studied retrospectively. Echocardiography-based original algorithm of PE diagnosis in such patients was analysed. RESULTS: Among 102 patients with CAF, 20 (19%) cases of PE were diagnosed, including 12 with acute PE (APE) and 8 suffering from chronic thromboembolic pulmonary hypertension (CTEPH). Patients with CAF and APE as well as with CAF and CTEPH had increased right ventricular dimension (p=0.0002 and p=0.001, respectively), higher tricuspid pressure gradient (p=0.005 and p=0.001, respectively) and shorter pulmonary artery acceleration time (p=0.00006 and p=0.0004, respectively) estimated in echocardiography as compared to patients with CAF but without PE. Subjects with CAF and PE had also significantly decreased left ventricular dimension and better left ventricular performance. CONCLUSIONS: A relatively high incidence of PE among patients with CAF not treated with anticoagulants or with poorly controlled anticoagulation therapy was noted. The important value of a diagnostic algorithm employing echocardiography in a diagnosis of clinically significant APE and CTEPH in this group of patients was also shown.
Assuntos
Fibrilação Atrial/complicações , Ecocardiografia , Embolia Pulmonar/diagnóstico por imagem , Adulto , Idoso , Idoso de 80 Anos ou mais , Doença Crônica , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Polônia/epidemiologia , Prevalência , Embolia Pulmonar/epidemiologia , Embolia Pulmonar/etiologia , Estudos RetrospectivosRESUMO
We present a case of a 61-year-old female who was admitted to the hospital with symptoms of congestive heart failure. Diagnosis of arteriovenous fistula was suggested by the echocardiographic signs of high-output state and a continuous murmur heard especially close to the surgical scar from an intervention on the L4-L5 disc that the patient had undergone eight months before. Aortography confirmed arteriovenous fistula between the right common iliac artery and inferior vena cava. After surgical closure of the fistula, normal cardiac function was restored.
Assuntos
Fístula Arteriovenosa/etiologia , Discotomia/efeitos adversos , Insuficiência Cardíaca/etiologia , Sopros Cardíacos/etiologia , Artéria Ilíaca , Veia Cava Inferior , Aortografia , Fístula Arteriovenosa/diagnóstico por imagem , Fístula Arteriovenosa/cirurgia , Feminino , Humanos , Deslocamento do Disco Intervertebral/cirurgia , Vértebras Lombares/cirurgia , Pessoa de Meia-IdadeRESUMO
UNLABELLED: It is little known on oxygen saturation in patients with chronic thromboembolic pulmonary hypertension (CTEPH). AIM OF THE STUDY: To assess the occurrence, evolution and clinical significance of oxygen desaturations (D) during 1-year observation in CTEPH patients. MATERIAL AND METHOD: The study involved 24 consecutive patients with CTEPH (6 males, 18 females, mean age 63, range 22-75 years). During 24-hour pulse oxymetry mean oxygen saturation (SpO2), number and duration of desaturations, defined as at least a 6% drop of SO2, below 88%, lasting a minimum of 8 s, were recorded at baseline and after 6 and 12 months of follow-up. Simultaneously echocardiographic study and blood gases analysis was performed. RESULTS: At baseline 18 of 24 (75%) CTEPH patients had desaturations. During follow-up none of nondesaturators had desaturations episodes and all baseline desaturators had desaturations episodes after 6 and 12 months. In desaturators there was trend to aggravate the number and duration of diurnal but not nocturnal desaturations episodes after 6 and 12 months. It was accompanied by trend (p = 0.05) to increase of pulmonary pressure as assessed by echocardiographic study, whereas the opposite trend to decrease of pulmonary pressure was seen in nondesaturators. CONCLUSIONS: Results of the study show that desaturations occur in most patients with CTEPH and desaturators may have worse clinical course than nondesaturators. It may suggest the need for long oxygen therapy in desaturating CTEPH patients to slow down progression of the disease.
Assuntos
Hipertensão Pulmonar/diagnóstico , Hipertensão Pulmonar/etiologia , Oxigênio/sangue , Embolia Pulmonar/complicações , Embolia Pulmonar/diagnóstico , Adulto , Idoso , Ritmo Circadiano , Progressão da Doença , Ecocardiografia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , OximetriaRESUMO
INTRODUCTION: Currently pulmonary endarterectomy is considered the method of choice in patients with chronic thromboembolic pulmonary hypertension (CTEPH). It is not known if this option should be recommended in all suitable patients as it is highly variable with respect to prognosis. There is also doubt about selection of adequate time to refer patients with CTEPH for surgery. AIM: To establish whether some patients with CTEPH may clinically benefit from isolated anticoagulation with drugs and if the use of anticoagulation may have any impact on the time of patient referral for pulmonary endarterectomy. METHODS: The prospective analysis involved 29 patients (9 male, 20 female) aged 37 to 82 years, with pulmonary arterial systolic pressure ranging from 39 to 133 mmHg and newly diagnosed CTEPH who had not been treated with pulmonary endarterectomy and were not receiving anticoagulation. Survival, functional status according to NYHA classification, duration of thromboembolism, exercise tolerance and echocardiographic parameters of right ventricular overload before and at one year after initiation of therapy with anticoagulants were evaluated. RESULTS: During follow-up, 3 patients with PASP ranging from 120 to 133 mmHg died. In 26 patients with PASP 39-115 mmHg, who survived, improvement in echocardiographic parameters of right ventricular overload, better exercise tolerance as well as functional status according to NYHA classification was observed. In 12 survivors, pulmonary pressure returned to normal. CONCLUSIONS: The results of this study suggest that favourable effects of isolated anticoagulation are likely in patients with newly detected CTEPH, mild and moderate baseline pulmonary hypertension and acceptable exercise tolerance. They also indicate the necessity of anticoagulation in these patients prior to possible referral for pulmonary endarterectomy.
Assuntos
Acenocumarol/uso terapêutico , Anticoagulantes/uso terapêutico , Endarterectomia , Hipertensão Pulmonar/prevenção & controle , Embolia Pulmonar/tratamento farmacológico , Embolia Pulmonar/cirurgia , Adulto , Idoso , Idoso de 80 Anos ou mais , Doença Crônica , Feminino , Seguimentos , Humanos , Hipertensão Pulmonar/etiologia , Estudos Longitudinais , Masculino , Pessoa de Meia-Idade , Prognóstico , Embolia Pulmonar/complicações , Fatores de Tempo , Resultado do TratamentoRESUMO
A case of a 31-year-old male with medical history, clinical symptoms and additional diagnostic tests strongly suggesting diagnosis of acute pulmonary embolism is presented. However, pulmonary emboli were not seen during pulmonary angiography. At autopsy bronchial carcinoma was found and this definitive diagnosis was confirmed by the results of histopathological study.
Assuntos
Adenocarcinoma/patologia , Neoplasias Brônquicas/patologia , Embolia Pulmonar/patologia , Adulto , Autopsia , Diagnóstico Diferencial , Evolução Fatal , Humanos , MasculinoRESUMO
We present two patients with aortic valve disease who developed acute infective endocarditis. In both patients the disease started with infection of the upper respiratory tract. The patients were treated with antibiotics due to pneumonia. The diagnosis of infective endocarditis was established 4 months and 9 weeks after the onset of infection. The first patient died whereas the second underwent successful aortic valve replacement.
Assuntos
Endocardite Bacteriana/diagnóstico , Endocardite Bacteriana/terapia , Adulto , Idoso , Valva Aórtica/cirurgia , Endocardite Bacteriana/patologia , Endocardite Bacteriana/cirurgia , Evolução Fatal , Implante de Prótese de Valva Cardíaca , Humanos , MasculinoRESUMO
Four males aged 17-42 years with ST-T segment changes suggesting perimyocarditis or non-Q acute myocardial infarction are presented. Coronary angiography was performed to establish the final diagnosis. Three patients had normal coronary arteries; two of them had typical clinical signs of perimyocarditis whereas the third patient had less typical changes. The fourth patient was a smoker, had a family history of coronary heart disease and left ventricular dysfunction due to a non-Q wave apical infarction. In this patient coronary angiography revealed small atheromatous plaques in the distal part of left anterior descending artery as well as left main and right coronary artery spasm. Angiospastic aetiology of infarction and probable endothelial dysfunction due to myocarditis were diagnosed. The authors conclude that coronary angiography is not always helpful if clinical, electrocardiographic and biochemical signs of perimyocarditis are observed.