Chronic obstructive pulmonary disease in patients admitted with heart failure.

OBJECTIVE: Chronic obstructive pulmonary disease (COPD) is an important differential diagnosis in patients with heart failure (HF). The primary aims were to determine the prevalence of COPD and to test the accuracy of self-reported COPD in patients admitted with HF. Secondary aims were to study a possible relationship between right and left ventricular function and pulmonary function. DESIGN: Prospective substudy. SETTING: Systematic screening at 11 centres. SUBJECTS: Consecutive patients (n = 532) admitted with HF requiring medical treatment with diuretics and an episode with symptoms corresponding to New York Heart Association class III-IV within a month prior to admission. INTERVENTIONS: Forced expiratory volume in 1 s (FEV(1)) and forced vital capacity (FVC) were measured by spirometry and ventricular function by echocardiography. The diagnosis of COPD and HF were made according to established criteria. RESULTS: The prevalence of COPD was 35%. Only 43% of the patients with COPD had self-reported COPD and one-third of patients with self-reported COPD did not have COPD based on spirometry. The prevalence of COPD in patients with preserved left ventricular ejection fraction (i.e. LVEF >or=45%) was significantly higher than in patients with impaired LVEF (41% vs. 31%, P = 0.03). FEV(1) and FVC were negatively correlated with right ventricular end-diastolic diameter and tricuspid annular plane systolic excursion and FVC positively correlated with systolic gradient across the tricuspid valve. CONCLUSION: Chronic obstructive pulmonary disease is frequent in patients admitted with HF and self-reported COPD only identifies a minority. The prevalence of COPD was high in both patients with systolic and nonsystolic HF.

Microvascular right-to-left pulmonary shunt demonstrated by a radionuclide method.

A 37-yr-old man with angiolymphoid hyperplasia (Kimura's syndrome), who had been treated unsuccessfully for suspected asthma, was investigated due to a decrease in arterial oxygen saturation (86%). Right heart catheterization and angiography of the pulmonary artery failed to demonstrate any right-to-left shunts. However, simultaneous scintigraphy over the lungs, kidneys, and head after injection of 150 MBq technetium-99m-labeled macroaggregated albumin i.v. and inhalation of 150 MBq krypton-81m demonstrated a right-to-left shunt in the lungs probably caused by precapillary pulmonary arteriovenous shunts.

Myocardial perfusion at fatal infarction: location and size of scintigraphic defects.

In a consecutive study of myocardial scintigraphy in acute ischemic syndrome, four patients had 99mTc-hexamibi injected intravenously before they developed fatal cardiogenic shock. Planar scintigraphy was performed after death. Slices of the hearts after autopsy were analyzed for scintigraphic and pathoanatomic abnormalities. Location of perfusion defects in planar views of the heart was in good agreement with the scintigraphied, sliced sections. The extent of infarction judged from inspection and formasan staining was much smaller (7%-40% and 6%-43% of the total slice area) than found at scintigraphy, where 83%-92% of the myocardium showed ischemia as defined by a 99mTc-hexamibi uptake below an arbitrary limit on half maximum uptake. Myocardial hypoperfusion might thus aggravate the functional impairment at myocardial infarction and lead to cardiogenic shock.

The effect of ticlopidine on platelet functions in acute myocardial infarction. A double blind controlled trial.

A group of 43 consecutive patients with AMI were randomized to treatment with a novel platelet inhibitor, ticlopidine, or placebo in a double blind study. Treatment was started within 12 hr after onset of precordial pain. Patients who had taken drugs with known platelet inhibitory effect prior to the onset of therapy were excluded. Platelet survival time (PS) was measured 24-36 hr after onset of precordial pain and after 3 months of treatment in both groups. In the early phase of AMI CK-MB and ASAT were taken twice daily for estimation of infarction size. Platelet function, coagulation factors and fibrinolysis parameters were followed sequentially for 21 days and repeated after 3 months. In the placebo group a significant reduction in PS (5.62 +/- 1.63 S. D. days) was measured in the acute phase of AMI compared to PS 3 months after infarction (8.03 +/- 1.20 S.D. days). In the ticlopidine group PS was normal during the acute phase (8.35 +/- 1.82 S.D. days). After 3 months of treatment PS was normal in both groups. During the first two weeks after AMI significant changes in coagulation parameters and fibrinolysis indicated an increased risk of thrombosis in both groups. These parameters were unaffected by the platelet inhibitory therapy. Estimated by peak CK-MB and ASAT, infarction size was significantly reduced in the ticlopidine group.

Long-term prognostic importance of hyperkinesia following acute myocardial infarction. TRACE Study Group. TRAndolapril Cardiac Evaluation.

The long-term prognostic importance of hyperkinesia is unknown following an acute myocardial infarction (AMI). The American Society of Echocardiography recommends that hyperkinesia should not be included in calculation of wall motion index (WMI). The objective of the present study was to determine if hyperkinesia should be included in WMI when it is estimated for prognostic purposes following an AMI. Six thousand, six hundred seventy-six consecutive patients were screened 1 to 6 days after AMI in 27 Danish hospitals. WMI was measured in 6,232 patients applying the 9-segment model and the following scoring system: 3 for hyperkinesia, 2 for normokinesia, 1 for hypokinesia, 0 for akinesia, and -1 for dyskinesia. All patients were followed with respect to mortality for at least 3 years. WMI was calculated in 2 different ways: 1 including hyperkinetic segments (hyperkinetic-WMI) and the other excluding nonhyperkinetic segments (nonhyperkinetic-WMI) by converting the hyperkinetic segments to normokinetic segments. Hyperkinesia occurred in 736 patients (11.8%). WMI was an important prognostic factor (relative risk 2.49; p = 0.0001) for long-term mortality together with heart failure, history of hypertension, angina, or diabetes, previous AMI, age, thrombolytic therapy, arrhythmias, and bundle branch block. In a multivariate analysis including nonhyperkinetic-WMI, hyperkinesia was associated with a relative risk of 0.84, which was statistically significant (confidence intervals 0.74 to 0.96; p = 0.01). When hyperkinesia was included, both in WMI (hyperkinetic-WMI) and as an independent variable, no additional prognostic information (relative risk 0.93; p = 0.26) was obtained. An echocardiographic evaluation shortly after an AMI gave important prognostic information, especially if the information concerning hyperkinesia was included. If WMI is used for prognostic purposes, hyperkinesia should be included in calculation of the index.

Effect of specific thromboxane-synthetase inhibition on thromboxane and prostaglandin synthesis in stable angina induced by exercise test.

14 patients with effort induced angina pectoris were treated with a specific TxB2 inhibitor Dazoxiben or verapamil for two weeks with a wash-out period of 14 days between the two regimens. A sub-maximal bicycle test was performed before treatment and at the end of each treatment period. The bicycle test induced a significant increase in serum TxB2 in patients without treatment and during verapamil therapy. This increase was significantly inhibited by Dazoxiben treatment. No alterations in plasma TxB2 or 6-keto-PGF1 alpha were observed on either regimen. Dazoxiben had no clinical effect, while verapamil caused a highly significant prolongation of exercise time.

Cardiac predictors of death after non-cardiac surgery evaluated by intention to treat.

Cardiac risk factors were studied among patients who were admitted to hospital with appendicitis or a fracture of the proximal femur less than one year after being admitted with myocardial infarction. Of 99 patients with myocardial infarction and appendicitis, 87 underwent appendicectomy; and of 221 with myocardial infarction and hip fracture, 179 were operated on. The patients were studied on an intention to treat basis. The mortality within one month was 9% and 16% respectively. A history of congestive heart failure was the dominating risk factor, while ischaemic heart disease (recent myocardial infarction or angina pectoris) had no independent association with mortality. If the ventricular function is known additional preoperative information about the heart is of negligible value when estimating the mortality of non-cardiac surgery.

[Assessment of the surgical risk. Is the time between myocardial infarction and a possible surgical procedure of significance for a surgical risk?]. / Operationsrisikovurdering. Er tiden fra et myokardieninfarkt indtil eventuel operation af betydning for operationsrisikoen?

During a five year period, 320 patients suffered from acute myocardial infarction (AMI) and within the next twelve months became candidates for surgery for either appendicitis (99 patients) or for a hip fracture (221 patients). An evaluation of the mortality at the second event (i.e. appendicitis or hip fracture) in relation to the time between AMI and second event, was done following the intention to treat principle. Appendicitis occurred with the same incidence during all 12 months following AMI. The second event mortality was independent of the time interval from AMI to second event. Age, infarction prior to index infarction and congestive heart failure were prognostically important in relation to second event mortality, but did not affect the constant second event mortality during the first year following AMI. Hip fracture occurred more often during the first months following AMI, where the second event mortality was highest. Congestive heart failure either prior to index infarction or at the index infarction was prognostically important in relation to second event mortality. The relatively high mortality in the first months after AMI could partly be explained by an association between congestive heart failure and hip fracture in the first months after AMI. We conclude that the "operative" mortality in patients with recent AMI is high. The mortality is related to congestive heart failure and not to the time between AMI and surgery.

[Does the patient obtain close contact with the hospital physician when a physician/nurse team is established?]. / Opnår patienten fast tilknytning til hospitalslaegen ved etablering af et laege-/sygeplejerske-team?

The contact between patients and doctors was examined having established smaller doctor/nurse teams to take care of the same seven to eight patients during the weekdays of their stay at hospital. Ten weekdays after their admission to hospital 63% of the patients had not had contact with any other doctor(s) than their personal doctor(s), and 70% of the patients had seen only two different doctors. During the same period the doctors saw their patients three times on an average. We conclude that organizing the hospital doctors in small teams is a way to obtain good continuity in the contact between the patient and the hospital doctor.

[Is it possible to establish a constant physician/nurse team at an emergency department of internal medicine?]. / Kan etablering af fast laege-/sygeplejerske-team gennemføres på en akut almen intern medicinsk afdeling?

In order to obtain better continuity in the contact between the patient and doctors/nurses during hospitalization in a medical department, small teams of nurses and doctors were established, so that the patients were attached to their personal doctor and nurse. In nearly three-fourth of the weekdays the patients saw their personal doctor and nurse. We conclude, that within the Danish public health care system and according to the contractual agreements it is possible to establish small doctor/nurse teams and by this to obtain a high continuity during daytime.

[Long-term survival of patients with angina pectoris admitted with suspected myocardial infarction]. / Langtidsoverlevelsen for patienter indlagt med angina pectoris på mistanke om akut myokardieinfarkt.

The long-term survival in 240 patients with severe angina pectoris was assessed. All of these patients had been admitted on account of suspected acute myocardial infarction but this diagnosis could be excluded. The mean age was 64.5 years, range 37-87 years. The one, five and ten year survivals were 83.9, 58.5 and 37.2%, respectively. During the first year after discharge, the risk of dying was 16% and decreases to 9% during the subsequent nine years. By means of univariat analysis, previous AMI and duration of ischaemic heart disease were shown to be of prognostic importance. The variables during hospitalization which were found to provide prognostic information were those concerning congestive heart failure, ventricular ectopic activity and type of angina pectoris. After inclusion of age and previous manifestations of ischaemic heart disease, only variables describing congestive heart failure and ventricular ectopic activity were found to provide prognostic information, by stepwise multivariate analysis.

[Cardiac risk in surgery. A review and guidelines for risk evaluation and reduction of cardiac risk in general surgery]. / Kardial risiko ved operation. En oversigt og vejledende retningslinier for vurdering og reduktion af kardial risiko ved almenkirurgiske indgreb.

Cardiac complications occur with an incidence of 2-6% and are a main cause (15-20%) of mortality after non-cardiac surgery. Cardiac risk should be determined and reduced by treatment preoperatively and by an intraoperative and postoperative care that has been adjusted to the increased risk. This review provides recommendations concerning risk evaluation and management.