Evaluation of right ventricular remodeling using cardiac magnetic resonance imaging in co-existent chronic obstructive pulmonary disease and obstructive sleep apnea.

Untreated chronic obstructive pulmonary disease (COPD) co-existing with obstructive sleep apnea (OSA), also known as overlap syndrome, has higher cardiovascular mortality than COPD alone but its underlying mechanism remains unclear. We hypothesize that the presence of overlap syndrome is associated with more extensive right ventricular (RV) remodeling compared to patients with COPD alone. Adult COPD patients (GOLD stage 2 or higher) with at least 10 pack-years of smoking history were included. Overnight laboratory-based polysomnography was performed to test for OSA. Subjects with an apnea-hypopnea index (AHI) >10/h were classified as having overlap syndrome (n = 7), else classified as having COPD-only (n = 11). A cardiac MRI was performed to assess right and left cardiac chambers sizes, ventricular masses, and cine function. RV mass index (RVMI) was markedly higher in the overlap group than the COPD-only group (19 ± 6 versus 11 ± 6; p = 0.02). Overlap syndrome subjects had a reduced RV remodeling index (defined as the ratio between RVMI and RV end-diastolic volume index) compared to the COPD-only group (0.27 ± 0.06 versus 0.18 ± 0.08; p = 0.02). In the overlap syndrome subjects, the extent of RV remodeling was associated with severity of oxygen desaturation (R(2) = 0.65, p = 0.03). Our pilot results suggest that untreated overlap syndrome may cause more extensive RV remodeling than COPD alone.

Obstructive airway disease and obstructive sleep apnea: effect of pulmonary function.

This study sought to determine whether reduced pulmonary function in obstructive airway disease (OAD) is an independent risk factor for obstructive sleep apnea (OSA). This was a prospective observational study conducted at an outpatient pulmonary clinic. Adults with a known diagnosis of COPD/asthma were enrolled as OAD group. Family members without a history of COPD/asthma who accompanied these patients to the clinic were enrolled as a control group. The Berlin Questionnaire (BQ) was used to assess OSA risk in the OAD group and controls. Forced expiratory volume in 1 second (FEV(1) % predicted) was determined from spirometry. The subjects at high risk for OSA were referred for a full overnight polysomnogram (PSG). The prevalence of patients with a high risk of OSA was 55.2% in the OAD group, which was higher than in the controls (7.5%, p < 0.0001). OAD subjects had a higher body mass index (BMI) and larger neck circumference than controls (p < 0.01). There was no difference in FEV(1) % predicted between the OAD patients at high risk and low risk of OSA. On receiver operator curve (ROC) analysis, FEV(1) % predicted was not a significant predictor of high OSA risk. Using logistic regression, FEV(1) % predicted had no association with OSA risk. There was no correlation between FEV(1) % predicted and total apnea-hypopnea index (AHI), oxygen desaturation index, % time spent below oxygen saturation 90%, and mean oxygen saturation on multiple regression analysis. OSA appears to be common in patients with COPD or asthma in an urban outpatient pulmonary clinic. However, the high prevalence of OSA in OAD patients appears to be due to obesity, and reduced pulmonary function is not an independent risk factor for OSA.

Sleep disordered breathing in patients with heart failure: pathophysiology and management.

OPINION STATEMENT: Sleep disordered breathing (SDB) is common in heart failure patients across the range of ejection fractions and is associated with adverse prognosis. Although effective pharmacologic and device-based treatment of heart failure may reduce the frequency or severity of SDB, heart failure treatment alone may not be adequate to restore normal breathing during sleep. Continuous positive airway pressure (CPAP) is the major treatment for SDB in heart failure, especially if obstructive rather than central sleep apnea (CSA) predominates. Adequate suppression of CSA by PAP is associated with a heart transplant-free survival benefit, although randomized trials are ongoing. Bilevel PAP (BPAP) may be as effective as CPAP in treating SDB and may be preferable over CPAP in patients who experience expiratory pressure discomfort. Adaptive (or auto) servo-ventilation (ASV), which adjusts the PAP depending on the patient's airflow or tidal volume, may be useful in congestive heart failure patients if CPAP is ineffective. Other therapies that have been proposed for SDB in congestive heart failure include nocturnal oxygen, CO(2) administration (by adding dead space), theophylline, and acetazolamide; most of which have not been systematically studied in outcome-based prospective randomized trials.

An unusual clinical presentation of a rare renal tumour.

We report an unusual clinical presentation of renal leiomyosarcoma. A woman, who received renal transplant from her mother, was diagnosed to have leiomyosarcoma in the donated kidney. The mother was found to have a right upper lobe lung mass 10 years later, which was diagnosed as leiomyosarcoma. It is possible that the mother had primary leiomyosarcoma of the donated kidney with micrometastases to the lung 10 years previously, which developed into a lesion in the donated kidney in her daughter. Ten years later, the slow-growing metastatic leiomyosarcoma developed into a lung mass.

Effect of omeprazole and domperidone on adult asthmatics with gastroesophageal reflux.

AIM: To study the effect of combined omeprazole (Ome) and domperidone (Dom) therapy on asthma symptoms and pulmonary function in asthmatics with gastroesophageal reflux. METHODS: We selected 198 asthmatics with gastroesophageal reflux diagnosed by 24-h esophageal pH monitoring to receive Ome 20 mg twice daily and Dom 10 mg three times daily or placebo for 16 wk (1:1 double-blind randomization). Spirometry was done at baseline and after 16 wk of treatment. The primary outcome measures were: mean daily daytime and nighttime asthma symptom scores. Mean daily reflux symptom scores, albuterol use as rescue medication (number of puffs), daytime and nighttime peak expiratory flow rate (PEFR), postbronchodilator forced expiratory volume in 1 second (FEV1) and postbronchodilator forced vital capacity (FVC) were secondary outcome measures. RESULTS: Comparison of mean change from baseline between antireflux therapy and placebo groups revealed significant reduction in daytime asthma symptom score (17.4% vs 8.9%), nighttime asthma symptom score (19.6% vs 5.4%), reflux symptom score (8.7% vs 1.6%) and rescue medication use (23.2% vs 3.1%) after antireflux therapy compared to mean change in placebo group (P < 0.001). There was significant improvement in morning PEFR (7.9% vs 0.2%), evening PEFR (9.8% vs 0.5%), FEV1 (11.1% vs 3.78%) and FVC (9.3% vs 1.52%) in the antireflux therapy group compared to placebo on comparing the mean change from baseline after 16 wk (P < 0.01). CONCLUSION: Combined therapy with Ome and Dom in adult asthmatics with gastroesophageal reflux may be beneficial by reducing asthma symptoms, rescuing medication use, and improving pulmonary function.

Effects of exogenous vitamin E supplementation on the levels of oxidants and antioxidants in chronic obstructive pulmonary disease.

Oxidative stress has been recognized as a central feature of smoke induced chronic obstructive pulmonary disease (COPD). Imbalance between oxidant and antioxidant enzymes is also an established fact in these patients. But studies in regard to stable COPD patients and effect of vitamin E supplementation are lacking. Thirty patients with COPD were included in the study. Their baseline clinical examination, spirometry, plasma malondialdehyde (MDA), alpha-tocopherol and red blood cell superoxide dismutase (SOD) levels were mea sured. Twenty healthy non-smokers who were matched for age and sex served as controls. All the above parameters were repeated after 12 weeks of supplementation with 400 IU of vitamin E daily. The mean malondialdehyde levels in the patients at baseline were higher than controls (5.91 +/- 1.23 nmol/ml vs 4.55 +/- 1.51 nmol/ml, P = 0 001), so also was plasma alpha-tocopherol levels (P < 0 001), while SOD levels were lower in the patients compared to controls (1692 +/- 259 units g/Hb vs 2451 +/- 131 units g/Hb, P < 0 001). Exogenous vitamin E (400 IU per day) supplementation did not bring about any significant change in plasma alpha-tocopherol and SOD levels. The Pearson s co-efficient of correlation between the levels of MDA, vitamin E, SOD; and spirometric measurements were not significant either on day 1 or after 12 weeks of vitamin E supplementation. The present study shows that initially the plasma lipid peroxide (MDA) levels are high and antioxidants (alpha-tocopherol and SOD) are low in patients with COPD. Exogenous supplementation with vitamin E does not have any significant effect on the spirometric measurements though it brings down the levels of MDA showing attenuation of further damage. However, inclusion of larger number of patients and supple mentation with vitamin E for longer periods may throw more light on free radical injury and protective effects of antioxidants.

Effect of esmolol on oxidant status and antioxidant activity in acute myocardial infarction.

AIMS AND OBJECTIVES: The role of oxygen free radicals in reperfusion injury to the heart in myocardial infarction (MI) has been postulated. In this study, the clinical and antioxidant effects of esmolol, an ultra-short acting beta blocker in patients of acute MI was studied. MATERIAL AND METHODS: This was a randomized, double-blind, controlled, prospective study. Total 30 patients with acute MI were included. All patients were thrombolysed with streptokinase. Fifteen of these patients were randomly selected to receive esmolol while other 15 patients served as controls. The parameters compared at 0, 2 and 24 hours between the esmolol group and the controls were--malondialdehyde (MDA), superoxide dismutase (SOD) and glutathione peroxidase (GPX). RESULTS: Patients with MI had 5.16 times higher MDA level at 0 hours (20.34 +/- 6.12 nmol/ml vs. 3.94 +/- 0.70 nmol/ml, p < 0.0001) than MDA level in normal healthy population. At 2 hours, patients with MI had 5.71 times higher MDA level compared to normal healthy population (22.51 +/- 5.51 nmol/ml vs. 3.94 +/- 0.70 nmol/ml, p < 0.0001). A statistically significant difference in MDA levels at 2 and 24 hours was observed in MI patients given esmolol (mean change 2.06 +/- 5.39 nmol/ml vs. -4.47 +/- 6.93 nmol/ml, p = 0.009). Esmolol infusion also caused significant difference in GPX level at 2 hours compared to controls (23.79 + 14.68 U/gm Hb vs 38.3 +/- 8.95 U/gm Hb, p = 0.003). CONCLUSION: Free radical levels are raised in patients with MI which may contribute to reperfusion injury. The antioxidant action of esmolol was clearly observed by significant difference in MDA level and GPX sparing effect. Large scale clinical trials may establish conclusively role of beta blockers as antioxidants as adjuvant to thrombolytic therapy in MI.

T1 measurements for detection of expansion of the myocardial extracellular volume in chronic obstructive pulmonary disease.

BACKGROUND: We aimed to assess whether chronic obstructive pulmonary disease (COPD) is associated with expansion of the myocardial extracellular volume (ECV) using T1 measurements. METHODS: Adult COPD patients Global Initiative for Chronic Obstructive Lung Disease [GOLD] stage 2 or higher and free of known cardiovascular disease were recruited. All study patients underwent measures of pulmonary function, 6-minute walk test, serum measures of inflammation, overnight polysomnography, and a contrast cardiac magnetic resonance study. RESULTS: Eight patients with COPD were compared with 8 healthy control subjects. The mean predicted forced expiratory volume at 1 second of COPD subjects was 68%. Compared with control subjects, patients had normal left ventricular (LV) and right ventricular size, mass, and function. However, compared with control subjects, the LV remodelling index (median, 0.87; interquartile range [IQR], 0.71-1.14; vs median, 0.62; IQR, 0.60-0.77; P » 0.03) and active left atrial emptying fraction was increased (median, 46; IQR, 41-49; vs median, 38; IQR, 33-43; P » 0.005), and passive left atrial emptying fraction was reduced (median, 24; IQR, 20-30; vs median, 44; IQR, 31-51; P » 0.007). The ECV was increased in patients with COPD (median, 0.32; IQR, 0.05; vs median, 0.27; IQR, 0.05; P = 0.001). The ECV showed a strong positive association with LV remodelling (r = 0.72; P = 0.04) and an inverse association with the 6-minute walk duration (r = -0.79; P = 0.02) and passive left atrial emptying fraction (r = -0.68; P = 0.003). CONCLUSIONS: Expansion of the ECV, suggestive of diffuse myocardial fibrosis, is present in COPD and is associated with LV remodelling, and reduced left atrial function and exercise capacity.

Adaptive servoventilation for treatment of sleep-disordered breathing in heart failure: a systematic review and meta-analysis.

BACKGROUND: Adaptive servoventilation (ASV) has demonstrated efficacy in treating sleep-disordered breathing (SDB) in patients with heart failure (HF), but large randomized trials are lacking. We, therefore, sought to perform a systematic review and meta-analysis of existing data. METHODS: A systematic search of the PubMed database was undertaken in March 2012. Publications were independently assessed by two investigators to identify studies of ≥ 1-week duration that compared ASV to a control condition (ie, subtherapeutic ASV, continuous or bilevel pressure ventilation, oxygen therapy, or no treatment) in adult patients with SDB and HF. Mean, variability,and sample size data were extracted independently for the following outcomes: apneahypopnea index (AHI), left ventricular ejection fraction (LVEF), quality of life (SF-36 Health Survey; Medical Outcomes Trust), 6-min walk distance, peak oxygen consumption ( VO 2 ) % predicted, and ventilatory equivalent ratio for CO 2 ( VE / Vco 2 ) slope measured during exercise. Random effects meta-analysis models were applied. RESULTS: Fourteen studies were identified (N = 538). Comparing ASV to control conditions, the weighted mean difference in AHI ( -14.64 events/h; 95% CI, -21.03 to - 8.25) and LVEF (0.40;95% CI, 0.08-0.71) both significantly favored ASV. ASV also improved the 6-min walk distance,but not peak O 2 % predicted, VE / VCO 2 slope, or quality of life, compared with control conditions. CONCLUSIONS: In patients with HF and SDB, ASV was more effective than control conditions in reducing the AHI and improving cardiac function and exercise capacity. These data provide a compelling rationale for large-scale randomized controlled trials to assess the clinical impact of ASV on hard outcomes in these patients.

Sleep in congestive heart failure.

Breathing disorders during sleep are common in congestive heart failure (CHF). Sleep-disordered breathing (SDB) in CHF can be broadly classified as 2 types: central sleep apnea with Cheyne-Stokes breathing, and obstructive sleep apnea. Prevalence of SDB ranges from 47% to 76% in systolic CHF. Treatment of SDB in CHF may include optimization of CHF treatment, positive airway pressure therapy, and other measures such as theophylline, acetazolamide, and cardiac resynchronization therapy. Periodic limb movements are also common in CHF.

A limited form of Churg-Strauss syndrome presenting without asthma and eosinophilia.

We report a young woman presenting with digital gangrene, paranasal sinusitis, mononeuritis multiplex, and rapidly progressive glomerulonephritis without asthma and eosinophilia - an extremely rare variant of this disease.