Diagnosis and treatment of right ventricular failure secondary to acutely increased right ventricular afterload (acute cor pulmonale): a clinical consensus statement of the Association for Acute CardioVascular Care of the European Society of Cardiology.

Acute right ventricular failure secondary to acutely increased right ventricular afterload (acute cor pulmonale) is a life-threatening condition that may arise in different clinical settings. Patients at risk of developing or with manifest acute cor pulmonale usually present with an acute pulmonary disease (e.g. pulmonary embolism, pneumonia, and acute respiratory distress syndrome) and are managed initially in emergency departments and later in intensive care units. According to the clinical setting, other specialties are involved (cardiology, pneumology, internal medicine). As such, coordinated delivery of care is particularly challenging but, as shown during the COVID-19 pandemic, has a major impact on prognosis. A common framework for the management of acute cor pulmonale with inclusion of the perspectives of all involved disciplines is urgently needed.

The Combination Clinical Value of Plasma Brain Natriuretic Peptide and Serum HbAlc in the Diagnosis of Chronic Pulmonary Heart Disease.

Objective: To analyze the combination clinical value of plasma brain natriuretic peptide and serum glycated hemoglobin (HbAlc) in chronic pulmonary heart disease. Methods: A total of 200 patients with chronic pulmonary heart disease admitted to our hospital from January 2021 to January 2022 were selected as the observation group, and 200 healthy subjects were selected as the control group during the same period. All subjects were examined by an ECG vector map and plasma BNP, and HbAlc levels were detected to analyze the value and clinical significance of each index in single diagnosis and combined diagnosis. Results: Plasma BNP and HbAlc levels in the observation group were significantly higher than those in the control group (P < 0.05). There were 154 BNP positive, 146 HbAlc positive, 164 parallel combined diagnosis positive, and 132 serial combined diagnosis positive. Sensitivity of series combination diagnosis was significantly higher than other indexes (P < 0.05); especially, parallel combination diagnosis was significantly higher than other indexes (P < 0.05). Besides, area under the ROC curve of parallel combination diagnosis and series combination diagnosis was significantly higher than that of each index alone diagnosis (P < 0.05). Conclusion: In the diagnosis of chronic pulmonary heart disease, the combination of plasma BNP and HbAlc can effectively improve the diagnostic specificity and sensitivity, as well as improve the area under the ROC curve.

Predictors of Prolonged Hospital Stay in Patients with Acute Pulmonary Thromboembolism- A Hospital Based Cohort Study.

AIMS AND OBJECTIVES: Patients with pulmonary thromboembolism (PTE) are commonly admitted to hospital and generally have a prolonged hospital stay in this part of the world. We aimed to determine different clinical and laboratory parameters that are associated with prolonged hospital stay in our set-up and to analyse effectiveness of Pulmonary Embolism Severity Index (PESI) score as a predictor of prolonged hospital stay in patients with PTE. MATERIALS AND METHODS: It was a hospital based observational prospective study. Confirmed cases of PTE defined as patients with evidence of thrombus on CT pulmonary angiogram (CTPA) were included in this study. Depending on the length of hospital stay, patients were divided into two cohorts: Shorter Hospital stay (less than mean i.e., < 10 Days) and Prolonged Hospital stay (longer than mean i.e., ≥ 10 Days). Logistic regression analysis was done to identify predictors of prolonged hospital stay. RESULTS: 150 patients were included in the study with 67 patients (44.67%) having shorter hospital stay (<10 days) and 83 patients (55.33%) having prolonged hospital stay (≥10 days). On multivariate regression analysis, parameters that were found to be statistically significant were hypotension at presentation, decreased level of consciousness, pco2 < 30 mmHg, presence of S1Q3T3 pattern on electrocardiogram (ECG) and high risk PESI (class III-V). CONCLUSION: PESI class can be effectively used to predict prolonged hospital stay in patients with pulmonary embolism. Patients with hypotension at presentation, decreased level of consciousness, pco2 less than 30 mmHg, and S1Q3T3 on ECG are more likely to have prolonged hospital stay in our healthcare setup.

Effect of ivabradine on heart rate, functional capacity and pulmonary artery pressure in patients of COPD with cor pulmonale.

We studied the effects of heart rate reduction by ivabradine to the ongoing therapy in patients with chronic obstructive pulmonary disease (COPD) and cor pulmonale.100 patients of COPD with cor pulmonale with sinus heart rate ≥ 90 bpm were randomly assigned to either ivabradine 5 mg twice daily (50 patients) or placebo (50 patients) alongwith standard therapy. Assessment was done at baseline and after 6 months which included 6 min walk test (6MWT), dyspnea scoring by modified borg scale, Lung function test by forced expiratory volume in 1 s (FEV1) and pulmonary artery systolic pressure (PASP) by echocardiogram. The drug group showed a significant reduction in heart rate from 95.1 ± 8.2 bpm to 71.1 ± 6.2 bpm (p < 0.001). This group also showed significant improvement in 6-min walk distance and dyspnea on modified Borg scale (p < 0.001) at 6 months follow up. However no significant difference was found between both groups regarding PASP or FEV1 at 6 months.

Saddle pulmonary embolism in a pediatric patient with nephrotic syndrome and recent COVID-19 pneumonia: A case report.

The pediatric population accounts for a small portion of those with severe disease related to COVID-19. There are few published reports of hypercoagulable states in children with COVID-19. We describe an 11-year-old male with nephrotic syndrome who required inpatient treatment for COVID-19 pneumonia eight weeks prior. He returned to the emergency department with vomiting, tachypnea and was found to have a pulmonary embolism. In this case report, we discuss the risk factors for, presentation and evaluation of hypercoagulable state and its relation to COVID-19 in a pediatric patient.

Diagnóstico etiológico de disnea mediante electrocardiograma / Aetiological diagnosis of dyspnoea using electrocardiogram

No disponible

[Cor pulmonale]. / Cœur pulmonaire.

Cor pulmonale is a disease of the heart characterised by dilatation of the right ventricle and paradoxical movement of the interventricular septum. The diagnosis depends on echocardiography even if pulmonary artery catheterisation suggests it. It is secondary to pulmonary disease or a disorder of the pulmonary circulation. These two mechanisms, which are often connected, involve pulmonary hypertension as the origin of a systolic and diastolic overload of the right ventricle, which then leads to the alterations of its structure and performance. Acute cor pulmonale is usually secondary to an acute respiratory distress syndrome or to a pulmonary embolism but it can also be seen in primary lactic acidosis, a vaso-occlusive crisis in a patient with sickle cell anaemia, severe acute asthma, and entry of air or injected crushed tablets into the circulation. Chronic cor pulmonale is the terminal stage of pulmonary hypertension. Clinically these patients are dyspnoeic with signs of chronic right heart failure. They should have an echocardiogram confirming the cardiac involvement. Certain precipitating factors, such as infection of any origin, have been reported, leading to acute on chronic cor pulmonale that has a particularly high mortality.

Why Use the Mini-FLOTAC to Detect Metastrongyloid Larvae in Dogs and Cats?

PURPOSE: Canine and feline cardiopulmonary disease is an emergent condition in several European countries, particularly in non-endemic regions, although it is often underestimated because of the limitations of the common diagnostic techniques. The aim of this study was to evaluate the performance of Mini-FLOTAC to detect cardiopulmonary larvae from dogs and cats compared to reference techniques such as Baermann and FLOTAC. METHODS: A total of 20 fresh faecal samples were collected from ten dogs and ten cats naturally infected with Angiostrongylus vasorum, and Aelurostrongylus abstrusus and Troglostrongylus spp., respectively. Three replicates were performed for each technique. FS3 (zinc sulfate, specific gravity = 1.200) was used as flotation solution for Mini-FLOTAC and FLOTAC. The results were expressed as the arithmetic mean of LPG (larvae per gram of faeces). RESULTS: The mean LPG calculated by means of Mini-FLOTAC was significantly higher (P < 0.05) than that obtained through the Baermann technique for A. vasorum, A. abstrusus and Troglostrongylus spp., whereas it was significantly higher (P < 0.05) than that obtained through the FLOTAC technique only for A. vasorum and A. abstrusus. CONCLUSIONS: Mini-FLOTAC can be considered a valid alternative for the detection of metastrongyloid larvae of dogs and cats, overcoming the limitation of time required by the Baermann test.

Chronic obstructive pulmonary disease and the early stage of cor pulmonale: A perspective in treatment with pulmonary arterial hypertension-approved drugs.

Cor pulmonale is right ventricular hypertrophy and/or dilation caused by pulmonary hypertension (PH) due to diseases affecting the lung function and structure. Recently, the definition of PH was revised from a mean pulmonary arterial pressure (mPAP) >25 mmHg to an mPAP >20 mmHg based on the Nice statement; this might expedite the detection of cor pulmonale. However, the only treatment for cor pulmonale for the past 3 decades has been to maintain the lung function and oxygen saturation. Chronic obstructive pulmonary disease (COPD) is the leading cause of cor pulmonale. Cor pulmonale in COPD is generally known to occur due to loss of vascular bed and chronic hypoxic pulmonary vasoconstriction (HPV) due to alveolar wall destruction. However, a recent study suggested that in some patients with COPD, the pulmonary vascular alterations include components that are primary lesions of the pulmonary artery. These alterations may be similar to the remodeling that occurs in pulmonary arterial hypertension (PAH). Although, there is no evidence supporting the treatment of COPD patients with PH using drugs approved for PAH, such drugs may be effective in the treatment of a selected group of COPD patients, whose disease includes PAH-like vascular components. To distinguish these patients, it is necessary to understand the histopathology of COPD and renew our understanding of the concept of cor pulmonale, which treats the heart and lung as a single unit. Herein, we review the recent histopathological concepts of COPD with respect to the progression of cor pulmonale.

Teste cardiopulmonar na avaliação dos mecanismos preponderantes da limitação funcional de pacientes com associação de doença cardíaca e respiratória / Cardiopulmonary testing in the evaluation of the predominant mechanisms of functional limitation in patients with associated heart and respiratory disease

INTRODUÇÃO: O teste cardiopulmonar (TCPE) é útil no diagnóstico, prognóstico e acompanhamento de doenças cardiovasculares e pulmonares. Diante de casos com múltiplas etiologias para intolerância ao esforço, se torna desafiador a identificação do principal componente causador através da discriminação dos mecanismos fisiopatológicos obtidos pelas inúmeras variáveis do TCPE. DESCRIÇÃO DO CASO: CVP, 68 anos, com antecedentes de febre reumática, fibrose pulmonar, hipertensão arterial pulmonar (HP), comissurotomia mitral em 1976 e lobectomia pulmonar direita em 1981. Recentemente em consulta ambulatorial, relatava dispneia Classe funcional (CF) II da NYHA. Ecocardiograma com FE59% de VE, disfunção de VD discreta, dupla lesão mitral (predomínio de estenose - moderada), HP importante (PSAP 98mmHg) e insuficiência tricúspede importante. Realizado TCPE máximo com restrição funcional importante (VO2 máx de 9ml/kg/min) e VE/VCO2 slope de 37,2 (Classe Ventilatória III de Arena). A espirometria pré esforço com padrão obstrutivo. Realizada análise de curva fluxo-volumétrica com discreta queda na capacidade inspiratória (CI), sem padrão de hiperinsuflação dinâmica. No pós-esforço, as espirometrias sequenciais evidenciaram queda da VEF1 de 12% na manobra do 5º min (associado a sibilos e crepitações pulmonares) com normalização no 15ºmin sem apresentar dessaturação durante a prova. DISCUSSÃO: O TCPE com obtenção das variáveis ventilatórias, cardiocirculatórias, metabólicas e de trocas gasosas, antes, durante e após o esforço, fornece bases de entendimento fisiopatológico e possibilita a identificação do mecanismo predominante para a intolerância ao exercício. Adicionalmente, fornece prognóstico e permite avaliação sequencial na evolução de diversas morbidades cardiorrespiratórias. No caso em discussão, o pulso de O2 com curva deprimida, a queda da pressão arterial sistólica, a ausência de dessaturação e a rápida recuperação do broncoespasmo induzido, sugerem o diagnóstico de restrição cardiocirculatória predominante (asma cardíaca por estenose mitral) para limitação funcional, associada secundariamente ao distúrbio ventilatório e vascular pulmonar. CONSIDERAÇÕES FINAIS: A interpretação dos dados do TCPE em conjunto permitiu distinguir o mecanismo fisiopatológico preponderante (estenose mitral) e encaminhar a paciente para o tratamento cirúrgico. Com três meses de pós-operatório, retornou em consulta com melhora importante da CF, redução da HP e boa evolução clínica. (AU)

Cor Pulmonale Revisited. From Ferrer and Harvey to the Present.

The term cor pulmonale has traditionally been used as a synonym for right heart failure due to chronic respiratory diseases, although this condition is less frequently seen in the modern era because of the use of long-term oxygen therapy along with aggressive measures directed at optimizing ventilation and gas exchange. The mechanisms by which adaptation or maladaptation of right heart structure and function in the broader setting of pulmonary vascular disease, either intrinsic to the pulmonary circulation or due to respiratory diseases, have garnered considerable interest along with the development of medical and surgical treatments for pulmonary hypertension. Thus, the right heart is no longer considered an "innocent bystander" in pulmonary hypertension, but rather a key component in its pathophysiology. Furthermore, the status of right heart function is a major determinant of outcome. Accordingly, the right heart has become a potential, appealing target for novel therapies to treat hypertensive pulmonary vascular disease.

Rethinking Chronic Obstructive Pulmonary Disease. Chronic Pulmonary Insufficiency and Combined Cardiopulmonary Insufficiency.

Almost 70 years ago, Drs. Baldwin, Cournand, and Richards defined chronic pulmonary insufficiency by the presence of respiratory symptoms, radiologic evidence of pulmonary emphysema on chest radiography, and physiologic gas trapping. A decade later, airflow obstruction on spirometry was added to the definition and insufficiency became a disease. Contemporary studies are reviving the diagnostic approach described by these early luminaries, with researchers finding that symptomatic smokers with preserved spirometry have increased exacerbations and that smokers and non-smokers with normal spirometry but emphysema on chest computed tomography have increased mortality. Hence, the Baldwin-Cournand-Richards concept of disease defined by respiratory symptoms, radiologic findings, and physiology-regardless of spirometric criteria-is being rediscovered. Baldwin, Cournand, and Richards also stated that "functionally, it is obvious that the pulmonary and circulatory apparatus are one unit," and they defined combined cardiopulmonary insufficiency as chronic pulmonary insufficiency with (left or right) cardiac and pulmonary artery enlargement. They appreciated the complexity of these interactions, which include the potential role of gas trapping in heart failure with reduced ejection fraction; the impact of emphysema on blood flow in heart failure with preserved ejection fraction; multiple contributions to cor pulmonale with increased pulmonary artery pressure; and cor pulmonale parvus in emphysema; all of which may be amenable to specific therapeutic interventions. Given the complexity of heart-lung interactions originally identified by Baldwin, Cournand, and Richards and the potentially large therapeutic opportunities, large-scale studies are still warranted to find specific therapies for subphenotypes of combined cardiopulmonary insufficiency.

Prevalencia y cambios dinámicos de las ondas T vagotónicas durante el ejercicio en una población futbolista de élite / Prevalence and dynamic changes of vagotonic T waves during exercise in elite soccer player population

Introducción: Las características del electrocardiograma del deportista son aún hoy en día objeto de múltiples publicaciones cuyo significado fisiológico se ha ido esclareciendo a medida que se han correlacionado las diferentes variantes con una evaluación cardiológica sofisticada y un seguimiento prolongado. Existen diferentes alteraciones de la repolarización descritas en la población deportista. Las ondas T vagotónicas son un hallazgo frecuente en esta población, aunque la dinámica de dichos hallazgos durante el ejercicio tiene actualmente un significado incierto. El objetivo de nuestro estudio fue determinar su prevalencia en una población de deportistas de élite y analizar su comportamiento en diferentes estadíos del ejercicio. Métodos: Se analizó una población de 91 futbolistas profesionales varones de un equipo de la máxima categoría de la liga de futbol española (edad 26 años ± 4,49 años). Se evaluó en el electrocardiograma basal la presencia de ondas T vagotónicas, así como su asociación con diferentes variables electrocardiográficas y ecocardiográficas. Además, se estudió la dinámica de la morfología de estas ondas durante las distintas etapas de una prueba de esfuerzo maximal. Resultados: Se identificaron 14 sujetos (15%) con presencia de ondas T vagotónicas en el ECG basal. En 13 de los 14 atletas (92%) se objetivó un comportamiento dinámico de las ondas, con desaparición progresiva durante el esfuerzo y posterior reaparición desde etapas precoces de la recuperación, con voltajes similares al electrocardiograma basal. Conclusiones: Este estudio evidencia que las ondas T vagotónicas se deben fundamentalmente al predominio del tono parasimpático. El ejercicio puede considerarse una estrategia de gran utilidad a la hora de su estudio

Introduction: The characteristics of the athlete's electrocardiogram are still today the subject of multiple publications whose physiological meaning has been clarified as the different variants have been correlated with a sophisticated cardiological evaluation and a prolonged follow-up. There are different alterations of repolarization described in the sports population, among them the most frequently reported in the literature are: early repolarization, vagotonic T waves, ST-T alterations, etc. Vagotonic T waves are a common finding in the athlete population, although currently, the dynamic changes of this finding during exercise, have an uncertain meaning. The aim of our study was to determine its prevalence in a population of elite athletes and analyze their behavior at different stages of the exercise. Methods: A population of 91 male, professional soccer players of a team of the first division of the Spanish football league (age 26 years ± 4.49 years) were analyzed. The presence of vagotonic T waves was assessed at baseline electrocardiogram and their association with different electrocardiographic and echocardiographic variables was also analyzed. The dynamic changes of the morphology of these waves were studied at different stages during a maximal effort trial. Results: The presence of vagotonic T waves was identified in the baseline ECG in 14 (15%) subjects. In 13 out of 14 athletes (92%), a dynamic behavior of the vagotonic waves was observed. It had a progressive disappearance during exercise and it reappeared at the early stages of recovery, with similar voltages to that observed at the baseline electrocardiogram. Conclusions: This study evidence that vagotonic T waves are mainly due to the predominance of parasympathetic tone. The exercise can be considered a useful strategy when study

Acute cor pulmonale due to pulmonary tumour thrombotic microangiopathy from renal cell carcinoma.

We report the case of a previously healthy man who presented with subacute dyspnoea after a long drive. He developed hypoxic respiratory failure, thought secondary to a massive pulmonary embolism and was treated with tissue plasminogen activator but died in the hospital despite aggressive medical measures. Autopsy revealed pulmonary tumour thrombotic microangiopathy (PTTM) from papillary renal cell carcinoma. PTTM is a rare clinicopathological syndrome that clinically results in symptoms of dyspnoea and right heart failure. Pathologically, a localised paraneoplastic process evolves from tumour microemboli in the pulmonary arterioles, resulting in fibrocellular proliferation and narrowing of the vessels, causing subacute right heart failure. To our knowledge, this is the first case of PTTM due to papillary renal cell carcinoma.

Pulmonary artery to aorta ratio and risk of all-cause mortality in the general population: the Rotterdam Study.

A pulmonary artery to aorta ratio (PA:A) >1 is a proxy of pulmonary hypertension. It is not known whether this measure carries prognostic information in the general population and in individuals with chronic obstructive pulmonary disease (COPD).Between 2003 and 2006, 2197 participants from the population-based Rotterdam Study (mean±sd age 69.7±6.7 years; 51.3% female), underwent cardiac computed tomography (CT) scanning with PA:A quantification, defined as the ratio between the diameters of the pulmonary artery and the aorta. COPD was diagnosed based on spirometry or clinical presentation and obstructive lung function measured by a treating physician. Cox regression was used to investigate the risk of mortality.We observed no association between 1-sd increase of PA:A and mortality in the general population. Larger PA:A was associated with an increased risk of mortality in individuals with COPD, particularly in moderate-to-severe COPD (hazard ratio 1.36, 95% CI 1.03-1.79). We demonstrated that the risk of mortality in COPD was driven by severe COPD, and that this risk increased with decreasing diffusing capacity.Larger PA:A is not associated with mortality in an older general population, but is an independent determinant of mortality in moderate-to-severe COPD. Measuring PA:A in CT scans obtained for other indications may yield important prognostic information in individuals with COPD.