M Schwaiblmair

Non-invasive diagnosis of pulmonary hypertension: ESC/ERS Guidelines with Updated Commentary of the Cologne Consensus Conference 2011 ✩

The 2009 European Guidelines on Diagnosis and Treatment of Pulmonary Hypertension have been adopted for Germany. The guidelines contain detailed recommendations for the diagnosis of pulmonary hypertension. However, the practical implementation of the European Guidelines in Germany requires the consideration of several country-specific issues and already existing novel data. This requires a detailed commentary to the guidelines, and in some aspects an update already appears necessary. In June 2010, a Consensus Conference organized by the PH working groups of the German Society of Cardiology (DGK), the German Society of Respiratory Medicine (DGP) and the German Society of Pediatric Cardiology (DGPK) was held in Cologne, Germany. This conference aimed to solve practical and controversial issues surrounding the implementation of the European Guidelines in Germany. To this end, a number of working groups was initiated, one of which was specifically dedicated to the non-invasive diagnosis of pulmonary hypertension. This manuscript describes in detail the results and recommendations of the working group which were last updated in October 2011.

Home treatment of patients with low-risk pulmonary embolism with the oral factor Xa inhibitor rivaroxaban. Rationale and design of the HoT-PE Trial.

Pulmonary embolism (PE) is a potentially life-threatening acute cardiovascular syndrome. However, more than 95 % of patients are haemodynamically stable at presentation, and among them are patients at truly low risk who may qualify for immediate or early discharge. The Home Treatment of Pulmonary Embolism (HoT-PE) study is a prospective international multicentre single-arm phase 4 management (cohort) trial aiming to determine whether home treatment of acute low-risk PE with the oral factor Xa inhibitor rivaroxaban is feasible, effective, and safe. Patients with confirmed PE, who have no right ventricular dysfunction or free floating thrombi in the right atrium or ventricle, are eligible if they meet none of the exclusion criteria indicating haemodynamic instability, serious comorbidity or any condition mandating hospitalisation, or a familial/social environment unable to support home treatment. The first dose of rivaroxaban is given in hospital, and patients are discharged within 48 hours of presentation. Rivaroxaban is taken for at least three months. The primary outcome is symptomatic recurrent venous thromboembolism or PE-related death within three months of enrolment. Secondary outcomes include quality of life and patient satisfaction, and health care resource utilisation compared to existing data on standard-duration hospital treatment. HoT-PE is planned to analyse 1,050 enrolled patients, providing 80 % power to reject the null hypothesis that the recurrence rate of venous thromboembolism is >3 % with α≤0.05. If the hypothesis of HoT-PE is confirmed, early discharge and out-of-hospital treatment may become an attractive, potentially cost-saving option for a significant proportion of patients with acute PE.

Central thromboembolism is a possible predictor of right heart dysfunction in normotensive patients with acute pulmonary embolism

BACKGROUND Right heart dysfunction is a crucial factor in risk stratification of normotensive patients with pulmonary embolism. Apart from biomarkers, determinants of right heart dysfunction in this group of patients are not yet well established. AIM AND METHOD In order to identify such determinants, we analysed data of 252 patients with acute pulmonary embolism admitted to our hospital in 2008. RESULTS 69 out of 140 patients showed right heart dysfunction by echocardiography within 24 hours after diagnosis, 71 did not. Right ventricular dysfunction was significantly more frequent in patients with central clots on computed tomography (p=0.004), a history of syncope (p<0.001) and among women on oral contraceptives (p=0.003). In multiple regression analysis, only central thromboembolism (p<0.001) was identified as individual predictor of right ventricular dysfunction. Age, gender, body mass index, idiopathic or recurrent thromboembolism, duration of symptoms, preceding surgery, room air oxygen saturation, carcinoma, hypertension, diabetes, renal disease, congestive left heart failure and concomitant lung disease were equally distributed. In comparison with NT-pro brain natriuretic peptide (PPV 67%, NPV 75%, p=0.782) and troponin I (PPV 76%, NPV 62%, p=0.336), central thromboembolism has shown to have a greater statistical power in predicting right heart dysfunction in normotensive patients with pulmonary embolism (PPV 78%, NPV 88%, p<0.001). CONCLUSION Among normotensive patients with acute pulmonary embolism, those with central clots seem to be at greater risk for echocardiographically evaluated right ventricular dysfunction.

Pharmacologic testing of the reversibility of an increased pulmonary vascular resistance before heart transplantation with prostaglandin I

An increased pulmonary vascular resistance (PVR) or an increased transpulmonary gradient (TPG) is a risk factor for increased 3-day and 3-month mortality after heart transplantation (HTx). The reversibility of increased PVR or TPG under pharmacologic testing is supposed to indicate a decreased probability of right ventricular failure/death after transplantation. We tested the response of an increased PVR (> 2.5 Wood units, WU) and/or of an increased TPG (> 15 mm Hg) in 29 right heart catheterizations (thermodilution catheter) of 23 patients (54 +/- 8 years, mean NYHA-class 3.1 +/- 0.6, ischemic n = 8, dilated cardiomyopathy n = 15). Increasing doses of prostaglandin I2 (PGI2, mean maximum dose 13.5 +/- 6.4 ng/kg/min) were applied stepwise over at least 10 min at the maximum dose level. We analyzed any dependence of the reversibility of PVR and TPG under prostaglandin I2 on hemodynamic values, echocardiographic parameters, demographic data, and laboratory findings. A decrease of PVR to a range usually accepted as no contraindication for HTx (< or = 4 WU) was found in each patient without symptomatic systemic hypotension during application of PGI2 (baseline value: 4.7 +/- 1.3 WU, during PGI2: 2.3 +/- 0.6 WU). An unresponsive, fixed increased PVR or TPG was not observed using PGI2. In 62% of investigations, both PVR and TPG decreased below 2.5 WU and 15 mmHg, respectively. The extent of reversibility of PVR and TPG was individually different and did not depend on the mean pulmonary artery pressure, mean capillary wedge pressure, cardiac output, mean systemic artery pressure or echocardiographic parameters (EDD, FS, ES-distance), sodium, urea or bilirubin levels, medication, age of the patients or the duration of the disease. The baseline PVR correlated inversely with its percentile value during PGI2 (r = -0.76, p < 0.05). In advanced heart failure, PGI2 decreases PVR in ranges of lower risk concerning orthotopic HTx, without causing an intolerable systemic hypotension. The individual extent of reversibility of PVR and TPG under PGI2 is not influenced by basic hemodynamic parameters or the patients demographic profile.

Lipidpneumonie – ein unterschätztes Krankheitsbild?

Lipoid pneumonia, first described by Laughlen 1925 may be classified as endogenous or exogenous. The endogenous form is seen when fat is deposited into the lung tissue. It is usually associated with proximal obstructive lesions, necrotic tissue after radio- or chemotherapy, with lipid storage disease or hyperlipidemia . Exogenous lipoid pneumonia results from inhaling or aspirating animal, vegetable or mineral oil. There are usually some underlying neurological defects or esophageal abnormalities. Patients may present with cough, sputum, hemoptysis and chest pain or may be asymptomatic. There is no classic chest film appearance: it may appear as diffuse airspace infiltration or localized consolidation simulating tumour. Computed tomography is diagnostically helpful and shows hypodense areas measuring from -100 to - 30 Hounsfield units. Bronchoscopic biopsies are mandatory for histological confirmation of the diagnosis. Treatment of exogenous lipoid pneumonia has always been conservative by discontinuing the use of oil, correction of underlying defects that may favor aspiration and treatment of intercurrent pneumonia. Other measures, for example corticosteroid therapy, are of uncertain benefit. Complications of lipoid pneumonia that worsen prognosis are recurrent bacterial pneumonias including nontuberculous mycobacteria or aspergillus, or lung cancer that has developed in areas of pre-existing exogenous lipoid pneumonia.

Nicht-invasive Diagnostik der pulmonalen Hypertonie

The 2009 European Guidelines on Diagnosis and Treatment of Pulmonary Hypertension have been adopted for Germany. The guidelines contain detailed recommendations for the diagnosis of pulmonary hypertension. However, the practical implementation of the European Guidelines in Germany requires the consideration of several country-specific issues and already existing novel data. This requires a detailed commentary to the guidelines, and in some aspects an update y appears necessary. In June 2010, a Consensus Conference organized by the PH working groups of the German Society of Cardiology (DGK), the German Society of Respiratory Medicine (DGP) and the German Society of Pediatric Cardiology (DGPK) was held in Cologne, Germany. This conference aimed to solve practical and controversial issues surrounding the implementation of the European Guidelines in Germany. To this end, a number of working groups was initiated, one of which was specifically dedicated to non-invasive diagnosis of PH. This commentary summarizes the results and recommendations of the working group on treatment of PAH.

Nicht-invasive Diagnostikder pulmonalen Hypertonie

The 2009 European Guidelines on Diagnosis and Treatment of Pulmonary Hypertension have been adopted for Germany. The guidelines contain detailed recommendations for the diagnosis of pulmonary hypertension. However, the practical implementation of the European Guidelines in Germany requires the consideration of several country-specific issues and already existing novel data. This requires a detailed commentary to the guidelines, and in some aspects an update y appears necessary. In June 2010, a Consensus Conference organized by the PH working groups of the German Society of Cardiology (DGK), the German Society of Respiratory Medicine (DGP) and the German Society of Pediatric Cardiology (DGPK) was held in Cologne, Germany. This conference aimed to solve practical and controversial issues surrounding the implementation of the European Guidelines in Germany. To this end, a number of working groups was initiated, one of which was specifically dedicated to non-invasive diagnosis of PH. This commentary summarizes the results and recommendations of the working group on treatment of PAH.

Lipidpneumonie – einunterschätztes Krankheitsbild?

Lipoid pneumonia, first described by Laughlen 1925 may be classified as endogenous or exogenous. The endogenous form is seen when fat is deposited into the lung tissue. It is usually associated with proximal obstructive lesions, necrotic tissue after radio- or chemotherapy, with lipid storage disease or hyperlipidemia . Exogenous lipoid pneumonia results from inhaling or aspirating animal, vegetable or mineral oil. There are usually some underlying neurological defects or esophageal abnormalities. Patients may present with cough, sputum, hemoptysis and chest pain or may be asymptomatic. There is no classic chest film appearance: it may appear as diffuse airspace infiltration or localized consolidation simulating tumour. Computed tomography is diagnostically helpful and shows hypodense areas measuring from -100 to - 30 Hounsfield units. Bronchoscopic biopsies are mandatory for histological confirmation of the diagnosis. Treatment of exogenous lipoid pneumonia has always been conservative by discontinuing the use of oil, correction of underlying defects that may favor aspiration and treatment of intercurrent pneumonia. Other measures, for example corticosteroid therapy, are of uncertain benefit. Complications of lipoid pneumonia that worsen prognosis are recurrent bacterial pneumonias including nontuberculous mycobacteria or aspergillus, or lung cancer that has developed in areas of pre-existing exogenous lipoid pneumonia.