Miguel Ángel Gómez

Standards of care in pulmonary hypertension.

Substantial progress in the diagnosis and treatment of patients with pulmonary hypertension in recent years has led to significant improvement in survival. Evidence-based clinical practice guidelines issued by scientific societies reflect these new developments. However, certain clinically relevant issues have not been covered in consensus guidelines because of the lack of conclusive scientific evidence. Therefore, the Spanish Society of Pulmonology and Thoracic Surgery (SEPAR) and the Spanish Society of Cardiology (SEC) have promoted the present consensus statement in order to define national standards of care in the evaluation and management of pulmonary hypertension in its various forms, as well as to outline a clinical pathway and the basic principles for organizing health care in this clinical setting, with special emphasis on the requirements for and functions of specialized referral units. To prepare the statement, SEPAR and SEC formed a task force composed of national experts in various aspects of pulmonary hypertension. The resulting consensus is based on international clinical guidelines, a review of available scientific evidence, and panel discussion among the task force members. The final statement, approved by all participants, underwent external review.

Estándares asistenciales en hipertensión pulmonar

En los ultimos anos se han producido importantes avances en el diagnostico y tratamiento de la hipertension pulmonar que han logrado una mejoria significativa en la supervivencia de esta enfermedad. Estas innovaciones se han recogido en guias de practica clinica basadas en la evidencia elaboradas por las sociedades cientificas. Sin embargo, no se incluyen en ellas, por falta de evidencia cientifica concluyente, algunos aspectos que inciden en la practica asistencial. Conscientes de ello, la Sociedad Espanola de Neumologia y Cirugia Toracica (SEPAR) y la Sociedad Espanola de Cardiologia (SEC) han promovido la elaboracion de un documento de consenso para definir en nuestro medio los estandares de calidad adecuados para el diagnostico y tratamiento de la hipertension pulmonar en sus diversas formas de presentacion, asi como la via clinica y las directrices basicas de la organizacion asistencial del cuidado de estos pacientes, haciendo especial hincapie en los requisitos y funciones de las unidades de referencia. Para su redaccion la SEPAR y la SEC designaron a un grupo de trabajo formado por expertos en los distintos aspectos de la enfermedad. Para la elaboracion del documento se han utilizado las guias clinicas internacionales existentes, la revision de la evidencia cientifica disponible y el debate en panel entre los expertos. El documento final, aprobado por todos los participantes, ha sido evaluado por revisores externos.Consensus Statement of the Spanish Society of Pulmonology and Thoracic Surgery (SEPAR) and the Spanish Society of Cardiology (SEC). Substantial progress in the diagnosis and treatment of patients with pulmonary hypertension in recent years has led to significant improvement in survival. Evidence-based clinical practice guidelines issued by scientific societies reflect these new developments. However, certain clinically relevant issues have not been covered in consensus guidelines because of the lack of conclusive scientific evidence. Therefore, the Spanish Society of Pulmonology and Thoracic Surgery (SEPAR) and the Spanish Society of Cardiology (SEC) have promoted the present consensus statement in order to define national standards of care in the evaluation and management of pulmonary hypertension in its various forms, as well as to outline a clinical pathway and the basic principles for organizing health care in this clinical setting, with special emphasis on the requirements for and functions of specialized referral units. To prepare the statement, SEPAR and SEC formed a task force composed of national experts in various aspects of pulmonary hypertension. The resulting consensus is based on international clinical guidelines, a review of available scientific evidence, and panel discussion among the task force members. The final statement, approved by all participants, underwent external review.

Clinical implications of supraventricular arrhythmias in patients with severe pulmonary arterial hypertension

Arrhythmias are an increasingly common problem in patients withpulmonary arterial hypertension (PAH) due to the morphologicalchangesintherightcardiacchambersandthemodulationofautonomicactivity [1]. We evaluated the impact of supraventricular tachycardia(SVT)inpatientswithpulmonaryhypertensiontoassessthesafetyandefficacy of electrophysiology study (EPS).We performed a retrospective cohort study between 1995 and2008. 282 patients with PAH, included in the group I of Dana Point PAHclassification [2] were included. PAH was defined as a mean pulmonaryarterial pressure (PAP) N25 mm Hg at rest along with a pulmonarycapillary wedge pressure (PCWP) b15 mmHg. Medical records ofpatients that experienced an episode of SVT were reviewed. All patientswith suspected intraventricular reentrant tachycardia (INRT) underwentEPS with ablation of slow pathway. In patients with suspected commonflutter an EPS with cavotricuspid isthmus ablation was performed.The mean age was 47.3±14.3 years and 16 patients (60.6%) werewomen.6patients(26.1%)hadidiopathicPAH,7(30.4%)aconnectivetissue disease, 6 (26.1%) toxic oil syndrome and 4 (17.4%) Eisenmen-ger syndrome. Theaverageintervalbetweenthe diagnosisof PAH andthe onset of SVT was 60.3±55.9 months. The total number of SVTevents was 28. The type of arrhythmia distribution was: AF (n=12,42.8%),uncommonflutter(n=7,25%),commonflutter(n=5,17.8%)and INRT (n=4, 14.2%). AF and flutter occurred in older patients

Punto de corte óptimo de NT-proBNP para el diagnóstico de insuficiencia cardiaca mediante un test de determinación rápida en atención primaria

INTRODUCTION AND OBJECTIVES Measurement of natriuretic peptides may be recommended prior to echocardiography in patients with suspected heart failure. Cut-off point for heart failure diagnosis in primary care is not well established. We aimed to assess the optimal diagnostic cut-off value of N-terminal pro-B-type natriuretic peptide on a community population attended in primary care. METHODS Prospective diagnostic accuracy study of a rapid point-of-care N-terminal pro-B-type natriuretic peptide test in a primary healthcare centre. Consecutive patients referred by their general practitioners to echocardiography due to suspected heart failure were included. Clinical history and physical examination based on Framingham criteria, electrocardiogram, chest X-ray, N-terminal pro-B-type natriuretic peptide measurement and echocardiogram were performed. Heart failure diagnosis was made by a cardiologist blinded to N-terminal pro-B-type natriuretic peptide value, using the European Society of Cardiology diagnosis criteria (clinical and echocardiographic data). RESULTS Of 220 patients evaluated (65.5% women; median 74 years [interquartile range 67-81]). Heart failure diagnosis was confirmed in 52 patients (23.6%), 16 (30.8%) with left ventricular ejection fraction <50% (39.6 [5.1]%). Median values of N-terminal pro-B-type natriuretic peptide were 715 pg/mL [interquartile range 510.5-1575] and 77.5 pg/mL [interquartile range 58-179.75] for patients with and without heart failure respectively. The best cut-off point was 280 pg/mL, with a receiver operating characteristic curve of 0.94 (95% confidence interval, 0.91-0.97). Six patients with heart failure diagnosis (11.5%) had N-terminal pro-B-type natriuretic peptide values <400 pg/mL. Measurement of natriuretic peptides would avoid 67% of requested echocardiograms. CONCLUSIONS In a community population attended in primary care, the best cut-off point of N-terminal pro-B-type natriuretic peptide to rule out heart failure was 280 pg/mL. N-terminal pro-B-type natriuretic peptide measurement improve work-out diagnoses and could be cost-effectiveness.

Chronic thromboembolic pulmonary hypertension: surgical treatment with thromboendarterectomy

Abstract Background and objectives Pulmonary thromboendarterectomy (PTE) is considered the potential curative treatment for chronic thromboembolic pulmonary hypertension (CTEPH). We analysed the results of the PTE application in our institution. Patients and methods From February 1996 to December 2007, 30 patients with CTEPH underwent videoassisted PTE. Preoperative hemodynamic data were: systolic pulmonary artery pressure (SPAP) 87±17 mmHg, mean pulmonary artery pressure (MPAP) 51±11 mmHg, pulmonary total resistance 1067±485 dynes·s·cm−5, pulmonary vascular resistance 873±389 dynes·s·cm−5 and cardiac index 2.2±0.5 l/min/m2. We analysed the influence of several factors on hospital mortality and survival, and we performed partial analysis of mortality since 2004. Results PTE resulted in significant improvements in SPAP (P Conclusions PTE effectively reduces pulmonary hypertension and offers CTEPH patients a substantial improvement in survival and quality of life.

Hipertensión pulmonar tromboembólica crónica: tratamiento mediante tromboendarterectomía quirúrgica

BACKGROUND AND OBJECTIVES Pulmonary thromboendarterectomy (PTE) is considered the potential curative treatment for chronic thromboembolic pulmonary hypertension (CTEPH). We analysed the results of the PTE application in our institution. PATIENTS AND METHODS From February 1996 to December 2007, 30 patients with CTEPH underwent video-assisted PTE. Preoperative hemodynamic data were: systolic pulmonary artery pressure (SPAP) 87+/-17mmHg, mean pulmonary artery pressure (MPAP) 51+/-11mmHg, pulmonary total resistance 1067+/-485dynes x s x cm(-5), pulmonary vascular resistance 873+/-389dynes x s x cm(-5) and cardiac index 2.2+/-0.5l/min/m(2). We analysed the influence of several factors on hospital mortality and survival, and we performed partial analysis of mortality since 2004. RESULTS PTE resulted in significant improvements in SPAP (P<0.001), MPAP (P=0.001) and cardiac index (P<0.001). Hospital mortality was 17% (5/30) (95% confidence interval, 6%-35%). From 2004, it dropped to 5% (1/20) (95% confidence interval, 0%-25%). Hospital mortality was influenced by preoperative pulmonary total resistance, preoperative pulmonary vascular resistance, postoperative SPAP, reduction of SPAP, reduction of MPAP, reperfusion pulmonary oedema and residual postoperative pulmonary hypertension (P=0.036; P=0.018;P=0.013; P=0.050; P=0.050; P=0.030; P=0.045). Survival after PTE, including hospital mortality, was 76+/-9% at 10 years. Through long-term follow-up, functional status (P=0.001), 6min walking distance (P=0.001), end-diastolic right ventricle size (P<0.001), and tricuspid regurgitation (P<0.001) significantly improved. CONCLUSIONS PTE effectively reduces pulmonary hypertension and offers CTEPH patients a substantial improvement in survival and quality of life.

Hypersensitivity Pneumonitis Due to Venlafaxine

Venlafaxine is a selective serotonin, noradrenalin, and dopamine reuptake inhibitor. Although side effects are rare, venlafaxine has very occasionally been associated with hypersensitivity pneumonitis. We report the case of a 61-year-old woman diagnosed with depressive disorder and treated with venlafaxine (Dobupal) at a dose of 150 mg/d for 18 months. When depression worsened, the dose was increased to 255 mg/d. Three weeks later she complained of nonproductive cough, shortness of breath with moderate effort, and asthenia. Clinical and radiologic findings, lung function, bronchoalveolar lavage, and histology of lung biopsies all indicated a diagnosis of hypersensitivity pneumonitis. Other causes were ruled out and venlafaxine was discontinued. Clinical, radiologic, and lung function findings then resolved without the use of corticosteroids or nonsteroid immune modulators. All findings were normal on follow-up after 3 months.