Paweł Kuca

Detectable Serum Cardiac Troponin T as a Marker of Poor Prognosis Among Patients With Chronic Precapillary Pulmonary Hypertension

Background—Right ventricular failure is a leading cause of death in patients with chronic pulmonary hypertension (PH). We checked whether detection of cardiac troponin T (cTnT), a specific marker of myocyte injury, could be useful in prognostic stratification of those patients. Methods and Results—Initial evaluation of 56 clinically stable patients (age 41±15 years) with pulmonary arterial (51 patients) or inoperable chronic thromboembolic (5 patients) PH (mean pulmonary arterial pressure 60±18 mm Hg) included cTnT test, allowing detection of its serum levels ≥0.01 ng/mL [cTnT(+)]. cTnT was detectable in 8 of 56 (14%) patients (mean±SD, 0.034±0.022; range, 0.010 to 0.077 ng/mL). Despite similar pulmonary hemodynamics, they had higher heart rate (92±15 versus 76±14 bpm, P =0.004), lower mixed venous oxygen saturation (50±10% versus 57±9%, P =0.04), and higher serum N-terminal pro-B–type natriuretic peptide (4528±3170 versus 2054±2168 pg/mL, P =0.03) and walked less during the 6-minute walk test (298±132 versus 396±101 m, P =0.02). Cumulative survival estimated by Kaplan-Meier curves was significantly worse at 24 months in cTnT(+) compared with cTnT(−) (29% versus 81%, respectively, log-rank test P =0.001). Multivariate analysis revealed cTnT status (hazard ratio, 4.89; 95% CI, 1.18 to 20.29; P =0.03), 6-minute walk test (hazard ratio, 0.93 for each 10 m; P =0.01), and pulmonary vascular resistance (hazard ratio, 1.13; P =0.01) as independent markers of mortality. All 3 cTnT(+) patients who survived the follow-up period converted to cTnT(−) during treatment. Conclusions—Detectable cTnT is a so-far ignored independent marker of increased mortality risk in patients with chronic precapillary PH, supporting the role of progressive myocyte injury in the vicious circle leading to hemodynamic destabilization.

Prevalence, severity and underdiagnosis of COPD in the primary care setting

Background: Chronic obstructive pulmonary disease (COPD) is a common disease with a steadily increasing prevalence and mortality. However, recent epidemiological estimates differ depending on the population studied and methods used. Aim: To investigate the prevalence, severity and burden of COPD in a primary care setting. Methods: From 4730 patients registered in a single primary care practice, all 2250 patients aged 40 years or more were invited to participate. Participants completed a questionnaire on smoking, respiratory symptoms, education and social status. A physical examination was followed by pre- and post-bronchodilator (BD) spirometry. Results: Of the eligible patients, 1960 (87%) participated. 92% of spirometric tests met the ATS criteria. Airflow limitation was demonstrated in 299 (15%) of the participants pre-BD and in 211 (11%) post-BD. COPD was diagnosed in 183 patients (9.3%). Of these patients, the degree of post-BD airflow limitation was mild in 30.6%, moderate in 51.4%, severe in 15.3% and very severe in 2.7%. Only 18.6% of these patients had previously been diagnosed with COPD; almost all of these had severe or very severe airflow limitation. As a result of the study, a diagnosis of asthma was made in 122 patients. Conclusions: The prevalence and underdiagnosis of COPD in adult patients in this primary care setting made case finding worthwhile. Large numbers of newly detected patients were symptomatic and needed treatment. Limiting investigations to smokers would have reduced the number of COPD diagnoses by 26%.

Effectiveness of intrapericardial administration of streptokinase in purulent pericarditis.

Background and Purpose:Purulent pericarditis is very rare. However, among patients suffering from this disease the mortality rate is very high. The aim of this study was to evaluate the effectiveness and side effects of intrapericardial streptokinase administration in patients with confirmed purulent pericarditis.Patients and Methods:Three patients, one 50-year-old man and two women aged 64 and 40 years, who were admitted to the intensive care unit (ICU) due to purulent pericarditis, entered the study. In all three cases a subxiphoid pericardiotomy followed by insertion of a drainage line into the pericardial space was performed. Antibiotic therapy was started immediately on admission to the hospital. Despite continued antibiotic therapy in all three patients, daily drainage from the pericardium—during several days after surgery—staggered between 50–200 ml/day. Due to considerable purulent pericardial drainage loculations and/or fibrin deposits confirmed by echocardiography, streptokinase (500,000 IU dissolved in 50 ml of normal saline) was administered into the pericardial space over 10 min, using the previously inserted drainage catheter. This regimen was repeated after 12 and 24 h. The total dose of streptokinase was 1,500,000 IU.Results:The clinical effect of intrapericardial streptokinase administration was excellent. Several days after intrapericardial administration of streptokinase, drainage of purulent pericardial fluid stopped. No complications associated with intrapericardial streptokinase administration were observed. In the follow-up echocardiography (in two patients repeated 6 and 9 months after delivery of streptokinase), pericardial fluid and echocardiographic signs of pericardial constriction were not observed.Conclusion:Intrapericardial administration of streptokinase in purulent pericarditis is effective and safe.ZusammenfassungBei drei Patienten mit purulenter Perikarditis konnte der Perikarderguss durch chirurgische Perikardiotomie nicht suffizient drainiert werden. Die komplikationslose Sanierung des lokulierten fibrinösen Ergusses gelang nach intraperikardialer Streptokinaseinstillation (50-ml-Lösung mit 500 000 IE Streptokinase, instilliert über 10 min in erster Sitzung, gefolgt von derselben Dosis nach 12 und 24 h). Im weiteren Verlauf ergab sich eine Restitutio ad integrum, ohne dass sich später eine konstriktive Perikarditis entwickelte.

The inefficacy of enoxaparin prophylaxis in a patient with congenital antithrombin deficiency.

and hemoptysis complicated the course of PE. Secondary prophylaxis with OA and international normalized ratio maintenance between 2 and 3 are being successfully continued. The presented case report shows a poorly investigated problem, demonstrating the imperative for a better understanding of the efficacy of antithrombotic measures used in patients with trauma and documented AT deficiency. According to the existing guidelines, thromboprophylaxis with LMWH should be started, if possible, in patients with trauma and prolonged immobilization with at least 1 risk factor of venous thromboembolism like the AT deficiency. Enoxaparin appeared to be insufficient in producing its major anticoagulant effect by activating AT, even at higher than the recommended dosage. This case provides further evidence that enoxaparin and related drugs require AT for their clinical efficacy.

Pulmonary artery stenosis due to embryonal carcinoma with primary mediastinal location

A 29-year old man was admitted to the intensive care unit after losing consciousness. On physical examination, a loud systolic murmur over the heart was found. Echocardiography revealed narrowing of pulmonary artery with high pressure gradient. Computed tomography of the chest revealed the presence of large tumour localised in the upper anterior mediastinum. Due to the risk of total closure of the pulmonary artery, interventional mediastinotomy was performed and diagnosis of carcinoma embryonale was established. Subsequent chemotherapy (BEP regimen) has brought regression of tumour and significant improvement in haemodynamic parameters (relief of pressure gradient in pulmonary artery). During the second surgery, the resection of all accessible tumour mass together with marginal resection of the right upper lobe was performed. No signs of cardiac or great vessels infiltration was found. Histopathologic examination revealed the necrotic masses and neoplastic foci diagnosed as teratoma immaturum. In a four-month follow-up the patients condition remained good. The patient is still under the care of both oncological and cardiological specialists. Thus far he has not required further chemotherapy. Holter ECG monitoring revealed no arrhythmia, but the patient is still treated with mexiletine. The patient is planning to return to work.

Silent venous thromboembolism (VTE) in patients undergoing thoracic surgery in the course of lung cancer

Background: Venous thromboembolism often occurs after thoracic surgery but can even occur before surgery in patients with lung cancer. Aims: The aim of the study was the investigation of the incidence of silent deep vein thrombosis (DVT) and pulmonary embolism (PE), confirmed by objective imaging tests, before and after thoracic surgery in the course of lung cancer. Methods: Venous ultrasound (US) imaging was performed to detect DVT before and after thoracic surgery in patients with non-small cell lung cancer. Plasma D-dimer (DD) levels as well as Caprini and Khorana risk scores were examined in all patients. All cases with signs or symptoms of PE after surgery were examined by computed tomography pulmonary angiography (CTPA). Results: The study was perfomed in 200 patients (M:K = 122:88) with lung cancer and hospitalized for thoracic surgery. All patients received primary antithromobotic prophylaxis by low molecular weight heparins. DVT was detected by US in 3 patients before thoracic surgery. There was no symptoms od DVT and DD Level was elevated in one case. PE was diagnosed by CTPA in 2 patients after surgery; there was no DVT in these cases. DD levels were elevated in both cases. Conclusions: Silent or subclinical VTE may occur before surgical treatment in many patients with non-small lung cell cancer. Risk factors for VTE as well as elevated DD level before treatment might not be sufficient for identification silent DVT in thoracic surgery. PE represent potentially lethal postoperative complication despite pharmacological prevention of VTE.

Diffuse alveolar haemorrhage complicated by pulmonary embolism — problems with treatment

Diffuse alveolar haemorrhage (DAH) refers to a clinical syndrome resulting from injury of the alveolar capillaries, arterioles and venules leading to red blood cel accumulation in the distal air spaces. The conditions associated with DAH and underlying disease determine the prognosis and the treatment regimen. The coexistence of DAH with venous thromboembolism (VTE) is a seroius problem for clinicians and poses a challenge in the therapeutic management. We describe a young patient who developed massive DAH in the course of anti-glomerular basement membrane (anti-GBM) disease (formerly called Goodpastures syndrome) complicated by pulmonary embolism (PE).

Venous thromboembolism — recommendations on the prevention, diagnostic approach and management. The 2017 Polish Consensus Statement

The 2017 Polish Consensus Statement (PCS 2017) includes updated recommendations on the prevention, diagnostic approach, and management of venous thromboembolism (VTE). For VTE without cancer, the authors of PCS 2017 recommend apixaban, edoxaban, rivaroxaban, and dabigatran over vitamin K antagonists (VKA) as long-term anticoagulant therapy. For VTE with cancer, the authors of PCS 2017 recommend low molecular weight heparins (LMWH) over VKA, apixaban, edoxaban, rivaroxaban and dabigatran. For extended secondary prevention of deep venous thrombosis (DVT), PCS 2017 recommends apixaban, edoxaban, rivaroxaban, dabigatran, VKA, and sulodexide. For extended secondary prevention of pulmonary embolism (PE), PCS 2017 recommends apixaban, edoxaban, rivaroxaban, dabigatran and VKA. For extended secondary prevention in patients with idiopathic DVT and a high risk of bleeding complications, the authors of PCS 2017 recommend NOT to stop anticoagulation and use sulodexide. For extended secondary prevention in patients with idiopathic PE and a high risk of bleeding, the authors of PCS 2017 recommend NOT to stop anticoagulation and suggest treatment with apixaban, edoxaban, rivaroxaban, and dabigatran in reduced doses adjusted to the risk of bleeding. For VTE treated with anticoagulants, PCS 2017 recommends against insertion of a vena cava filter. For patients with DVT, PCS 2017 suggests USING compression stockings routinely to prevent postthrombotic syndrome. For subsegmental PE without proximal DVT, PCS 2017 suggests clinical surveillance over anticoagulation with a low risk of recurrent VTE, and anticoagulation over clinical surveillance with a high risk of recurrent VTE. The 2017 Polish Consensus Statement suggests thrombolytic therapy for PE with hypotension, and systemic therapy over catheter-directed thrombolysis. For recurrent VTE on a non-LMWH anticoagulant, PCS 2017 suggests LMWH, and for recurrent DVT and/or PE on LMWH, PCS 2017 suggests increasing the dose of LMWH.

European Spirometry Driving License in Poland — first polish spirometry training in the framework of ERS HERMES Spirometry project

1 Address for correspondence: Waldemar Tomalak, National TB and Lung Diseases Research Institute, Rabka Branch, J. Rudnika 3b, 34−700 Rabka Zdrój, e-mail: wtomalak@igrabka.edu.pl DOI: 10.5603/PiAP.2016.0002 Received: 06.01.2016 Copyright

NIV Adaptation Process: Implications of Team: Key Practical Recommendations and Evidence

Over the past two decades, noninvasive ventilation (NIV) has assumed a central role in the treatment of patients with respiratory failure in the acute or chronic setting. The adaptation process plays an important role in the efficacy and safety of NIV treatment, but this problem is poorly addressed in the literature. Interventions to improve adaptation for continuous positive airway pressure in the adult population with obstructive sleep apnea are reviewed, and implementation protocols for NIV in acute respiratory failure are described. Two adaptation strategies for the chronic setting are delineated: one for patients with chronic obstructive pulmonary disease, based on high-intensity NIV and started in the hospital, and a second for patients with restrictive, neuromuscular, and obesity problems with ventilation, with hospital or home implementation. Common problems with the adaptation process depend on staff members or organizing structure, and troubles with equipment malfunctions, important for adaptation, are discussed.