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Recovery of right and left ventricular function after acute pulmonary embolism.

AIM: To evaluate recovery of cardiac function after acute pulmonary embolism (PE).

MATERIALS AND METHODS: Routine breath-held computed tomography (CT)-pulmonary angiography was performed in patients with suspected PE to confirm or exclude the diagnosis of PE at initial presentation. Electrocardiogram (ECG)-triggered cardiac CT was performed to assess biventricular function. After 6 months, cardiac magnetic resonance imaging (MRI) was performed. In total, 15 consecutive patients with PE and 10 without were studied. A significant change in ventricular volume was defined as a >15% change in end-diastolic or -systolic volumes (EDV, ESV), and significant ventricular function improvement as a >5% increase in ejection fraction (EF) as based on reported cut-off values.

RESULTS: Right and left ventricular (RV and LV) EDV and ESV changed non-significantly (<1.3%) in the patients without PE, indicating good comparability of those values measured by CT and MRI. PE patients with baseline normal RV function (RVEF ≥47%) revealed a >5% improvement in the RVEF (+5.4±3.1%) due to a decrease in the RVESV. Patients with baseline abnormal RV function showed a >5% improvement in the RVEF (+14±15%) due to decreases in both the RVESV and RVEDV. Furthermore, the LVEDV increased in this latter patient group.

CONCLUSIONS: The present study demonstrated an improvement in RV function in the majority of patients with PE, independent of baseline RV function. The degree of RV and LV recovery was dependent on the severity of baseline RV dysfunction.

Heart Disease May Be a Risk Factor for Pulmonary Embolism Without Peripheral Deep Venous Thrombosis.

Heart diseases increase the risk of arterial embolism; whether they increase the risk of pulmonary embolism without peripheral venous thrombosis is less certain.Methods and Results-We conducted a nationwide, population-based case-control study in Denmark using patients diagnosed with pulmonary embolism and/or deep venous thrombosis between 1980 and 2007.

We computed odds ratios to estimate relative risks associating preceding heart disease with pulmonary embolism, pulmonary embolism and deep venous thrombosis, or deep venous thrombosis alone.

In this study, 45 282 patients had pulmonary embolism alone, 4680 had pulmonary embolism and deep venous thrombosis, and 59 790 had deep venous thrombosis alone; 541 561 were population controls. Myocardial infarction and heart failure in the preceding 3 months conferred high risks of apparently isolated pulmonary embolism (odds ratio, 43.5 [95% confidence interval (CI), 39.6-47.8] and 32.4 [95% CI, 29.8-35.2], respectively), whereas the risks of combined pulmonary embolism and deep venous thrombosis (19.7 [95% CI, 16.0-24.2] and 22.1 [95% CI, 18.7-26.0], respectively) and deep venous thrombosis alone (9.6 [95% CI, 8.6-10.7] and 12.7 [95% CI, 11.6-13.9], respectively) were lower. Left-sided valvular disease was associated with an odds ratio of 13.5 (95% CI, 11.3-16.1), whereas the odds ratio was 74.6 (95% CI, 28.4-195.8) for right-sided valvular disease. Restricting the analysis to cases diagnosed after 2000 led to lower risk estimates but the same overall pattern.

Heart diseases increase the near-term risk for pulmonary embolism not associated with diagnosed peripheral vein thrombosis.

Preventing Deep Vein Thrombosis After Stroke: Strategies and Recommendations.

OPINION STATEMENT: The risk of deep vein thrombosis (DVT) after stroke is increased in patients with restricted mobility, a previous history of DVT, dehydration, or comorbidities such as malignant diseases or clotting disorders. Patients with an increased risk of DVT should receive prophylactic treatment.

To reduce the chance of DVT, patients should be mobilized as soon as possible and should be kept well hydrated. Anti-embolism stockings cannot be recommended, because they have been demonstrated not useful for preventing DVT or pulmonary embolism in patients with stroke, and they are associated with a significantly increased risk of skin breaks. The usefulness of intermittent pneumatic compression is currently under study in a randomized clinical trial. Treatment with subcutaneously administered low-dose unfractionated heparin is preferred to unfractionated heparin and may be considered in patients with ischemic stroke if the risk of DVT is estimated to be higher than the risk of hemorrhagic complications. Aspirin may also be effective for patients with ischemic stroke who have contraindications to anticoagulants, although direct comparisons with anticoagulants are not available.

In patients with intracerebral hemorrhage, low-dose subcutaneous low-molecular-weight heparin is probably safe after documentation of cessation of active bleeding, and may be considered on an individual basis after 3 to 4 days from stroke onset.

Airway angiogenesis in stable and exacerbated chronic obstructive pulmonary disease.

Angiogenesis is a prominent feature of structural tissue remodeling that occurs in chronic airway diseases, including chronic obstructive pulmonary disease (COPD).

The aim of this study was to evaluate the airway levels of VEGF, angiogenin, IL-8, and TNF-α in COPD patients during the stable phase and during acute exacerbation of the disease.

We analyzed induced sputum samples from 28 COPD patients. Thirteen of these patients were followed up and second samples of sputum were obtained during acute exacerbation of the disease. The two control groups consisted of 12 healthy smokers and 7 healthy nonsmokers, all with normal lung-function tests.

Concentrations of VEGF, angiogenin, IL8, TNF-α, and bFGF were measured by Cytometric Bead Array. In the induced sputum of patients with stable COPD, concentrations of VEGF (p < 0.001, p = 0.02), angiogenin (p < 0.0001, p < 0.0001), IL-8 (p < 0.0001, p = 0.0021), and TNF-α (p < 0.001, p = 0.03) were significantly elevated in comparison to healthy smokers and nonsmokers. No additional elevation of angiogenic factors was demonstrated at the time of exacerbation. There was a significant negative correlation between FEV1 and VEGF (p < 0.05, r = -0.38), angiogenin (p < 0.0001, r = -0.68), and IL-8 (p < 0.001, r = -0.54) among smokers (smoking COPD patients and healthy smokers). No significant differences were observed between groups of healthy smokers and nonsmokers.

These results showed increased airway angiogenesis in COPD patients. Moreover, VEGF, IL-8, and angiogenin negatively correlated with pulmonary function, which suggests their important role in COPD airway remodeling. However, no additional angiogenic activation was found during exacerbation of COPD.

Effect of adjunct fluticasone propionate on airway physiology during rest and exercise in COPD.

Combination therapy with corticosteroid and long-acting β(2)-agonists (LABA) in a single inhaler is associated with superior effects on airway function and exercise performance in COPD compared with LABA monotherapy. The physiological effects of adding inhaled corticosteroid monotherapy to maintenance bronchodilator therapy (long-acting anticholinergics and LABA singly or in combination) in COPD are unknown.

METHODS: This was a randomized, double-blind, placebo-controlled, crossover study (NCT00387036) to compare the effects of inhaled fluticasone propionate 500 μg (FP500) twice-daily and placebo (PLA) on airway function during rest and exercise, measured during constant work rate cycle exercise at 75% of maximum incremental cycle work rate, in 17 patients with COPD (FEV(1) ≤ 70% predicted).

RESULTS: After treatment with FP500 compared to PLA, there were significant increases in post-dose measurements of FEV(1) (+115 mL, P = 0.006) and the FEV(1)/FVC ratio (+2.5%, P = 0.017), along with decreases in plethysmographic residual volume (-0.32L; P = 0.031), functional residual capacity (-0.30L, P = 0.033), and total lung capacity (-0.30L, P = 0.027) but no changes in vital capacity or inspiratory capacity (IC). Post-treatment comparisons demonstrated a significant improvement in endurance time by 188 ± 362 s with FP500 (P = 0.047) with no concomitant increase in dyspnea intensity. End-inspiratory and end-expiratory lung volumes were reduced at rest and throughout exercise with FP500 compared with PLA (P < 0.05).

CONCLUSION: Inhaled FP500 monotherapy was associated with consistent and clinically important improvements in FEV(1), static lung volumes, dynamic operating lung volumes, and exercise endurance when added to established maintenance long-acting bronchodilator therapy in patients with moderate to severe COPD.

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