Prognostic role of alveolar-arterial oxygen pressure difference in acute pulmonary embolism.

BACKGROUND: This study investigated the utility of the alveolar - arterial oxygen pressure difference (AaDO (2)) in predicting the short-term prognosis of acute pulmonary embolism (PE). METHODS AND RESULTS: This study retrospectively enrolled 114 consecutive patients with acute PE, diagnosed by either spiral computed tomography or high probability ventilation - perfusion lung scans. During the first 24 h of admission, all patients had initial artery blood gas collected under room air. Patient exclusion criteria were chronic lung disease, septic emboli, and moderate and low probability lung scans. Patients were assigned to 2 groups based on either 30-day death or a 30-day composite event. Receiver operating characteristic analyses was used to determine the AaDO(2) cut-off value for predicting primary and composite endpoints. Statistical analysis demonstrated significant differences in AaDO(2) between the 30-day composite endpoint group and the 30-day composite event-free survival group (p=0.012). The AaDO(2) had a strong trend between the 30-day death group and the survival group (p=0.062). The best cut-off value for AaDO(2) was 53 mmHg and using this, the positive predictive value for 30-day death was 25% and the negative predictive value was 92%. For the 30-day composite endpoint, the positive predictive value for AaDO(2) was 35%, and the negative predictive value was 84%. In this study, thrombocytopenia was also an indicator of poor prognosis for patients with acute PE. CONCLUSION: The AaDO(2) measurement is a highly useful and simple measurement for predicting short-term prognosis in patients with acute PE. It has high negative predictive value and moderate positive predictive value for 30-day death and 30-day composite event. Aggressive thrombolytic treatment strategies should be considered for patients with an initial poor prognostic parameter (ie, AaDO(2) >or=53 mmHg).     

胸部CT平扫诊断急性肺栓塞的临床意义

目的研究胸部CT平扫在临床急性肺栓塞中的诊断意义。方法分析110例肺栓塞(PE)CT平扫的患者,依据肺部梗塞面积的大小对急性肺栓塞患者进行影像学分类:大面积和次大面积共70例,非大面积40例。结果研究组的CT征象中,无梗死性肺部炎症病变的改变清楚,对于那些经典的楔形影、马赛克征等的影象学征象却表现不明。大面积和次大面积的肺栓塞与非大面积肺栓塞的临床CT表观征象比较差异均无统计学意义(P>0.05)。结论肺梗塞和非梗塞的病理变化在临床CT征象上表现相似,两者比较无特异性CT征象,两者容易误诊,甚至漏诊。     

Correlation of chest radiographic findings with biopsy-proven acute lung rejection.

The purpose of this study was to determine the chest radiographic findings of acute rejection and the accuracy of chest radiography in making this diagnosis in patients undergoing lung transplantation. For each of 100 transbronchial biopsies performed on 25 lung transplant recipients (single lung in three, double lung in 22), chest radiographs obtained within 24 hours before the biopsy were reviewed retrospectively without knowledge of clinical or biopsy information. Transbronchial biopsy revealed 42 instances of acute rejection in 17 patients and 58 instances of no acute rejection (normal, n = 43; other processes, n = 15). All pulmonary parenchymal radiographic abnormalities were assessed. Acute rejection was associated with the presence of middle or lower lung reticular interstitial or airspace disease in 21 lungs (sensitivity = 0.50 [21/42]). This pattern was seen in 18 lungs without acute rejection (specificity = 0.69 [40/58]). There was no difference in the appearance of the lungs between grades 1 and 2 acute rejection. Normal lungs were noted in 20 instances of acute rejection (48%). The authors conclude that chest radiograph findings are abnormal in about 50% of instances of biopsy-proven acute rejection. Because the appearance of acute rejection is similar to that of other conditions, the diagnosis cannot be made accurately by chest radiography.     

Relation between nocturnal arterial oxygen desaturation and morning blood pressure

OBJECTIVE: Arterial oxygen saturation (SpO2) in volunteers had been previously investigated, and the possibility that a decrease in SpO2 leads to an increase in blood pressure (BP) in airline passengers experiencing oxygen desaturation at high altitudes was reported. It was also shown that mean nocturnal SpO2 was lower in subjects with high-normal BP or mild hypertension than in those with normal BP. The present study investigated nocturnal SpO2, evening BP, and morning BP of volunteers during daily life and examined the relation between nocturnal SpO2 and change in BP (morning BP minus evening BP) to determine the influence of SpO2 on BP. METHODS: Sixty-two volunteers (31 men and 31 women) aged 40-87 years (mean: 55.9 +/- 12 [SD] years) underwent measurement of SpO2 and heart rate with a ring-shaped pulse oximeter during sleep at home. Evening BP and morning BP were measured by automatic BP recorder. Subjects that were classified as having high SpO2 (mean nocturnal SpO2 >or= 95%; n = 23, 10 men and 13 women; mean age: 53.2 +/- 12 years) or low SpO2 (mean nocturnal SpO2 < 94%; n = 21, 12 men and 9 women; mean age: 58.7 +/- 13 years) were compared. The relation between mean nocturnal SpO2 and morning BP and the relation between mean nocturnal SpO2 and change in BP were investigated. RESULTS: There was a significant negative correlation between mean nocturnal SpO2 and morning systolic BP (SBP; r = -0.50, p < 0.01) and between mean nocturnal SpO2 and morning diastolic BP (DBP; r = -0.37, p < 0.01). A significant negative correlation between mean nocturnal SpO2 and change in SBP was observed (r = -0.57, p < 0.01). Morning BP was significantly higher in the low nocturnal SpO2 group than in the high nocturnal SpO2 group (p < 0.001). CONCLUSION: The increase in morning BP from evening BP was significantly greater in subjects with a low nocturnal SpO2. The decrease in SpO2 during sleep may affect morning BP rise.     

Diagnostic value of B-Type natriuretic peptide and chest radiographic findings in patients with acute dyspnea

PURPOSE: To compare chest radiographic findings and circulating B-type natriuretic peptide (BNP) levels as an adjunct to clinical findings in the diagnosis of heart failure in patients presenting with acute dyspnea. METHODS: The diagnostic performance of radiographic evidence of cardiomegaly/redistribution and BNP levels > or =100 pg/mL as indicators of heart failure were assessed in 880 patients presenting with acute dyspnea to the emergency departments of five U.S. and two European teaching hospitals. BNP levels were determined by a rapid, point-of-care device. Two blinded cardiologists reviewed all clinical data and categorized patients as to whether they had acute heart failure (n = 447) or not (n = 433). RESULTS: Three-factor analyses showed that BNP levels > or =100 pg/mL contributed significantly to the prediction of heart failure over each of the radiographic indicators. In a multivariate logistic regression analysis, both BNP levels > or =100 pg/mL (odds ratio [OR] = 12.3; 95% confidence interval [CI]: 7.4 to 20.4) and radiographic findings of cardiomegaly (OR = 2.3; 95% CI: 1.4 to 3.7), cephalization (OR = 6.4; 95% CI: 3.3 to 12.5), and interstitial edema (OR = 7.0; 95% CI: 2.9 to 17.0) added significant, predictive information above historical and clinical predictors of heart failure. CONCLUSION: In patients presenting to the emergency department with acute dyspnea, BNP levels and chest radiographs provide complementary diagnostic information that may be useful in the early evaluation of heart failure.     

Does the patient's posture affect the detection of chest radiographic findings suggestive of pulmonary embolism?

Although it is accepted that thoracic structures are enlarged in supine chest radiographs, it is not known whether the lying posture may also influence the radiographic detection of abnormalities, such as those suggestive for pulmonary embolism (PE). For this purpose, we performed planar chest radiographs both in the seated and supine positions, keeping the target-to-film distance at 2 m, in 20 patients with acute PE. Chest radiograph was then repeated 1 month later in either position with the radiological conditions unchanged to investigate the effect of posture on the detection of resolution of signs. The detection of signs due to modifications of preexisting thoracic structures (elevation of the diaphragm and enlargement of the heart, right descending pulmonary artery and azygos vein) in acute PE was different between films taken in the supine and seated positions: both hemidiaphragms were more elevated (p less than 0.001), heart and central vessels were wider (p less than 0.05 or less) when patients were supine. On the contrary, the detection of signs of new occurrences ('sausage'-like appearance of the descending pulmonary artery, linear atelectasis, densities compatible with pulmonary infarction, pleural effusion and focal hyperlucency) was not influenced by the patient's position. During recovery, both kinds of abnormalities were reduced concomitantly in seated and supine radiographs. In conclusion, in acute PE, chest radiographs should be obtained in the seated position since the supine posture may overestimate signs due to modifications of preexisting thoracic structures even though it does not influence the detection of signs of new occurrences. On the contrary, films taken in either position are useful to follow the evolution of PE, provided the film is obtained in the same position and with the same technique as in the acute phase.     

Normal D-dimer levels in patients with pulmonary embolism.

BACKGROUND: Pulmonary embolism (PE) is frequently evaluated in acute care settings. Despite this, the clinical diagnosis of PE is difficult. Results of ventilation-perfusion (V/Q) scans may be inconclusive, and pulmonary angiograms (PAGs) are cumbersome, involve risk, and are often unavailable. Using PAG as the standard criterion, we evaluated the relationship between PE, V/Q scans, and semiquantitative latex agglutination (LA) D-dimer levels. METHODS: Ninety-eight patients who underwent V/Q scanning for suspected PE were enrolled; based on the results of the scans, the patients were scheduled for PAG. Blood samples were drawn for LA D-dimer assays during the PAGs at Saint Joseph Hospital, Denver, Colo, from January 1, 1996, to February 1, 1997. A detailed medical record review was performed for all enrollees. RESULTS: The mean+/-SEM patient age was 56.6+/-1.9 years; 52 (53%) were men, 13 (13%) had cancer, 23 (23%) had undergone surgery within 30 days of their PAG, and 13 (13%) were receiving warfarin sodium. There were no differences in warfarin therapy, hypercoaguable state, or cancer prevalence between patients with negative and positive PAGs (P = .53). Ventilation-perfusion scan results were available for all study patients. Eight (27%) of 30 patients who had positive angiogram results had LA D-dimer levels less than 250 ng/mL. Patients with positive PAGs (n = 30) had the following V/Q scan results: normal, 0; low probability, 7; intermediate or indeterminate probability, 22; and high probability, 1. In patients with low-probability V/Q scan results (n = 34), a positive D-dimer result for PE (>250 ng/mL) had a sensitivity of 71.4% (95% confidence interval, 0.29-0.97) and a negative predictive value of 87.5% (95% confidence interval, 0.62-0.98). We found a significant difference in D-dimer levels in patients with an abnormal angiogram result (mean, 750 ng/mL) compared with patients with a normal angiogram result (mean, 250 ng/mL) (P= .01, chi2 test). CONCLUSIONS: Eight patients had normal D-dimer levels with angiographic evidence of PE. Algorithms in acute care settings have been proposed; they exclude PE with normal D-dimer levels using the enzyme-linked immunosorbent assay technique. These cannot be extrapolated to the more widely used LA assays. A normal LA D-dimer level alone or with V/Q scan results is not recommended to preclude the treatment of PE.     

Relationship between ECG findings and pulmonary artery pressure in patients with acute massive pulmonary thromboembolism.

Pulmonary thromboembolism (PTE) is associated with various electrocardiogram (ECG) abnormalities, but the utility of evaluating the severity of PTE based on ECG abnormalities alone has not been investigated in Japanese patients previously. The purpose of this study was to examine the relationship between ECG abnormalities and the mean pulmonary artery pressure (MPAP) in patients with acute massive PTE (AMPTE). ECG examination of 21 patients, who were diagnosed with AMPTE by pulmonary arteriography, found that S(1)Q(3)T (3) was the most frequently observed abnormality (in 67% of the patients), followed by negative T (62%), clockwise rotation (57%), and ST elevation (48%). When these patients were divided into 2 groups based on the level of MPAP, 8 of the 11 ECG findings, which were associated with PTE in a previous report, were more frequently observed in Group H (MPAP >/=40 mmHg) than in Group L (MPAP <40 mmHg). MPAP correlated significantly with the total number of ECG abnormalities (r=0.82, p<0.001). In particular, at least 5 ECG abnormalities were noted in patients with MPAP >/=45 mmHg. These results suggested that the total number of ECG abnormalities in patients with AMPTE can be used to evaluate the severity of APTE, including PAP level.     

White blood cell count and mortality in patients with acute pulmonary embolism

Although associated with adverse outcomes in other cardiovascular diseases, the prognostic value of an elevated white blood cell (WBC) count, a marker of inflammation and hypercoagulability, is uncertain in patients with pulmonary embolism (PE). We therefore sought to assess the prognostic impact of the WBC in a large, state‐wide retrospective cohort of patients with PE. We evaluated 14,228 patient discharges with a primary diagnosis of PE from 186 hospitals in Pennsylvania. We used random‐intercept logistic regression to assess the independent association between WBC count levels at the time of presentation and mortality and hospital readmission within 30 days, adjusting for patient and hospital characteristics. Patients with an admission WBC count <5.0, 5.0–7.8, 7.9–9.8, 9.9–12.6, and >12.6 × 10⁹/L had a cumulative 30‐day mortality of 10.9%, 6.2%, 5.4%, 8.3%, and 16.3% (P < 0.001), and a readmission rate of 17.6%, 11.9%, 10.9%, 11.5%, and 15.0%, respectively (P < 0.001). Compared with patients with a WBC count 7.9–9.8 × 10⁹/L, adjusted odds of 30‐day mortality were significantly greater for patients with a WBC count <5.0 × 10⁹/L (odds ratio [OR] 1.52, 95% confidence interval [CI] 1.14–2.03), 9.9–12.6 × 10⁹/L (OR 1.55, 95% CI 1.26–1.91), or >12.6 × 10⁹/L (OR 2.22, 95% CI 1.83–2.69), respectively. The adjusted odds of readmission were also significantly increased for patients with a WBC count <5.0 × 10⁹/L (OR 1.34, 95% CI 1.07–1.68) or >12.6 × 10⁹/L (OR 1.29, 95% CI 1.10–1.51). In patients presenting with PE, WBC count is an independent predictor of short‐term mortality and hospital readmission. Am. J. Hematol. 88:677–681, 2013. © 2013 Wiley Periodicals, Inc.     

70例肺栓塞心电图的分析

目的:探讨肺栓塞(PE)及合并冠心病(CAD)患者的心电图(ECG)变化。方法:回顾我院心内科2003年1月至2005年7月确诊为肺栓塞70例患者的ECG变化。患者均经核素肺通气灌注扫描和冠状动脉造影明确诊断。其中50例患者PE合并CAD。结果:70例PE患者ECG异常的发生率为70.0%。其中有助于PE诊断的ECG变化包括:肺型P波、SⅠQⅢTⅢ、完全性右束支传导阻滞(RBBB)以及心前导联T波倒置的总发生率为22.9%。比较单纯PE与PE合并CAD患者ECG异常变化,2组患者ECG异常发生率差异无统计学意义(χ2=2.99,P=0.084)。结论:ECG异常变化对临床PE提供的诊断价值较低。     

Echocardiographic findings in patients with proved pulmonary embolism

Echocardiographic studies were performed in 105 patients with acute and recurrent pulmonary emboli. Pulmonary embolism was confirmed by pulmonary angiography (n = 48), autopsy (n = 6), and lung perfusion scintigraphy (n = 51). Seventy of 93 patients (75%) displayed a dilated right ventricle, 38 of 91 patients (42%) had reduced left ventricular cavity dimension, 41 of 82 patients (50%) had a decreased EF slope of the mitral valve, and 78 of 101 patients (77%) showed dilatation of the right pulmonary artery. The motion of the interventricular septum was abnormal in 41 of 93 patients (44%). Right-sided thrombi were seen in 13 patients within the right pulmonary artery (n = 11) and in the right ventricle (n = 3); in one patient they were found in the superior vena cava, in the innominate vein, and the right atrium. Two patients suffered from right-sided endocarditis. Thus echocardiographic changes were frequently found in patients with proved pulmonary emboli. The echocardiographic findings of right-sided cardiac and pulmonary artery abnormalities indicate hemodynamically active pulmonary emboli.     

NT-proBNP levels on admission predicts pulmonary hypertension persistence in patients with acute pulmonary embolism

BackgroundChronic thromboembolic pulmonary hypertension (CTEPH) is a rare, but due to its unfavorable prognosis, feared complication of thromboembolic disease. We assessed the incidence and risk factors for pulmonary hypertension (PH) in a cohort of consecutive patients admitted with pulmonary embolism to the tertiary University Hospital.MethodsIn our cohort of 120 consecutive patients with proved pulmonary embolism (PE) we studied the course of biochemical and echocardiographic parameters with regard to risk factors predicting pulmonary hypertension at the end of hospitalization.ResultsEchocardiographic signs of pulmonary hypertension were present at the time of discharge in more than one half (50.8%) of patients admitted with pulmonary embolism. Predictors of persisting pulmonary hypertension were initial pulmonary hypertension, high initial NT-proBNP levels and age.ConclusionResidual pulmonary hypertension at discharge was present in 50.8% cases, at this time there was a strong relationship between PH and elevated NT-proBNP on admission. The patients will be followed-up and possible development of CTPEH will be evaluated at 6, 12 and 24-month period.     

Prevalence of increased cardiac troponin I levels in patients with and without acute pulmonary embolism and relation of increased cardiac troponin I levels with in-hospital mortality in patients with acute pulmonary embolism

Cardiac troponin I levels were increased in 24 of 147 patients (16%) with documented acute pulmonary embolism and in 20 of 594 patients (3%) without pulmonary embolism (p <0.001). In patients with acute pulmonary embolisms, 8 of 24 (33%) with increased cardiac troponin I levels and 9 of 123 (7%) with normal cardiac troponin I levels died during hospitalization (p <0.001).     

Different chest radiographic findings of pulmonary paragonimiasis in two endemic countries

We compared the chest radiographic findings of patients with pulmonary paragonimiasis in the Lao People's Democratic Republic (PDR) with a report from Korea. The clinical and radiological characteristics of 50 confirmed Laotian pleuropulmonary paragonimiasis patients were studied between March 2003 and June 2007. In 49 patients, the chest radiographs showed abnormal findings (98%). Pulmonary parenchymal abnormalities were found in all 49 patients, whereas pleural effusion was only found in 11 patients (22%). The three most common intraparenchymal findings were multiple small cysts (90%), irregular linear densities (68%), and nodular opacities (40%). The numbers of patients who had these three findings were significantly different from the Korean report (P < 0.001). In conclusion, radiographic findings of pulmonary paragonimiasis may vary among countries.     

实验性急性肺栓塞溶栓疗法与动脉血浆内皮素水平变化

目的：自体血栓注入法建立急性肺栓塞动物模型，探讨内皮素在急性血栓栓塞性肺动脉高压中的作用和溶栓疗法对肺动脉释放内皮素的影响。方法：14只杂种犬，自体血栓注入法建立急性肺栓塞模型。模型犬随机分入溶栓组和对照组，溶栓组7只犬给予尿激酶20000U/kg，100ml液体稀释后30分钟静脉滴入，对照组同期输入等量的生理盐水。分别于注栓前、溶栓前（对照组同期）、溶栓后（对照组同期）血液动力学测定，采动脉血放免法测定血浆内皮素水平。结果：溶栓组犬静注尿激酶30分钟后，伴随肺动脉压力和肺血管阻力的显著性下降，动脉血浆内皮素水平显著升高，溶栓后30小时为99.25±12.90pg/L，与注栓前51．63±10．09pg/L比较P＜005，与对照组同期值55．93±2.10pg/L比较P＜001，对照组犬栓塞后4小时内肺动脉压力和肺血管阻力无显著变化，内皮素水平亦无显著性改变。结论：内皮素可能与急性血栓栓塞性肺动脉高压的形成有关，动脉血浆内皮素水平的增加可能是血管再通的一个标志。     

Prognostic role of echocardiography among patients with acute pulmonary embolism and a systolic arterial pressure of 90 mm Hg or higher

BACKGROUND: The prognostic role of echocardiographic right ventricular (RV) dysfunction for predicting mortality in patients with acute pulmonary embolism and a preserved systemic arterial pressure remains controversial. METHODS: We evaluated 1035 patients with pulmonary embolism from the International Cooperative Pulmonary Embolism Registry who (1) presented with systolic systemic arterial pressure of 90 mm Hg or higher and (2) who underwent echocardiography within 24 hours of a diagnosis of pulmonary embolism, showing presence (n = 405) or absence (n = 630) of RV hypokinesis. The main outcome measure was the cumulative survival rate through 30 days in patients with and without RV hypokinesis. RESULTS: In patients with RV hypokinesis, the initial systolic systemic pressure was lower (125 +/- 22 mm Hg vs 131 +/- 22 mm Hg; P<.001), and the initial heart rate was higher (104 +/- 21 beats per minute vs 99 +/- 22 beats per minute; P<.001) than in patients without RV hypokinesis. Cancer was less often present (14.1% vs 22.5%, P = .001). The 30-day survival rates in patients with and without RV hypokinesis were 83.7% (95% confidence interval [CI], 79.3%-87.0%) and 90.6% (95% CI, 88.0%-92.6%), respectively (log-rank P value <.001). The univariate hazard ratio of RV hypokinesis for predicting 30-day mortality was 2.11 (95% CI, 1.41-3.16; P<.001). Right ventricular hypokinesis remained an independent predictor of 30-day mortality (hazard ratio, 1.94; 95% CI, 1.23-3.06) after adjusting for univariately significant predictors, including cancer, congestive heart failure, chronic lung disease, age older than 70 years, systolic arterial pressure of 100 mm Hg or lower, administration of thrombolytic therapy, and heart rate greater than 100 beats per minutes. CONCLUSION: Among patients with pulmonary embolism who present with a systolic arterial pressure greater than or equal to 90 mm Hg, echocardiographic RV hypokinesis is an independent predictor of early death.