Incremental prognostic and diagnostic value of exercise echocardiography in patients with indeterminate or abnormal diastolic function

Background Exercise echocardiography (ExE) may assess LV systolic and diastolic function (DF). We aimed to assess the diagnostic and prognostic value of diastolic parameters at exercise (ratio of early LV inflow velocity to early tissue Doppler septal annulus velocity [E/e'] and systolic pulmonary artery pressure [sPAP]) in patients with indeterminate or abnormal resting DF referred for a clinically indicated ExE. Methods Data from 299 patients (72±9 years, 50% women) with LV-DF evaluated according to EACVI-Guidelines 2016, and LVEF ≥50 were extracted from our database. LV systolic and DF and mitral regurgitation (MR) were evaluated at rest. At peak exercise we assessed regional/global LV systolic function, MR, E/e', and sPAP. Abnormal ExE was defined as ischemia or fixed wall motion abnormalities, elevated E/e'values as >15 at rest and at exercise. Considered events were overall mortality, myocardial infarction, admission for unstable angina or cardiac failure, revascularization, pulmonary thromboembolism, and stroke. Results Abnormal resting DF was present in 221 patients (29%), indeterminate in 78 (10%). Exercise E/e' >15 was found in 37% of patients with abnormal DF, and in 21% with indeterminate DF; exercise E/e >15 plus sPAP>51 mmHg in 13% with abnormal DF, and in 9% with indeterminate DF. Based on exercise E/e' >15 (n=16), change from altered relaxation to restrictive pattern with exercise (n=8), or maintenance of a restrictive pattern for >65 years (n=4), indeterminate DF was reclassified to abnormal DF in 28/78 patients (36%). Among the other 50 patients with indeterminate DF and exercise E/e' ≤15, sPAP>51 mmHg was found in 21, having these subjects altered relaxation at rest and at exercise (n=19) or atrial fibrillation (n=2). Abnormal ExE was seen in 18% of patients with indeterminate resting DF, in 30% with abnormal resting DF, and in 40% with raised exercise E/e'. During median follow-up of 1 year (25th-75th percentiles 0.4–1.7) there were 53 events including 12 deaths, 6 myocardial infarctions, and 18 cardiac failures. Independent predictors were history of coronary disease (HR=2.50, 95% CI=1.31–4.75, p=0.005), ACEI/ARAII (HR=0.43, 95% CI=0.23–0.81, p=0.008), positive clinical or exercise ECG testing (HR=2.42, 95% CI=1.33–4.40, p=0.004), peak LVEF (HR=0.94, 95% CI=0.92–0.96, p<0.001), significant exercise MR (HR=3.96, 95% CI=1.58–9.97, p=0.004) and peak E/e'(HR= 1.06, 95% CI=1.02–1.10, p=0.004). Annualized event rates were 59% in patients with (+) ExE plus raised exercise E/e', 24% in those with (+) ExE and normal exercise E/e', 14% in (−) ExE and raised exercise E/e', and 5.4% with both variables normal (Figure). Conclusions ExE reclassified 21 to 36% of patients with indeterminate DF to abnormal DF, and was able to detect non-cardiac exercise-induced pulmonary hypertension. E/e'at postexercise further predicted outcome on top of ExE results in patients with indeterminate or abnormal resting DF. FUNDunding Acknowledgement Type of funding sources: None.

Radiological and functional pulmonary complications in patients recovered from COVID-19

Background: The COVID-19 disease caused by the new severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), which appeared at the end of 2019 in Hubei Province, Wuhan Region of the People's Republic of China. Objective: To determine radiological and functional pulmonary complications in patients recovered from COVID-19. Methods: We included observational studies, studies of radiological and functional pulmonary complications related to COVID-19 in patients discharged from hospital, studies of available text and studies in English and Spanish. A formal narrative synthesis of the collected data was carried out; no formal statistical synthesis was carried out. The synthesis focused on qualitative analysis. The methodological quality of the articles was assessed using the quality assessment tools of the National Heart, Lung, and Blood Institute. Results: In this systematic review it was observed that the functional pulmonary complications that the patients manifested were: 45.05 % of impaired diffusion capacity (DLCO), 30.1 % of restrictive pattern (FEV1) and 20.4 % of obstructive pattern (FEV1/FVC). Radiological complications were: 59.7% ground-glass opacity (GGO), 18.75% consolidation, 9.3% bronchiectasis, 6% thickening of the underlying pleura, 3.9% thickening of the interlobular septum, 3.83% crazy-paving and 0.96% pleural effusion. Conclusion: This review concludes that post-COVID-19 infection patients showed impaired lung and radiological functions, with DLCO and GGO being the most important.

A comparative analysis of lung function and spirometry parameters in genotype-controlled natives living at low and high altitude

BackgroundThe reference values for lung function are associated to anatomical and lung morphology parameters, but anthropometry it is not the only influencing factor: altitude and genetics are two important agents affecting respiratory physiology. Altitude and its influence on respiratory function has been studied independently of genetics, considering early and long-term acclimatization.ObjectiveThe objective of this study is to evaluate lung function through a spirometry study in autochthonous Kichwas permanently living at low and high-altitude.MethodologyA cross-sectional study of spirometry differences between genetically matched lowland Kichwas from Limoncocha (230 m) at Amazonian basin and high-altitude Kichwas from Oyacachi (3,180 m) in Andean highlands. Chi-square method was used to analyze association or independence of categorical variables, while Student’s t test was applied to comparison of means within quantitative variables. ANOVA, or in the case that the variables didn’t meet the criteria of normality, Kruskal Wallis test were used to compare more than two groups.ResultsPeople from Oyacachi (high altitude) showed a higher predicted values than those from Limonocha (low altitude). The FVC and the FEV1 were significantly greater among highlanders than lowlanders (p value < 0.001). The FEV1/FVC was significantly higher among lowlanders than highlanders for men and women. A restrictive pattern was found in 12.9% of the participants.ConclusionResidents of Oyacachi had greater lung capacity than their peers from Limoncocha, a finding physiologically plausible according to published literature. When analyzing the spirometric patterns obtained in these populations, it was evident that no person had an obstructive pattern, while on the other hand, the restrictive pattern appeared in Limoncocha and Oyacachi populations in 12.9% although it is clear that there is a predominance of this in the individuals belonging to Limoncocha.

Effects of metabolic syndrome on pulmonary function tests

Background: Metabolic syndrome is defined as at least three of the five following medical conditions: central obesity(mandatory), high blood pressure, high blood sugar, high serum triglycerides, and low serum high-density lipoprotein (HDL). It has been shown that obesity causes physiological impairment in respiratory system.Methods: In this observational cross sectional study, 60 patients who fulfilled the IDF criteria for metabolic syndrome were included after applying the exclusion criteria and were subjected to spirometry.Results: Most of the patients had a restrictive pattern (43.3%) (n=26). 33.3% (n=20) of the patients had a mixed pattern while 16.7% (n=10) of the patients had a normal picture. Only 6.7% (n=4) of the patients had an obstructive pattern (p<0.001). Mean value of FEV1 had no correlation with increasing number of components of metabolic syndrome whereas mean value of FVC showed a decreasing trend with increasing number of components of metabolic syndrome. Mean FEV1 of the patients was significantly higher in males (1.82±0.71 L) than females (1.24±0.42 L) (p 0.007). Similarly, the mean FVC was significantly higher in males as compared to females. Mean FVC was 2.45 (±0.86) L in males while females had a mean FVC of 1.65 (±0.49) L (p 0.002).Conclusions: In conclusion, Patients with metabolic syndrome have significant impairment of the pulmonary function with restrictive pattern being the most common one.

Significance of frequent spirometry test in treated pulmonary tuberculosis patients in tertiary care teaching hospital

Tuberculosis is one of the most important communicable disease, which poses a global public health threat and remains the leading cause of death among infectious diseases, especially in undeveloped and developing countries.It was a prospective, observational, hospital based study conducted in the department of Respiratory Medicine, IPGMER SSKM Hospital, Kolkata from January 2020 to December 2020. Atotal of 80 cases, with history of adequately treated one episode of pulmonary tuberculosis, were included in this study.According to pulmonary function test results, 30(37.5%) patients had obstructive pattern and 11(13.8%) had restrictive pattern, in spirometry. Another 15(18.8%) patients had, mixed obstructive/restrictive pattern, while in rest 24 (30%) patients, spirometry test results were normal. The distribution of various pulmonary function test results among patients with obstructive pattern (N=30), ATT completion history was 7.57 ± 2.77 years back in average. Whereas average duration of symptoms in them was found to be 4.03 ± 1.96 years. For patients with restrictive pattern (N=11), these durations were 10.91 ± 2.51years and 7.59 ± 2.35 years respectively. Patients with mixed pattern (N=15), both durations were 11.33 ± 3.50 years and 7.33 ± 2.94 years respectively. Whereas among patients with normal lung function (N=24), ATT completion duration was 2.83 ± 2.21 years and symptom onset duration was 0.63 ± 0.34 years.There was emphatically found thatduration of anti-tubercular treatment, duration of symptoms and pulmonary function abnormalities. Hence clinical suspicion, early diagnosis and early treatment strategy are required to prevent further deterioration of pulmonary function in treated Pulmonary tuberculosis (PTB) patients. So, frequent or annual spirometry is required in these patients.

Shrinking lung syndrome in pediatric systemic lupus erythematosus

Shrinking Lung Syndrome (SLS) is a rare and little known complication associated with Systemic Lupus Erythematosus (SLE), characterized by progressive and unexplainable dyspnea, pleuritic pain, small pulmonary volumes and elevation of the diaphragm on chest X-rays as well as restrictive pattern on pulmonary function tests. Objective To describe clinical, radiological and treatment characteristics in pediatric patients with SLS. Material and methods This is a descriptive and retrospective study in patients under 16 years old with the diagnosis of SLE complicated by SLS at the General Hospital. National Medical Center La Raza. Clinical, radiological and treatment variables were analyzed. Results are shown in frequencies and percentages. Results Data from 11 patients, 9 females and 2 males were collected. Mean age at diagnosis of SLS was 12.2 years. Age at diagnosis of SLE was 11.1 years. SLEDAI 17.3. Renal desease 72%, hematological 91%, lymphopenia 63%, mucocutaneous 72%, neurological 9%, arthritis 54%, serositis 91%, fever 81%, secondary antiphospholipid syndrome, low C3 72%, low C4 81%, positive ANA 91%, positive anti-DNA 91%. Regarding clinical manifestations of SLE: cough 81%, dyspnea 91%, hipoxemia 81%, pleuritic pain 71%, average oxygen saturation 83%. Chest X-rays findings: right hemidiaphragm affection 18%, left 63%, bilateral 18%. Elevated hemidiaphragm 91%, atelectasis 18%, pleural effusion 91%, over one third of the cardiac silhouette under the diphragm 36%, bulging diaphragm 45%, 5th. anterior rib that crosses over the diaphragm 91%. M-mode ultrasound: diaphragmatic hypomotility 100%, pleural effusion 63%. Pulmonary function tests: restrictive pattern in 45% of the cases. Treatment was with supplementary oxygen 100%, intubation 18%, antibiotics 100%, steroids 100%, intravenous immunoglobulin 54%, plasmapheresis 18%, cyclophosphamide 54% and rituximab 18%. The clinical course was favorable in 81%. Conclusions SLS should be suspected in patients with SLE and active disease who present hipoxemia, pleuritic pain, cough, dyspnea, pleural effusion and signs of restriction on chest X-rays. Therefore, a diaphragmatic M-mode ultrasound should be performed in order to establish the diagnosis.

Frequency of restrictive pulmonary function tests in patients with chronic Hepatitis C

Hepatis C infection is a common health problem world wide and is the major cause of chronic liver disease in Pakistan. Common complications of chronic hepatitis c infection are cirrhosis, ascities and hepatocellular carcinoma. Also HCV infection is associated with several extra hepatic manifestations including interstitial lung fibrosis. It has been found that frequency of pulmonary fibrosis is increased in patients with cirrhosis of liver as the stage of cirrhosis advances.This lung fibrosis can cause restrictive pattern of pulmonary function tests. This study was conducted to determine frequency of restrictive pulmonary function in patients with different stages of chronic hepatitis C infection, based on child pough classification. Study design This is descriptive case study Method 99 patients of age range 20 to 80 year, both males and females having chronic hepatitis C infection and interferon based treatment naïve patients were included from outpatient and inpatient department were selected. Patients were divided into three groups according to child’s criteria i.e. group A, group B, and group C. Pulmonary function tests were performed on patients in all three groups to look for FEV1/FVC ratio in all patients. FEV1/FVC ratio more than 80 was considered as restrictive pulmonary function. Results Out of 99 patients 32(35%) were found to have restrictive pattern of pulmonary functions Conclusion Chronic hepatitis C infection is associated with restrictive pattern of pulmonary function, suggestive of pulmonary fibrosis.

A STUDY OF INTERSTITIAL LUNG DISEASE ASSOCIATED WITH RHEUMATOID ARTHRITIS

BACKGROUND: Rheumatoid Arthritis (RA) is a common systemic disease that manifests as inflammatory arthritis of multiple joints and produces a wide variety of extra-articular manifestations. Interstitial Lung Disease (ILD) is one of the important pulmonary manifestation of RA like other Connective Tissue Disease(CTD). However RA-ILD differs from CTD-ILD in terms of histopathology and prognosis. OBJECTIVES: To study the clinical features, laboratory profile, radiological patterns, pulmonary function tests including spirometry and DLCO in patients with RA-ILD. MATERIALS AND METHODS: This study was a cross sectional study carried out in the department of Respiratory Medicine at MMIMSR,Mullana, Haryana. A total of 10 patients were included in the study after verifying inclusion and exclusion criteria. After complete history and investigations details were documented in a proforma. RESULTS: A total of 10 patients comprising of 3 males and 7 females with a mean age of 56.5 years were included. Dry cough (100%) was the most common presenting complaints followed by excertional dyspnoea (80%). Among the 10 patients 8 were smokers. Bilateral basal Velcro creps was the most common feature (70%) followed by clubbing(20%).In HRCT the most common pattern was UIP (typical UIP-10%, probable UIP-70%) followed by Non-IPF pattern (20%). Spirometry showed restrictive pattern in all cases. DLCO was severely reduced in typical UIP pattern. CONCLUSION: HRCT chest is the most sensitive tool for early diagnosis of ILD, while DLCO is most sensitive for monitoring the prognosis. RA-ILD can be prevented and treated at an early state.