Background: One of the commonest causes of pulmonary hypertension (PH) is left heart dysfunction associated with elevated pulmonary capillary wedge pressure (PCWP). In contrast, the pathology of pulmonary arterial hypertension (PAH) originates in the pulmonary vascular bed. Accurate diagnosis of PAH requires right heart catheterization (RHC) with normal PCWP. This study examines the role of computed tomography of the chest (CT chest) in evaluating left atrial (LA) size as an indicator of elevated PCWP in patients undergoing PH evaluation. Methods: CT chest and RHC data were reviewed in 37 subjects at the Baylor PH Center. Both subjective estimates and objective measurements of left atrial size from the CT chest were recorded separately by 3 investigators. Patients were categorized as Group I (small-normal LA) and Group II (large LA) and RHC results compared.The objective and subjective measurements were compared by receiver operator characteristic (ROC).
In addition to the previously discussed findings of Utsunomiya et al. (15), evidence about the relationship between RAP and RV-E/e’ in the setting of PH also comes from the study by Tsutsui et al. (23), where the cohort had a mean pulmonary artery pressure of 36±10 mmHg, presumably due to the acute decompensated heart failure which they were reported to have. Unsurprisingly given both left and right heart pathophysiology, and as described above, a weak correlation was found between RV-E/e’ and RAP, accuracy was modest and precision poor.In a study of paediatric PH, due to intracardiac shunt, Cevik et al. (31) reported no association between RV-E/e’ and RAP (r=-0.065, p=0.737). TTE and RHC measurements were made simultaneously but no ROC or Bland-Altman analyses were performed. The mean RAP was 4.8±2.2mmHg suggesting that most patients had a non-elevated RAP.
acute marginal branch (AMB) of the RCA and being con- nected to the aneurysm. Since the surgery aimed to de- compress the aneurysm and eliminate the shunt at the fistula site, identifying the entrance and exit vessels of the aneurysm was of vital necessity. To reduce the blood flow and pressure by closing the entrance vessel as much as possible without causing myocardial ischemia, the prox- imal RCA was ligated first. But intraoperative ECG monitoring showed elevated ST segment, ischemic myocardium and weakening contraction of the right ven- tricle (RV). Hence, the ligation was performed 3 cm from the distal end of the AMB. After ligation, no elevated ST segment was found. Transesophageal echocardiography (TEE) showed no ventricular wall motion abnormalities and the aneurysm was obviously downsized. The fistula was then occluded through the RA under TEE guidance in the absence of CPB. First, the guide wire and catheter sheath were inserted and passed through the fistula. Then a 30 mm atrial septal defect (ASD) occluder (BEIJING HUAYISHENGJIE) was applied to achieve maximal clos- ure of the aneurysm (Fig. 4). TEE showed the size of the
Results: ET-1 levels at peripheral artery and vein in ASD patients were significantly higher than in the volunteers (p < 0.0001). The ASD subjects with highest ET-1 level presented the larger area of right ventricle and right atrium and higher pulmonary artery systolic pressure(p < 0.05). The ASD subjects with lower ET-1 level demonstrated longer time of exercise and higher peak oxygen consumption (p < 0.05). There was a decrease of ET-1 at peripheral artery (5.128 ± 8.8 vs. 2.22 ± 6.2; p < 0.001) and at peripheral vein (4.401 ± 3.33 vs. 2.05 ± 1.35; p < 0.001) within 48 hours after ASD closure, as compared to the baseline data. After 6 and 12 months farther drop in ET-1 level was observed. Conclusions: 1. The level of ET-1 in ASD patients is elevated in compare to healthy subject.
cians recognized, but did not record, a diagnosis of elevated BP on the date of the incident elevated measurement. Problem lists and past medical histories were not examined, because it was not possible to determine whether the di- agnoses listed represented resolved ver- sus active issues; this approach could have potentially affected our ability to exclude those with known (ie, second- ary) causes of hypertension. Finally, de- spite the demographic and geographic diversity of the study population, results may not generalize to other patient populations, particularly patients lack- ing health insurance or consistent access to routine medical care. In summary, in this study of BP mea- surement during outpatient care, 8.4% of children and adolescents had an in- cident elevated BP. The great majority of abnormal BP measurements were not repeated within 1 month. However, rel- atively few individuals with an incident elevated BP subsequently met the de ﬁ - nition of hypertension. Whereas the use of EHR-based alerts or other strategies could improve recognition, revisions to existing guidelines may also be indicated to focus resources on identifying chil- dren and adolescents most likely to have persistent hypertension.
Elevated intraocular pressure (IOP) is a major risk factor for glaucoma. Although glaucoma pathogenesis has not been completely understood, high IOP levels may directly damage axons of ganglion cells and reduce blood support to the optic nerve, resulting in ischemia and neurodegeneration. 4 Additional factors are probably implicated, such as
Pulse pressure (PP) is a predictor and major risk factor for cardiovascular (CV) diseases as left ventricular hypertrophy, myocardial infarction, carotid hypertrophy, atherosclerosis, congestive heart failure and stroke as well as chronic renal failure progression. PP has been proved a strong forecaster of CV risk, particularly when it is higher than 60 mm Hg and more strongly relates to carotid hypertrophy and exte nt of atherosclerosis than systolic pressure. Isolated systolic hypertension (ISH) is common among the elderly and is accompanied by elevated pulse pressure. However, treatment of ISH may further raise the PP if diastolic pressure is lowered to a greater extent than systolic pressure. Several drugs for hypertension have the side effect of increasing resting PP irreversibly, other antihypertensive drugs, such as ACE inhibitors, have been shown to lo wer the PP. Various approaches made by researchers for the maintenance of normal PP to reduce the mortality caused due to CV events based on the abnormal PP. We briefly review the therapeutic consequences for the attenuation of elevated PP associated with various CV events.
Infusion of atrial natriuretic peptide (ANP) increases the glomerular filtration rate (GFR), and ANP is released from cardiac myocytes in response to extracellular fluid volume expansion. Since diabetes mellitus is associated with glomerular hyperfiltration and volume expansion, we investigated the relationship between ANP and GFR in diabetic rats given insulin to achieve stable moderate hyperglycemia or normoglycemia. At 2 wk after induction of
Despite functional and structural measurements consis- tent with glaucoma, it was felt that these deficits were likely due to ONH. Additionally, in the absence of any amblyogenic factors, it was also concluded that the patient’s bilateral “amblyopia” was the result of ONH. In that the patient pre- sented with elevated intraocular pressure, a significant and modifiable risk factor for glaucomatous development, and pre-existing retinal nerve fiber layer and visual field defects, a trial of Travatan Z was initiated in the left eye.
There is no unified opinion on how to treat patients with RAA. There are two main approaches: conservative and surgical. Conservative approach is suggested to pa- tients, who are asymptomatic and who are diagnosed with mild to moderate atrial dilatation. As suggested by Harder et al. those patients should receive low-dose as- pirin thromboprophylaxis and they should be followed up regularly. They also emphasize that patients with se- vere dilatation of the atrium and symptomatic patients should be treated surgically . The main indications for surgery are: atrial arrhythmia, intraatrial thrombus formation, major atrial dilatation, and compression of other heart chambers [1, 6, 7, 14]. Binder et al. state that surgical resection of rightatrial aneurysm has a low mortality risk . It is believed that early correction pre- vents further dilatation of the RA and complications asso- ciated with the presence of the RAA (such as heart failure, supraventricular arrhythmias, thrombus formation, and pulmonary or paradox embolism) [1–5, 10, 11, 15, 16]. As there are no studies that compare the two approaches we believe that each patient should be approached individu- ally. In our case the patient was symptomatic and in critical condition. In this situation a decision to perform surgery was made as recommended by literature.
stroke volume, has been advocated to discriminate between patients whose stroke volume increases in response to volume expansion and those who do not respond . Conversely, PPV due to increased right ven- tricular afterload and right ventricular dysfunction may misleadingly suggest volume responsiveness [13-15]. Increased pulmonary artery pressure and moderate or transient right ventricular dysfunction are not rare in intensive care patients requiring hemodynamic support. For example, transient right ventricular dysfunction occurs after cardiac surgery [16,17], and high pulmonary artery pressures and dysfunction of both ventricles are common in septic shock [18,19].
Ambulatory blood pressure monitoring (ABPM) performed over a 24-hour period is a more accurate method for evaluating blood pressure (BP) compared with office measurements and home BP measurements. Reference values for normal and abnormal ABPM results have been derived from epidemiologic research for both adults and children. These reference values vary slightly among different sources but are available for clinical use. Data from large prospective cohort studies establish that ABPM correlates more strongly with cardiovascular outcomes compared with other methods of BP measurement. Prospective cohort studies also indicate that white coat hypertension (WCH), as defined by ABPM, is associated with an intermediate risk of cardiovascular outcomes compared with
Among RAS blockers, angiotenisn receptor blockers (ARBs) have shown greater cerebrovascular protective effects in clinical trials and meta-analyses compared to different clas- ses of drugs [ 43 , 44 ]. This is mainly due to the selective blockade of the RAS, which plays a central role in the devel- opment and maintenance of the structural and functional alter- ations in the cardiovascular system, typically associated with stroke occurrence [ 45 – 47 ]. In the MOSES trial (Morbidity and Mortality After Stroke, Eprosartan Compared With Nitrendipine for Secondary Prevention), ARB did demon- strate the ability to reduce stroke recurrence compared to cal- cium channel blockers, though in a limited population sample [ 43 ]. ACE inhibitors did not show similar consistent protec- tive effects; rather, in some trials, ACE inhibitors performed inferiorly to other classes of drugs in preventing stroke [ 40 – 42 ], unless they were used in combination therapy. In secondary stroke prevention in the PROGRESS trial (Perindopril Protection Against Recurrent Stroke Study), ACE inhibitors in combination with diuretics showed a sig- nificant reduction of cerebrovascular events [ 48 ]. However, this was apparently due mostly to the blood pressure lowering effect of the diuretic indapamide. In fact, combination therapy using a diuretic and another different class of drugs has shown to be successful in stroke prevention, particularly in the elderly and in higher cardiovascular risk patients [ 45 , 49 – 51 ]. The use of combination therapy is quite common in clinical practice, since about 70–80 % of treated hypertensive patients may require combination therapy (at least two classes of drugs) in order to achieve the recommended blood pressure goals, par- ticularly in high cardiovascular risk patients. Despite this ev- idence and the recommendations, a relatively small percent- age of hypertensive patients (about 30–40 %) still achieve recommended blood pressure goals in clinical trials [ 52 ], and more than 50 % of patients still receive monotherapy.
The simplified PESI score is a validated index in the esti- mation of 30-day mortality in patients with acute PE. It incorporates the baseline demographics and comorbidities and the size of the pulmonary embolus based on hemodynamic status of the patient on admission. It is sim- pler to use and has similar prognostic accuracy and clin- ical utility as the original PESI score [3,25,26]. It comprised of six variables of equal weight (1 point per variable): age > 80 years old, history of cancer, history of chronic cardiopulmonary disease (chronic lung disease and/or heart failure), heart rate ≥110 beats per minute, systolic blood pressure <100 mmHg and arterial oxy- haemoglobin saturation level <90%. Patients with a simpli- fied PESI score of <1 are classified as low risk and had a 30-day mortality of 1.0% compared to 10.9% mortality amongst high risk patients (simplified PESI score ≥1) .
The final test used was measurement of crystallinity, done by DSC. A Shimadzu TA-60 DSC was used for testing. A small piece of the filament, 5-15 mg, treated in each run, was weighed and hermetically sealed in an aluminum pan. An empty aluminum pan was also sealed in the same way and placed on the reference side of the instrument. The sample pan was placed right of this reference and the instrument sealed to its operating state. The program run is listed in Table 3.6. A rate of 10 C/min heating and cooling was chosen for consistency to related work (Kong & Hay, 2002; Millot, Fillot, Lame, Sotta, & Seguela, 2015). This did have an effect on the ability to detect relevant information from the testing. Namely, some runs had erroneous bumps that cannot be explained due to the resolution afforded by the rate. A slower rate may have accentuated these bumps more clearly for analysis (Sichina, 2000).
Characteristics of the total study population and strati- fied according to (pre)diabetes are given in Tables 1, 2 and Additional file 2: Table S2. Participants with (pre)dia- betes had a worse cardiovascular risk profile; they were older and more often men, had a higher body mass index, greater waist circumference, higher blood pressure, lower HDL, higher triglycerides, lower eGFR, and less physical activity. They also more frequently had prior cardiovas- cular disease, hypertension and albuminuria, and more often used antihypertensive and lipid-modifying medica- tion (Table 1, Additional file 2: Table S2).
It has been reported that in a rat model of severe PAH plexiform-like lesions [8, 10], characteristic of advanced PAH, develop . This model (the Sugen/Hypoxia model) is based on a single percutaneous injection in rats of a vascular endothelial growth factor receptor blocker (SUGEN5416) which is combined with chronic exposure to hypoxia for three weeks. As classical rodent models of mild to moderate pulmonary hypertension (PH), the chronic hypoxia and monocrotaline models have been used to investigate the mechanistic basis for the de- velopment of PH . However, they lack phenotypically altered proliferated endothelial cells (ECs) in the lumen of pulmonary arteries and their defining pulmonary vascular remodeling was medial muscular thickening of proliferat- ing smooth muscle cells (SMC) . Therefore, there has been no obvious report focusing on the Heath-Edwards classification in these rodent models. On the other hand, in this model, not only plexiform-like lesions, but also all the pulmonary vascular abnormalities described in the Heath-Edwards classification, develop in a time- dependent manner. Importantly there is also a linear correlation between the right ventricular (RV) systolic pressure (RVSP) and the number of obliterated vessels . Remarkably, although the rats in this model de- velop severe PAH at five weeks after the SUGEN5416 injection, only grade 1 and 2 lesions of the Heath-Edwards classification were identified at this time point. This suggests that the severely elevated pulmonary arterial pressure observed in this rat model is due to these grade 1 and 2 lesions and/or the vascular tone increase in the early stage of the disease. The intimal occlusive lesions gradually progress in this rat model while the degree of medial thickness is decreasing . These results suggest that a Heath-Edwards grade greater than 2, i.e., intimal lesions rather than medial lesions, appear to be mainly responsible for the increased pulmonary arterial blood pressure and the increased pulmonary arterial resistance (PVR) during the later stages of the disease. More recently de Raaf et al. used telemetry to monitor the time course of the increase in the RVSP  and found a reversible hypoxic vasoconstriction component in the Sugen/Hypoxia model and progressive intima remodeling and a media muscularization that was in proportion to the chronic hypoxia challenge.
Flower & Bowman (1986) and Miller & Maahs (1977) have done the majority of research on soot production in laminar diffusion flames at elevated pressures. As stated in § 1.2, the work of Flower & Bowman was performed up to a maximum pressure of 10 atm and evaluated an ethylene-air flame. To achieve a stable, axisymmetric flame at pressures greater than 2 atm, Flower and Bowman used fuel flow rates ranging from 0.102 to 0.294 SLPM, with an air flow rate of 252 SLPM at 1 atm (Flower & Bowman, 1986). The fuel flow rates used by Flower and Bowman were much lower than those used to generate the previously discussed unstable flame in the present work, and the air flow rate was significantly greater. Flower & Bowman described their flame as being “greatly overventilated” and stated that “this air flow is 60 times the stoichiometric requirement for the highest fuel flows studied.” It was theorized that this overventilation helped to maintain a stable flame structure, but unfortunately, with the air flow meters and air supply system used in this work such high air flow rates could not be achieved, particularly at higher pressures. This proposed connection between extreme overventilation and flame stability was further supported by the work of Miller and Maahs (1997), who studied nitrogen oxide (NO x ) formation in a laminar methane-air diffusion flame at pressures up to
(30 mg/Kg ip). The left femoral vein (LFV) was exposed and dissected to allow introduction of the catheter system. The catheter system consisted of a polyethylene catheter with a steel guide wire. The catheter system was prepared by flushing the external wall and the lumen of the catheter with heparinized sterile saline. The catheter system was in- troduced into the LFV to the entrance of the right atrium under echocardiographic guidance (Figure 1-A). When the catheter system touched the atrial septum, it was necessary to adjust the direction of the guide wire to advance the sys- tem pointing to the tricuspid valve (Figure 1-B) and then