Fluid loading during the hemodynamic evaluation of pulmonary hypertension: a cross-sectional study.

Background: Compensated pulmonary hypertension due to left heart disease (PH-LHD) may be difficult to identify based on resting hemodynamics. Fluid challenge is commonly used to unmask occult PH-LHD. We sought to determine the hemodynamic effect of fluid loading and its association with the clinical pretest probability of PH-LHD. Methods: We included consecutive patients evaluated for PH who underwent right heart catheterization (RHC) with fluid challenge at Cleveland Clinic between April 2013 and January 2019. We obtained hemodynamic measurements at rest and after intravenous rapid fluid challenge (500 mL of normal saline). We calculated the pretest probability of PH-LHD based on the 6th World Symposium on PH proceedings. For statistical analyses we used t-test, analysis of variance (ANOVA), Chi-square, paired t-test, Wilcoxon signed-rank test and linear regression as indicated. Results: We included 174 patients with mean ± standard deviation (SD) age of 63.7±13.0 years and 123 (71%) of female sex. Baseline pulmonary artery wedge pressure (PAWP) was 11±5 mmHg, with a PAWP/cardiac output (CO) ratio of 2.1±1.1 Wood units (WU). The absolute increase in PAWP and PAWP/CO was 6.9±3.6 mmHg and 1.06±0.91 WU, respectively. The change in PAWP was inversely associated with baseline PAWP (P<0.001). The PAWP with fluids was >18 mmHg in 81% of the patients with baseline PAWP 13-15 mmHg. We found no strong associations between the change in PAWP, PAWP/CO or right atrial pressure to pulmonary arterial wedge pressure ratio (RAP/PAWP) and the pretest probability of PH-LHD. Conclusions: The absolute change in PAWP, PAWP/CO, or achieving a PAWP >18 mmHg with rapid fluid loading was not robustly associated with the pretest probability of PH-LHD. Patients with PAWP between 13-15 mmHg commonly had a positive fluid challenge, questioning the utility of this intervention in these patients.

An 81-Year-Old Man With Shortness of Breath After Chemotherapy and Radiation Therapy for Lung Cancer.

CASE PRESENTATION: An 81-year-old man was admitted for evaluation of progressive dyspnea over the previous 4 weeks. He initially noticed dyspnea when walking briskly, but this progressed to dyspnea after only walking several feet. He also endorsed a dry cough without hemoptysis. Review of systems revealed a history of intermittent low-grade fevers, malaise, and nonexertional chest pain. He had been treated for a urinary tract infection twice over the past 3 weeks with prolonged courses of levofloxacin; while his urinary symptoms improved, his respiratory symptoms did not. Medical history was pertinent for lung adenocarcinoma stage IIIb status post right upper lobectomy 10 years prior with recurrence of lung adenocarcinoma in the right lower lobe and was recently diagnosed with stage 1 primary pancreatic adenocarcinoma. He had been a longstanding tobacco smoker but quit two decades ago. Treatment of his recurrent lung adenocarcinoma included four cycles of carboplatin-pemetrexed over the preceding 5 months and intensity-modulated radiation therapy totaling 60 Gy over 30 fractions to his right lower lobe 2 months prior to presentation. He also received stereotactic body radiation therapy totaling 45 Gy over five fractions to his pancreas.

A Woman in Her 80s With Weakness, Hypoxia, and Bone Marrow Granulomas.

A white woman in her 80s presented to the ED with nonproductive cough, fever, and 2 weeks of progressive generalized weakness. Previously ambulatory, she now was so weak she required assistance out of bed.

A 39-Year-Old Postpartum Woman With Foot Drop and Shortness of Breath.

A 39-year-old white woman with a history of adult-onset asthma, chronic sinusitis, and nasal polyposis presented to the ED with dyspnea and left lower extremity weakness and pain. Three months prior to her presentation she had an uncomplicated delivery of her second child, but during her pregnancy she experienced increasing asthma symptoms and nasal congestion. These symptoms progressed after delivery despite treatment with albuterol inhalers and antibiotics.