Measurement of blood pressure, ankle blood pressure and calculation of ankle brachial index in general practice.

BACKGROUND: Low ankle brachial index (ABI) is a sensitive measure of 'burden' of atherosclerosis, indicating cardiovascular risk of the asymptomatic patient. Conventionally, ABI values <0.90 are considered pathological, indicating peripheral arterial disease. AIMS: The purpose of this study was to establish whether GPs after a short training course can reliably determine ABI compared to assessment in a specialized hospital department. DESIGN: Epidemiological observational study. METHODS: A total of 6 GPs and 12 general practice nurses from six practices were recruited for the study. Doppler measurements and ABI calculations were performed according to guidelines used by the Department of Nuclear Medicine, Odense University Hospital. RESULTS: On average, blood pressure measurements in general practice yielded lower values than those measured at the hospital. Differences in brachial and ankle blood pressure were -7 mmHg (-43 to 30 mmHg) and -14 mmHg (-63 to 33 mmHg), respectively. Sensitivity and specificity of ABI in general practice were 1.00 (0.87-1.00) and 0.79 (0.69-0.88), respectively. Predictive value of ABI measured <0.9 in general practice was 0.62 (0.46-0.76). CONCLUSIONS: Findings in general practice and at the Department of Nuclear Medicine were concordant with regard to the threshold value of ABI 0.9. However, this study does not warrant a recommendation of doppler measurements or assessment of ABI as screening or diagnostic procedure due to low specificity of assessments in general practice. Our results indicate a high number of false-positive tests if the method is applied for screening in general practice.

Prognostic importance of quantitative echocardiographic evaluation in patients suspected of first non-massive pulmonary embolism.

AIMS: Patients suspected of acute pulmonary embolism (PE) frequently undergo echocardiography as a part of the initial work-up. Prognostic implication of routine echocardiography in patients suspected of PE remain to be established. METHODS AND RESULTS: Transthoracic echocardiography, including tissue Doppler imaging, was performed in 283 consecutive patients referred for ventilation/perfusion scintigraphy (V/Q scan) on suspicion of first non-massive PE. The prognostic information of quantitative measures of right ventricular (RV) size, function, and pressure was assessed. Patients with PE had a follow-up echocardiography after 1 year and changes in the parameters were assessed. Patients with PE and normal V/Q scans had similar age-adjusted 1 year mortality [10 and 12%, NS (not significant)], although patients with indeterminate scans carried a poorer prognosis (16% survival, P=0.0004). Among all patients left ventricular (LV) ejection fraction as well as shortening of the pulmonary artery (PA) acceleration time (a measure of RV after-load) was associated with increased mortality [hazard ratio (HR)=0.84 per 10 ms increase, P<0.0001]. In patients with confirmed PE, the PA acceleration time is predictive of event-free survival (all-cause mortality and heart failure hospitalizations) adjusted for LV ejection fraction, age, and sex (HR=0.78 per 10 ms increase, P=0.04). Measures of regional myocardial function were not related to outcome in this study, regardless of presence of PE. CONCLUSION: PA acceleration time and LV systolic function are independent predictors of mortality in patients suspected of PE, and are independent predictors of event-free survival in patients with confirmed PE.

Quantification of right ventricular function in acute pulmonary embolism: relation to extent of pulmonary perfusion defects.

AIMS: The relation of the extent of obstruction of the pulmonary vasculature in pulmonary embolism (PE) and impact on right ventricular (RV) hemodynamics is not well established. This study evaluated the relation of size of perfusion defects and changes in echocardiographic measures of global and regional RV dysfunction in 58 consecutive patients with non-massive PE. METHODS AND RESULTS: Patients were compared with 58 age-matched controls that had normal ventilation/perfusion scintigraphies. A 2D, Doppler and Tissue Doppler echocardiography performed on the same day, quantified RV pressure and global and regional performance. Intermediate and large pulmonary emboli were associated with a significant impact on RV pressure and function. For small pulmonary emboli obstructing <25% of the pulmonary vasculature, the acceleration time of the pulmonary artery (PA) outflow was significantly shortened, 85 +/- 22 ms vs. 117 +/- 35 ms, P < 0.0001. Peak systolic strain in the middle segment of RV free wall was reduced in patients with perfusion defect greater than 25%, -1 +/- 13% vs. -13 +/- 17%, P < 0.001. CONCLUSION: Mid ventricular longitudinal dysfunction consistent with the 'McConnell-sign' is found in patients with moderate degrees of perfusion defects, whereas the acceleration time of the PA flow is reduced even in patients with small pulmonary emboli.

Quantitative measures of right ventricular dysfunction by echocardiography in the diagnosis of acute nonmassive pulmonary embolism.

BACKGROUND: Transthoracic echocardiography (TTE) is used in the risk assessment of patients with pulmonary embolism (PE), but the incremental diagnostic information from quantitative measures of right ventricular (RV) size, pressure, and function by TTE has yet to be fully evaluated. METHODS: In 300 consecutive patients with suspected first nonmassive PE, TTE and ventilation/perfusion scintigraphy were performed. RESULTS: Among measures of RV anatomy, RV pressure estimates, and estimates of global and regional RV function with significant diagnostic information in a logistic regression analysis, the acceleration time of RV outflow less than 89 milliseconds, the ratio of RV to left ventricular diameter greater than 0.78, RV outflow tract fractional shortening less than 35%, and signs of RV strain on electrocardiogram had independent, incremental diagnostic information (area under the receiver operating characteristics curve = 0.81). If D-dimer greater than 4.1 mmol/L was included, the area under the curve increased to 0.88. The negative and positive predictive values if any 2 of 3 factors in the final model were present were 88% and 70%, respectively. CONCLUSION: TTE is able to identify differential diagnoses and enhance pretest probability of PE significantly. TTE could therefore be considered as an integral part of the initial diagnostic workup of patients suspected of PE, especially if definitive diagnostic imaging has limited availability.

[Vascular reconstruction of venous occlusion in the lower extremities. Experiences in 12 patients]. / Karkirurgisk rekonstruktion ved venøs okklusion i underekstremiteterne. Erfaringer fra 12 patienter.

INTRODUCTION: This paper describes the late results after surgical reconstruction for deep venous occlusion in the lower extremities. MATERIAL AND METHODS: Twelve patients were treated, two women and 10 men (median age 46, range 17-66 years) over a 6-year period. Seven patients had chronic venous occlusion with venous claudication or ulcer, two had DVT with severely affected limbs, and three were reconstructed, because of tumour involvement. Externally supported ePTFE grafts were used in 11 patients and vein material in the last patient. The median follow-up period was 18 months (range 1-96 months). Evaluation of patency included clinical examination and duplex ultrasound or phlebography. RESULTS: One patient died three weeks postoperatively of multiorgan failure. Another died one year postoperatively of pulmonary metastases from a leiomyosarcoma of the common femoral vein. At follow-up, 50% of the reconstructions had remained open for a median period of five years. DISCUSSION: The results are comparable with those of the literature. The selection of patients requires, in addition to anatomic visualisation of the occluded segment, a haemodynamic demonstration of venous obstruction, i.e. by a pressure gradient across the occluded segment. Surgical reconstruction is possible in the case of a strong indication.

[Adrenal insufficiency after unilateral adrenalectomy for primary hyperaldosteronism]. / Adrenal insufficiens efter unilateral adrenalektomi på grund af primaer hyperaldosteronisme.

A case of unexpected insufficiency of the remaining adrenal gland after unilateral adrenalectomy for primary hyperaldosteronism is described. The patient recovered from the initial disease, but postoperative tests repeatedly showed insufficient response to injection of ACTH. This case raises the question of interaction between the renin-angiotensin system and the hypothalamic-pituitary-adrenal-axis. Furthermore, it stresses the importance of testing the function of the remaining adrenal gland after unilateral adrenalectomy.