Diagnostic and therapeutic challenges in patients with coexistent chronic obstructive pulmonary disease and chronic heart failure

Chronic obstructive pulmonary disease (COPD) and heart failure (CHF) are common conditions. The prevalence of COPD ranges from 20% to 30% in patients with CHF. The diagnosis of CHF can remain unsuspected in patients with COPD, because shortness of breath is attributed to COPD. Measurement of plasma B-type natriuretic peptide (BNP) levels helps to uncover unsuspected CHF in patients with COPD and clinical deterioration. Noninvasive assessment of cardiac function may be preferable to BNP to uncover unsuspected left ventricular (LV) systolic dysfunction in patients with stable COPD. Patients with COPD or CHF develop skeletal muscle alterations that are strikingly similar. Functional intolerance correlates with severity of skeletal muscle alterations but not with severity of pulmonary or cardiac impairment in COPD and CHF, respectively. Improvement of pulmonary or cardiac function does not translate into relief of functional intolerance in patients with COPD or CHF unless skeletal muscle alterations concomitantly regress. The mechanisms responsible for skeletal muscle alterations are incompletely understood in COPD and in CHF. Disuse and low-level systemic inflammation leading to protein synthesis/degradation imbalance are likely to contribute. The presence of COPD impacts on the treatment of CHF, as COPD is still viewed as a contraindication to beta-blockade. Therefore, COPD often deprives patients with CHF due to LV systolic dysfunction of the most beneficial pharmacologic intervention. A large body of data indicates that patients with COPD tolerate well selective beta-blockade that should not be denied to CHF patients with concomitant COPD.

The risk profile for obstructive sleep apnea does not affect the recurrence of atrial fibrillation

BACKGROUND

Obstructive sleep apnea (OSA) has been linked to increased prevalence and recurrence of atrial fibrillation (AF). We hypothesized that OSA may aggravate AF in patients with pacemakers implanted for sinus bradycardia who had documented paroxysmal AF.

METHODS

Seventy-two patients (36 M, aged 77 +/- 6 years) completed the study. All patients received a dual-chamber pacemaker equipped with diagnostic and preventive functions for AF. OSA was diagnosed with the Berlin Questionnaire, which is validated to identify patients with OSA. Four-month continuous pacemaker recordings were collected for all patients.

RESULTS

OSA was diagnosed in 28% of patients. Patients at high risk for OSA (HR group) and patients at low risk for OSA (LR group) were equivalent for gender, age, and body mass index. The rate of hypertension was higher in HR than in LR group (90% vs 44%, P < 0.01). The prevalence of paroxysmal AF during the study period was similar in HR and LR group (53% vs 44%, P = NS). Overall number of AF episodes per month was not significantly different between HR and LR group (7 +/- 13 vs 36 +/- 122, P = NS). Similarly, AF burden (AF%) was not significantly different between HR and LR group (0.3 +/- 0.6 vs 2.0 +/- 4.8, P = NS). Circadian distribution of AF episodes was similar in both groups.

CONCLUSION

Long-term pacemaker recording of AF recurrence, AF burden, and its circadian distribution is similar in patients with paroxysmal AF at high risk for OSA and those at low risk for OSA.

Temporal Variation in Optimal Atrioventricular and Interventricular Delay During Cardiac Resynchronization Therapy

BACKGROUND

Tailored atrioventricular delay (AVd) and interventricular delay (VVd) combination improves hemodynamics in patients treated with cardiac resynchronization therapy (CRT). Whether tailored AVd-VVd combination changes over time is not known.

METHODS AND RESULTS

Twenty-two patients (18 M, aged 69.9 +/- 12.5 years, New York Heart Association class III, QRS > or = 130 ms, ejection fraction 29.6 +/- 8.8%) were implanted with a biventricular device with programmable VVd. Myocardial performance index (MPI) was evaluated during pacing at different VVds and AVds at baseline and after 6 and 12 months. The optimal AVd-VVd combination was identified by the minimum MPI. After optimization, the appropriate AVd-VVd combination was programmed in each patient. MPI at 6-month follow-up after optimization was significantly higher compared with baseline (.79 +/- .21 vs. .59 +/- .15, P < .05). Re-optimization of AVd-VVd combination was required after 6 months in 21 of 22 (95%) patients. Re-optimization significantly reduced MPI compared with the value prior to re-optimization (.56 +/- .15 vs. .79 +/- .21, P < .05). The MPI remained unchanged at 12-month compared with 6-month follow-up (.59 +/- .19 vs. .56 +/-.15, P = NS). Clinical symptoms and reverse left ventricular remodeling were sustained at 6-month and 12-month follow-up.

CONCLUSION

Optimal AVd and VVd combination changes over time in patients with heart failure. Sustained improvement in clinical symptoms and reverse left ventricular remodeling after CRT are not temporally associated with improvement in MPI.

Diagnostic usefulness of B-type natriuretic peptide and functional consequences of muscle alterations in COPD and chronic heart failure

COPD affects up to one third of patients with chronic heart failure. The coexistence of COPD and chronic heart failure presents clinicians with diagnostic and therapeutic challenges. Measurement of B-type natriuretic peptide plasma levels facilitates the diagnosis of acute dyspnea in patients known to have both COPD and chronic heart failure. Patients with COPD or chronic heart failure have skeletal muscle abnormalities that limit functional capacity independently from primary organ failure. Exercise training reverses skeletal muscle abnormalities in patients with COPD or chronic heart failure and may be particularly indicated in patients with coexistent COPD and chronic heart failure.

Pharmacoeconomic analysis of adjuvant oral capecitabine vs intravenous 5-FU/LV in Dukes' C colon cancer: the X-ACT trial

Oral capecitabine (Xeloda®) is an effective drug with favourable safety in adjuvant and metastatic colorectal cancer. Oxaliplatin-based therapy is becoming standard for Dukes' C colon cancer in patients suitable for combination therapy, but is not yet approved by the UK National Institute for Health and Clinical Excellence (NICE) in the adjuvant setting. Adjuvant capecitabine is at least as effective as 5-fluorouracil/leucovorin (5-FU/LV), with significant superiority in relapse-free survival and a trend towards improved disease-free and overall survival. We assessed the cost-effectiveness of adjuvant capecitabine from payer (UK National Health Service (NHS)) and societal perspectives. We used clinical trial data and published sources to estimate incremental direct and societal costs and gains in quality-adjusted life months (QALMs). Acquisition costs were higher for capecitabine than 5-FU/LV, but higher 5-FU/LV administration costs resulted in 57% lower chemotherapy costs for capecitabine. Capecitabine vs 5-FU/LV-associated adverse events required fewer medications and hospitalisations (cost savings £3653). Societal costs, including patient travel/time costs, were reduced by >75% with capecitabine vs 5-FU/LV (cost savings £1318), with lifetime gain in QALMs of 9 months. Medical resource utilisation is significantly decreased with capecitabine vs 5-FU/LV, with cost savings to the NHS and society. Capecitabine is also projected to increase life expectancy vs 5-FU/LV. Cost savings and better outcomes make capecitabine a preferred adjuvant therapy for Dukes' C colon cancer. This pharmacoeconomic analysis strongly supports replacing 5-FU/LV with capecitabine in the adjuvant treatment of colon cancer in the UK.

Extracorporeal Membrane Oxygenation in Pregnancy

BACKGROUND

Safety and efficacy of extracorporeal membrane oxygenation (ECMO) in pregnancy is unknown.

CASE

A 33-year-old pregnant woman at 23 weeks of gestation presented with acute respiratory distress syndrome unresponsive to conventional mechanical ventilation. Early initiation of ECMO therapy along with protective mechanical ventilation strategy resulted in an excellent maternal and fetal outcome.

CONCLUSION

Extracorporeal membrane oxygenation can be life saving when initiated early in pregnant patients with severe acute respiratory insufficiency unresponsive to conventional mechanical ventilation.

Analysis of drug delivery and outcome differences in platinum-based chemotherapy for advanced non-small cell lung cancer (NSCLC)

17120

Background: Dose intensity (DI) is the dominant treatment design variable with respect to the degree of therapeutic response while total dose (TD) correlates best with the duration of response in an incurable patient population. To further explore the nature of the relationship of response to treatment (RR) and stable disease (SD) with median survival in advanced NSCLC, we performed an analysis of dose intensity and total dose of platinum compounds in first-line treatment of advanced NSCLC. Methods: Individual patient data from three phase 2/3 studies conducted at the Institute for Oncology and Radiology of Serbia from 1990 to 2001 were reviewed to perform an analysis of DI and TD for responding patients (CR+PR) and stable disease ones (SD). All patients were treated with cisplatin (120 mg/m2) or carboplatin (500 mg/m2 and thereafter AUC 6) based doublets or triplets, every four weeks (second-generation regimens). Results: 109 case records were analyzed, 93 patients received cisplatin-based and 16 carboplatin-based regimens. For responding patients (N=36) median DI of cisplatin was 29.84 mg/m2/wk (range 24.17–36.42) and for stable disease patients (N = 57) median DI was 29.94 mg/m2/wk (range 27.11–40.91). Wilcoxon rank sum test p = 0.28. In percentage, responders had DI of 0.985 of planned dose, and stabilizations had DI 0.99 of planned dose. Regarding TD, responders received median of 577.5 mg/m2 of cisplatin (236.1–1070) while stable disease patients received median of 475 mg/m2 (231.3–929.4), Wilcoxon p=0.0045. Median survival for responders was 9.5 months and for SD patients 6.0 months (log-rank test, p = 0.021). For carboplatin-receiving patients (N = 16) median DI was 122.85 mg/m2/wk (111.91–141.04) and median TD 1900.30 mg/m2/wk (1000–3000). Conclusions: Received DI of cisplatin was the same for responders and stable disease patients, but responders received more drug than stable-disease patients and lived significantly longer. The optimal duration of treatment for stable disease patients as probably the most frequent advanced NCSLC population requires careful consideration, especially while we are still in the era of platinum-based chemotherapy.

No significant financial relationships to disclose.

5,10-methylenetetrahydrofolic acid with 5-fluorouracil as first line treatment in metastatic colorectal cancer: Phase II study results

3599

Background: 5-Fluorouracil (FU) plus Leucovorin (LV) has historically been the standard first line treatment of colorectal cancer. Although LV modestly enhances FU activity, it can increase systemic toxicity and also must be intracellularly converted in multiple steps to its active metabolite, 5,10-methylenetetrahydrofolate (CoFactor [CO]). Unlike LV, CO directly modulates FU inhibition of thymidylate synthase without the need for metabolic conversion. Preclinical models show reduced hematologic toxicity of CO+FU with enhanced efficacy compared to FU+LV. We evaluated CO+FU chemotherapy in patients with previously untreated mCRC. Methods: Patients (pts) had performance status ECOG 0–2 and objectively measurable mCRC. Prior adjuvant therapy was allowed including FU+LV. Fifty pts were enrolled and treated with CO 60mg/m2 and FU 450mg/m2 (weekly IV bolus) for 6 weeks, followed by 14 day rest. Response was measured at 16 wks (WHO criteria). Results: As of January 2006, 50 pts received at least 1 dose of drug and are no longer on treatment. Patient demographics: median age = 65 (range 42–86), M/F = 60%/40%. Mean number of doses was 18.0 (range 2–41). Overall incidence of grade 3/4 AEs was 14 (28%). No grade 3/4 drug-related hematologic toxicity was observed. There was no significant effect on HCT, Bili, WBC, ALT, and AST during the course of the study. Objective response rate (CR + PR) to first line treatment with CO+FU based on independent blinded review was 35% (2 CR, 14 PR, 23 SD, 7 PD; 95% CI: 21.4–50.2) based on 46 pts evaluable for response. Median time to tumor progression was 163 days (95% CI: 105 -189). Twenty pts are deceased and median survival has not been reached. Conclusions: The results suggest thatCO+FU is safe, well tolerated, and has activity in mCRC. In the optimum treatment strategy afforded by the availability of numerous drugs, the high level of activity and low toxicity of CO+FU suggests that this combination may be a good initial treatment in a sequential strategy of mCRC management, especially among pts who would benefit by minimizing initial toxicity.

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HER-2 status of the primary breast cancer in patients with relapse at least five years after the initial diagnose

10631

Background: HER-2 status of the primary breast carcinoma in the subgroup of patients who relapsed after many years is not well known. The aim of this paper is to determine the HER-2 status of the primary breast cancer in patients with late relapse, defined as local recurrence, distant metastases or carcinoma in the contralateral breast, at least five years after the initial diagnosis Methods: During six month period (June-November 2005) 1256 patients were diagnosed with primary or relapsed breast cancer at the IORS. HER-2 (HercepTest, DAKO) status was determined on the archived pathological specimens of patients with late relapse. Results: One hundred eleven patients (111/1256; 8,8%) were diagnosed with late relapse. At the time of the initial diagnose, majority of patients have been treated for early breast carcinoma. Median age at the initial diagnose was 50 years (33–74). Initial tumor characteristic were: ductal carcinoma 49%; lobular carcinoma 41%;cancer mastitis 6,5%;not reported 3,5%; T1 34%; T2 52%; T3 4,5%; T4 6%;unknown 3,5%; Nodal status: positive 73,5%; negative 23%;not reported 3,5% Steroid receptor status: ER and/or PR positive 59%; both negative 14%; unknown 27%. Median time to relapse is 7 years, (range 5–29), the most frequent first relapse sites were: local recurrence (22%); carcinoma of the contralateral breast (18%); bone metastases (18%). Archived pathological specimens are identified for 63/111 (56,7%) patients and HER-2 status of the those primary breast carcinoma is: 0+ 36,5%; 1+ 34,9%; 2+ 9,5%; 3+ 14,2%; Thirty four patients (30,6%) had disease free interval 10 or more years, and HER-2 3+ in this subgroup is 17,6% (6/34). Conclusions: Long disease free interval in breast cancer patients is usually explained by initial more favorable cancer characteristics. Still, a significant percentage (14,2%) of our patients with median time to relapse of 7 years, initially had breast cancers with HER-2 3+.

No significant financial relationships to disclose.

Fluoropyrimidine therapy: hyperbilirubinemia as a consequence of hemolysis

BACKGROUND

Hemolytic anemia has been noted during treatment with a variety of chemotherapeutic agents. We observed mild compensated hemolytic anemia in a patient receiving capecitabine during a randomized, controlled trial of adjuvant therapy. In order to investigate the hypothesis that hemolysis is the underlying cause of the hyperbilirubinemia sometimes observed during capecitabine treatment, we evaluated factors associated with hemolysis in ten patients. Factors were also analyzed in ten patients receiving 5-fluorourocil/leucovorin (5-FU/LV).

METHODS

Twenty chemotherapy-naïve patients undergoing surgery for Dukes' C colon cancer were included in the phase III, 'X-ACT' trial, and randomized to receive 24-week adjuvant treatment with either oral capecitabine (eight cycles of 1,250 mg/m2 twice daily for 14 days, followed by a 7-day rest period) (n=10) or 5-FU/LV administered according to the Mayo Clinic regimen (six cycles of LV 20 mg/m2 followed by 5-FU 425 mg/m2, administered as an i.v. bolus on days 1-5 every 28 days) (n=10). Ten patients randomized in each treatment arm were evaluated. Hemolytic parameters evaluated included bilirubin, lactate dehydrogenase, haptoglobin, and reticulocytes.

RESULTS

Seven patients receiving capecitabine and three patients receiving 5-FU/LV experienced grade 1/2 elevations of bilirubin during the 24-week treatment period. In most cases, hyperbilirubinemia was associated with concomitant alterations in other hemolytic parameters. Five episodes of grade 1 compensated hemolytic anemia were reported in four capecitabine-treated patients, all of which were associated with hyperbilirubinemia.

CONCLUSION

Adjuvant treatment with capecitabine or 5-FU/LV in a small sample of patients with Dukes' C colon cancer was associated with alterations in hemolytic parameters. These alterations, in particular hyperbilirubinemia, were associated in some patients with low-grade compensated hemolytic anemia. All changes were clinically insignificant, fully reversible, and may represent a fluoropyrimidine class effect. Further studies are indicated to evaluate the incidence and implications of this effect.

Increased sympathetic and decreased parasympathetic cardiovascular modulation in normal humans with acute sleep deprivation

Cardiovascular autonomic modulation during 36 h of total sleep deprivation (SD) was assessed in 18 normal subjects (16 men, 2 women, 26.0 +/- 4.6 yr old). ECG and continuous blood pressure (BP) from radial artery tonometry were obtained at 2100 on the first study night (baseline) and every subsequent 12 h of SD. Each measurement period included resting supine, seated, and seated performing computerized tasks and measured vigilance and executive function. Subjects were not supine in the periods between measurements. Spectral analysis of heart rate variability (HRV) and BP variability (BPV) was computed for cardiac parasympathetic modulation [high-frequency power (HF)], sympathetic modulation [low-frequency power (LF)], sympathovagal balance (LF/HF power of R-R variability), and BPV sympathetic modulation (at LF). All spectral data were expressed in normalized units [(total power of the components/total power-very LF) x 100]. Spontaneous baroreflex sensitivity (BRS), based on systolic BP and pulse interval powers, was also measured. Supine and sitting, BPV LF was significantly increased from baseline at 12, 24, and 36 h of SD. Sitting, HRV LF was increased at 12 and 24 h of SD, HRV HF was decreased at 12 h SD, and HRV LF/HF power of R-R variability was increased at 12 h of SD. BRS was decreased at 24 h of SD supine and seated. During the simple reaction time task (vigilance testing), the significantly increased sympathetic and decreased parasympathetic cardiac modulation and BRS extended through 36 h of SD. In summary, acute SD was associated with increased sympathetic and decreased parasympathetic cardiovascular modulation and decreased BRS, most consistently in the seated position and during simple reaction-time testing.

The effect of ventilation on spectral analysis of heart rate and blood pressure variability during exercise

Heart rate variability (HRV) and systolic blood pressure variability (BPV) during incremental exercise at 50, 75, and 100% of previously determined ventilatory threshold (VT) were compared to that of resting controlled breathing (CB) in 12 healthy subjects. CB was matched with exercise-associated respiratory rate, tidal volume, and end-tidal CO(2) for all stages of exercise. Power in the low frequency (LF, 0.04-0.15 Hz) and high frequency (HF, >0.15-0.4 Hz) for HRV and BPV were calculated, using time-frequency domain analysis, from beat-to-beat ECG and non-invasive radial artery blood pressure, respectively. During CB absolute and normalized power in the LF and HF of HRV and BPV were not significantly changed from baseline to maximal breathing. Conversely, during exercise HRV, LF and HF power significantly decreased from baseline to 100% VT while BPV, LF and HF power significantly increased for the same period. These findings suggest that the increases in ventilation associated with incremental exercise do not significantly affect spectral analysis of cardiovascular autonomic modulation in healthy subjects.

Therapeutic Update: Non-Selective Beta- and Alpha-Adrenergic Blockade in Patients With Coexistent Chronic Obstructive Pulmonary Disease and Chronic Heart Failure

Patients with chronic heart failure (CHF) have a resting restrictive ventilatory defect. Any type of exercise requires patients with CHF to markedly increase their minute ventilation. Patients with chronic obstructive pulmonary disease (COPD) have airflow obstruction that leads to dynamic lung hyperinflation and reduced ventilatory response to exercise. Because exercise is associated with abnormally high minute ventilation in patients with CHF and with a limited minute ventilation increase in patients with COPD, functional capacity is severely impaired in patients with coexistent CHF and COPD. Optimal treatment of both conditions is a prerequisite to maximally improve functional capacity in patients with CHF and COPD. Unfortunately, beta-adrenergic blockade, the current cornerstone of CHF therapy, is frequently omitted in patients with CHF and COPD for fear of inducing bronchoconstriction. Furthermore, when prescribed, beta-adrenergic blockade is often attempted with a moderate dose of metoprolol tartrate, a beta-1-blocker that results in lesser clinical benefits than combined non-selective beta-blockade with carvedilol at the maximally recommended dose. Recent experience indicates that combined non-selective beta- and alpha-blockade with carvedilol is well tolerated in patients with COPD who do not have reversible airway obstruction. Alpha-adrenergic blockade may promote mild bronchodilation that offsets non-selective beta blockade-induced bronchoconstriction in patients with obstructive airway disease.