Congestive heart failure masquerading as primary pulmonary disease

Phenylephrine contracts porcine pulmonary veins via alpha(1B)-, alpha(1D)-, and alpha(2)-adrenoceptors

We have recently shown that the postjunctional alpha(2)-adrenoceptor mediating contraction of porcine pulmonary veins is of the alpha(2C)-subtype. We could also demonstrate that alpha(1)-adrenoceptors might contribute to the contraction in that blood vessel. In the present study, we aimed at characterising the alpha(1)-adrenoceptor subtype(s) involved using pharmacological and molecular biological methods. In isolated rings of porcine pulmonary veins the typical alpha(1)-adrenoceptor agonist phenylephrine caused a concentration-dependent contraction that was inhibited by the alpha(1B)-adrenoceptor selective antagonists 1-[4-(4-amino-6,7-dimethoxyquinazolin-2-yl)piperazin-1-yl]-2-[2-(isopropyl)-6-methoxyphenoxy]ethan-1-one (Rec15/2615; pA(2) 8.96+/-0.13) and 4-amino-2-[4-[1-(benzyloxycarbonyl)-2(S)-[[(1,1-dimethylethyl)amino]carbonyl]-piperazinyl]-6,7-dimethoxyquinazoline (L-765,314; pA(2) 7.22+/-0.05), as well as the alpha(1D)-adrenoceptor selective antagonist 8-[2-[4-(2-methoxyphenyl)-1-piperazinyl]ethyl]-8-azaspiro[4.5]decane-7,9-dione (BMY7378; pA(2) 8.29+/-0.15, slope of the Schild plot 0.75+/-0.09, significantly different from unity, P<0.05), but not by the alpha(1A)-adrenoceptor selective antagonists (+/-)-1,3,5-trimethyl-6-[[3-[4-((2,3-dihydro-2-hydroxymethyl)-1,4-benzodioxin-5-yl)-1-piperazinyl]propyl]amino]-2,4(1H,3H)-pyrimidinedione (B8805-033) and N-[2-(2-cyclopropylmethoxyphenoxy)ethyl]-5-chloro-alpha,alpha-dimethyl-1H-indole-3-ethanamine (RS-17053). These findings suggest that phenylephrine activates both alpha(1B)- and alpha(1D)-adrenoceptors. The observation was confirmed by reverse-transcriptase polymerase chain reaction (RT-PCR) in porcine pulmonary veins, where mRNA signals for alpha(1B)- and alpha(1D)-adrenoceptors could be detected. However, the antagonist properties of rauwolscine and yohimbine (non-subtype selective alpha(2)-adrenoceptor antagonists) against phenylephrine showed that this agonist also activates alpha(2)-adrenoceptors in pulmonary veins. This was strengthened in experiments using tissues that were stimulated with forskolin (cell permeable activator of adenylyl cyclase). Phenylephrine mimicked the effect of the selective alpha(2)-adrenoceptor agonist UK14304 by causing an inhibition of forskolin-stimulated cAMP accumulation that was blocked by rauwolscine. It is concluded that, in addition to alpha(1B)- and alpha(1D)-adrenoceptors, phenylephrine can stimulate alpha(2)-adrenoceptors in porcine pulmonary veins.

The pulmonary manifestations of left heart failure

Determining whether a patient's symptoms are the result of heart or lung disease requires an understanding of the influence of pulmonary venous hypertension on lung function. Herein, we describe the effects of acute and chronic elevations of pulmonary venous pressure on the mechanical and gas-exchanging properties of the lung. The mechanisms responsible for various symptoms of congestive heart failure are described, and the significance of sleep-disordered breathing in patients with heart disease is considered. While the initial clinical evaluation of patients with dyspnea is imprecise, measurement of B-type natriuretic peptide levels may prove useful in this setting.

Multiple pulmonary air fluid levels as a presentation of congestive heart failure

Congestive heart failure and emphysema are common diseases in western society. The presence of these diseases in a single patient can lead to diagnostic uncertainty. A case of congestive heart failure presenting as multiple air fluid levels within lung bullae is reported.

Left heart function in chronic obstructive lung disease

In patients with varying degrees of chronic obstructive pulmonary disease (COPD), simultaneous measurements of central hemodynamics and left ventricular radionuclide ventriculograms at rest and during exercise were made. In 21 of these patients, satisfactory echocardiograms could be performed. In seven of the patients, arterial blood pressure at rest was increased. Decreased compliance of the left ventricle was thought to be present in patients with COPD and additional arterial hypertension. The left ventricular ejection fraction (LVEF) at rest was in the high normal range in all patients. During exercise, no further increase was observed. This pattern of LVEF response seems to be typical in patients with COPD. Because the highest values were observed in the more severe COPD and right ventricular hypertrophy, it is unlikely that an impairment of left ventricular function is caused by COPD. In five of 27 patients, an abnormal decrease of LVEF and regional hypokinesis occurred during exercise, thus suggesting additional coronary heart disease. The fact that at least 30% of the patients with COPD suffered from arterial hypertension and 20% of the patients exhibited unexpected ischemia detected by regional hypokinesis in RNV during exercise, but not in the ECG, may be of practical relevance. Coronary angiography was not indicated because most of these patients were over 65 and the factor limiting the working capacity was ventilatory impairment and not angina pectoris, in all patients. For this reason, a diagnostic uncertainty remains with regard to additional coronary heart disease in the older patients with advanced chronic obstructive pulmonary disease.

Pulmonary disease in the immunocompromised host. 1

With few exceptions, pulmonary complications in the immunocompromised host will proceed to death unless the clinician intercedes. The differential diagnosis of diffuse pulmonary disease in this setting includes (1) infection, most commonly from opportunistic organisms; (2) recurrence or extension of the basic underlying disease process to involve the lungs; (3) adverse pulmonary reaction to drugs; (4) a new, unrelated disease process such as cardiac pulmonary edema or pulmonary emboli; and (5) any combination of these categories. Up to a third of these patients have two or more complications, such as pneumonitis from two different opportunistic organisms or an opportunistic infection and a drug-induced pulmonary complication. An understanding of the host defense that is compromised enables the clinician to narrow the differential diagnosis. The most common types of impairment of defense mechanisms are reductions in the number of granulocytes, B-lymphocytes, or T-lymphocytes, and not uncommonly, two or all three of these types of cells are involved. Impairment of each of these cell types is associated with an increased frequency of infection by a particular group of organisms. Consequently, the clinician can be somewhat selective if empiric therapy is being considered. In the immunocompromised patient, most pulmonary complications, including drug-induced pulmonary disease and pulmonary emboli, are associated with fever that mimics an infection. Up to 25% of the pulmonary complications in these patients are noninfectious.

Pulmonary radiology in the intensive care unit

The techniques of the standard chest film and the use of specialized views for specific problems are reviewed. The radiographic manifestations of the major presenting causes of acute respiratory failure are described and compared, and the evolution of the radiograph during the progression of these diseases is considered. Radiographic manifestations of commonly encountered complications in the intensive care unit are also presented.

Detection of left ventricular failure in patients with adult respiratory distress syndrome

Fourteen patients with adult respiratory distress syndrome were admitted to the medical intensive care unit and received bedside heart catheterization with the use of a balloon-tipped, flow directed catheter. Four of the 14 (29 percent) were found to have left ventricular failure (LVF), defined as a pulmonary artery wedge pressure greater than 12 mm Hg. Analysis of the standard clinical and laboratory data demonstrated no criteria which could differentiate those patients with LVF from those without. Three of the four patients indentified as having LVF responded to therapy directed toward LVF with substantial clinical improvement.