Family Medicine Update

Alleviation of Pulmonary Hypertension by Cardiac Resynchronization Therapy is Associated with Improvement in Central Sleep Apnea.

Pacing Clin Electrophysiol. 2008 Dec;31(12):1522-7

Authors: Yiu KH, Lee KL, Lau CP, Siu CW, Miu KM, Lam B, Lam J, Ip MS, Tse HF

Background: Recent studies have demonstrated that cardiac resynchronization therapy (CRT) reduces sleep apnea in heart failure (HF); however, the mechanism of benefit remains unclear. Methods: Overnight polysomnography (PSG) was performed in consecutive HF patients who were scheduled for CRT implant. Patients with sleep apnea defined by an apnea-hypopnea index (AHI) of >10/hour were recruited and underwent echocardiogram examination at baseline and 3 months after CRT. Results: Among 37 HF patients screened, 20 patients (54%) had sleep apnea and 15 of them consented for the study. After 3 months of CRT, there was a significant improvement in New York Heart Association functional class (3.1 +/- 0.1 vs 2.1 +/- 0.1, P < 0.01), quality-of-life (QoL) score (62.9 +/- 3.3 vs 56.1 +/- 4.5, P = 0.02), left ventricular ejection fraction (LVEF, 28.8 +/- 2.5% vs 38.1 +/- 2.3%, P < 0.01), and reduction in pulmonary artery systolic pressure (PASP, 41.0 +/- 2.7 vs 28.6 +/- 2.2 mmHg; P < 0.01) compared with baseline. Repeated PSG after CRT demonstrated a reduction in the duration of arterial oxygen desaturation </=95% (251.2 +/- 36.7 vs 141.0 +/- 37.1 minutes), AHI (27.5 +/- 4.7 vs 18.1 +/- 3.0, P = 0.05), and number of central sleep apnea (CSA) (7.8 +/- 2.6 vs 3.0 +/- 1.3/hour, P = 0.03), but not number of obstructive sleep apnea (OSA, 8.6 +/- 3.3 vs 7.2 +/- 2.3/hour, P = 0.65) compared to baseline. Percentage change in PASP was significantly correlated with percentage changes in LVEF (r=-0.57, P = 0.04), AHI (r = 0.5, P = 0.05), and number of CSA episodes (r = 0.55, P = 0.02). Conclusions: The results demonstrated that CRT significantly reduces CSA in patients with HF. Importantly, we have noted a decrement of PASP correlated to drop in CSA which maybe one of the mechanisms explaining this observation. Future studies are required to confirm our finding and elucidate other possible mechanisms in this regard.

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Do family physicians’ records fit guideline diagnosed COPD?

Fam Pract. 2009 Feb 19;

Authors: Albers M, Schermer T, Molema J, Kloek C, Akkermans R, Heijdra Y, van Weel C

BACKGROUND: In family practice, chronic obstructive pulmonary disease (COPD) is usually not diagnosed until clinically apparent and of moderately advanced severity. OBJECTIVE: To analyse the diagnostic process from early development onwards and to assess the current state of underpresentation and underdiagnosis of COPD and asthma in primary care in the Netherlands. METHODS: The population-based study sample consisted of formerly undiagnosed subjects (n = 532) from family practice. Family physicians’ (FPs) chronic respiratory disease diagnoses (as recorded over 10 years in their patient records) were compared to a cross-sectional but extensive diagnostic assessment by a chest physician. Logistic regression modelling was used for a retrospective analysis on the relation between respiratory symptoms, practice visit rate and FPs’ diagnosis of COPD. RESULTS: After 10 years, the chest physician diagnosed 26% of subjects as COPD and 16% as (late-onset) asthma. Underpresentation of these patients in family practice was 46%, whereas underdiagnosis occurred in 37% of patients. A chest physician diagnosis of COPD was associated with the presence of chronic cough [odds ratio (OR) = 2.3, 95% confidence interval (CI) 1.1-4.6], a FP diagnosis of COPD with chronic phlegm (OR = 10.6, 95% CI 1.3-83.6). Repeated practice visits (OR = 1.8) and presence of wheeze and breathlessness (OR = 5.5) appeared to trigger the diagnostic process in family practice. CONCLUSIONS: There is still considerable underpresentation and underdiagnosis of COPD in family practice. As FPs focus on presented symptoms and as detection increases with the frequency of practice visits, diagnostic guidelines should stress the importance of persistent cough and phlegm to support timely diagnosis of COPD in family practice.

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