Latest News on Heart Rate: Jan 2021

Determinants of heart rate variability

Objectives. This study sought to examine clinical determinants of heart rate variability and to report normative reference values for eight heart rate variability measures.

Background. Although the clinical implications of heart rate variability have been described, clinical determinants and normative values of heart rate variability measures have not been studied systematically in a large community-based population.

Methods. The first 2 h of ambulatory electrocardiographic recordings obtained in Framingham Heart Study subjects attending a routine examination were reprocessed for heart rate variability. Recordings with transient or persistent nonsinus rhythm, premature beats >10% of total beats, <1-h recording time or processed time <50% of recorded time were excluded; subjects receiving antiarrhythmic medications also were excluded. Among five frequency domain and three time domain measures that were obtained, low frequency power (0.04 to 0.15 Hz), high frequency power (0.15 to 0.40 Hz) and the standard deviation of total normal RR intervals based on 2-h recordings were selected for the principal analyses. Variables with potential physiologic effects or possible technical influences on heart rate variability measures were chosen for multiple linear regression analysis. Normative values, derived from a subset of healthy subjects, were adjusted for age and heart rate.

Results. There were 2,722 eligible subjects with a mean age (±SD) of 55 ± 14 years. Three separate multiple linear regression analyses revealed that higher heart rate, older age, beta-adrenergic blocking agent use, history of myocardial infarction or congestive heart failure, diuretic use, diastolic blood pressure ≥ 90 mm Hg, diabetes mellitus, consumption of three or more cups of coffee per day and smoking were associated with lower values of one or more heart rate variability measures, whereas longer processed time, start time in the morning, frequent supraventricular and ventricular premature beats, female gender and systolic blood pressure ≥160 mm Hg were associated with higher values. Age and heart rate were the major determinants of all three selected heart rate variability measures (partial R2 values 0.125 to 0.389). Normative reference values for all eight heart rate variability measures are presented.

Conclusions. Age and heart rate must be taken into account when assessing heart rate variability. [1]

Heart Rate Monitoring

Over the last 20 years, heart rate monitors (HRMs) have become a widely used training aid for a variety of sports. The development of new HRMs has also evolved rapidly during the last two decades. In addition to heart rate (HR) responses to exercise, research has recently focused more on heart rate variability (HRV). Increased HRV has been associated with lower mortality rate and is affected by both age and sex. During graded exercise, the majority of studies show that HRV decreases progressively up to moderate intensities, after which it stabilises. There is abundant evidence from cross-sectional studies that trained individuals have higher HRV than untrained individuals. The results from longitudinal studies are equivocal, with some showing increased HRV after training but an equal number of studies showing no differences. The duration of the training programmes might be one of the factors responsible for the versatility of the results. [2]

Heart rate variability: a review

Heart rate variability (HRV) is a reliable reflection of the many physiological factors modulating the normal rhythm of the heart. In fact, they provide a powerful means of observing the interplay between the sympathetic and parasympathetic nervous systems. It shows that the structure generating the signal is not only simply linear, but also involves nonlinear contributions. Heart rate (HR) is a nonstationary signal; its variation may contain indicators of current disease, or warnings about impending cardiac diseases. The indicators may be present at all times or may occur at random—during certain intervals of the day. It is strenuous and time consuming to study and pinpoint abnormalities in voluminous data collected over several hours. Hence, HR variation analysis (instantaneous HR against time axis) has become a popular noninvasive tool for assessing the activities of the autonomic nervous system. Computer based analytical tools for in-depth study of data over daylong intervals can be very useful in diagnostics. Therefore, the HRV signal parameters, extracted and analyzed using computers, are highly useful in diagnostics. In this paper, we have discussed the various applications of HRV and different linear, frequency domain, wavelet domain, nonlinear techniques used for the analysis of the HRV. [3]

Fetal Heart Rate Interpretation in the Second Stage of Labour: Pearls and Pitfalls

It is vital to determine whether a fetus is showing a normal physiological response to the stress of labour or if the fetus is exposed to intrapartum hypoxia to ensure timely and appropriate management. Failure to interpret fetal heart rate correctly during second stage of labour may lead to increased maternal and neonatal morbidity due to an unnecessary caesarean section or an instrumental vaginal delivery. Conversely, delay in timely and appropriate intervention can also result in increased perinatal morbidity and mortality.

This review addresses the pathophysiology behind features observed on the CTG trace as well as the types of intrapartum hypoxia during second stage of labour and aims to identify common pitfalls including inadvertent monitoring of maternal heart rate as well as monitoring and interpretation of cardiotocograph of twin pregnancies in the second stage of labour. [4]

Differentiation of Hemodynamics of Top Athletes Depending on Heart Rate Variability after Training

Aims: To predict the functional status of the cardiorespiratory system of athletes based on results of responses to exercise.

Study Design: Case-control study.

Place and Duration of Study: Palace of Sports “Dynamo” in Lviv, between January and February 2016.

Methodology: 32 qualified waterpolo male athletes aged 20.6±3.0 years were examined. The research included the study of physical parameters, HR and BP by using routine methods and changes of these parameters during the first 3 minutes after the Martinet Test (1 hour before training) and also the study of cardiorespiratory system using SACR before and during the first 5 minutes after training in state of relative relax in the sitting position. To assess the research results we have used the distribution-free method of statistical analysis, using which we can evaluate the Wilcoxon and Mann-Whitney criteria, and also percentile method analysis based on determining the individual assessments of each indicators that take into consideration falling in appropriate limits of percentile ranges.

Results: Hypokinetic type of hemodynamic is observed in 64% of athletes (EG2) and in 88.2% of athletes (EG1). According to the parameters of central hemodynamic, describing the size of the left ventricle in athletes from EG2, significantly greater (p<0.01) is the end-diastolic volume (EDV)-116.3(107.1;118.8) cm3 and end-systolic volume (ESV)-37.2 (33.9;39.2) cm3 comparing to EDV 92.5(87.0;107.6) cm3 and ESV 27.1(22.4;33.7) cm3 in EG1. Significantly larger (p<0.05) was a stroke volume 78.7(72.5;79.8) cm3 comparing to 64.9 (61.6;77.1) cm3 in EG1.The rate of α-factor that characterizes the BRS and predicts the effectiveness of the regulation of cardiac pump function was significantly higher (p<0.01) with EG2: BRSLF: 19.8(17.3;22.1) versus 10.7(8.7;17.5), BRSHF in EG2: 25.4(17.0;29.7) comparing to 12.8(8.9;24.9) in EG1.

Conclusion: The research revealed that the mentioned features of changes in heart rate variability in the high-frequency range after training have rather accurate determinants in hemodynamic securing an athlete, which in turn can be used to predict and adequately assess the state of the athlete in the recovery period after the competition. [5]

Reference

[1] Tsuji, H., Venditti, F.J., Manders, E.S., Evans, J.C., Larson, M.G., Feldman, C.L. and Levy, D., 1996. Determinants of heart rate variability. Journal of the American College of Cardiology, 28(6), pp.1539-1546.

[2] Achten, J. and Jeukendrup, A.E., 2003. Heart rate monitoring. Sports medicine, 33(7), pp.517-538.

[3] Acharya, U.R., Joseph, K.P., Kannathal, N., Lim, C.M. and Suri, J.S., 2006. Heart rate variability: a review. Medical and biological engineering and computing, 44(12), pp.1031-1051.

[4] McDonnell, S. and Chandraharan, E. (2018) “Fetal Heart Rate Interpretation in the Second Stage of Labour: Pearls and Pitfalls”, Journal of Advances in Medicine and Medical Research, 7(12), pp. 957-970. doi: 10.9734/BJMMR/2015/17022.

[5] Guzii, O. and Romanchuk, A. (2017) “Differentiation of Hemodynamics of Top Athletes Depending on Heart Rate Variability after Training”, Journal of Advances in Medicine and Medical Research, 22(3), pp. 1-10. doi: 10.9734/JAMMR/2017/33619.

Latest News on Ischemic Stroke : Dec 2020

Risk factors and outcomes for ischemic stroke

Stroke continues to have a great impact on public health in the United States. Stroke is frequent, recurring, and is more often disabling than fatal. The annual incidence of new strokes in the United States is nearly one half million, with over 3 million stroke survivors alive today. Identifying risk factors for initial ischemic stroke, as well as characterizing the determinants of outcome (stroke recurrence and mortality) after ischemic stroke, is the basis for stroke prevention strategies. Modifiable and nonmodifiable risk factors for ischemic stroke have been identified and include age; gender; race/ethnicity; heredity; hypertension; cardiac disease, particularly atrial fibrillation; diabetes mellitus; hypercholesterolemia; cigarette smoking; and alcohol abuse. New risk factors, such as hypercoagulable states and patient foramen ovale, are currently being investigated. Follow-up studies have quantified case-fatality rates, early recurrence risk, and long-term mortality and recurrence risks. Despite advances in stroke prevention strategies and treatments, stroke recurrence is still the major threat to any stroke survivor. A major goal set by the Public Health Service in its National Health Promotion and Disease Prevention Objectives for the year 2000 is “to reduce stroke deaths to no more than 20 per 100,000.” Part of this can be achieved if the risk of stroke recurrence is reduced. However, the frequency and determinants of stroke recurrence are poorly understood. Data from epidemiologic studies can help identify risk factors and outcomes after ischemic stroke, as well as the selection of high-risk individuals for focused risk-factor modification. Current information on these topics is discussed. [1]

Morning increase in onset of ischemic stroke.

The time of onset of ischemic stroke was determined for 1,167 of 1,273 patients during the collection of data by four academic hospital centers between June 30, 1983, and June 30, 1986. More strokes occurred in awake patients from 10:00 AM to noon than during any other 2-hour interval. The incidence of stroke onset declined steadily during the remainder of the day and early evening. The onset of stroke is least likely to occur in the late evening, before midnight. [2]

Tissue Plasminogen Activator for Acute Ischemic Stroke

BACKGROUND

Thrombolytic therapy for acute ischemic stroke has been approached cautiously because there were high rates of intracerebral hemorrhage in early clinical trials. We performed a randomized, double-blind trial of intravenous recombinant tissue plasminogen activator (t-PA) for ischemic stroke after recent pilot studies suggested that t-PA was beneficial when treatment was begun within three hours of the onset of stroke.

METHODS

The trial had two parts. Part 1 (in which 291 patients were enrolled) tested whether t-PA had clinical activity, as indicated by an improvement of 4 points over base-line values in the score of the National Institutes of Health stroke scale (NIHSS) or the resolution of the neurologic deficit within 24 hours of the onset of stroke. Part 2 (in which 333 patients were enrolled) used a global test statistic to assess clinical outcome at three months, according to scores on the Barthel index, modified Rankin scale, Glasgow outcome scale, and NIHSS.

RESULTS

In part 1, there was no significant difference between the group given t-PA and that given placebo in the percentages of patients with neurologic improvement at 24 hours, although a benefit was observed for the t-PA group at three months for all four outcome measures. In part 2, the long-term clinical benefit of t-PA predicted by the results of part 1 was confirmed (global odds ratio for a favorable outcome, 1.7; 95 percent confidence interval, 1.2 to 2.6). As compared with patients given placebo, patients treated with t-PA were at least 30 percent more likely to have minimal or no disability at three months on the assessment scales. Symptomatic intracerebral hemorrhage within 36 hours after the onset of stroke occurred in 6.4 percent of patients given t-PA but only 0.6 percent of patients given placebo (P<0.001). Mortality at three months was 17 percent in the t-PA group and 21 percent in the placebo group (P = 0.30).

CONCLUSIONS

Despite an increased incidence of symptomatic intracerebral hemorrhage, treatment with intravenous t-PA within three hours of the onset of ischemic stroke improved clinical outcome at three months. [3]

Combined Intestinal Ischemia, Cerebral Stroke and Thrombosis of Thoracoabdominal Aorta and Splenic Artery in a Thrombophilic Woman: A Case Report

Aim: To present an uncommon, life-threatening case of intestinal ischemia complicated by cerebral stroke, thoraco-abdominal aorta and splenic artery thrombosis, in a woman with thrombophilia presenting common clinical signs.

 

Presentation of Case: A 42-year-old woman was admitted to hospital for lower abdominal pain, vomiting and fever. Emergency abdominal surgery evidenced intestinal ischemia requiring 80 cm ileum resection. The day following surgery, the patient lost consciousness and was admitted to the stroke unit. Thereafter, the patient was transferred to the intensive care unit due to respiratory failure. A brain-thoracic-abdominal CT-angiography showed occlusion of left medium cerebral artery, a thrombotic formation in thoracic and abdominal aorta, and partial occlusion of splenic artery. Homocysteine levels were 56.8mmol/l, screening for homozygosis mutation MTHFRC677T positive. Resolution of systemic thrombosis lasted one month. Patient was finally transferred to a rehabilitation center.

Discussion: Vascular disease and ischemic stroke have rarely been reported in subjects with thrombophilia and MTHFR polymorphisms. Our patient, affected by thrombophilia and high homocysteine levels, faced multiple vascular and cerebral complications. High concentration of homocysteine, with consequent vessel deposits, was detrimental for endothelium and vessel walls, due to action on blood coagulation factors and lipoproteins, with increased platelet adhesion and aggregation.

Conclusion: This case report represents an uncommon, sudden, life-threatening complication in thrombophilic patients, in spite of the common clinical signs presented. This clinical report should alert physicians to the importance of carrying out a careful clinical examination in the presence of thrombophilic patients presenting with apparently common clinical signs, such as abdominal pain, vomiting and fever. [4]

Ischemic Stroke: A Complication of Tuberculous Meningitis

We report a case of a 45-year old Hispanic male who was diagnosed with tuberculous meningitis (TBM) presented to the emergency department (ED) with altered mental status, confusion, and violent behavior. Computed tomography (CT) scan of the head was normal and repeated lumbar puncture (LP) did not yield new findings. Magnetic resonance imaging (MRI) of head showed multiple ischemic infarcts. Non-tPA stroke protocol was followed and anti-TB medicines were continued. With continuous cardiac monitoring, echocardiogram (ECHO) was normal so arrhythmia was less likely. Soon he was more responsive and alert with no further episodes of agitation and behavioral changes. Then, he was able to walk with assistance and was discharged to acute rehabilitation facility. [5]

Reference

[1] Sacco, R.L., 1995. Risk factors and outcomes for ischemic stroke. Neurology, 45(2 Suppl 1), p.S10.

[2] Marler, J.R., Price, T.R., Clark, G.L., Muller, J.E., Robertson, T., Mohr, J.P., Hier, D.B., Wolf, P.A., Caplan, L.R. and Foulkes, M.A., 1989. Morning increase in onset of ischemic stroke. Stroke, 20(4), pp.473-476.

[3] National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group, 1995. Tissue plasminogen activator for acute ischemic stroke. New England Journal of Medicine, 333(24), pp.1581-1588.

[4] Giordano, C., Penna, O., Amato, A., Bruno, R., Tripodi, V. F., Vadalà, E. G., Pennisi, N. C., Mondello, E. and Fodale, V. (2015) “Combined Intestinal Ischemia, Cerebral Stroke and Thrombosis of Thoracoabdominal Aorta and Splenic Artery in a Thrombophilic Woman: A Case Report”, Journal of Advances in Medicine and Medical Research, 10(12), pp. 1-7. doi: 10.9734/BJMMR/2015/20540.

[5] Azharuddin, M., Lalani, I., Du, D. and Ghali, W. (2016) “Ischemic Stroke: A Complication of Tuberculous Meningitis”, International Neuropsychiatric Disease Journal, 8(3), pp. 1-6. doi: 10.9734/INDJ/2016/29820.

News Update on Heart Failure Research: Jan – 2020

HFSA 2010 Comprehensive Heart Failure Practice Guideline.

Heart failure (HF) may be a syndrome characterized by high mortality, frequent hospitalization, reduced quality of life, and a posh therapeutic regimen. Knowledge about HF is accumulating so rapidly that individual clinicians could also be unable to readily and adequately synthesize new information into effective strategies of look after patients with this syndrome. Trial data, though valuable, often don’t give direction for individual patient management. These characteristics make HF a perfect candidate for practice guidelines. The 2010 coronary failure Society of America comprehensive practice guideline addresses the complete range of evaluation, care, and management of patients with HF. [1]

Epidemiology of heart failure

Analysis of 34 years of follow-up of Framingham Study data provides clinically relevant insights into the prevalence, incidence, secular trends, prognosis, and modifiable risk factors for the occurrence of coronary failure during a general population sample. coronary failure was found to be highly prevalent, affecting about 1% of persons in their 50s and rising progressively with age to afflict 10% of persons in their 80s. The annual incidence also increased with age, from about 0.2% in persons 45 to 54 years, to 4.0% in men 85 to 94 years, with the incidence approximately doubling with each decade aged. Women lagged slightly behind men in incidence in the least ages. Male predominance was due to a better rate of coronary heart condition, which confers a fourfold increased risk of coronary failure. coronary failure , once manifest, was highly lethal, with 37% of men and 33% of girls dying within 2 years of diagnosis. [2]

Cardiac Resynchronization in Chronic Heart Failure

BACKGROUND: Previous studies have suggested that cardiac resynchronization achieved through atrial-synchronized biventricular pacing produces clinical benefits in patients with coronary failure who have an intraventricular conduction delay. We conducted a double-blind trial to guage this therapeutic approach.

METHODS: Four hundred fifty-three patients with moderate-to-severe symptoms of coronary failure related to an ejection fraction of 35 percent or less and a QRS interval of 130 msec or more were randomly assigned to a cardiac-resynchronization group (228 patients) or to an impact group (225 patients) for 6 months, while conventional therapy for coronary failure was maintained. the first end points were the ny Heart Association functional class, quality of life, and therefore the distance walked in six minutes. [3]

Relationship of extracellular volume assessed on cardiac magnetic resonance and serum cardiac troponins and natriuretic peptides with heart failure outcomes

Measures of serum cardiac troponins and natriuretic peptides became established as prognostic coronary failure risk markers. additionally to detecting myocardial fibrosis through late gadolinium enhancement (LGE), extracellular volume fraction (ECV) measures by cardiac resonance (CMR) have emerged as a phenotypic imaging risk marker for incident coronary failure outcomes. We sought to look at the connection between cardiac troponins, natriuretic peptides, ECV and their associations with incident coronary failure events during a CMR referral base. Mid short axis T1 maps were divided into 6 cardiac segments, each classified as LGE absent or present. Global ECV was derived from T1 maps using the area-weighted average of only LGE-absent segments. ECV was considered elevated if measured >30%, the upper 95% bounds of a reference healthy group without known cardiac disease (n = 28). Patients were dichotomized by presence of elevated ECV. [4]

Dipeptidyl Peptidase-4 Inhibitors and Cardiovascular Risk: Retrospective Study of 50 Type 2 Diabetic Patients with Chronic Heart Failure

Objectives: the selection of antidiabetics in patients with coronary failure may be a major clinical concern. Some antidiabetic agents like thiazolidinediones, more or less sulfonamides and insulin increase the danger of exacerbation of coronary failure . there’s controversy with reference to the cardiovascular risk related to dipeptidyl peptidase-4 (DPP-4) inhibitors. The aim of this study was to guage the cardiovascular risk in patients with diabetes and coronary failure treated with these medications.

Patients and methods: A retrospective study was administered from January 2014 to April 2015 at the Centre Hospitalier de Haguenau. The frequency of re-hospitalizations was studied (primary endpoint), because the duration of hospitalization and death in patients with type 2 diabetes and coronary failure . Patients were divided into 2 groups, those treated with DPP-4 inhibitors (cases) and people not treated with DPP-4 inhibitors (controls). [5]

Reference

[1] Lindenfeld, J., Albert, N.M., Boehmer, J.P., Collins, S.P., Ezekowitz, J.A., Givertz, M.M., Katz, S.D., Klapholz, M., Moser, D.K., Rogers, J.G. and Starling, R.C., 2010. HFSA 2010 comprehensive heart failure practice guideline. Journal of cardiac failure, 16(6), (Web Link)

[2] Kannel, W.B. and Belanger, A.J., 1991. Epidemiology of heart failure. American heart journal, 121(3), (Web Link)

[3] Abraham, W.T., Fisher, W.G., Smith, A.L., Delurgio, D.B., Leon, A.R., Loh, E., Kocovic, D.Z., Packer, M., Clavell, A.L., Hayes, D.L. and Ellestad, M., 2002. Cardiac resynchronization in chronic heart failure. New England Journal of Medicine, 346(24), (Web Link)

[4] Relationship of extracellular volume assessed on cardiac magnetic resonance and serum cardiac troponins and natriuretic peptides with heart failure outcomes
Eric Y. Yang, Mohammad A. Khan, Edward A. Graviss, Duc T. Nguyen, Arvind Bhimaraj, Vijay Nambi, Ron C. Hoogeveen, Christie M. Ballantyne, William A. Zoghbi & Dipan J. Shah
Scientific Reports volume 9, (Web Link)

[5] Assene, N., Hassler, P., Deharvengt, C., Jingi, A., Gladin, M. and Andrès, E. (2017) “Dipeptidyl Peptidase-4 Inhibitors and Cardiovascular Risk: Retrospective Study of 50 Type 2 Diabetic Patients with Chronic Heart Failure”, Journal of Advances in Medicine and Medical Research, 20(11), (Web Link)

Latest Research News on Pulmonary Artery: Jan – 2020

CT-determined pulmonary artery diameters in predicting pulmonary hypertension.

This study was to work out if the diameters of pulmonary arteries measured from computed tomographic (CT) scans might be used 1) as indicators of arteria pulmonalis hypertension and 2) as a reliable base for calculating mean arteria pulmonalis pressure. The diameters of the most , left, proximal right, distal right, interlobar, and left descending pulmonary arteries were measured from CT scans in 32 patients with cardiopulmonary disease and in 26 age- and sex-matched control subjects. Diameters were measured employing a special computer virus that would display a CT density profile of the artery and its adjacent tissues. The upper limit of normal diameter for the most arteria pulmonalis was found to be 28.6 mm (mean + 2 SD). within the patient group, the diameters were correlated with data from cardiac catheterization. In these patients, a diameter of the most arteria pulmonalis above 28.6 mm readily predicted the presence of pulmonary hypertension. [1]

Transplantation of a Tissue-Engineered Pulmonary Artery

To the Editor: Various vascular grafts are commonly utilized in the reconstruction of cardiovascular tissues. However, prosthetic or bioprosthetic materials lack growth potential and thus in children require replacement because the children grow. Tissue engineering offers the potential to make replacement structures from autologous cells and biodegradable polymer scaffolds. Since they contain living cells, these structures have the potential to grow, to repair themselves, and to transform themselves.14 A four-year-old girl had been found to possess one ventricle and pulmonary atresia and had undergone pulmonary-artery angioplasty and therefore the Fontan procedure at the age of three years, three. [2]

Prognostic value of pulmonary artery pressure in chronic obstructive pulmonary disease.

In 175 patients with chronic obstructive lung disease (157 chronic bronchitic and 18 emphysematous patients) exhibiting moderate to severe airway obstruction (mean FEV1/vital capacity = 40.2 11.1%), cumulative survival rates calculated by the actuarial method were compared in subgroups consistent with the initial level of mean arteria pulmonalis pressure, pulmonary volumes, and blood gases. Patients were catheterised between 1968 and 1972 and were followed for a minimum of five years. The results emphasise the high prognostic value of PAP since survival rates after four and 7 years were significantly lower within the subgroup with PAP greater than 20 mmHg (2.7 kPa). Certain other parameters (“driving” pressure across the circulation , FEV1 and Paco2) appear to be equally good at predicting survival as PAP in these obstructed patients. [3]

Health risk stratification based on computed tomography pulmonary artery obstruction index for acute pulmonary embolism

Early effective identification of high-risk patients for acute embolism (APE) contributes to timely treatment. The arteria pulmonalis obstruction index (PAOI) in computerized tomography angiography (CTA) may be a semi-quantitative observation index, commonly wont to evaluate the severity of a patient’s condition. This study explores the power of PAOI to assess the danger stratification of APE. Thirty patients with APE were analysed. They were classified consistent with the rules , and therefore the PAOI and cardiovascular parameters were measured in CTA. The difference of PAOI between different risk stratification patients was compared, and therefore the predictive value of the PAOI for high-risk stratification was evaluated by the receiver operating characterisic function. [4]

Coexistence of Sarcoidosis and Tuberculosis Presenting with Severe Pulmonary Artery Hypertension: A Clinical Dilemma

Background: Chronic granulomatous conditions affecting the systema respiratorium like tuberculosis and sarcoidosis have similar case presentations suggesting them to be polar ends of an equivalent disease spectrum thus putting physicians into a clinical dilemma. This case report highlights one such unique presentation.

Case Presentation: A young female, presented with respiratory distress and significant weight loss. Investigations showed severe arteria pulmonalis hypertension (PAH), kidney failure and generalized lymphadenopathy suggesting multisystem involvement. The initial diagnosis was sarcoidosis warranting corticosteroids but since Mantoux test suggested tuberculosis we were during a dilemma regarding therapeutic options. [5]

Reference

[1] Kuriyama, K.E.I.K.O., Gamsu, G.O.R.D.O.N., Stern, R.G., Cann, C.E., Herfkens, R.J. and Brundage, B.H., 1984. CT-determined pulmonary artery diameters in predicting pulmonary hypertension. Investigative radiology, 19(1), (Web Link)

[2] Shin’oka, T., Imai, Y. and Ikada, Y., 2001. Transplantation of a tissue-engineered pulmonary artery. New England Journal of Medicine, 344(7), (Web Link)

[3] Weitzenblum, E., Hirth, C., Ducolone, A., Mirhom, R., Rasaholinjanahary, J. and Ehrhart, M., 1981. Prognostic value of pulmonary artery pressure in chronic obstructive pulmonary disease. Thorax, 36(10), (Web Link)

[4] Health risk stratification based on computed tomography pulmonary artery obstruction index for acute pulmonary embolism
Fei Guo, Guanghui Zhu, Junjie Shen & Yichuan Ma
Scientific Reports volume 8, (Web Link)

[5] Bhagwat, B. and Thyagaraj, V. (2018) “Coexistence of Sarcoidosis and Tuberculosis Presenting with Severe Pulmonary Artery Hypertension: A Clinical Dilemma”, Journal of Advances in Medicine and Medical Research, 26(7), (Web Link)