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Posts Tagged ‘chest’

                                  Even as cardiology community is preoccupied with systemic hypertension & CAD  ,  pulmonary arterial hypertension(PAH) is a much neglected , still  an important clinical cardiac problem encountered . The irony is self evident , there are half a dozen methods to grade systemic hypertension not even a single stadardised grading available for pulmonary arterial hypertension. The WHO  working group defined pulmonary hypertension  few decades ago and was not clinically graded .The only grading available is based on  the pulmonary vascular biopsy changes (Heath Edwards) 

                                   Currently PAH management has gone through revolutionary changes. There is an urgent  need for grading  this entity .This will facilitate to  diagnose , manage and assess the efficacy of the currently available treatment.

                                Developing countries like ours have a great number of PAH due to rampant rheumatic heart disease.  A simple study was done in  100 patients with PAH .Bulk of the study population had RHD .Few had primary pulmonary  hypertension .Systolic , diastolic, and mean pressure was assessed by doppler echocardiographic analysis of tricuspid regurgitation (TR) and pulmonary regurgitaion(PR) jets. TR jet provided the systolic PA pressure , PR jet provided mean as well as diastolic PA pressure .TR jet was available in all patients. PR jet was available only in 60 patients .Hence the diastolic andmean PA pressure data has been extrapolated in some  and  was plotted in a scatter diagram. Five equal quintiles were divided. Patients in first  and 2nd quintiles were graded 1   and third  and 4th  quintile were  graded 2 ,  5 th  was graded 3 respectively. From this cut off points for  various grades of PAH were identified .The top 3% of patients  with highest PAP were graded as grade 4 and all of them had supra systemic PAH. 

The following grading is suggested for PAH* 

 *This is a preliminary  attempt to grade PAH. This could be applicable mainly in rheumatic heart disese and primary pulmonary hypertension .Further refining of methodology is  required.PAH grading may be little different in congenital left to right shunts.

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                                 The pleura and pericardium are very close anatomical companions within the thorax. Both contain minimal levels of physiological fluid.  It is quiet common to find combined pleural and pericardial  effusion. While the commonest explanation for combination of pleural and pericardial effusion is inflammation of both  in systemic disorders like polyserositis or malignancy . In cardiac failure also both effusions can  occur explained by raised venous pressure.

But there has always been a curious relationship between these two spaces.

                         Is there a antomical or physiological link between these two spacs ?  In fact a large pleural effusion some times result in sympathetic pericardial  effusion.  Tapping of pleural effusion may regress this pericardial fluid as well.

                         This is purely a clinical observation and needs an explanation .It is  believed , there is  some  non functional lymphatic channels shared between pericardial  and pleural spaces.This may get opened up in pathology of either of them.

 

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