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<recommendedContent xmlns="http://api.mspoke.com">
    <recommendedItem id="20100101_19_218"
                     title="Even Mild COPD Affects the Heart (CME/CE)"
                     score="-0.002"
                     href="http://www.medpagetoday.com/Pulmonology/SmokingCOPD/tb/18070?impressionId=1265790294965"
                     
      Chronic lung disease begins to affect cardiac function at even mild levels of emphysema, data from a large prospective cohort study showed.&lt;br&gt;
&lt;br&gt;A 10-point increase in percent emphysema by lung CT had a linear inverse relationship with left ventricular end-diastolic volume (LVEDV), stroke volume, and cardiac output (&lt;em&gt;P&lt;/em&gt;&amp;lt;0.001 for all parameters), researchers reported in the Jan. 21 issue of the &lt;em&gt;New England Journal of Medicine&lt;/em&gt;.&lt;br&gt;
&lt;br&gt;Current smoking status increased the magnitude of the association compared with former smokers and nonsmokers, the researchers found.&lt;br&gt;
&lt;br&gt;Left ventricular ejection fraction did not change with increasing percent of emphysema and airflow obstruction.&lt;br&gt;
&lt;br&gt;&quot;Previously, it has been well known that in very severe lung disease, the damage to the lungs affects heart function,&quot; lead author R. Graham Barr, MD, of Columbia University in New York, said in an interview.&lt;p&gt;&lt;/p&gt;
&lt;p&gt;&quot;What we have shown is that a similar physiology, a similar relationship, would appear to extend up and down the spectrum of lung disease from mild, subclinical COPD and emphysema, all the way to moderately severe lung disease.&quot;&lt;/p&gt;
&lt;p&gt;Severe COPD can lead to cor pulmonale, characterized by increased vascular resistance and right heart failure, accompanied by reduced left ventricular filling, left ventricular stroke volume, and cardiac output.&lt;/p&gt;
&lt;p&gt;However, left ventricular ejection fraction (LVEF) usually is preserved. Whether similar changes occurred with less severe COPD had not been determined, and examining that question was the principal objective of the study by Barr and colleagues.&lt;/p&gt;
&lt;p&gt;The study population comprised a subgroup of patients enrolled in the Multi-Ethnic Study of Atherosclerosis (MESA), which is exploring the prevalence, correlates, and progression of subclinical cardiovascular disease. The MESA Lung Study comprised 2,816 MESA participants who underwent cardiac MRI assessment of left ventricular structure and function.&lt;/p&gt;
&lt;p&gt;Investigators in the lung study excluded patients who had a restrictive pattern on spirometry, defined as a forced vital capacity (FVC) below the lower limit of normal and an FEV&lt;sub&gt;1&lt;/sub&gt;:FVC ratio &amp;gt;0.7.&lt;/p&gt;
&lt;p&gt;Information collected for the lung study included patient demographics, smoking history, medical history, level of physical activity, height, weight, resting blood pressure, serum glucose, C-reactive protein, and fibrinogen levels.&lt;/p&gt;
&lt;p&gt;Extent of emphysema was calculated from lung fields of cardiac CT scans, which included 70% of the lung volume from the carina to the base. Investigators defined extent of emphysema as the percentage of voxels below -910 Hounsfield units in the lung windows of cardiac CT scans.&lt;/p&gt;
&lt;p&gt;Participants who smoked at least one cigarette in the 30 days before CT or who had urinary cotinine levels &amp;gt;100 ng/mL were classified as current smokers.&lt;/p&gt;
&lt;p&gt;The mean age of the lung population was 61, and 51% were women. Current smokers accounted for 13% of the participants, former smokers for 38%, and nonsmokers for 49%. LVEF averaged about 70%.&lt;/p&gt;
&lt;p&gt;Mean spirometric measures were normal, as were measures of left ventricular structure and function. Median percent emphysema was 15%. Comparison of percent emphysema with left ventricular measures showed that a 10-point increase in percent emphysema was associated with a: &lt;ul&gt; &lt;li&gt;4.1 mL decrement in LVEDV&lt;/li&gt; &lt;li&gt;2.7 mL decrement in stroke volume&lt;/li&gt; &lt;li&gt;0.19 L/min decrement in cardiac output&lt;/li&gt; &lt;/ul&gt;&lt;/p&gt;
&lt;p&gt;The investigators observed no evidence of an association between percent emphysema and LVEF, reflected in a 0.02-point mean increase with each 10-point increase in extent of emphysema.&lt;/p&gt;
&lt;p&gt;Smoking status significantly influenced associations of percent emphysema with LVEDV (&lt;em&gt;P&lt;/em&gt;&amp;lt;0.001 for interaction) and stroke volume (&lt;em&gt;P&lt;/em&gt;=0.008 for interaction).&lt;/p&gt;
&lt;p&gt;The magnitude of the association was greater among smokers than former smokers, and greater among former smokers than nonsmokers. However, the associations were evident in smokers and nonsmokers alike.&lt;/p&gt;
&lt;p&gt;&quot;The apparent effect of emphysema on left ventricular end-diastolic volume and cardiac output was similar to that of traditional cardiac risk factors previously reported in MESA and, among smokers, was greater than that of traditional cardiac risk factors,&quot; the authors wrote.&lt;/p&gt;
&lt;p&gt;The linearity of associations across the study population &quot;suggests that even early-stage COPD influences stroke volume and left ventricular size,&quot; Anton Vonk-Noordegraaf, MD, of Vrije University Medical Center in Amsterdam, wrote in an accompanying editorial.&lt;/p&gt;
&lt;p&gt;&quot;Since oxygen delivery is directly related to cardiac output, a lower cardiac output in patients with COPD leads to impaired oxygen delivery,&quot; Vonk-Noordegraaf continued.&lt;/p&gt;
&lt;p&gt;&quot;Although the effects on cardiac output were small in this study population, they may be more pronounced in severe cases of emphysema and during exercise, as has been shown previously. The question is whether the striking clinical resemblance between COPD and chronic heart failure can be explained in part by a factor both diseases have in common: decreased cardiac output.&quot;&lt;/p&gt;
&lt;div style=&quot;float:left;border-style:solid;border-width:1px;border-color:#8dabbc;font-family:arial;font-size:12px;background-color:#DBE9F2;padding:5px;&quot;&gt;&lt;p&gt;Co-author Paul L. Enright disclosed relationships with Pfizer and Gilead.&lt;/p&gt;&lt;p&gt;Coauthor Eric A. Hoffman disclosed relationships with VIDA Diagnostics, sanofi-aventis, AstraZeneca, and Chiesi Pharmaceuticals.&lt;/p&gt;&lt;p&gt;Coauthor Kawut disclosed a relationship with Pfizer.&lt;/p&gt;&lt;p&gt;Co-author Jo&amp;#227;o A. C. Lima disclosed relationships with Toshiba Medical Systems and General Electric.&lt;/p&gt;&lt;p&gt;Co-author Lewis J. Smith disclosed relationships with Merck and KarmelSonix.&lt;/p&gt;&lt;p&gt;Vonk-Noordegraaf had no disclosures.&lt;/p&gt;&lt;/div&gt;&lt;div style=&quot;clear:both;&quot;&gt;&lt;/div&gt;
    </recommendedItem>
    <recommendedItem id="20090101_19_680"
                     title="Inhaling Helium Boosts COPD Pulmonary Rehabilitation"
                     score="-0.005"
                     href="http://www.medpagetoday.com/Pulmonary/SmokingCOPD/tb/13143?impressionId=1265790294965"
                     
      CALGARY, Alberta, March 5 -- For decades, scientists and youngsters at birthday parties have known that breathing helium has one powerful but short-lived side effect: it makes your voice sound like Donald Duck.
              &lt;p&gt; 
              &lt;p&gt;Now there&apos;s a more useful application: researchers here say that breathing a heady mix of helium and oxygen may boost pulmonary rehabilitation for patients with chronic obstructive pulmonary disease (COPD).
              &lt;p&gt; 
              &lt;p&gt;Patients who breathed 60% helium and 40% oxygen during rehabilitation were able to exercise longer and harder throughout the program compared with those who breathed normal air (&lt;em&gt;P&lt;/em&gt;&amp;lt;0.05), Neil D. Eves, Ph.D., of the University of Calgary here, and colleagues reported in the March issue of &lt;em&gt;Chest&lt;/em&gt;.
              &lt;p&gt; 
              &lt;p&gt;The standard mix of gases in the air is dominated by nitrogen (78%) with 21% oxygen and only a trace of helium. 
              &lt;p&gt; 
              &lt;p&gt;Providing extra oxygen reduces demand on the lungs while replacing the other gases with lighter-than-air helium cuts down on the problem of expiratory flow limitation to ease exhalation, Dr. Eves&apos; group said.
              &lt;p&gt; 
              &lt;p&gt;In an accompanying editorial, Roger S. Goldstein, M.D., and Thomas E. Dolmage, both of the West Park Healthcare Center in Toronto, called the intervention a creative and promising way to reduce the load on the lungs to reduce dyspnea during training.
              &lt;p&gt; 
              &lt;p&gt;&quot;Although pulmonary rehabilitation improves symptoms and quality of life, it is challenging for most COPD patients to train at levels sufficiently high to improve peak oxygen uptake,&quot; they wrote.
              &lt;p&gt; 
              &lt;p&gt;But it remains to be seen whether helium is better than supplemental oxygen, a nitrogen-oxygen gas mixture, a ventilator to take over some of the work of breathing, or a training program with short bursts of intense exercise, they added.
              &lt;p&gt; 
              &lt;p&gt;&quot;The possibility of longer term improvements in health risk and even mortality, in keeping with the rationale for most fitness programs, makes pursuing this theme worthwhile,&quot; Dr. Goldstein and Dolmage said.
              &lt;p&gt; 
              &lt;p&gt;So Dr. Eves&apos; group randomized 38 nonhypoxemic patients with stable COPD to a pulmonary rehabilitation program in which they breathed either normal room air or a mix of 60% helium and 40% oxygen.
              &lt;p&gt; 
              &lt;p&gt;They exercised with 30 minutes of cycling, three days per week for six weeks at an intensity level that increased as they were able to tolerate it.
              &lt;p&gt; 
              &lt;p&gt;Patients breathed their designated gas through a tightly sealed mask supplied by a bag hung from the ceiling above. They weren&apos;t allowed to talk during or shortly after their exercise, lest the high-pitched voices of the helium give them away and unblind the intervention.
              &lt;p&gt; 
              &lt;p&gt;For the primary outcome, exercise tolerance rose in both groups. But by the end of the study, the helium group had a significantly greater change in constant-load exercised time than the regular air breathers (9.5 versus 4.3 minutes, &lt;em&gt;P&lt;/em&gt;=0.047). 
              &lt;p&gt; 
              &lt;p&gt;Likewise, substantially more patients in the helium-oxygen group were able to achieve a clinically relevant improvement of 1 minute, 45 seconds or more. 
              &lt;p&gt; 
              &lt;p&gt;The helium-oxygen group also showed higher oxygen consumption at peak incremental exercise (16.3 versus 14.2 mL/kg/minute, &lt;em&gt;P&lt;/em&gt;&amp;lt;0.001), and they worked at a higher output rate (86 versus 74 W, &lt;em&gt;P&lt;/em&gt;&amp;lt;0.001) without a difference in exertional symptoms or heart rate.
              &lt;p&gt; 
              &lt;p&gt;Patients who breathed the helium mix showed a clinically meaningful improvement in health-related quality of life, measured on the St. George Respiratory Questionnaire, compared with those who breathed air (change  -7.6 versus -3.6 points, &lt;em&gt;P&lt;/em&gt;&amp;lt;0.05).
              &lt;p&gt; 
              &lt;p&gt;Peak exercise exertional symptoms were similar between groups. For the same exercise time, patients who breathed helium and oxygen had a decrease in leg discomfort not seen in the air group, but without any significant differences between treatment groups.
              &lt;p&gt; 
              &lt;p&gt;One potential downside: researchers noted that the helium-oxygen mix -- at about $190 per patient for six weeks -- is more expensive than supplemental oxygen alone.  The large suspension bags of gas also complicate the treatment regimen.
              &lt;p&gt; 
              &lt;p&gt;Given this proof-of-concept, the researchers concluded that a larger randomized trial with cost-benefit analysis is needed to compare the helium treatment with supplemental oxygen in a real-world pulmonary rehabilitation setting.
              &lt;p&gt; 
              &lt;p&gt;&lt;table cellspacing=&quot;0&quot; hspace=&quot;1&quot; style=&quot;border-style:solid; border-width:1px; border-color:#8dabbc; font-family:arial; font-size:12px; background-color:#DBE9F2; padding:5px 5px 5px 5px;&quot;&gt;
&lt;tr&gt;&lt;td&gt;The study was funded by the Medical Services Incorporated Foundation and the Caritas Health Group.
              &lt;p&gt; 
              &lt;p&gt;One author reported conflicts of interest for GlaxoSmithKline, Altana Pharma, AstraZeneca, and Boehringer Ingelheim, Pfizer, and Abbott. 
              &lt;p&gt; 
              &lt;p&gt;The editorialists reported no conflicts of interest.&lt;/td&gt;&lt;/tr&gt;&lt;/table&gt;
         
    </recommendedItem>
    <recommendedItem id="20090101_3_677"
                     title="Exercise and Respiratory Training Ease Life With Pulmonary Hypertension"
                     score="-0.005"
                     href="