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Air travel and adults with cyanotic congenital heart disease
IN C O N S U L T A T I O N
been the focus of much clinical debate. This is particularly so in patients with underlying cardiac and pulmonary disease, because these disorders frequently cause low-probability lung scans in the absence of pulmonary embolism. Historically, the clinical response has been to exclude pulmonary embolism and withhold treatment on the basis of a lowprobability lung scan, which has been regarded as synonymous with a good prognosis. Methods: A prospective cohortanalytic study to evaluate prognosis, using long-term followup, in patients with inadequate cardiorespiratory reserve who have presented with suspected pulmonary embolism (inadequate cardiorespiratory reserve, ie, pulmonary edema, right-ventricular failure, hypotension, syncope, acute tachyarrhythmia, abnormal spirometry [forced expiratory volume in 1 second, <1.0, or ~qtal capacity, <1.5 L], or abnormal arterial blood gases [PO2, <50 mm Hg, or PCO 2 >45 mm Hg]). Results: The outcomes of the 77 consecutive patients with low-probability lung scans, suspected pulmonary embolism, and inadequate cardiorespiratory reserve were compared with those in 711 consecutive patients with good cardiorespiratory reserve and nondiagnostic lung scans who were entered into the study over the same period of time. Six (7.8%) of the 77 patients died within days of entry with autopsy-proven pulmonary embolism compared with one (0.14%) of the 711 patients with nondiagnostic lung scans (P < .0001). Conclusions: Our findings indicate that the term low-probability lung scan should be abandoned in reference to patients with inadequate cardiorespiratory reserve, because it is not synonymous with a good prognosis and is, indeed, misleading.
No one should use nicotinic acid in these doses without continued careful supervision of a physician.
Air Travel and Adults With Cyanotic Congenital Heart Disease Eric Harinck, Paul A. Hutter, Iheo M. Hoorntje,MarinusSimons,Avram A. Benatar, ]ohan C. Fischer,Dagmar de Bruijn, Erik Jan Meijboom.WilhelminaUniversity Children'sHospital,Utrecht, Netherlands.Circulation1996;93:272-6. Background: Concern has been expressed that a reduction of partial oxygen pressure during flight in commercial aircraft may induce dangerous hypoxemia in patients with cyanotic congenital heart disease. Methods and Results: To evaluate the validity of this concern, the t r a n s c u t a n e o u s Sao2 was measured in 12 adults with this type of heart disease and 27 control subjects during simulated commercial flights of 1.5 and 7 hours in a hypobaric chamber. Ten of those patients and 6 control subjects also were evaluated during two actual flights of approximately 2.5 hours in a DC-10 and an A-310, respectively. During the prolonged simulated and actual flights, the capillary blood pH, gases, and lactic acid were analyzed in the patients and during one of the actual flights also in the control subjects. During the simulated flights the S a o 2 w a s at all times lower in the patients than in the control subjects. However, the maximal mean actual percentage decrease, as compared with sea level values, did not exceed 8.8% in either patients or control subjects. During the actual flights, this maximal decrease in the patients was 6%. Inflight reduction of the capillary Po 2 was considerable in the control subjects but not in the patients. It is our hypothesis that the lack of a significant decrease of the Po x in the patients might possibly be due to a high concentration of 2.3 diphosphoglycerate in the red cells. The flights had no influence on the capillary blood pH, Pco 2, bicarbonate, or lactic acid levels in either patients or control subjects. Conclusions: Atmospheric pressure changes during commercial air travel do not appear to be detrimental to patients with cyanotic congenital heart disease.
The Prevalence of Side Effects With Regular and Sustained-Release Nicotinic Acid L.W. Gibbons,V. Gonzalez,N. Gordon, S. Grundy.CooperClinic,Dallas,TX. Am J Med 1995;99:378-85. Purpose: To document the prevalence and nature of the side effects that occur with the use of regular and sustainedrelease nicotinic acid in everyday clinical practice. Patients and Methods: One hundred and ten patients seen in a private medical clinic who were given 133 separate trials o f nicotinic acid during a 5-year period. The occurrence of side effects, particularly those severe enough to warrant discontinuing the drug, were carefully monitored. Results: Forty-three percent of individuals given regular nicotinic acid and 42% of those given sustained-release nicotinic acid were forced to discontinue the medication because of side effects; some of these side effects necessitating discontinuing nicotinic acid did not occur until the patient had been taking the drug for 1 or 2 years. Conclusion: Nicotinic acid in both regular and sustained-release forms is a powerful drug when used in doses needed to treat lipid disorders and causes disturbing side effects a very high percentage of the time.
The Role of the "Pericardial Window" in AIDS D.R. Flum,].T. McGinnJr., D.H. Tyras. Divisionof CardiothoracicSurgery,Department of Surgery,St. Vincent'sHospital/MedicalCenter, New York, NY. Chest 1995;107: 1522-5. Background: The leading cause of pericardial effusion in urban hospitals is now AIDS-related pathologies. Clinically, these effusions are a diagnostic and management dilemma. In our institution, pericardial biopsy and operative drainage have become part of the diagnostic and management plan. Surgical intervention, however, has appeared to have little clinical impact. Methods: A retrospective review was conducted of all patients (n = 29) diagnosed as having AIDS who underwent "pericardial window" for pericardial effusions from 1986 to 1994. Results: Fluid cultures and peri-
ACC CURRENTJOURNAL REVIEW May/June 1996
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been the focus of much clinical debate. This is particularly so in patients with underlying cardiac and pulmonary disease, because these disorders frequently cause low-probability lung scans in the absence of pulmonary embolism. Historically, the clinical response has been to exclude pulmonary embolism and withhold treatment on the basis of a lowprobability lung scan, which has been regarded as synonymous with a good prognosis. Methods: A prospective cohortanalytic study to evaluate prognosis, using long-term followup, in patients with inadequate cardiorespiratory reserve who have presented with suspected pulmonary embolism (inadequate cardiorespiratory reserve, ie, pulmonary edema, right-ventricular failure, hypotension, syncope, acute tachyarrhythmia, abnormal spirometry [forced expiratory volume in 1 second, <1.0, or ~qtal capacity, <1.5 L], or abnormal arterial blood gases [PO2, <50 mm Hg, or PCO 2 >45 mm Hg]). Results: The outcomes of the 77 consecutive patients with low-probability lung scans, suspected pulmonary embolism, and inadequate cardiorespiratory reserve were compared with those in 711 consecutive patients with good cardiorespiratory reserve and nondiagnostic lung scans who were entered into the study over the same period of time. Six (7.8%) of the 77 patients died within days of entry with autopsy-proven pulmonary embolism compared with one (0.14%) of the 711 patients with nondiagnostic lung scans (P < .0001). Conclusions: Our findings indicate that the term low-probability lung scan should be abandoned in reference to patients with inadequate cardiorespiratory reserve, because it is not synonymous with a good prognosis and is, indeed, misleading.
No one should use nicotinic acid in these doses without continued careful supervision of a physician.
Air Travel and Adults With Cyanotic Congenital Heart Disease Eric Harinck, Paul A. Hutter, Iheo M. Hoorntje,MarinusSimons,Avram A. Benatar, ]ohan C. Fischer,Dagmar de Bruijn, Erik Jan Meijboom.WilhelminaUniversity Children'sHospital,Utrecht, Netherlands.Circulation1996;93:272-6. Background: Concern has been expressed that a reduction of partial oxygen pressure during flight in commercial aircraft may induce dangerous hypoxemia in patients with cyanotic congenital heart disease. Methods and Results: To evaluate the validity of this concern, the t r a n s c u t a n e o u s Sao2 was measured in 12 adults with this type of heart disease and 27 control subjects during simulated commercial flights of 1.5 and 7 hours in a hypobaric chamber. Ten of those patients and 6 control subjects also were evaluated during two actual flights of approximately 2.5 hours in a DC-10 and an A-310, respectively. During the prolonged simulated and actual flights, the capillary blood pH, gases, and lactic acid were analyzed in the patients and during one of the actual flights also in the control subjects. During the simulated flights the S a o 2 w a s at all times lower in the patients than in the control subjects. However, the maximal mean actual percentage decrease, as compared with sea level values, did not exceed 8.8% in either patients or control subjects. During the actual flights, this maximal decrease in the patients was 6%. Inflight reduction of the capillary Po 2 was considerable in the control subjects but not in the patients. It is our hypothesis that the lack of a significant decrease of the Po x in the patients might possibly be due to a high concentration of 2.3 diphosphoglycerate in the red cells. The flights had no influence on the capillary blood pH, Pco 2, bicarbonate, or lactic acid levels in either patients or control subjects. Conclusions: Atmospheric pressure changes during commercial air travel do not appear to be detrimental to patients with cyanotic congenital heart disease.
The Prevalence of Side Effects With Regular and Sustained-Release Nicotinic Acid L.W. Gibbons,V. Gonzalez,N. Gordon, S. Grundy.CooperClinic,Dallas,TX. Am J Med 1995;99:378-85. Purpose: To document the prevalence and nature of the side effects that occur with the use of regular and sustainedrelease nicotinic acid in everyday clinical practice. Patients and Methods: One hundred and ten patients seen in a private medical clinic who were given 133 separate trials o f nicotinic acid during a 5-year period. The occurrence of side effects, particularly those severe enough to warrant discontinuing the drug, were carefully monitored. Results: Forty-three percent of individuals given regular nicotinic acid and 42% of those given sustained-release nicotinic acid were forced to discontinue the medication because of side effects; some of these side effects necessitating discontinuing nicotinic acid did not occur until the patient had been taking the drug for 1 or 2 years. Conclusion: Nicotinic acid in both regular and sustained-release forms is a powerful drug when used in doses needed to treat lipid disorders and causes disturbing side effects a very high percentage of the time.
The Role of the "Pericardial Window" in AIDS D.R. Flum,].T. McGinnJr., D.H. Tyras. Divisionof CardiothoracicSurgery,Department of Surgery,St. Vincent'sHospital/MedicalCenter, New York, NY. Chest 1995;107: 1522-5. Background: The leading cause of pericardial effusion in urban hospitals is now AIDS-related pathologies. Clinically, these effusions are a diagnostic and management dilemma. In our institution, pericardial biopsy and operative drainage have become part of the diagnostic and management plan. Surgical intervention, however, has appeared to have little clinical impact. Methods: A retrospective review was conducted of all patients (n = 29) diagnosed as having AIDS who underwent "pericardial window" for pericardial effusions from 1986 to 1994. Results: Fluid cultures and peri-
ACC CURRENTJOURNAL REVIEW May/June 1996
66