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загадка "одышка "

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Pawel Hertz
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Re: загадка "одышка "

Сообщение Pawel Hertz » Пт авг 17, 2018 12:47 am

Pyankov Vasily писал(а):
Пт авг 17, 2018 12:28 am
Не совсем логичный путь к диагнозу. Невизуализирующий стресс-тест в 72 года с одышкой при физ. нагрузке?! Интересно, что явилось причиной DVT? Вторичная тромбофилия? Онкопатологии не выявлено?

P.S. Артемий! Какой бы диагностический алгоритм выбрали Вы у данного пациента?
Reason at the moment unknown. He is under procedure and because he was "mine" from the beginning I decidet to take whole package tests: Total CT with contrast (caput, abdomen, thorax already taken), gastroscopy, colonoscopy, PSA, Thyroidea sonography... These are ambulatory tests and he is under examination when I am on vacation now :D We, in Norway take no thrombophylia tests on patient over 50. Normal, we do not take so thoroughly examination in all as well. This is disscusssed individually on the plenum and there is no standards in Norway on it now
Последний раз редактировалось Pawel Hertz Пт авг 17, 2018 10:02 am, всего редактировалось 2 раза.

Pawel Hertz
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Re: загадка "одышка "

Сообщение Pawel Hertz » Пт авг 17, 2018 1:02 am

AOkhotin писал(а):
Пт авг 17, 2018 12:03 am
Impressive images. Had you performed thrombolysis?
One can argue but we in Norway do not undertake thrombolysis if patient is not hemodynamicly affected and he (it was a man) wasn't. In Germany they do trhombolysis if hemodynamic is affected or right ventricle overloaded

sokolov166
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Re: загадка "одышка "

Сообщение sokolov166 » Пт авг 17, 2018 2:59 am

Thank you Pawel, your case for teaching... 175w... 60 km i wouldn't worry about at any time. But you had patient face-to face and many good ideas. And what will be in his future life?
Александр Соколов

Pawel Hertz
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Re: загадка "одышка "

Сообщение Pawel Hertz » Пт авг 17, 2018 9:58 am

sokolov166 писал(а):
Пт авг 17, 2018 2:59 am
Thank you Pawel, your case for teaching... 175w... 60 km i wouldn't worry about at any time. But you had patient face-to face and many good ideas. And what will be in his future life?
Thank you. It wass lesson for me also. Suddenly I asked myself: "What is the reason at this optimistic and aktiv man dissimulate ?"

AOkhotin
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Re: загадка "одышка "

Сообщение AOkhotin » Пт авг 17, 2018 12:36 pm

Pyankov Vasily писал(а):
Пт авг 17, 2018 12:28 am
Не совсем логичный путь к диагнозу. Невизуализирующий стресс-тест в 72 года с одышкой при физ. нагрузке?! Интересно, что явилось причиной DVT? Вторичная тромбофилия? Онкопатологии не выявлено?

P.S. Артемий! Какой бы диагностический алгоритм выбрали Вы у данного пациента?
Мы при одышке проводим стресс-эхо, а не ЭКГ-пробу, и я бы хотел сказать, что мы бы сделали стресс-эхо, а затем пошли по тому же пути, что доктор Павел Хертц и поставили бы диагноз, но боюсь, что хорошая переносимость физической нагрузки и нормальные результаты стресс-эхо сбили бы меня с толку и я пропустил бы диагноз.

We perform stress-echo in patients with exertional dyspnea, and I would like to say that I would perform stress-echo and then go by the same pathway as Dr. Hertz. But I am afraid that I would miss the diagnosis in case his stress-echo was normal.
с уважением, Артемий Охотин
https://telegram.me/valsalvaru
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Pawel Hertz
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Re: загадка "одышка "

Сообщение Pawel Hertz » Пт авг 17, 2018 3:52 pm

AOkhotin писал(а):
Пт авг 17, 2018 12:36 pm
Pyankov Vasily писал(а):
Пт авг 17, 2018 12:28 am
Не совсем логичный путь к диагнозу. Невизуализирующий стресс-тест в 72 года с одышкой при физ. нагрузке?! Интересно, что явилось причиной DVT? Вторичная тромбофилия? Онкопатологии не выявлено?

P.S. Артемий! Какой бы диагностический алгоритм выбрали Вы у данного пациента?
Мы при одышке проводим стресс-эхо, а не ЭКГ-пробу, и я бы хотел сказать, что мы бы сделали стресс-эхо, а затем пошли по тому же пути, что доктор Павел Хертц и поставили бы диагноз, но боюсь, что хорошая переносимость физической нагрузки и нормальные результаты стресс-эхо сбили бы меня с толку и я пропустил бы диагноз.

We perform stress-echo in patients with exertional dyspnea, and I would like to say that I would perform stress-echo and then go by the same pathway as Dr. Hertz. But I am afraid that I would miss the diagnosis in case his stress-echo was normal.
Ok. Thank you for tip. I didn't know that in dyspnea stress is better than ekg exercise. I am doing stress-echo self but ekg exercise is first choice, and then when big suspition - stress. Why stress is better in dyspnea ?
P.S. I prefer Adenosin (140mikro/kg/min in 4 min and second step with 280mikro/kg/min in 2 min) it gives no tachy, no relative hypovolemia, and much, much better pictures. In literature states that after such a protocoll sensitivity and spesyfisity comes up to 98% 99% !!! ??

Wojtek Guzowski
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Re: загадка "одышка "

Сообщение Wojtek Guzowski » Пт авг 17, 2018 4:13 pm

High costly, How much is 1 amp Adenosinum?
with respect sincerely yours

AOkhotin
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Re: загадка "одышка "

Сообщение AOkhotin » Пт авг 17, 2018 4:24 pm

Pawel Hertz писал(а):
Пт авг 17, 2018 3:52 pm
Ok. Thank you for tip. I didn't know that in dyspnea stress is better than ekg exercise. I am doing stress-echo self but ekg exercise is first choice, and then when big suspition - stress. Why stress is better in dyspnea ?
P.S. I prefer Adenosin (140mikro/kg/min in 4 min and second step with 280mikro/kg/min in 2 min) it gives no tachy, no relative hypovolemia, and much, much better pictures. In literature states that after such a protocoll sensitivity and spesyfisity comes up to 98% 99% !!! ??
I use supine ergometry, it is more physiological than pharmacologic stress. Data on sensitivity and specificity concerns ischemia, but there are many other causes of dyspnea, that can be revealed by stress echo and not by ECG-exercise test: exercise-induced LVOT obstruction, diastolic dysfunction or pulmonary hypertension, valvular dysfunction. We can suppose that in your patient severity of pulmonary hypertension would significantly increase with exercise giving another clue to diagnosis pulmonary embolism.
с уважением, Артемий Охотин
https://telegram.me/valsalvaru
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Wojtek Guzowski
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Re: загадка "одышка "

Сообщение Wojtek Guzowski » Сб авг 18, 2018 4:34 pm

Paweł,how many MET's at exercise test?
Max and average puls?
with respect sincerely yours

Pawel Hertz
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Re: загадка "одышка "

Сообщение Pawel Hertz » Сб авг 18, 2018 4:42 pm

puls max, MET
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Wojtek Guzowski
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Re: загадка "одышка "

Сообщение Wojtek Guzowski » Сб авг 18, 2018 6:17 pm

Unadequate pressure reaction,you did not mention
with respect sincerely yours

Pawel Hertz
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Re: загадка "одышка "

Сообщение Pawel Hertz » Сб авг 18, 2018 7:11 pm

AOkhotin писал(а):
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Pawel Hertz писал(а):
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Ok. Thank you for tip. I didn't know that in dyspnea stress is better than ekg exercise. I am doing stress-echo self but ekg exercise is first choice, and then when big suspition - stress. Why stress is better in dyspnea ?
P.S. I prefer Adenosin (140mikro/kg/min in 4 min and second step with 280mikro/kg/min in 2 min) it gives no tachy, no relative hypovolemia, and much, much better pictures. In literature states that after such a protocoll sensitivity and spesyfisity comes up to 98% 99% !!! ??
I use supine ergometry, it is more physiological than pharmacologic stress. Data on sensitivity and specificity concerns ischemia, but there are many other causes of dyspnea, that can be revealed by stress echo and not by ECG-exercise test: exercise-induced LVOT obstruction, diastolic dysfunction or pulmonary hypertension, valvular dysfunction. We can suppose that in your patient severity of pulmonary hypertension would significantly increase with exercise giving another clue to diagnosis pulmonary embolism.
Supin ergometry is my dream. I must talk about it with hospital administration again. How do you estimate diastolic function with supin ergometry ?

AOkhotin
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Re: загадка "одышка "

Сообщение AOkhotin » Сб авг 18, 2018 7:37 pm

Yes, supine ergometry is really great.
E/e', e' and TR velocity (according to ASE guide). Pulmonay veins flow if visualization is good, pulmonary ultrasound (B-lines) is also useful.
But E/e' is the most important.
Jae Oh from Mayo Clinic have told on EuroECHO that treadmill is good enough for diastolic stress test, because diastolic function recovers slowly after stress, you have at least few minutes to make all measurements and allow tachycardia and tachypnea to subside. E/e' > 14 is diagnostic, but > 12 is enough for establishing HFpEF.


http://asecho.org/wordpress/wp-content/ ... nction.pdf
The successful acquisition of Doppler signals during exercise
and the interpretation of the diastolic stress test require a higher
level of experience than that needed for evaluation of diastolic
function at rest. The test is considered definitely abnormal indicating
diastolic dysfunction when all of the following three
conditions are met: average E/e' > 14 or septal E/e' ratio > 15
with exercise, peak TR velocity > 2.8 m/sec with exercise and
septal e0 velocity is < 7 cm/sec or if only lateral velocity is acquired,
lateral e0 < 10 cm/sec at baseline. The results are normal
when average (or septal) E/e' ratio is <10 with exercise and peak
TR velocity is <2.8 m/sec with exercise. One should be cautious
in drawing conclusions on the basis of an isolated increase in
exercise peak TR velocity as normal subjects can have a significant
increase in peak TR velocity related to the increased pulmonary
blood flow. In the absence of these results, the test is
considered indeterminate. In these patients, an invasive hemodynamic
investigation, including the use of exercise, maybe necessary.
с уважением, Артемий Охотин
https://telegram.me/valsalvaru
Изображение

Pawel Hertz
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Re: загадка "одышка "

Сообщение Pawel Hertz » Сб авг 18, 2018 7:42 pm

Wojtek Guzowski писал(а):
Сб авг 18, 2018 6:17 pm
Unadequate pressure reaction,you did not mention
No, we have problems with cuff. This new bought ekg -stress machine "sucks"

Pawel Hertz
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Re: загадка "одышка "

Сообщение Pawel Hertz » Сб авг 18, 2018 7:48 pm

AOkhotin писал(а):
Сб авг 18, 2018 7:37 pm
Yes, supine ergometry is really great.
E/e', e' and TR velocity (according to ASE guide). Pulmonay veins flow if visualization is good, pulmonary ultrasound (B-lines) is also useful.
But E/e' is the most important.
Jae Oh from Mayo Clinic have told on EuroECHO that treadmill is good enough for diastolic stress test, because diastolic function recovers slowly after stress, you have at least few minutes to make all measurements and allow tachycardia and tachypnea to subside. E/e' > 14 is diagnostic, but > 12 is enough for establishing HFpEF.


http://asecho.org/wordpress/wp-content/ ... nction.pdf
The successful acquisition of Doppler signals during exercise
and the interpretation of the diastolic stress test require a higher
level of experience than that needed for evaluation of diastolic
function at rest. The test is considered definitely abnormal indicating
diastolic dysfunction when all of the following three
conditions are met: average E/e' > 14 or septal E/e' ratio > 15
with exercise, peak TR velocity > 2.8 m/sec with exercise and
septal e0 velocity is < 7 cm/sec or if only lateral velocity is acquired,
lateral e0 < 10 cm/sec at baseline. The results are normal
when average (or septal) E/e' ratio is <10 with exercise and peak
TR velocity is <2.8 m/sec with exercise. One should be cautious
in drawing conclusions on the basis of an isolated increase in
exercise peak TR velocity as normal subjects can have a significant
increase in peak TR velocity related to the increased pulmonary
blood flow. In the absence of these results, the test is
considered indeterminate. In these patients, an invasive hemodynamic
investigation, including the use of exercise, maybe necessary.
Fine. Thanks

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