TY - JOUR A1 - Stoeckel, M. Cornelia A1 - Esser, Roland W. A1 - Gamer, Matthias A1 - Büchel, Christian A1 - von Leupoldt, Andreas T1 - Brain Responses during the Anticipation of Dyspnea JF - Neural Plasticity N2 - Dyspnea is common in many cardiorespiratory diseases. Already the anticipation of this aversive symptom elicits fear in many patients resulting in unfavorable health behaviors such as activity avoidance and sedentary lifestyle. This study investigated brain mechanisms underlying these anticipatory processes. We induced dyspnea using resistive-load breathing in healthy subjects during functional magnetic resonance imaging. Blocks of severe and mild dyspnea alternated, each preceded by anticipation periods. Severe dyspnea activated a network of sensorimotor, cerebellar, and limbic areas. The left insular, parietal opercular, and cerebellar cortices showed increased activation already during dyspnea anticipation. Left insular and parietal opercular cortex showed increased connectivity with right insular and anterior cingulate cortex when severe dyspnea was anticipated, while the cerebellum showed increased connectivity with the amygdala. Notably, insular activation during dyspnea perception was positively correlated with midbrain activation during anticipation. Moreover, anticipatory fear was positively correlated with anticipatory activation in right insular and anterior cingulate cortex. The results demonstrate that dyspnea anticipation activates brain areas involved in dyspnea perception. The involvement of emotion-related areas such as insula, anterior cingulate cortex, and amygdala during dyspnea anticipation most likely reflects anticipatory fear and might underlie the development of unfavorable health behaviors in patients suffering from dyspnea. KW - brain response KW - dyspnea KW - cardiorespiratory disease KW - anticipation Y1 - 2016 U6 - http://nbn-resolving.de/urn/resolver.pl?urn:nbn:de:bvb:20-opus-166238 VL - 2016 IS - 6434987 ER - TY - THES A1 - Küsters, Franziska T1 - Charakterisierung persistierend symptomatischer Patienten im Langzeitverlauf nach Lungenembolie T1 - Characterization of persistent symptomatic patients in the long-term outcome after pulmonary embolism N2 - Im Rahmen eines symptom-orientierten Interviews fand sich eine große Anzahl an noch subjektiv belastungsintoleranten Patienten nach einer akuten Lungenembolie. Ein Hauptaugenmerk der Arbeit lag auf der weiteren Differenzierung des funktionellen Outcomes dieser Patienten anhand der objektivierbaren Leistungseinschränkung in der Spiroergometrie und den differentialdiagnostischen Ursachen dieser anhaltenden Beschwerden. So gaben im Follow-Up nach akuter Lungenembolie nach drei Monaten 40% der Patienten, nach sechs, zwölf und 24 Monaten jeweils über 20% der Patienten subjektive Belastungsintoleranz an. Neben einer chronisch-thromboembolischen pulmonalen Hypertonie und einer chronisch- thromboembolischen Erkrankung leiden diese Patienten bedingt durch entsprechende Komorbiditäten auch an anderen präkapillären und postkapillären Non-CTEPH-PH-Entitäten sowie kardialer und ventilatorischer Limitierung, was Ausdruck anderer kardiopulmonaler Begleiterkrankungen sein kann. Danach sollte ebenso im Rahmen einer Lungenembolienachsorge gefahndet werden, um nach Diagnosestellung schnellstmöglich eine adäquate, zielgerichtete Therapie einzuleiten. Ein symptom-basiertes Follow-Up Programm basierend auf einem Telefonmonitoring mit Fragebogen gefolgt von weiterführender klinischer Diagnostik kann helfen Patienten mit einer chronisch-thromboembolischen pulmonalen Hypertonie zu detektieren. Diese Studie hat die Spiroergometrie als wichtige komplementäre diagnostische Methode für eine frühzeitige CTEPH-Diagnose weiter etabliert. Sowohl das Telefonmonitoring als auch die Spiroergometrie zeigten sich effektiv und führten so zu einer CTEPH-Inzidenz von 5,4%. Ein solches Follow-Up Programm nach einer Lungenembolie sollte umgesetzt werden, um eine CTEPH frühzeitig zu diagnostizieren. Neben der oben genannten Auswertung des funktionellen Outcomes der noch symptomatischen Patienten liegen weitere Schwerpunkte dieser Arbeit auf der Analyse des zwölf- und 24 Monats-Follow-Up, auf der Risikostratifizierung anhand der Baseline- Parameter aus Echokardiografie und Spiroergometrie sowie dem Mortalitäts-Outcome. So konnten Prädiktoren für eine CTEPH aus den Baseline-Untersuchungen zum Zeitpunkt der akuten Lungenembolie ermittelt werden und die Erhebung der Komorbiditäten bei Einschluss die Risikostratifizierung von CTEPH-Patienten verdeutlichen. Eine Auswertung der oralen Antikoagulationstherapie konnte Hinweise auf das Blutungs- bzw. Rezidivrisiko geben sowie einen Vergleich der herkömmlichen Vitamin-K-Antagonisten mit den neuen oralen Antikoagulantien leisten. Über eine inkomplette Thrombusresolution nach akuter Lungenembolie ohne Symptome zu verursachen wurde berichtet. Natürlich wäre es interessant anhand von quantitativen und qualitativen Daten zu sehen wie viele solch asymptomatischer Patienten mit pathologischem Lungenperfusionsscan eine CTEPH entwickeln. Jedoch ist solch eine umfassende Follow-Up Untersuchung inklusive aller technischer Modalitäten wie Echokardiografie, CT und Ventilations-/Perfusionsscans von allen Patienten mit akuter Lungenembolie zu kostenintensiv und aus strahlenhygienischer Sicht nicht vertretbar. Daher stellt ein auf symptomatische Patienten fokussiertes strukturiertes Nachsorgeprogramm eine ethisch vertretbare und effektive Herangehensweise dar und ein wirksames Konzept um relevante CTEPH-Erkrankungen zu detektieren. N2 - Based on a symptom-oriented interview, a large number of patients with subjective stress intolerance after acute pulmonary embolism were found. A main focus of this work was the further differentiation of the functional outcome of these patients on the basis of the objectifiable performance limitation in cardiopulmonal exercise testing and the differential diagnostic causes of these persistent complaints. In the follow-up after acute pulmonary embolism, 40% of patients reported subjective exercise intolerance after three months, and after six, twelve, and 24 months, over 20% each. Besides chronic thromboembolic pulmonary hypertension and chronic thromboembolic disease, these patients also suffer from other precapillary and postcapillary non-CTEPH-PH entities as well as cardiac and ventilatory limitations, which may be an expression of other cardiopulmonary comorbidities. These cormobidities should also be a relevant part of a pulmonary embolism aftercare to initiate an adequate, targeted therapy as soon as possible after diagnosis. A symptom-based follow-up program based on a questionnaire telephone monitoring followed by advanced clinical diagnostics may help to detect patients with chronic thromboembolic pulmonary hypertension. This study has further established the cardiopulmonary exercise testing as an important complementary diagnostic tool for early CTEPH diagnosis. Both telephone monitoring and cardiopulmonary exercise testing were effective and resulted in a CTEPH incidence of 5.4%. Such a pulmonary embolism follow-up program should be implemented to diagnose CTEPH early. In addition to the above-mentioned evaluation of the functional outcome of the persistent symptomatic patients, this work is focused on the analysis of the 12- and 24-month follow-up as well as the possible risk stratification based on baseline parameters. For example, possible predictors for a future CTEPH-diagnosis from echocardiography and cardiopulmonary exercise testing at the time of acute pulmonary embolism were identified. An evaluation of the oral anticoagulation therapy could provide information on the risk of bleeding or recurrence as well as a comparison of the conventional vitamin-K-antagonists with the „new oral anticoagulants“. An incomplete thrombus resolution after acute pulmonary embolism without symptoms was reported. Of course, it would be interesting to investigate from quantitative and qualitative data how many asymptomatic patients with pathological lung perfusion scan develop CTEPH. However, such a comprehensive follow-up examination including all technical modalities such as echocardiography, CT and ventilation/perfusion-scans of all patients with acute pulmonary embolism seems to be too cost-intensive and also not acceptable from a radiation exposure point of view. Therefore, a structured follow-up program focused on symptomatic patients represents an ethical and effective approach detecting patients with relevant CTEPH. KW - Chronisch thromboembolische pulmonale Hypertonie KW - Lungenembolie KW - Spiroergometrie KW - Belastungsdyspnoe KW - pulmonary embolism KW - chronic-thromboembolic pulmonary hypertension KW - Cardiopulmonary exercise testing KW - dyspnea Y1 - 2018 U6 - http://nbn-resolving.de/urn/resolver.pl?urn:nbn:de:bvb:20-opus-156743 ER - TY - JOUR A1 - Held, Matthias A1 - Hesse, Alexander A1 - Gött, Franziska A1 - Holl, Regina A1 - Hübner, Gudrun A1 - Kolb, Philipp A1 - Langen, Heinz Jakob A1 - Romen, Tobias A1 - Walter, Franziska A1 - Schäfers, Hans Joachim A1 - Wilkens, Heinrike A1 - Jany, Berthold T1 - A symptom-related monitoring program following pulmonary embolism for the early detection of CTEPH: a prospective observational registry study JF - BMC Pulmonary Medicine N2 - Background Chronic thromboembolic pulmonary hypertension (CTEPH) is a long-term complication following an acute pulmonary embolism (PE). It is frequently diagnosed at advanced stages which is concerning as delayed treatment has important implications for favourable clinical outcome. Performing a follow-up examination of patients diagnosed with acute PE regardless of persisting symptoms and using all available technical procedures would be both cost-intensive and possibly ineffective. Focusing diagnostic procedures therefore on only symptomatic patients may be a practical approach for detecting relevant CTEPH. This study aimed to evaluate if a follow-up program for patients with acute PE based on telephone monitoring of symptoms and further examination of only symptomatic patients could detect CTEPH. In addition, we investigated the role of cardiopulmonary exercise testing (CPET) as a diagnostic tool. Methods In a prospective cohort study all consecutive patients with newly diagnosed PE (n=170, 76 males, 94 females within 26 months) were recruited according to the inclusion and exclusion criteria. Patients were contacted via telephone and asked to answer standardized questions relating to symptoms. At the time of the final analysis 130 patients had been contacted. Symptomatic patients underwent a structured evaluation with echocardiography, CPET and complete work-up for CTEPH. Results 37.7%, 25.5% and 29.3% of the patients reported symptoms after three, six, and twelve months respectively. Subsequent clinical evaluation of these symptomatic patients saw 20.4%, 11.5% and 18.8% of patients at the respective three, six and twelve months time points having an echocardiography suggesting pulmonary hypertension (PH). CTEPH with pathological imaging and a mean pulmonary artery pressure (mPAP) ≥ 25 mm Hg at rest was confirmed in eight subjects. Three subjects with mismatch perfusion defects showed an exercise induced increase of PAP without increasing pulmonary artery occlusion pressure (PAOP). Two subjects with pulmonary hypertension at rest and one with an exercise induced increase of mPAP with normal PAOP showed perfusion defects without echocardiographic signs of PH but a suspicious CPET. Conclusion A follow-up program based on telephone monitoring of symptoms and further structured evaluation of symptomatic subjects can detect patients with CTEPH. CPET may serve as a complementary diagnostic tool. KW - follow-up KW - pulmonary embolism KW - pulmonary hypertension KW - pulmonary circulation KW - chronic thromboembolic pulmonary hypertension KW - pulmonary artery pressure KW - pulmonary artery KW - cardiopulmonary exercise testing KW - dyspnea Y1 - 2014 U6 - http://nbn-resolving.de/urn/resolver.pl?urn:nbn:de:bvb:20-opus-119281 VL - 14 ER -