Traditionally, patients with pulmonary issues would present to cardiologists with issues related mostly to overt ischemic and valvular heart diseases. But with the evolution of patients' diseases, technological advancements, and increasing medical complexities, there are a number of new ways that patients with pulmonary issues now may present themselves to cardiologists. In this article, we briefly describe some common clinical situations that pulmonary, sleep and critical care practitioners are now more likely to refer patients to our cardiology colleagues with key attention to what some might consider to be "paradigm shifts" in disease and clinical management.

Diastolic Heart Failure

The evaluation of unexplained dyspnea is still one of the most common reasons that a pulmonologist's expertise is warranted, and evaluation of cardiac function is often one of the most basic tests routinely ordered, often with a test preceding the pulmonologist's referral. Most clinicians, especially with the easy availability of echocardiography, can recognize overt signs of systolic heart failure. But many clinicians still struggle with what we see as an 'epidemic' of diastolic heart failure and management of such often involves cardiac evaluation or even re-evaluation. Some studies cite that over half of the heart failure population as having predominance of diastolic heart failure, and in the Olmsted County Heart Function Study in just four years of examinations the prevalence of diastolic heart failure increased from 23.8% to 39.2%.¹ Given the aging of the population, the increased prevalence of comorbidities associated with development of diastolic dysfunction (e.g., hypertension, diabetes mellitus, obesity), and a number of other complex factors, more patients are developing this phenomenon. Moreover, many are struggling in regards to the best treatment strategies for diastolic heart failure, and therefore all the more important for there to be collaboration between the pulmonologist and the cardiologist in such patients.

Pulmonary Arterial Hypertension Evaluation and Management

Traditionally pulmonary arterial hypertension (PAH) was of uncommon interest and really limited to "idiopathic" or primary causes. But with an aging and more medically complex population and the advancement of pulmonary vasodilator therapies, many pulmonologists are trying to understand if their patients with primary and now even with secondary causes of PAH would be well-served with these therapies. Increasing echocardiographic accuracy in predicting elevated right-sided cardiac pressures has improved the ability for both primary and secondary PAH to be recognized. Still, proper patient identification and treatment often requires invasive hemodynamic measurements, especially if patients are to be initiated on expensive therapies that are potentially to be continued life-long. The success of these therapies is evident in the improvement in symptom management, quality of life, and dramatic reduction in organ transplantation needs for primary PAH patients.² But initiation of these therapies often requires close collaboration with cardiologists that are skilled in right-sided cardiac hemodynamic measurements, recognize and help assist patients that might benefit from therapies, and collaborate with pulmonologists and other providers in long-term disease management. Given the greater prevalence of secondary PAH patients, many who may have developed PAH from long-standing pulmonary diseases (e.g., COPD, Bronchiectasis, Obesity-Hypoventilation, Pulmonary Fibrosis) it is likely that more patients will be initiated and maintained on such therapies in the near future.

Advanced Systolic Heart Failure and Life Support Modalities

There has been a dramatic shift in many medical centers regarding the viability of patients with advanced systolic heart failure. In the arena of critical care, such as in the setting of cardiogenic shock, cardiac arrest, severe chronic systolic heart failure perhaps worsened by an acute and potentially reversible process, a number of clinicians would have simply either not advanced or withdrawn life support in the setting of overwhelming illnesses. But with the advent and increasing expertise, availability, and deployment of a number of advanced cardiac sustaining therapies, many critical care physicians are now re-engaging the cardiac community to assess whether patients are candidates for such life-sustaining cardiac devices. There has also been a shift in some of these therapies from being seen as temporizing measures towards definitive therapies such as transplantation, to now the majority of these devices being used as "destination therapies."³ Additional research is needed to assess short and long-term impacts of such therapies including complex medical, physical, psychological, financial and social factors that are affected by the use of these therapies. Nevertheless, astute clinicians should be well-apprised of these advancements as we learn how to utilize such therapies appropriately; an engaged and interested partnership with the cardiology community will be paramount to future successes in these efforts.

Sequalae of Major Paradigm Shifts in Lung Cancer Diagnostics and Treatments

There has been a dramatic interest in the diagnosis and treatment of lung cancer both at early and now even in advanced stages in the United States and internationally. This may affect several domains that will be relevant to understanding the impact this may have on the cardiology community:

• Screening for Lung Cancer in High Risk Groups. Recently the U.S. Preventative Services Task Force is likely to recommend Chest CT scanning to screen for lung cancer, which may impact the number of lung cancers diagnosed, and during the CT scanning and evaluation process, more cardiac diseases potentially elicited. Moreover, since biopsies of lung nodules are becoming less invasive, often occur earlier and faster than traditional means, this means that more procedures may be looming that require rapid cardiac perioperative evaluations. Lastly, more coronary artery disease may be uncovered with routine chest CT scanning, likely prompting more referrals to cardiologists via this route.⁴
• Advancement and Renewed Interest in Therapies for Lung Cancer
  • Surgical therapies are now often less invasive, which for higher cardiovascular risk patients may now be tenable and may signify more complex patients proceeding towards evaluation and management of any uncovered cardiovascular diseases.
  • More patients on medical therapies including newer biological therapies may have cardiovascular effects (e.g., doxorubicin's direct cardiotoxicity), or cardiologists may have to adjust patients' antiplatelet drug regimens to account for thrombocytopenia or other acquired coagulapathies.
  • Radiation therapies are advancing to be able to administer higher doses of radiation therapy more focally, but the effects to myocardial tissue are still not well-understood and may have short-term and long-term sequelae.
• Long-term Cardiovascular Effects of Lung Cancer Survival. Long-term cardiovascular effects of lung cancer survival are still evolving, but given a parallel increased risk of long-term cardiovascular diseases from survivors of breast cancer,⁵ it would not be surprising if the same could be said out about lung cancer survivors and that additional cardiac risk evaluation might be needed.

Dysrhythmia Management
There are a host of diseases, clinical scenarios, and opportunities for the cardiology community to collaborate on dysrhythmia management with special interest in helping the pulmonary, sleep and critical care communities identify when various strategies can or should be employed. Some examples include:

• Dysrhythmias noted during a sleep study — often these are cited or noted but the patient may not be seen by a cardiologist as it is often assumed that treatment of obstructive sleep apnea will help. Yet, such dysrhythmia evaluation is often not followed through with objective testing towards resolution. Systematized care might be helpful in this aspect, such as rapid triage to cardiologists that understand how nocturnal dysrhythmias may change with initiation of therapies directed toward sleep-disordered breathing for example.
• Tachycardia management from bronchodilators — beta-agonist (e.g., albuterol, salmeterol) and/or anticholinergic therapies (e.g., ipratropium, tiotroprium) that are used to treat obstructive airways diseases such as asthma or chronic obstructive pulmonary disease (COPD) often elicit tachycardias and such side effects may result in drug discontinuation. More commonly, pulmonologists may refer to cardiologists to help manage the tachycardia syndromes so that therapy may be continued.
• Arrhythmias from effects of chronic lung diseases either through effects of pulmonary hypertension, right heart strain, shared infiltrative processes that affect pulmonary parenchyma and myocardium (e.g., sarcoidosis) or other mechanisms may require rigorous diagnostic evaluation and treatments.

Venous thromboembolism Disease Management
Increasingly patients with ileofemoral deep venous thrombi (DVT), pulmonary emboli (PE) or other forms of venous thromboembolic diseases are identified in whom traditional oral or intravenous anticoagulation may either be contraindicated or less desirable than other treatments. With recent advances in localized fibrinolytic and/or mechanical therapies, as well as the utility of retrievable filters, this would be an arena in which if cardiologists desire a patient population there would be robust areas of opportunities. Many of these patients are currently being seen by interventional radiologists, but cardiologists have a unique opportunity to not only take advantage of cardiac catheterization lab abilities to mobilize patients quickly, but also the ability to assess these patients in clinic for long-term follow-up and thereby ensure care is optimized. Moreover, this would be a natural means to also assist in complications related to pulmonary hypertension as mentioned earlier.⁶

In summary, a number of opportunities exist for an increasing collaboration between pulmonologists and cardiologists. Just as our patient populations, technologies, and services are changing so are there newer ways that pulmonary, sleep, and critical care patients are being seen by cardiologists.

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References

1. Kane GC, Karron BL, Mahoney DW, Redfield MM, Roger VL, Burnett JC, Jacobsen SJ, Rodeheffer RJ. Progression of Left Ventricular Diastolic Dysfunction and Risk of Heart Failure. JAMA 2011; 306:856-863.
2. McLaughlin VV, Archer SL, Badesch DB, Barst RJ, Farber HW, Lindner JR, Malthier MA, McGoon MD, Park MH, Rosenson RS, Rubin LJ Tapson VF, Varga J. A Report of the American College of Cardiology Foundation Task Force on Expert Consensus Documents and the American Heart Association. J Am Coll Cardiol 2009;53:1573-1619.
3. Rector TS, Taylor BC, Greer N, Rutks I, and Wilt TJ. Use of Left Ventricular Assist Devices as Destination Therapy in End-Stage Congestive Heart Failure: A Systematic Review. VA-ESP Project #09-009; 2012.
4. de Jong PA, Gondrie MJ, Buckens CF, Jacobs PC, Mali WP, van der Graaf Y. Prediction of cardiovascular events by using non-vascular findings on routine chest CT. PLoS One 2011;6: e26036.
5. Hooning MJ, Botme A, Aleman BMP, Baiijens MHA, Bartelink H, Klijn JGM, Taylor CW, van Leeuwen FE. Long-Term Risk of Cardiovascular Disease in 10-Year Survivors of Breast Cancer. J Natl Cancer Inst 2007;99:365-375.
6. Jaff MR, McMurty S, Archer SL et al. Management of Massive and Submassive Pulmonary Embolism, Ileofemoral Deep Venous Thrombosis, and Chronic Thromboembolic Pulmonary Hypertension: A Scientific Statement from the American Heart Association. Circulation 2011;123:1788-1830.

Keywords: Heart Valve Diseases, Critical Care

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