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Today's Practice of Cardiopulmonary MedicineAmiodarone Pulmonary Toxicity: Recognition and Pathogenesis (Part I)
Section snippets
CLINICAL PRESENTATION
In many cases, there appear to be two separate types of presentation of patients with APT,16,18,22,23 which has been recognized by very few authors. One is the more common variety of an insidious onset of nonproductive cough, dyspnea, weight loss, and occasionally fever associated with parenchymal infiltrates, predominantly a diffuse interstitial pattern. The chest x-ray almost always correlates with the clinical symptoms, meaning that the symptoms usually do not precede the change in the chest
RISK FACTORS FOR TOXICITY
There are several reports suggesting that preexisting lung disease—ie, abnormal chest roentgenogram findings and/or pulmonary function status prior to the initiation of therapy—predisposes to APT.8,9,15, 16, 17, 18, 19,22,28 Kudenchuk et al15 prospectively studied 69 patients before and during amiodarone therapy and found that 28 percent with a pretreatment Dsb of less than 80 percent predicted eventually showed changes consistent with APT compared to only 5 percent if the pretreatment Dsb was
METHOD OF DIAGNOSIS
There are no laboratory or clinical data currently available that alone unequivocally establish the diagnosis of APT. To make a “clinical” diagnosis of APT requires the exclusion of other diagnostic possibilities (especially occult congestive heart failure) together with a reasonable constellation of symptoms or findings consistent with the diagnosis. Kudenchuk et al15 defined APT as any two of the following findings: (1) new or worsening symptoms; (2) new abnormalities on, or worsening of
THERAPEUTIC OPTIONS
Once the clinical diagnosis of APT has been made, a limited number of therapeutic options are available to the clinician. First, the most frequently used option is simply to discontinue amiodarone. In most cases, symptoms and findings will begin to resolve within a few days, although near-complete resolution may require several months. In general, the more insidious the onset of the disease, the slower the resolution. Clearly, the unusual occurrence of progressive pulmonary toxicity is possible
SUMMARY
Amiodarone represents an important new approach in the treatment of serious cardiac rhythm disturbances and is associated with significant pulmonary toxicity in approximately 5 to 10 percent of patients. The recognition of APT in patients receiving the drug early in the course of the disease will likely preclude the development of a permanent loss of pulmonary function in these patients. It is important for the clinician to individualize both the diagnostic and therapeutic approach to the
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Supported in part by NIH grant HL36124.
Part 2 will appear in the next issue of Chest.