Barr et al. describe a linear decline in left ventricular cardiac output with an increasing extent of emphysema and degree of airflow obstruction among patients who did not have severe COPD.1 The speculated pathophysiol-ogy was impaired left ventricular filling caused by increased pulmonary vascular impedance. However, the authors do not discuss the prevalence of diuretic use and its potential negative effect on left ventricular filling. When right ventricular afterload is increased, the normally preload-dependent right ventricle maintains its output by augmenting preload, which may lead to dependent edema.
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