|Year : 2020 | Volume
| Issue : 2 | Page : 88-91
Echocardiographic evaluation of stable chronic obstructive pulmonary disease (COPD) patients
Hemant Kumar1, Ajay Kumar Verma2, Anuj Kumar Pandey2, Utkarsh Kumar Srivastava3, Manoj Kumar Pandey1, Rishabh Chaudhary1, Surya Kant2
1 Department of Respiratory Medicine, Dr. Ram Manohar Lohia Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
2 Department of Respiratory Medicine, King George’s Medical University, Lucknow, Uttar Pradesh, India
3 Mayo Institute of Medical Sciences, Barabanki, Uttar Pradesh, India
|Date of Submission||23-Oct-2019|
|Date of Acceptance||12-Apr-2020|
|Date of Web Publication||10-Sep-2020|
Dr. Ajay Kumar Verma
MD, Professor Junior Grade, Department of Respiratory Medicine, King George’s Medical University, Lucknow, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
Context: Chronic obstructive pulmonary disease (COPD) is the second leading cause of mortality in India, cardiovascular disease (CVD) comorbidity further increases morbidity and mortality of COPD. Early detection of CVD by echocardiography in COPD helps to reduce mortality and morbidity. Objective: We aimed to assess the echocardiographic findings in stable COPD patients. Materials and Methods: Patients with stable COPD, confirmed by spirometry, were recruited from the two tertiary care centre of India between August 2017 and August 2019. After thorough clinical examinations, patients have undergone echocardiography for CVD evaluation. Results: A total of 110 COPD patients were recruited, 91 male and 19 female. On echocardiographic evaluation, pulmonary arterial hypertension (PAH) was seen in 45.5% of COPD with mild, moderate, severe 14.5%, 11% and 20% respectively. Cor-pulmonale was seen in 9.1%. Left ventricular hypertrophy (LVH), left ventricular diastolic dysfunction (LVDD) and left ventricular systolic dysfunction (LVSD) was seen in 11%, 39.1% and 13.6% of COPD respectively. CVD involvement was more common in very severe COPD (40.1%). Conclusion: In this study, 78.2% of COPD have at least one form of CVD as co-morbidity. A simple, cheaper, non-invasive, widely an available investigation like echocardiography is useful to detect CVD at an early stage.
Keywords: Cardiovascular diseases, chronic obstructive pulmonary disease, echocardiography, spirometry
|How to cite this article:|
Kumar H, Verma A, Pandey A, Srivastava U, Pandey M, Chaudhary R, Kant S. Echocardiographic evaluation of stable chronic obstructive pulmonary disease (COPD) patients. J Assoc Chest Physicians 2020;8:88-91
|How to cite this URL:|
Kumar H, Verma A, Pandey A, Srivastava U, Pandey M, Chaudhary R, Kant S. Echocardiographic evaluation of stable chronic obstructive pulmonary disease (COPD) patients. J Assoc Chest Physicians [serial online] 2020 [cited 2020 Sep 25];8:88-91. Available from: http://www.jacpjournal.org/text.asp?2020/8/2/88/294589
| Introduction|| |
Chronic obstructive pulmonary disease (COPD) is caused by a combination of exposure to noxious particles like smoking, biomass fuel exposure, air pollution, occupational exposure and host-factor like aging population, childhood poor lung growth, exposure to childhood infections, etc. In India, post tubercular etiology is a major risk factor for chronic airway disease like COPD. Co-morbidities often co-exist with COPD and increase morbidity and mortality of COPD. Prevalence of cardiovascular disease in COPD as high as five times as compared to non-COPD population. Symptoms of COPD and the the cardiovascular disease (CVD) are common and overlapping, like dyspnoea and chest tightness which are typical symptoms of COPD, also seen in coronary artery disease. So excessive symptoms in patients of COPD always warrants additional investigation to see cardiovascular co-morbidity. Co-morbidity usually caused by physical inactivity by COPD patients and smoking. Identification of co-morbidity is important as its presence increases COPD. Also, cardiac manifestations are the most common comorbidities in COPD accounts for approximately 50% of all hospitalized COPD patients and cause nearly one-third of all death in mild to moderate COPD. The severity of COPD increases the incidence of cardiovascular events, every 10% decrement in FEV1, cardiovascular mortality increases by 28% and nonfatal coronary events by almost 20%. Pathology of pulmonary arterial hypertension in COPD is complex as alveolar hypoxia caused by COPD causes pulmonary artery vasoconstriction which increases pressure in pulmonary artery. COPD also causes destruction of capillary bed, lung hyperinflation and increased blood viscosity which also leads to pulmonary arterial hypertension. A permanent increase in pressure increases right ventricular enlargement and failure later on. This entity is called cor-pulmonale.
Cardiac evaluation in COPD can be done by echocardiography in OPD basis itself; it is non-invasive and rapid method to identify various cardiac parameters like pulmonary arterial pressure, right ventricular function, left ventricular function and valvular function, etc. Echocardiography is as good as an invasive method like right heart catheterisation in estimating pulmonary arterial pressure and its consequences. Early identification of cardiovascular disease by the non-invasive, cheaper method like echocardiography can help in timely management of CVD and reduces co-morbidity and mortality. Left ventricle (LV) also involved in COPD due to many factors like hypoxemia, ischemic heart disease and bulging of the interventricular septum towards left ventricle because of right ventricular enlargement (ventricular interdependence). This phenomenon causes left ventricular diastolic dysfunction (LVDD) which leads to poor LV filling and reduced cardiac output. So that in the present study we had evaluated echocardiographic findings in stable COPD patients.
| Subjects and methods|| |
The present study was conducted from the two tertiary care centre of India. The study was approved by the institutional ethical committee of both institutes. All patients of stable COPD were enrolled in the study between August 2017 to August 2019. These patients underwent spirometry to confirm diagnosis and grading of severity of COPD. Post bronchodilator FEV1/ FVC ratio less than 0.7 were taken as a diagnostic tool of COPD. Grading of COPD was done according to GOLD guidelines as mild (FEV1 > 80%), moderate (FEV1= 50–79%), severe (FEV1= 30–49%) and very severe (FEV1 < 30%). All confirmed stable COPD patients with more than 40 years age were included, while patients having an acute exacerbation, hypertension, and or primary cardiac disease was excluded.
After confirmation and grading of COPD, detailed history, examination and resting two-dimension trans-thoracic Doppler echocardiography (2-D ECHO) was done to see cardiovascular abnormality. In 2-D ECHO, pulmonary arterial hypertension was labeled if systolic pulmonary arterial pressure (sPAP) is >30 mmHg. It is further divided in to mild (sPAP=30–50mmHg), moderate (sPAP=50–70mmHg) and severe (sPAP> 70mmHg). Cor-pulmonale was called when right ventricular chamber was enlarged more than its normal range i.e. 0.9 to 2.6 cm. Left ventricular chamber was assessed with the help of LV ejection fraction. Other functions like Left ventricular diastolic function, right ventricular systolic and diastolic function were also assessed. All patients were managed according to GOLD guidelines.
| Results|| |
Total of 110 patients were enrolled in the study; the majority of the patient population was male [Figure 1]. This gender predominance is due to more habits of a smoker, occupational exposure, and outdoor air pollution exposure among males as compared to females.
COPD is common in old age due to prolonged exposure of noxious particles that are required to develop airway obstruction and alveolar damage. In our studied population, the majority of patients are in age the group of 61–70 years and the second majority are in the age group of 71–80 years [Figure 1]. Younger patients less than 40 years were excluded from the study as COPD in these patients is due to genetic factors like alpha antitrypsin deficiency. The majority of patients falls in severe (FEV1 = 49–30%) and very severe (FEV1 < 30%) group [Table 1]. This grading of presentation is due to lack of awareness and ignoring of early symptoms of COPD.
|Table 1 Severity of COPD evaluated by spirometry and as per GOLD 2019 guidelines|
Click here to view
The most common cardiovascular disease in COPD is pulmonary arterial hypertension (PAH). Overall 45.5% of the COPD population has PAH and among PAH, severe PAH is common (20%). 10 patients (9.1%) had decompensated right heart failure i.e. cor-pulmonale. Second most common cardiac co-morbidity is left ventricular diastolic dysfunction (LVDD) which affects the filling of left ventricle hence reduces cardiac output. As the severity of COPD increases, cardiovascular co-morbidities increase as much as 40.7% in very severe COPD and only 9.3% in mild COPD. Echocardiographic measurements of COPD patients, as well as co-relation between echocardiographic findings and severity of COPD was depicted in [Table 2] and [Table 3].
|Table 3 Correlation between echocardiographic finding and severity of COPD|
Click here to view
| Discussion|| |
Cardiovascular diseases are a common cause of morbidity and mortality in COPD patients. Since COPD is old age disease so our study population is also older with the mean age is 63.5 years with the range from 45 years to 91 years old. In our study male are more common than the female with a male: female ratio 4.8, it means male has more exposure of noxious particles like cigarette smoke, occupational exposure, outdoor air pollution etc., in a developing country like India, still, female smokers are far less than male so smoker COPD is more in male. Females usually developed COPD mainly because of exposure to biomass fuel used for cooking purposes. Cardiac co-morbidity is very common in COPD; we found cardiac involvement in 78.2% of COPD. Kaur et al. found cardiac involvement in 76% of COPD which is comparable to our study while Gupta NK et al., had found cardiac involvement in 50% cases.
COPD causes alveolar hypoxia which leads to PAH. PAH is the most common cardiac abnormality in COPD. In our study, we found PAH in 45.5% of COPD with mild, moderate, and severe PAH in 14.5%, 11% and 20%, respectively. A previous study showed PAH in 70% of COPD patients  while Tiwari et al. found PAH in 51.6% of COPD. Saurabh et al. had demonstrated that mild, moderate and severe PAH is 17.4%, 10.5% and 18.6% respectively. All these data support our study.
Severe PAH leads to right ventricular strain which leads to right ventricular failure and this entity is called cor pulmonale. Incidence of cor pulmonale is as high as 40% of patients of COPD in one autopsy study by Rigolin et al., but in live patients, it has lower incidence as we found in 9.1% of COPD patients, while another study found cor-pulmonale in 17% of COPD only.Left ventricular hypertrophy (LVH) occur in long term COPD patients, it usually co-exists with right ventricular failure which increases mortality. Surprisingly LVH incidence in our study was low i.e. only 11% while in a study done by Gupta et al. it was 22.5%. A study by Wilke SH et al. showed LVH of 31% of COPD patients. Left ventricular diastolic dysfunction (LVDD) causes poor filling of left ventricles which in term causes low cardiac output. In our study, LVDD was found in 39.1% of COPD patients which is comparable to other studies like 47.5% in a study by Gupta et al.. Left ventricular systolic dysfunction (LVSD) is also common but less common as compared to LVDD, in our study we found LVSD in 13.6% of COPD patients while in the study by Gupta et al. LVSD was present in 7.5% of COPD.
| Conclusion|| |
CVD are very common co-morbidity in COPD which increases mortality and morbidity. In developing countries like India 2D ECHO is still, an under-utilised tool to detect CVD in COPD. 2D ECHO which is non-invasive, cheaper and easily available investigation to diagnose various CVD helps in early diagnosis and management of COPD.
Financial support and sponsorship
Financial assistance to Anuj Kumar Pandey was provided in the form of fellowship from ICMR, New Delhi (No. 3/1/2/1/(Env)/2018-NCD-I).
Conflicts of interest
There are no conflicts of interest.
| References|| |
Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global strategy for the diagnosis, management and prevention of chronic obstructive pulmonary disease: 2019 Report. (Accessed September 04, 2019).
Feary JR, Rodrigues LC, Smith CJ, Hubbard RB, Gibson JE. Prevalence of major comorbidities in subjects with COPD and incidence of myocardial infarction and stroke: a comprehensive analysis using data from primary care. Thorax 2010;65:956.
Anthonisen N, Connett JE, Kiley JP, Altose MD, Bailey WC. Effects of smoking intervention and the use of an inhaled anticholinergic bronchodilator on the rate of decline of FEV1. JAMA 1994;272:1497-505.
Sin DD, Man SF. Chronic obstructive pulmonary disease as a risk factor forcardiovascular morbidity and mortality. Proc Am Thorac Soc 2005;2:8-11.
Daniels LB, Krummen DE, Blanchard DG. Echocardiography in pulmonary vascular disease. Cardiol Clin 2004;22:383-99.
Robotham JL, Lixfeld W, Holland L, MacGregor D, Bryan AC, Rabson J. Effects of respiration on cardiac performance. J Appl Physiol 1978;44:703-9.
Chemla D, Castelain V, Humbert M, Hébert JL, Simonneau G, Lecarpentier Y et al.
New formula for predicting mean pulmonary artery pressure using systolic pulmonary artery pressure. Chest 2004;126:1313-17.
Madhurmay XX, Suryakant XX, Kumar H, Kumar S, Prasad R, Verma AK et al.
Study of association between exposure to indoor air pollution and chronic obstructive pulmonary disease among non-smokers in a North Indian population − a case-control study. Indian J Respir Care 2019;8:71-5. [Full text]
Kaur S, Khurana A, Dhoat PS, Mohan G. Cardiac evaluation of COPD patients by ECHO and its correlation with different grades of severity of COPD. Int J Adv Med 2017;4:98-102.
Gupta NK, Agrawal RK, Srivastav AB, Ved ML. Echocardiographic evaluation of heart in chronic obstructive pulmonary disease patient and its co-relation with the severity of disease. Lung India 2011;28:105-9.
] [Full text]
Tiwari VK, Agarwal R, Kumar A, Kumar A, Kumar R. The cardiac evaluation in chronic obstructive pulmonary disease patients. Indian J Applied Res 2015;15:434-5.
Saurabh Singh L, Agarwal A, Tandon R, Kumar H. Echocardiographical evaluation and cardiovascular changes in chronic obstructive pulmonary disease patients in tertiary care hospital. JMSCR 2016;11:148-51.
Rigolin VH, Robiolio PA, Wilson JS, Harrison JK, Bashore TM. The forgotten chamber: the importance of the right ventricle. Cathet Cardiovasc Diagn 1995;35:18-28.
Wilke SH, Spruit MA, Uszko-Lencer NMHK, Otkinska G, Vanfleteren LE, Jones PW et al.
Echocardiographic abnormalities and their impact on health status in patients with COPD referred for pulmonary rehabilitation. Respirology 2017;22:928-934.
[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3]