Table of Contents  
ORIGINAL ARTICLE
Year : 2019  |  Volume : 13  |  Issue : 1  |  Page : 12-16

Cardiac evaluation of patients with chronic obstructive pulmonary disease using echocardiography


1 Professor of Chest Diseases, Head of Chest Department, Faculty of Medicine, Ain Shams University, Cairo, Egypt
2 Professor of Cardiac Diseases, Faculty of Medicine, Ain Shams University, Cairo, Egypt
3 Assistant Professor of Chest Diseases, Faculty of Medicine, Ain Shams University, Cairo, Egypt
4 Pulmonology Resident, Al Abbasia Chest Hospital, Cairo, Egypt

Date of Web Publication13-Feb-2019

Correspondence Address:
Nehal Qadry Abd ElHameed
Pulmonology Resident, Al Abbasia Chest Hospital, Cairo, 11111
Egypt
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 0.4103/ejb.ejb_2_18

Rights and Permissions
  Abstract 

Background Chronic obstructive pulmonary disease (COPD) is a significant cause of death. Cardiovascular disease is a significant cause of morbidity and mortality in COPD.
Aim We used echocardiography to evaluate cardiac function in patients with COPD and correlated echocardiographic findings with COPD severity.
Patients and methods We performed a prospective cross-sectional study on 60 patients with stable COPD who presented to the Abbasia Chest Hospital during the period from November 2016 till August 2017. Spirometry was performed for all participants using American and European Thoracic Society (2005) recommendations. They were classified according to GOLD guidelines (2017) and evaluated by two-dimensional Doppler echocardiography according to American and European Association of Echocardiography ASE recommendations.
Results Echocardiographic examination of left ventricular functions revealed no cases of left ventricular systolic dysfunction, but left ventricular diastolic dysfunction was found in ∼25%. Right ventricle dilatation was found in ∼18% of the patients. Tricuspid regurge was seen in ∼75%, with variable grades from mild to severe. Pulmonary hypertension (PH) was found in ∼40% of the patients. It was more prevalent in patients with severe and very severe disease. Correlation between echocardiographic findings and severity of COPD revealed significant positive correlation only with right ventricle size, tricuspid regurgitation, and PH.
Conclusion Left ventricular diastolic dysfunction appears to be frequent in patients with COPD, but it is not related to the disease severity. Abnormal right heart changes could be expected. Presence of PH has a linear relationship with COPD severity.

Keywords: chronic obstructive pulmonary disease, correlation, echocardiography, pulmonary hypertension, severity


How to cite this article:
Mohammed YM, ElShahid GS, Osman NM, Abd ElHameed NQ. Cardiac evaluation of patients with chronic obstructive pulmonary disease using echocardiography. Egypt J Bronchol 2019;13:12-6

How to cite this URL:
Mohammed YM, ElShahid GS, Osman NM, Abd ElHameed NQ. Cardiac evaluation of patients with chronic obstructive pulmonary disease using echocardiography. Egypt J Bronchol [serial online] 2019 [cited 2024 Mar 28];13:12-6. Available from: http://www.ejbronchology.eg.net/text.asp?2019/13/1/12/252192


  Introduction Top


Chronic obstructive pulmonary disease (COPD) is expected to be the third leading cause of mortality in 2020 [1].

Association between cardiovascular disease and COPD can be explained by many risk factors [2], including cigarette smoking [3], systemic effect of the inflammation [4], impaired vascular function, and hyperinflation of the lungs [5].

Echocardiography is an easy, noninvasive method for evaluation of changes of the heart secondary to COPD [6].

This study aimed to evaluate cardiac function by echocardiography in patients with COPD and correlated echocardiographic findings with COPD severity.


  Patients and methods Top


We performed a prospective cross-sectional study on 60 patients with stable COPD who presented to the Abbasia Chest Hospital during the period from November 2016 till August 2017.

We excluded patients with other chronic lung diseases than COPD, systemic hypertension, any primary heart disease, and any disease that causes pulmonary hypertension (PH), as well as patients with severe COPD having respiratory failure and patients who could not undergo spirometric test.

We based on history, physical examination, chest radiography, and that post bronchodilator ratio of forced expiratory volume in 1st sec (FEV1) to vital capacity is less than 0.7 to diagnose COPD according to GOLD guidelines 2017. Ratio was measured by spirometry (3500 Spirometer; Viasys Micro Lab., England) with consideration of recommendations of American Thoracic Society/European thoracic society (2005) [7].

We classified severity of COPD according to FEV1% of predicted as follows: mild (FEV1≥80% of predicted), moderate (50%≤FEV1<80% predicted), severe (30%≤FEV1<50% predicted), and very severe (FEV1<30% predicted) [1].

Two-dimensional transthoracic, M-mode, and Doppler echocardiography examination was done for all patients by Siemens SONOLINE G60 S system (Siemens, USA), and a transducer array of 4–2 MHz.

We measured all parameters with American Society and European Association of Echocardiography recommendations [8]. All parameters were measured at end expiration as follows: we used M-mode and two-dimensional techniques to asses left ventricular ejection fraction and dimension techniques in short-axis and long-axis left parasternal views. We measured peak velocity of early diastolic flow (E), peak velocity of atrial contraction (A), and their ratio (E/A) to evaluate left ventricular diastolic function. We measured them over the mitral valve in apical four-chamber view with color flow imaging for optimal alignment of pulsed wave Doppler with blood flow. Right ventricular (RV) size was assessed by measurement of right internal mid-cavity dimension in apical four-chamber view. We measured tricuspid annular plane systolic excursion (TAPSE) in apical four-chamber view to asses RV systolic function. We used color flow Doppler technique to identify tricuspid regurge flow and continuous wave Doppler for measurement of the maximum jet velocity. The modified Bernoulli equation was used to estimate right ventricular systolic pressure (RVSP). Bossone et al. [9] consider RVSP to be equal to the systolic pulmonary artery pressure (sPAP): sPAP (mmHg)=RVSP=trans-tricuspid pressure gradient+right atrial pressure. Right atrial pressure was predicted by using the inferior vena cava size and collapsibility index. We defined PH as sPAP more than or equal to 35 mmHg [10].

Our study was approved by local ethical committee of scientific research.

Statistical analysis

We used IBM statistical analysis of social sciences statistics software (version 22.0, 2013; IBM Corp., Chicago, Illinois, USA), for statistical analysis. We used descriptive statistics for normally distributed quantitative data such as minimum and maximum range with mean±SD and for qualitative ones, number and percentage.

We used independent t test in cases of two independent groups with normally distributed data for quantitative variables, and for analysis of qualitative data, we used inferential analyses for independent variables. χ2 test was used for differences between proportions, and Fisher’s exact test for variables with small expected numbers. Pearson’s correlation was used for qualitative data and partial correlation test for controlling age. We considered that level of significance at P value less than 0.050 is significant, and more than that value is not significant.


  Results Top


Our study included 56 (93.3%) males and four (6.7%) females, with mean age of 58.4±7.7 years, ranging from 40 to 79 years old.

Most patients had severe to very severe obstruction. Demographic characteristics and spirometric results of our cases are shown in [Table 1].
Table 1 Demographic characteristics and spirometric results of the studied cases

Click here to view


Echocardiographic examination of left ventricular systolic functions revealed mild to moderate left ventricular dimensions dilatation in ∼35% of patients, whereas mild impairment of systolic function of left ventricle was seen in ∼28% of patients, but no cases of left ventricular systolic dysfunction (LVSD) (ejection fraction<40%) were detected.

However, left ventricular diastolic dysfunction (LVDD) measured by E/A ratio was seen in ∼25% of the patients.

Motion wall abnormalities were not found in the patients of this study.

RV examination revealed RV dilatation in ∼18% of the patients. Tricuspid regurge was found in ∼75%, with variable grades from mild to severe, with positive correlation between grades of obstruction and tricuspid regurge. TAPSE was normal in all patients.

PH was found in ∼40% of patients. It appeared more in severe and very severe grades of COPD than in mild/moderate grades (55.7 and 16.7%, respectively). Most of the patients (30%) who developed PH had mild degree of PH (35–49 mmHg).

Correlation between respiratory functions and echocardiography findings revealed a statistically significant negative correlation between FEV1 and FEV1/forced vital capacity ratio and RV size and RVSP, that is, when FEV1 and FEV1/forced vital capacity ratio decrease, RV size, and RVSP increase ([Table 2]).
Table 2 Correlation between respiratory functions and echocardiography findings

Click here to view



  Discussion Top


COPD is considered a worldwide cause of chronic morbidity and mortality [1]. Patients with COPD have a high risk of cardiovascular disease, and it can be a cause of their death [11],[12].

COPD can affect pulmonary blood vessels, right side of the heart, and may affect left side of the heart [13],[14].

Echocardiographic changes seen in patients with COPD were studied and correlated with severity of the disease.

The current study found that there were no cases with LVSD, ejection fraction less than 40%. However, the presence of mild LVSD was seen in ∼28% of patients, whereas mild to moderate left ventricular dimensions dilated in ∼35%.

True prevalence of LVSD is unknown. It varies widely, from 0 to 25%, as reported by Portillo et al. [15], who stated that the prevalence may depend on selecting patients with or without coronary artery disease, the presence or absence of associated PH, and airflow obstruction degree.

In the current study, no motion wall abnormalities were found in the echo findings of the patients.

This disagreed with Freixa et al. [16] who found that 30% of patients with LVSD presented left ventricle wall motion abnormalities. This difference might be owing to a large number of included patients.

In current study, no statistical significant correlation was found between left ventricular systolic function and dimensions and the severity of COPD. This is similar to Freixa et al. [16].

Frequent reports about the prevalence of LVDD in patients with COPD have been shown in many studies. The prevalence of LVDD in this study was ∼25%. This was in contrary to Huang and colleagues, who showed a higher frequency of LVDD in patients with COPD (65.6%) and Caram and colleagues who reported high frequency up to 88%. Another study by López-Sánchez et al. [19] focused on severe COPD outpatients and showed a highest prevalence of LVDD (90%) [17],[18].

The difference in the frequency of LVDD in patients with COPD between this study and previous studies might be owing to the difference of inclusion criteria such as different age group, absence of comorbidities, and unavailability of tissue Doppler echocardiography, which made the detection of diastolic dysfunction more accurate.

In this study, there was no correlation between LVDD and the severity of COPD. This is similar to the study conducted by Huang et al. [17].

The current study showed that RV dilatation was found in early stages of COPD. This agreed with Hilde et al. [20].

Moreover, there was a positive correlation between severity of COPD and RV size. This is similar to the study conducted by Jatav et al. [21].

In the present study, tricuspid regurgitation was present in ∼75% of the patients with variable grades from mild to severe. There was a positive correlation between grades of obstruction and tricuspid regurge. Similar findings were observed in study of Maula et al. [22].True prevalence of PH in COPD is unknown. A reported elevation of pulmonary arterial pressure is between 20 and 90% measured by right heart catheterization, with some evidence that PH increases with increase airflow obstruction [14],[23],[24]. The current study showed that the presence of PH, that is, pulmonary artery systolic pressure more than 35 mmHg, was 40%. PH appeared more in severe and very severe grades of the disease than in mild/moderate disease.

These results agreed with Jatav et al. [21] and El Wahsh et al. [25] who showed that increased pulmonary artery systolic pressure was found in 44 and 55.56% of patients, respectively, and also showed a positive correlation with severity of COPD.

Most of the patients (30%) in the current study with PH had mild degree of PH, and this was in agreement with Freixa et al. [16] who found that the magnitude of PH was mild in most cases and only 3% of patients had severe PH.

In the current study, TAPSE was used as easily obtainable measure of RV systolic function, and it was normal in all patients, which is in contrary to Hilde et al. [20] who included some patients with COPD with very severe degree of obstruction with respiratory failure and TAPSE was lower in them than controls.

In this study, there were some limitation such as using two-dimensional Doppler echocardiogram with color flow without using tissue Doppler echocardiography, which made the assessment of prevalence of LVDD less accurate. Right heart catheterization was not available for definitive diagnosis of PH and detection of its prevalence.


  Conclusion Top


LVDD appears to be frequent in patients with COPD but it is not related to the disease severity. Abnormal right heart changes could be expected. Prevalence of PH has a linear relationship with severity of COPD.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Global Initiative for Chronic Obstructive Lung Disease (GOLD 2017). Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease. 2017. Available at: www.goldcopd.org. [Accessed 2 January 2018].  Back to cited text no. 1
    
2.
Ekstrom MP, Wagner P, Strom KE. Trends in cause-specific mortality in oxygen-dependent chronic obstructive pulmonary disease. Am J Respir Crit Care Med 2011; 183:1032–1036.  Back to cited text no. 2
    
3.
Calverley PM, Scott S. Is airway inflammation in chronic obstructive pulmonary disease (COPD) a risk factor for cardiovascular events? COPD 2006; 3:233–242.  Back to cited text no. 3
    
4.
Sinden NJ, Stockley RA. Systemic inflammation and comorbidity in COPD: a result of ’overspill’ of inflammatory mediators from the lungs? Review of the evidence. Thorax 2010; 65:930–936.  Back to cited text no. 4
    
5.
Watz H, Waschki B, Meyer T, Kretschmar G, Kirsten A, Claussen M et al. Decreasing cardiac chamber sizes and associated heart dysfunction in COPD: role of hyperinflation. Chest 2010; 138:32–38.  Back to cited text no. 5
    
6.
Barbera JA, Peinado VI, Santos S. Pulmonary hypertension in chronic obstructive pulmonary disease. Eur Respir J 2003; 21:892–905.  Back to cited text no. 6
    
7.
American Thoracic Society/European thoracic society. Standardization of spirometry. Eur Resp J 2005; 26:319–338.  Back to cited text no. 7
    
8.
Lang RM, Badano LP, Mor-Avi V, Afilalo J, Armstrong A, Ernande L et al. Recommendations for cardiac chamber quantification by echocardiography in adults: an update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging. J Am Soc Echocardiogr 2015; 28:1–39.e14.  Back to cited text no. 8
    
9.
Bossone E, D’Andrea A, D’Alto M, Citro R, Argiento P, Ferrara F et al. Echocardiography in pulmonary arterial hypertension: From diagnosis to prognosis. J Am Soc Echocardiogr 2013; 26:1–14.  Back to cited text no. 9
    
10.
Rudski LG, Lai WW, Afilalo J, Hua L, Handschumacher MD, Chandrasekaran K et al. Guidelines for the echocardiographic assessment of the right heart in adults: a report from the American Society of Echocardiography. J Am Soc Echocardiogr 2010; 23:685–713.  Back to cited text no. 10
    
11.
Hillas G, Perlikos F, Tsiligianni I, Tzanakis N. Managing comorbidities comorbidities in COPD. Int J Chron Obstruct Pulmon Dis 2015; 10:95–109.  Back to cited text no. 11
    
12.
Decramer M, Janssens W, Miravitlles M. Chronic obstructive pulmonary disease. Lancet 2012; 379:1341–1351.  Back to cited text no. 12
    
13.
Burgess MI, Mogulkoc N, Bright-Thomas RJ, Bishop P, Egan JJ, Ray SG. Comparison of echocardiographic markers of right ventricular function in determining prognosis in chronic pulmonary disease. J Am Soc Echocardiogr 2002; 15:633–639.  Back to cited text no. 13
    
14.
Shujaat A, Bajwa AA, James D. Cury. Pulmonary hypertension secondary to COPD. Pulm Med 2012; 2012:203952.  Back to cited text no. 14
    
15.
Portillo K, Abad-Capa J, Ruiz-Manzano J. Chronic obstructive pulmonary disease and left ventricle. Arch Bronconeumol 2015; 51:227–234.  Back to cited text no. 15
    
16.
Freixa X, Portillo K, Paré C, Garcia-Aymerich J, Gomez FP, Benet M et al. Echocardiographic abnormalities in patients with COPD at their first hospital admission. Eur Respir J 2013; 41:784–791.  Back to cited text no. 16
    
17.
Huang YS, Feng YC, Zhang J, Bai L, Huang W, Li W, Sun Y. Impact of chronic obstructive pulmonary diseases on left ventricular diastolic function in hospitalized elderly patients. Clin Interv Aging 2015; 10:81–87.  Back to cited text no. 17
    
18.
Caram LM, Ferrari R, Naves CR, Tanni SE, Coelho LS, Zanati SG et al. Association between left ventricular diastolic dysfunction and severity of chronic obstructive pulmonary disease. Clinics (Sao Paulo) 2013; 68:772–776.  Back to cited text no. 18
    
19.
López-Sánchez M, Munoz-Esquerre M, Huertas D, Gonzalez-Costello J, Ribas J, Manresa F et al. High prevalence of left ventricle diastolic dysfunction in severe COPD associated with a low exercise capacity: a cross-sectional study. PLOS ONE 2013; 8:e68034.  Back to cited text no. 19
    
20.
Hilde JM, Skjørten I, Grøtta OJ, Hansteen V, Melsom MN, Hisdal J et al. Right ventricular dys- function and remodeling in chronic obstructive pulmonary dis- ease without pulmonary hypertension. J Am Coll Cardiol 2013; 62:1103–1111.  Back to cited text no. 20
    
21.
Jatav VS, Meena SR, Jelia S, Jain P, Ajmera D, Agarwal V et al. Echocardiographic findings in chronic obstructive pulmonary disease and correlation of right ventricular dysfunction with disease severity. IJAM 2017; 4:476–480.  Back to cited text no. 21
    
22.
Maula F, Nadeem M, Adil M, Ullah J, Rauf A. echocardiographic findings in chronic pulmonary disease(COPD) patients. PJCM 2012;2309–9844  Back to cited text no. 22
    
23.
Weitzenblum E, Hirth C, Ducolone A, Mirhom R, Rasaholinjanahary J, Ehrhart M. Prognostic value of pulmonary artery pressure in chronic COPD. Thorax 1981; 36:752–758.  Back to cited text no. 23
    
24.
Thabut G, Dauriat G, Stern JB, Logeart D, Levy A, Marrash-Chahla R, Mal H. Pulmonary hemodynamics in advanced COPD candidates for lung volume reduction surgery or lung transplantation. Chest 2005; 127:1531–1536.  Back to cited text no. 24
    
25.
El Wahsh RA, Ahmed MK, Yaseen RI. Evaluation of left ventricular function in patients with chronic obstructive pulmonary disease with or without pulmonary hypertension. Egypt J Chest Dis Tuber 2013; 62:575–582.  Back to cited text no. 25
    



 
 
    Tables

  [Table 1], [Table 2]



 

Top
 
 
  Search
 
Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)

 
  In this article
Abstract
Introduction
Patients and methods
Results
Discussion
Conclusion
References
Article Tables

 Article Access Statistics
    Viewed2169    
    Printed131    
    Emailed0    
    PDF Downloaded198    
    Comments [Add]    

Recommend this journal


[TAG2]
[TAG3]
[TAG4]