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A Study of Echocardiographic Evaluation in the Chronic Obstructive Pulmonary Disease Patients at a Tertiary Health Care Centre

 

J. N. Patel1*, Gordhan Gondaliya2, Kshitij Mandke3, Bhavik Patel4, Prashant Gohil5

1Professor and HOD, 2Associate Professor,3Sr. Resident, 4, 5 Resident, Department of Pulmonology, C. U. Shah Medical College, Surendranagar, Gujarat, INDIA.

Email: jasupatel56@gmail.com

 

Abstract          Chronic obstructive pulmonary disease (COPD) is the most common medical problem in India. The purpose of this study is to evaluate the echocardiography based cardiac function in COPD patients (200) of C.U. Shah Medical College and Hospital during 05th August 2012 to 12th September 2013. 126 cases (63%) of the COPD patients were in age group 60-75 years, 34 cases (17.0%) in 45-59 years of age and 40 cases (20%) in the 76-90 years age groups. Of the total patients (200), significant number of patients 45 cases had poor LVEF (22.5%). 86 patients (43%) showed features of chronic corpulmonale followed by valvular heart disease in 74 cases 37%), diastolic dysfunction in 72 cases (36%) and left ventricular hypertrophy in 25 (12.5%). Mild pulmonary artery hypertension (PAH) was detected in 102 patients (51%), followed by moderate PAH in 41 patients (20.5%), Severe PAH in 18 patients (9%) Tran thoracic echocardiography was found to be very useful to identify various concomitant cardiac abnormalities demanding special treatment consideration in managing clinically COPD like patients.

Key Word: COPD, Chronic corpulmonale, echocardiography, DCM, PAH.

               

INTRODUCTION

Chronic obstructive pulmonary disease (COPD) has been defined by the presence of airways obstruction, which does not change markedly over several months and unlike asthma, is not fully reversible. Chronic cough, chronic sputum production, dyspnea and history of exposure to risk factors like tobacco smoking are the clues for the diagnosis of COPD. Global Initiative for Chronic Obstructive Lung Disease (GOLD) has described COPD as a disease that is preventable and curable. Estimates suggest that COPD will rise from the sixth rank as the cause of death in 1990 to the third rank as the most common cause of death worldwide by 2020. COPD is the most common medical problem in India according to a hospital-based evaluation and has significant morbidity and mortality. We are presenting our echocardiography based cardiac evaluation in COPD patients.

 

MATERIALS AND METHODS

Two Hundreds patients who are suffering from chronic obstructive pulmonary disease(COPD) and were assessed in C.U. Shah Medical College Teaching Hospital during 05th August 2012 to 12th September 2013. Patients underwent echocardiographic evaluation at our hospital. Echocardio graphic examination was undertaken as per the recommendation of American Society of Echocardiography. During echocardiographic evaluation left ventricle ejection fraction (LVEF)calculated, Estimated systolic pulmonary artery pressure (PAP) has been calculated, PAP has been arbitrarily sub-grouped in mild (40-59 mmHg), moderate (60-79 mm Hg) and severe (>80 mm Hg) groups and Diastolic functions, Other valvular abnormalities and Ventricular abnormalities were assessed.

RESULTS

Two Hundreds patients who are suffering from chronic obstructive pulmonary disease(COPD) and were assessed in C.U. Shah Medical College Teaching Hospital during 05th August 2012 to 12th September 2013.Table 1 Shows 126 cases (63%) of the COPD patients were in age group 60-75 years, 34 cases (17.0%) in 45-59 years of age and 40 cases (20%) in the 76-90 years age groups. Table 3 Shows out of the total patients (200), significant number of patients 45 cases had poor LVEF (22.5%). 86 patients (43%) showed features of chronic corpulmonale followed by valvular heart disease in 74 cases (37%), diastolic dysfunction in 72 cases (36%) and left ventricular hypertrophy in 25 (12.5%). Table 2 shows Mild pulmonary artery hypertension (PAH) was detected in 102 patients (51%), followed by moderate PAH in 41 patients (20.5%), Severe PAH in 18 patients (9%) and other concomitant disease. the As a single patient may have more than one echocardiography-based diagnosis, total may be more than the number of patients undergoing echocardiography. Table 4 Shows the concomitant diseases among COPD patients (N =200) as per clinical diagnosis. A significant number of patients (43%) had already developed features of chronic corpulmonale clinically. Rest concomitant diseases are shown in Table 4.

 

Table 1: Age Distribution in Patients

Age group

45-59 yrs.

60-75 yrs.

76-90 yrs.

Number of cases

34

126

40

Cases %

17%

63%

20%

 

Table 2: Severity of PAH in COPD Patients

Pulmonary artery Pressure

< 40 mm Hg

40-59 mm Hg

60-79 mm Hg

>80 mm Hg

Number of Cases

39

102

41

18

Cases %

19.5%

51%

20.5%

9%

 

Table 3: Echocardiography Diagnosis in COPD Patients

Echo Findings

Number of Cases

Cases %

Corpulmonale

86

43%

Dilated Cardiomyopathy

22

11%

Left ventricular hypertrophy

25

12.5%

Pericardial effusion

26

13%

Valvular heart disease

74

37%

Diastolic Dysfunction

72

36%

Thickened Mitral Valve

4

2%

Thickened aortic valve

16

8%

Poor lvef

45

22.5%

Normal echo

20

10%

 

 

 

 

 

Table 4: Concomitant Disease in COPD

Concomitant disease

Number of Cases

Cases %

Chronic corpulmonale

86

43%

Respiratory failure

20

10%

Hypertension

22

11%

Dilated cardiomyopathy

5

2.5%

Valvular heart disease

74

37%

Ischemic heart disease

4

2%

Congestive cardiac failure

8

4%

Left ventricular hypertrophy

25

12.5%

Other cardiovascular disease

7

3.5%

Diabetes mellitus

6

3%

Pulmonary tb

8

4%

Chest infection

9

4.5%

Broncogenic carcinoma

2

1%

Other respiratory disease

6

3%

Chronic kidney disease

3

1.5%

Acid peptic disease

5

2.5%

Neurological disease

4

2%

Hepatobiliary disease

11

5.5%

 

 

DISCUSSION

COPD is the most common medical problem in India and has significant morbidity and mortality. We present here our echocardiography based cardiac evaluation in admitted COPD patients. Age group wise distribution of COPD as shown in Table 1showed patients of COPD appeared dramatically after the age of 45 years, and peaking at the age group 60-75 years. COPD is a chronic illness taking more than 10packs year of smoking to develop it. Chronic corpulmonale is an important complication of COPD and the development of pulmonary hypertensionis associated with higher mortality and morbidity. Longterm oxygen therapy is beneficial in COPD with chronic corpulmonale. Significant proportion of COPD patients had features of chronic corpulmonale (Table-3, 4). This data supports the excessive need of domiciliary oxygen therapy. As cylinder based oxygen supply is available in big cities only and are quite expensive for ordinary poor Indian people, management of COPD is not that easy in India. Though oxygen concentrator machines are introduced, frequent electric power cuts affects patients with good purchasing power as well. Introduction of liquid oxygen will be very useful milestone in the management of COPD, as it will help really ambulatory oxygen therapy to COPD patients. COPD is usually managed with inhaled bronchodilators like rapid acting and slow acting beta 2 adrenoceptoragonists like salbutamol, salmeterol, for moterol, anticholinergic drugs like ipratropium, tiotropiumand steroid like fluticasone. When component of heart failure is prominent, it may be good to introduce gradually specific beta 1 blocker like Metoprolol or Bisoprolol along with in halationalbronchodilator therapy after optimizing the heart failure therapy with drugs like angiotgensin converting enzymeinhibitor, digoxin and diuretic as specific beta 1 blocker may be more appropriate and compatible with beta 2stimulants e.g. Salbutamol, Terbutaline, Salmeterol. Specific beta 1 blockers lose their specificity at higher dose, demanding extreme care in avoiding higher dose. Improved clinical outcomes have been previously reportedwith long term oxygen therapy. Significant number of COPD patients in this study had mild to moderate PAH shown in Table 2, reflecting the high oxygen demand inpoor patients. Though the reports of improved cardiopulmonary function in severe COPD are available with the combination of nitric oxide and oxygen, these strategies are not yet practiced in rural India but should be used in selected severe COPD patients if it is affordable. Though critically ill COPD patients require in gmechanical ventilation have higher mortality, noninvasive mechanical ventilation is better in terms of mortality. Use of echocardiography based cardiac evaluation in COPD to evaluate the status of pulmonary arterialhypertension and other concomitant cardiac lesions, is very valuable in the management of COPD. Selectingpatients with moderate or severe pulmonary arterial hypertension for long term oxygen therapy with or withoutnitric oxide and selecting poor LVEF patients for optimizing heart failure therapy has the potential to have further improvement in severe COPD patients havingapparently poor response in usual COPD management.

 

REFERENCES

  1. Innes JA, Reid PT. Respiratory disease: Chronic ObstructivePulmonary Disease (COPD). In Boon NA, College NR, Walker BR, Hunter JAA, editors. Davidson’s Principles and Practice of Medicine, (20th Ed). Edinburg: ChurchillLivingstone Elsevier 2006; 678-84.
  2. Global Initiative for Chronic Obstructive Lung Disease. Global strategy for the diagnosis, management and prevention of chronic obstructive pulmonary disease. Executive summary. Medical Communications Resources, Inc 2007; 1-43.
  3. Lopez AD, Murray CC. The global burden of disease, 1990-2020. Nature Med 1998; 4: 1241-3.
  4. Reilly JJ, Silverman EK, Shapiro SD. Chronic obstructive pulmonary disease. In Kasper DL, Braunwald E, Fauci AS, Hauser SL, Longo DL, Jameson JL, editors. Harrison’s Principles of Internal Medicine (16th Ed.) New York: McGraw-Hill Medical Publishing Division 2005; 1547-54.
  5. Schmailzl KJG. Conventional Echocardiography: Examination Procedure, Fundamental measurement and Assessment Tasks. In Schmailzl JG, Ormerod O, Editors. Ultrasound in Cardiology (1st Ed.). Berlin: Blackwell Science 1994; 49-8.
  6.  Oh JK, Seward JB, Tajik AJ. The Echo Manual: the Mayo Clinic (13rd Ed.). New Delhi: Lippincott Williams 2006; 7-28.
  7. Rich S, McLaughlin VV. Pulmonary Hypertension Associated with Disorders of the Respiratory System: Chronic Obstructive Pulmonary Disease In Zipes DB, Libby P, BonowRO, Braunwald E , editors. Braunwald’s Heart Disease: Atextbook of cardiovascular medicine (7th Ed) Philadelphia: Elsevier Saunders 2005: 1831-5.
  8. Weitzenblum E, Hirth C, Ducolonea et al. Prognostic value of pulmonary artery pressure in chronic obstructive pulmonary disease. Thorax 1981; 36: 752-8.
  9. Siafakas NM, Vermeire P, Pride NB et al. Optimal assessment and management of chronic obstructive pulmonary disease (COPD). The European Respiratory Society Task Force.EurRespir1995; 8: 1398-420.
  10. Medical Research Council Working Party. Long term domiciliary oxygen therapy in chronic hypoxic corpulmonale complicating chronic bronchitis and emphysema. Lancet 1981; 1: 681-6.
  11. Nocturnal Oxygen Therapy Trial Group. Continuous ornocturnal oxygen therapy in hypoxemic chronic obstructive lung disease: a clinical trial. Ann Intern Med 1980; 93: 391-8.
  12. Weitzenblum E, Sautegeau A, Ehrhart M et al. Long-termoxygen therapy can reverse the progression of pulmonary hypertension in patients with chronic obstructive pulmonarydisease. Am Rev Respir Dis 1985; 131: 493-8.
  13. Packer M, Bristow MR, Cohn JN et al. The effect of carvedilolon morbidity and mortality in patients with chronic heartfailure. N Engl J Med 1996; 334: 1349-55.
  14. Packer M, Coats AJS, Fowler MB et al. The effect ofcarvedilol on the survivial in severe chronic heart failure. NewEngl J Med 2001; 344: 1651-8.
  15. MERIT-HT Study Group. Effect of metoprolol CR/XL inchronic heart failure: Metoprolol CR/XL RandomisedIntervention Trial in congestive heart failure (MERIT-HF).Lancet 1999; 353: 2001-7.
  16. CIBIS II Investigators and Committees. The CardiacInsufficiency Bisoprolol Study II (CIBIS II): a randomizedtrial. Lancet 1999; 353: 9-13.
  17. Poole-Wilson PA, Swedberg K, Cleland JGF et al. Comparison of carvedilol and metoprolol on clinicaloutcomes in patients with chronic heart failure in theCarvedilolor Metoprolol European Trial (COMET): randomized controlled trial. Lancet 2003; 362: 7-13.
  18. Remme WJ, Cleland JG., Di Lenarda A et al. Carvedilol betterprotects against vascular events than metoprolol in heartfailure: results from COMET. J AmerCollCardiol 2007; 49: 96371.
  19. Jenkins CR, Chow CM, Fisher BL, Marlin GE. Comparisonof ipratropium bromide and salbutamol by aerosolizedsolution. Aust N Z J Med 1981; 11: 513-6.
  20. Jarvis b, Markham A. Inhaled salmeterol: a review of itsefficacy in chronic obstructive pulmonary disease. Drugs Aging 2001; 18: 441-72.
  21.  Cheer SM, Scott LJ. Formoterol: a review of its use in chronicobstructive pulmonary disease. Amer J RespirMed2006; 1: 285-300.
  22. Brown IG, Chan CS, Kelly CA, Dent Ag, Zimmerman PV. Assessment of the clinical usefulness of nebulised ipratropiumbromide in patients with chronic airflow limitation. Thorax1984; 39: 272-6.
  23. Keam SJ, Keating GM. Tiotropium bromide. A review of its use as maintenance therapy in patients with COPD TreatRespir Med 2004; 3: 247-68.
  24. Soriano JB, Kiri VA, Pride NB, Vestbo J. Inhaledcorticosteroids with/ without long-acting beta-agonists reducethe risk of rehospitalization and death in COPD patients. AmerJ Respir Med 2003; 2: 67-74.
  25. Khan MG. Cardiac drug therapy: Beta-Blockers: The Cornerstone of Cardiac Drug Therapy. 6th ed. USA: Saunders 2003; 1-52.
  26. Germann P, Ziesche R, Leitner C et al. Addition of nitricoxygen to oxygen improves cardiopulmonary function inpatients with severe COPD. Chest 1998; 114: 29-35.
  27. Yashida M, Taguchi O, Gabazza EC et al. Combinedinhalation of nitric oxide and oxygen in chronic obstructivepulmonary disease. Amer J RespirCrit Care Med1997; 155: 526-9.
  28. Katayama Y, Higenbottam TW, Diaz de Atauri MJ et al.Inhaled nitric oxide and arterial tension in patients withchronic obstructive pulmonary disease and severe pulmonaryhypertension. Thorax 1997; 52: 120-4.
  29. Vonbank K, Ziesche R, Higenbottam TW et al. controlledprospective randomized trial on the effects on pulmonaryhaemodynamics of the ambulatory long term use of nitricoxide and oxygen in patients with severe COPD.Thorax2003; 58: 289-93.Limthongkul S, Wongthim S, Udompanich V, Charoenlap P,Nuchprayoon CJ. Mechanical and non-mechanical ventilationof respiratory failure in chronic obstructive pulmonarydisease. J Med Assoc Thai 1993; 76: 1-8.
  30. Vitacca M, Clini E, Rubini F, Nava S, Foglio K, Ambrosino N.Non-invasive mechanical ventilation in severe chronicobstructive lung disease and acute respiratory failure: shortand Long-term prognosis. Intensive Care Med 1996; 22: 94-100.
  31. Vitacca M, Rubini F, Foglio K, Scalvini S, Nava S, AmbrosinoN. Non-invasive modalities of positive pressure ventilationimproves the outcome of acute exacerbations in COLD Patients. Intensive Care Med 1993; 19: 450-5.
  32. Arcasoy SM, Christie JD, Ferrari VA et al. Echocardiographicassessment of pulmonary hypertension in patients with advancedlung disease. Amer J RespirCrit Care Med 2003; 167: 735.0

 


 

 

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