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7/29/2019 Cardiac Complication in COPD and Its Management
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NAMA : Agus Subagjo
INSTANSI : LAB / SMF KARDIOLOGI DAN
KEDOKTERAN VASKULAR
FK Unair RSU Dr. SOETOMO
Lahir : Kediri, 14 Agustus 1956
Lulus dokter : FK Unair 1984
Lulus Spesialis : Ilmu Penyakit Jantung dan
Pembuluh Darah 1996
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CARDIOVASCULAR COMPLICATIONSIN COPD AND ITS MANAGEMENT
AGUS SUBAGJO
Cardiology and Vascular Medicine Departement
Medical Faculty of Airlangga University - Soetomo General Hospital Surabaya
November 04, 2007
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INTRODUCTION
COPD (Chronic Obstructive Pulmonary Disease) is amajor public health problem.
COPD is a disease characterized by airflow limitation: not fully reversible
progressive associated with an abnormal inflammatory response
of the lungs to noxious particles or gases
The anatomical & functional relationship
between the lungs & the heart very strong
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INTRODUCTION
The inter-relationship can be of two types:
1. An association between pathologies, which sharesimilar risks and substrate (such as: CAD, COPD andcigarette smoking)
2. Dysfunction of the heart from primary lung disease(such as: pulmonary hypertension and rightventricular dysfunction)
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INTRODUCTION
COPD:
More than a lung disease
A systemic disease
Cause of hospitalization & mortality is cardiovascularin nature
Some cardiovascular complications which are oftenoccurs:
1. Secondary Pulmonary Hypertension (SPH)
2. Cor Pulmonale (CP)3. Ischemic Heart Disease
4. Arrhythmia
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1. Secondary Pulmonary Hypertension (SPH)
Secondary pulmonary hypertension (SPH)
Relatively common
Underdiagnosed nonspecific signs and symptoms
a pulmonary artery systolic pressure >30 mmHg or a pulmonary artery mean pressure > 20 mmHg
Complication of pulmonary diseases, cardiac andextrathoraxic conditions
At autopsy, in up to 40 % patient with COPD
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Pathophysiology of SPH
Regardless of the underlying causeleads to rightventricular failure.
PH can expand to exceed of COPD itself can impairedmorbidity and mortality
Alveolar hypoxia, acidosis and hypercarbia can increasepulmonary arterial pressure.
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Diagnosis of SPH
Non specific signs and symptom Difficult to separate with underlying diseases
Should be suspected in patients with:
increasing dyspnea on exertion a known cause of pulmonary hypertension
Two-dimensional echocardiography with Doppler
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DIAGNOSIS OF SPH
Further evaluation may include assessment of: Oxygenation Pulmonary function testing (pulmonary obstruction or
restriction) CT scan of the chest
Ventilation-perfusion lung Cardiac catheterization performed in patients with
unexplained pulmonary hypertension
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MANAGEMENT OF SPH
Treatment of the underlying disease and correction ofhypoxemia.
Long-term oxygen therapy
Diet of low salt and diuretic
Pharmacological therapy:
Endothelin antagonist
Prostacycline therapy
Inhaled NO (Nitric Oxide)
Lung transplantation if no respond to medicalmanagement
HP primer
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2. COR PULMONALE
Cor pulmonale:
PH dilatation and hypertrofi RV resulting fromdisorders of the pulmonary parenchyma, the thoraxiccage, or the neuromuscular system,
excluding congenital heart disease and disorders ofthe left side of the heart
Cor pulmonale can occur:
1. Acutely 2. Chronically PH resulting lung disease
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Pathophysiology of CP
6 - 7% of all adult heart diseases in the US
Half cases of chronic CP is due to COPD
If untreated:
overloadthe right ventricle
1st response: expand the size of the RVmusclecompensated cor pulmonale
Decompensated cor pulmonale (elevated neckveins, congestive liver, and peripheral edema)
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Clinical features of cor pulmonale
The same as SPH cyanosis, chest pain, hemoptysis,
neurologic symptoms (hipoxemia),
low cardiac output syndrome
Early detection may be difficult domination the underlying lung disease
Inadvanced PH stages, the RV pressure increased
elevated JVP, hepatomegaly, cardiac cirrhosis, jaundice,ascites, and etc)
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Diagnosis of cor pulmonale
COPD : chronic cough, productive, dispneau Spirometry, Chest X-ray, Blood Gas Analysis,
polycythemia
Electrocardiography: Right ventricular hypertrophy; Poor progression of R,Ventricular and Supraventricular arrhythmias
Echocardiography:
Estimation systolic pulmonary artery pressure To excluded congenital and left heart abnormality
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MANAGEMENT OF COR PULMONALE
I. Medical therapy : The underlying pulmonary disease
Improvement of oxygenation and right ventricularfunction
If right heart failure is already occurred :
1. Reduce of pulmonary hypertension
2. Improvement heart failure
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Management of cor pulmonale
1. Reduce of pulmonary hypertension:
Oxygen therapy: 1-2 l/m continuous (minimally19
hours/ day) reduction in the 46% mortality rate
delaying right heart failure
strong vasodilator effects
Bronchodilator: to improve pulmonary function andreduce hypoxia.
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Management of cor pulmonale
Pulmonary vasodilator:
FDA: prostanoid, be careful monitoroxygen saturation
prostacycline analogues; phosphodiesterase-5-inhibitor ~ inhaled NO
Cardiac glycosides, such as digitaliscontroversial
Vasodilator be careful (fatal hypotension)
Phlebotomy
Diuretics
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Management of cor pulmonale
Diuretics Improvement of the function RV & LV
Reduce mean blood circulation pressure, CO and renalblood flow
Hypokalemic & metabolic acidosis:
- Arrhythmia
- Diminish respiratory stimulation
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Management of cor pulmonale
2. Improvement heart failure:
vasodilator, diuretic, digitalis, and etc.
II. Surgical treatment:Single-lung, double-lung, and heart-lung transplantation
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3. ISCHEMIA HEART DISEASE
COPD increases the risk of cardiovascular disease by twoto three fold
Smoking:
a major cause of chronic obstructive pulmonarydisease (COPD) and cardiovascular disorders,including coronary heart disease (CHD) andperipheral arterial disease.
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PATHOFISIOLOGY OF ISCHEMIA HEART DISEASE
Cigarette smoking, other environmental irritants andinfectious organisms: may activate alveolar macrophages, bronchial
epithelial cells, & other cellular elements
produce a variety of signaling molecules:chemokines.
also produce cytokines such as IL-8, macrophage chemotactic protein-1,
interferongamma-inducible protein-10
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Pathophysiology of ischemic heart disease
Produce IL-6 and IL-1: induce local pro-inflammatory changes
escape into the systemic circulation
stimulate hepatocytes to synthesize acute phase
proteins(CRP and fibrinogen)
IL-6 and GMC-SF stimulate the bone marrow toproduce leukocytes and platelets
Conjunction with traditional risk factorspromoteatherogenesis and cardiovascular disease.
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Management of ischemic heart disease
Similar with treatment conventional ischemic heartdisease.
COPD + Ischemic heart disease
be careful to use beta blocker and ACE inhibitorin sensitive patient!!!
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4. Arrhythmia
Supraventricular and ventricular arrhythmias arecommon among patients with COPD
The most frequent arrhythmias in COPDMAT=Multifocal Atrial Tachycardia
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Arrhythmia
Multiplefactors contribute to the development ofarrhythmiasin COPD, including:
Medications (theophylline, -agonists, digoxin)
Cardiac autonomic dysfunction
Right and/or left ventricular failure Elevated catecholamine levels associated with hypoxia
Hypokalemia and hypomagnesemia
Respiratory failure and Respiratory acidosis
Comorbidities: CAD; Systemic arterial hypertension
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Arrhythmia
Mehylxanthine (Theophylline and Aminophylline) increases heart rate, enhance atrial automaticity accelerate intracardiac conduction.
have been associated with the following rhythm
disturbances: sinus tachycardia, premature atrial beats,supraventricular tachycardia, atrial fibrillation, unifocaland multifocal atrial tachycardia, and ventriculararrhythmias.
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Arrhythmia
Beta-Agonist therapy:
Tachycardia
Acceleration of atrioventricular nodes
Long Q-T syndrome
Shorten atrioventricular nodes refractory periods
Slow repolarization
Can leads spontaneous arrhythmias
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Arrhythmia
Attention in handling arrhythmiasin COPD: Correction of precipitated factors (hypoxemia,
hypercapnea, acid-base and metabolic disorder,abnormality of electrolyte, and acute ischemiamyocard)
Avoiding usage drugs which may prolonged Q-T
The reduction of arrhythmogenic drugs
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Management of arrhythmias in COPD
Principal treatment of non stable arrhytmias:
Hemodynamic state
Signs and symptoms
Is there any signs of cardiac failure?
If there one of themElectrical cardioversion
Stable tachyarrhytmias:
Vagal manouver
Anti arrhytmogenic drugs (adenosine, CCB, amiodarone,etc)
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Arrhythmias
Things to be considered in using antiarrhytmogenicdrugs:
Beta blocker contraindication in bronchospam and
wheezing patients.
Adenosine induced bronchospasm
Long treatment Amiodarone 15% lung toxicity.
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SUMMARY
The anatomical & functional relationship between thelungs & the heart is very strong
COPD is more than a lung disease, it is a systemicdisease with effects in the cardiovascular system.
Some cardiac complications which is often occurs inCOPD patients are 1. Secondary PulmonaryHypertension; 2. Cor Pulmonale; 3. Ischemia HeartDisease; 4. Arrhythmia
SPH is a pulmonary artery systolic pressure >30 mm Hgor a pulmonary artery mean pressure > 20 mm Hg, ascomplication of many pulmonary, cardiac andextrathoracic conditions
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SUMMARY
Cor pulmonale is a PH resulting from disorders of thepulmonary parenchyma, the thoracic cage, or theneuromuscular system, excluding congenital heartdisease and disorders of the left side of the heart
Medical treatment of CP is generally focused ontreatment of theunderlying pulmonary disease &improving oxygenation and right ventricular function
COPD increases the risk of cardiovascular disease by twoto three fold
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SUMMARY
Smoking is a major cause of COPD and cardiovascular
disorders, including CHD and peripheral arterial disease
Cigarette smoking, etc, may activate alveolarmacrophages and than promote atherogenesis and
cardiovascular disease.
Supraventricular and ventricular arrhythmias arecommon among patients with COPD, the most frequent
arrhythmias in COPD is MAT (Multifocal AtrialTachycardia)
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ECG signs of right ventricular hypertrophy
(tall right precordial R waves,right axis deviation and right ventricular strain)
Recommended