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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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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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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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)

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Cardiac Complication in COPD and Its Management