Pulmonary Disease, Chronic Obstructive

IJCS

Editorial

Advanced Echocardiographic Techniques for the Diagnosis of Subclinical Right Ventricular Dysfunction in Chronic Obstructive Pulmonary Disease

Chronic obstructive pulmonary disease (COPD) is a common and treatable disease in the general population, accounting for high morbidity and mortality rates. In patients with severe COPD, hypoxemia is the main cause of complications such as pulmonary hypertension (PH) and right ventricle (RV) dysfunction. However, the presence of RV vascular structural and functional changes may occur in the early stages of COPD, even before significant hypoxemia or PH. Subclinical RV dysfunction often precedes the development of signs and symptoms of RV failure; thus, there is an evident need to detect it from the onset of the disease.

The importance of the RV in cardiovascular physiology has been underestimated for decades. Previously considered a mere conduit, the chamber is now known to play a major role in maintaining global cardiac function intact. Impairment of RV systolic function is an essential determinant of clinical outcomes in different scenarios and should thus be considered in the individualized management of patients.^,

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Editorial

To Dip or not to Dip Blood Pressure in Chronic Obstructive Pulmonary Disease: That is the Question!

Sofia F. Furlan et al. Luciano F. Drager

Chronic obstructive pulmonary disease (COPD) is a major health problem worldwide. It is characterized as a chronic inflammatory lung disease that causes obstructed airflow from the lungs. It is typically caused by long-term exposure to cigarette smoke, but household air pollution, ambient particulate matter, ozone, and occupational particulates, including coal dust, also contribute to COPD. According to the Global Burden of Disease, 544.9 million people worldwide had a chronic respiratory disease in 2017, which represents an increase of 39.8% compared with 1990. Among the respiratory diseases, COPD remained the most prevalent disease-specific condition in 2017, accounting for 55.1% of chronic respiratory disease prevalence among men and 54.8% among women globally. More importantly, most chronic respiratory disease-attributable deaths and disability-adjusted life years were due to COPD.

Consistent evidence has indicated that COPD is associated with increased cardiovascular risk, which is an important cause of death in COPD patients.^, Systemic inflammation, chronic hypoxia, sympathetic activation, lung hyperinflation, secondary erythrocytosis, and loss of pulmonary vascular surface are responsible for increasing the rate of conditions such as pulmonary hypertension, right ventricular dysfunction, arrhythmias, ischemic coronary disease, among others. More recently, the association between COPD and hypertension has gained increasing attention. In a Danish cohort of more than 70,000 COPD patients, 47.6% of the patients had hypertension (the most common comorbidity in these patients). Although it is not clear whether COPD increases the incidence of hypertension, uncontrolled blood pressure (BP) is associated with poor prognosis in patients with COPD. These findings pave the way for additional characterization of the impact of COPD on BP variability.

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Original Article

Evaluation of Dipper and Non-dipper Blood Pressure Patterns and Quality of Life Among Patients with Chronic Obstructive Pulmonary Disease

Meryem Askın et al. Esra Meltem Koc Kaan Sozmen Muzaffer Onur Turan … Zeki Soypacacı Saliha Aksun

Abstract

Background

Non-dipper blood pressure is defined by less than a 10% reduction in nighttime blood pressure, and it is associated with cardiovascular disease. Inflammation is thought to play a role in the pathogenesis of both chronic obstructive pulmonary disease (COPD) and non-dipper blood pressure pattern, and both diseases are associated with lower quality of life.

Objective

The aim of this study was to investigate the effects of non-dipper blood pressure pattern in patients with COPD.

Methods

A cross-sectional study was carried out with 142 patients with COPD. The Saint George Respiratory Questionnaire and the Euro Quality of Life Scale were used to collect data. To understand arterial stiffness, the augmentation index and pulse wave velocity were measured, and 24-hour ambulatory blood pressure monitoring was subsequently performed. A multivariable logistic regression model was used to understand the relationship between different independent variables and blood pressure pattern. P values lower than 0.05 were considered statistically significant.

Results

As a result, 76.1% (n = 108) of the patients had non-dipper blood pressure pattern. Non-dipper patients had higher C-reactive protein (OR:1.123; 95% CI:1.016;1.242), augmentation index (OR: 1.057; 95% CI: 1.011;1.105) and Saint George Respiratory Questionnaire total score (OR: 1.021; 95% CI: 1.001;1.042) than dipper patients. Also, as the number of people living at home increased, non-dipper blood pressure pattern was found to be more frequent (OR: 1.339; 95% CI: 1.009;1.777).

Conclusion

Non-dipper blood pressure pattern may increase cardiovascular risk by triggering inflammation and may adversely affect the prognosis of COPD by lowering the disease-related quality of life. (Arq Bras Cardiol. 2020; [online].ahead print, PP.0-0)

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Review Article

Pulmonary Hypertension in General Cardiology Practice

Daniela Calderaro et al. José Leonidas Alves Junior Caio Júlio César dos Santos Fernandes Rogério Souza

Abstract

The finding of pulmonary hypertension (PH) by echocardiography is common and of concern. However, echocardiography is just a suggestive and non-diagnostic assessment of PH. When direct involvement of pulmonary circulation is suspected, invasive hemodynamic monitoring is recommended to establish the diagnosis. This assessent provides, in addition to the diagnostic confirmation, the correct identification of the vascular territory predominantly involved (arterial pulmonary or postcapillary). Treatment with specific medication for PH (phosphodiesterase type 5 inhibitors, endothelin receptor antagonists and prostacyclin analogues) has been proven effective in patients with pulmonary arterial hypertension, but its use in patients with PH due to left heart disease can even be damaging. In this review, we discuss the diagnosis criteria, how etiological investigation should be carried out, the clinical classification and, finally, the therapeutic recommendations for PH.

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Image

Challenging Evaluation of Aortic Regurgitation: More Than a Quadricuspid Valve

Gonçalo Pestana et al. Carla Sousa Teresa Pinho Sara Maia M. Júlia Maciel

A 61-year-old female patient with chronic obstructive pulmonary disease, and no other comorbidities, was referred for cardiological assessment due to aggravated exertional dyspnea (New York Heart Association – NYHA class III) and atypical chest pain. Physical examination disclosed only a diastolic murmur in the second intercostal space in the right sternal border.

The transthoracic echocardiogram (TTE) showed aortic regurgitation (), with non-dilated cardiac chambers and preserved biventricular function. The acoustic window limited the evaluation of the valvular lesion severity and its importance in the context of the complaints, although the continuous Doppler spectrum suggested significant regurgitation (). The evaluation was further impaired by a systolic flow acceleration in the Left Ventricular Outflow Tract (LVOT), with no significant gradient and an undetermined cause. The aortic root had normal size, but it was not possible to carry out an adequate morphological and functional characterization of the valve.

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Case Report

Giant and Calcified Post-Infarction True Left Ventricular Aneurysm: What to Do?

Alexandre Hideo Kajita et al. Marcos Danillo Peixoto Oliveira Fernando Reis Menezes Marcelo Franken … Luciano Moreira Baraciolli José Carlos Nicolau

Introduction

A calcified true left ventricular aneurysm (LVA) is a serious complication in the chronic phase post an acute myocardial infarction (MI); however, it is seldom observed in modern clinical practice¹. LVA may be asymptomatic; however, it can be the cause of refractory heart failure, sustained ventricular arrhythmias, and arterial embolism. The indications for left calcified ventricular aneurysmectomy remain controversial.^– We report a case of a giant, true LVA that was reasonably managed clinically in an inoperable patient.

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Artigo Original

Reliability of symptoms suggestive of angina in patients with chronic obstructive pulmonary disease

Yilmaz Gunes et al. Mustafa Tuncer Unal Guntekin Hasan Ali Gumrukcuoglu … Serkan Akdag Bulent Ozbay Bunyamin Sertogullarindan

BACKGROUND: Due to overlapping symptoms and inadequate exercise capacity, noninvasive diagnosis of coronary artery disease (CAD) may be under- or overestimated in patients with chronic obstructive pulmonary disease (COPD). OBJECTIVE: To assess outcomes of coronary angiography in COPD patients depending on baseline clinical characteristics. METHODS: Medical records of 157 patients with COPD and 157 patients without COPD matched for baseline clinical characteristics who had undergone diagnostic coronary angiography for the first time were reviewed retrospectively. RESULTS: The frequency of significant CAD was significantly lower in COPD patients than in the control group (52.8% vs. 80.2%, p<0.001). Frequencies of CAD risk factors (older age, hypertension, diabetes, smoking history) were significantly more frequent among COPD patients having significant CAD. Among patients reporting stable angina pectoris, significant CAD was detected in 32.7% of COPD patients and 71.0% of non-COPD patients (p<0.001). However, among the patients with a diagnosis of unstable angina pectoris, significant CAD was detected in 87.5% of COPD patients and 90.2% of non-COPD patients (p=0.755). CONCLUSION: Diagnosis of CAD in COPD patients by symptomatology may be difficult. However, clinical diagnosis of CAD in the setting of unstable angina is accurate in most of the COPD patients. Therefore, further noninvasive diagnostic methods or careful follow up may be more appropriate for COPD patients reporting stable angina pectoris.

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