Cardiovascular function in pulmonary emphysema

Prognostic impact of chronic obstructive pulmonary disease and bronchial asthma in patients with heart failure

PURPOSE

To analyze the impact of chronic obstructive pulmonary disease (COPD) and bronchial asthma on therapeutic management and prognosis of patients with heart failure (HF).

METHODS

Analysis of the information collected in a clinical registry of patients referred to a specialized HF unit from January-2010 to June-2012. Clinical profile, treatment and prognosis of patients was evaluated, according to the presence of COPD or asthma. Survival analyses were conducted by means of Kaplan-Meier and Cox's methods. Median follow-up was 1493 days.

RESULTS

We studied 2577 patients, of which 251 (9.7%) presented COPD and 96 (3.7%) bronchial asthma. Significant differences among study groups were observed regarding to the prescription of beta-blockers (COPD=89.6%; asthma=87.5%; no bronchopathy=94.1%; p=0.002) and SGLT2 inhibitors (COPD=35.1%; asthma=50%; no bronchopathy=38.3%; p=0.036). Also, patients with bronchial disease received less frequently a defibrillator (COPD=20.3%; asthma=20.8%; no broncopathy=29%; p=0.004). COPD was independently associated with increased risk of all-cause mortality (HR=1.64; 95% CI 1.33-2.02), all-cause death or HF admission (HR=1.47; 95% CI 1.22-1.76) and cardiovascular death or heart transplantation (HR=1.39; 95% CI 1.08-1.79) as compared with patients with no bronchopathy. Bronchial asthma was not significantly associated with increased risk of adverse outcomes.

CONCLUSIONS

COPD, but not asthma, is an adverse independent prognostic factor in patients with HF.

Group 3 Pulmonary Hypertension: From Bench to Bedside

Pulmonary hypertension (PH) because of chronic lung disease is categorized as Group 3 PH in the most recent classification system. Prevalence of these diseases is increasing over time, creating a growing need for effective therapeutic options. Recent approval of the first pulmonary arterial hypertension therapy for the treatment of Group 3 PH related to interstitial lung disease represents an encouraging advancement. This review focuses on molecular mechanisms contributing to pulmonary vasculopathy in chronic hypoxia, the pathology and epidemiology of Group 3 PH, the right ventricular dysfunction observed in this population and clinical trial data that inform the use of pulmonary vasodilators in Group 3 PH.

Pulmonary rehabilitation: promising nonpharmacological approach for treating asthma?

PURPOSE OF REVIEW

Asthma is a heterogeneous disease, usually characterized by chronic airway inflammation with a history of respiratory symptoms that vary over time and in intensity, together with variable expiratory airflow limitation. The goal of asthma treatment is to reach symptoms control, reduction in future risk and improvement in quality of life (QoL). Guideline-based pharmacologic therapies and the effect of inhaled steroids and bronchodilators have been widely studied over the past decades. We provide an overview of the available evidence on pulmonary rehabilitation as a nonpharmacologic therapy in asthmatic patients.

RECENT FINDINGS

Recently, some studies have highlighted the promising role of nonpharmacologic therapies in asthma, such as pulmonary rehabilitation demonstrating that a pulmonary rehabilitation programme consisting of exercise training, breathing retraining, educational and psychological support, improve exercise capacity, asthma control and QoL and reduce dyspnea, anxiety, depression and bronchial inflammation at any step of the disease.

SUMMARY

Pulmonary rehabilitation shows positive results on exercise tolerance, respiratory symptoms and QoL in asthmatic patients at any steps of the diseases. However, additional information is required to better characterize rehabilitation programmes in order to improve clinical care in asthma.

The Effects of Endobronchial Coil Therapy on Right Ventricular Functions

Lung hyperinflation is an important therapeutic target in symptomatic emphysema patients. Endobronchial therapies that reduce end-expiratory lung volume are increasingly being used in advanced cases. However, there is paucity of data regarding the effects of these therapies on the heart functions. The aim of this study is to evaluate the right ventricular functions before and after the procedure in patients who underwent endobronchial coil therapy (EBCT).Patients who were between 18 and 80 years of age and scheduled for EBCT with GOLD 3-4 were enrolled in the study. Right heart functions were evaluated using MPI, TAS, TAPSE. Right atrium area and maximum velocity of tricuspid regurgitation were also noted.A total of 23 patients were enrolled in the study. 21 patients underwent bilateral intervention, while only 2 patients received unilateral treatment. There was an improvement in MPI (0.49 ± 0.15 vs 0.39 ± 0.11, p < 0.001) and TAS (11.6 (9 - 15) vs 13.2 (9.80 - 17.0), p = 0.001). Peak TRV (2.52 ± 0.6, 2.38 ± 0.6, p = 0.02) and PASP values were lower in the post-operative period (41.15 ± 5.94 vs 36.83 ± 8.01 p = 0.019).In this current study, we found improved echocardiographic RtV parameters in patients who received EBCT treatment.

Does gallic acid improve cardiac function by attenuation of oxidative stress and inflammation in an elastase-induced lung injury?

Objective(s):

Cardiovascular disease has an important role in mortality caused by lung injury. Emphysema is associated with impaired pulmonary gas exchange efficiency and airflow limitation associated with small airway inflammation. The aim was to evaluate the interactions between lung injury, inflammation, and cardiovascular disease. Since gallic acid has antioxidant and anti-inflammatory effects, we hypothesized that gallic acid protects the lung and the related heart dysfunction in elastase-induced lung injury.

Materials and Methods:

Forty-eight Sprague-Dawley male rats were randomly divided into six groups: Control, Porcine pancreatic elastase (PPE) , PPE+GA, and 3 groups for different doses of gallic acid (GA 7.5, GA 15, GA 30 mg/kg). PPE was injected intra-tracheally on days 1 and 10 of the test. In each group, electrocardiography, hemodynamic parameters, oxidative stress, and bronchoalveolar lavage fluid were examined.

Results:

PPE administration showed a decrease in HR and QRS voltage of electrocardiogram parameters, as well as in hemodynamic parameters (P<0.05, P<0.01, and P<0.001) and superoxide dismutase (SOD) (P<0.05). Tumor Necrosis Factor α (TNF-α) (P<0.001), interleukin 6 (IL-6) (P<0.001), interleukin 6 (MDA) (P<0.001), and the total number of white blood cells (P<0.001) showed an increase in PPE groups. Gallic acid preserved the values of hemodynamic properties, oxidative stress, inflammation, and electrocardiogram parameters in comparison to the PPE group.

Conclusion:

Briefly, this study showed the valuable effect of gallic acid in cardiac dysfunction related to elastase-induced lung injury. These findings suggested that gallic acid, as a natural antioxidant, has a potential therapeutic effect on preventing oxidative stress, inflammation, and subsequent cardiovascular disease.

The link between dynamic hyperinflation, autonomic dysfunction and exercise testing parameters with masked heart failure in patients with non-severe obstructive pulmonary disease

OBJECTIVES

Autonomic dysfunction (AD) and dynamic hyperinflation (DH) have been implicated as pathophysiological mechanisms of heart failure with preserved ejection fraction (HFpEF) in chronic obstructive pulmonary disease (COPD) patients. Their association, however, remains elusive: The aims of the study were: (1) to determine the prevalence of AD and DH in non-severe COPD patients, with exertional dyspnea, without clinically overt cardio-vascular (CV) comorbidities; (2) to analyze the correlation and clinical significance between DH, AD, and maksed HFpEF.

METHODS

We applied CPET in 68 subjects. Echocardiography was performed before CPET and 1-2 min after peak exercise. IC manoeuvres were applied. Patients were divided into two groups: patients with and without masked HFpEF. Wilkoff method calculated the meatabolic - chronotropic relationship (MCR). Chronotropic incompetence (CI) and abnormal HR recovery (HRR) were determined.

RESULTS

The prevalence of CI was 77 vs. 52% in patients with/without masked HFpEF; of abnormal HRR - 98 vs. 62% respectively; of DH - 53 vs. 29%. ICdyn was associated with AD. Univariate regression showed association between masked HFpEF, ICdyn, HRR, oxygenuptake ('VO₂), 'VO₂ at anaerobic threshold, oxygen (O₂) pulse and 'VE/'VCO₂ slope. None of these parameters is an independent predictor for masked HFpEF.

CONCLUSIONS

DH, AD, and masked HFpEF are prevalent in non-severe COPD patients, who complain of exertional dyspnea and are free of clinically overt CV comorbidities. DH is independently associated with AD. Neither AD, nor DH and CPET are independent predictors for masked HFpEF.

Pulmonary Rehabilitation and Asthma

Asthma is a chronic inflammatory disease characterized by airflow limitation and variable respiratory symptoms. It is characterized by variable symptoms such as cough, wheeze, chest tightness, and shortness of breath which vary in intensity and time. In order to reach a comprehensive approach of disease management, the importance of non-pharmacological treatment in addition to pharmacological therapy has been recently highlighted. Studies have documented that pulmonary rehabilitation has beneficial effects in patients with asthma, at any stage of the disease, improving exercise capacity, asthma control, and quality of life and reducing wheezing, anxiety, depression, and bronchial inflammation. Although several evidences suggest a role of pulmonary rehabilitation in patients with asthma, additional information is required to identify a specific program in order to improve clinical care based on specific patient’s needs.

Liver disease and heart failure

INTRODUCTION

Several systemic conditions, inflammatory disease, infections and alcoholism, may affect both the heart and the liver. Common conditions, such as the non-alcoholic fatty liver disease (NAFLD), may increase the risk of cardiac dysfunction. Patients with acute decompensated HF (ADHF) may develop acute ischemic hepatitis and, chronic HF patients may develop congestive hepatopathy (CH).

EVIDENCE ACQUISITION

Laboratory anomalies of hepatic function may predict the outcome of patients with advanced HF and the evaluation of both cardiac and hepatic function is very important in the management of these patients. In clinically apparent ischemic hepatitis more than 90% of patients have some right-sided HF. There are systemic disorders characterized by the accumulation of metals or by metabolism defects that may affect primarily the liver but also the heart leading to symptomatic hypertrophic cardiomyopathy (HCM).

EVIDENCE SYNTHESIS

Abnormal LFTs indicate the mechanism of liver injury: liver congestion or liver ischemia. In AHF, it's important an adequate evaluation of heart and liver function in order to choose the treatment in order to ensure stable hemodynamic as well as optimal liver function.

CONCLUSIONS

Measurements of LFTs should be recommended in the early phase of ADHF management. Physicians with interest in HF should be trained in the evaluation of LFTs. It's very important for cardiologists to know the systemic diseases affecting both heart and liver and the first imaging or laboratory findings useful for a diagnosis. it is very important for internists, nephrologists, cardiologists, primary physicians and any physicians with interest in treating HF to recognize such signs and symptoms belong to rare diseases and liver diseases that could be mistaken for HF.

Prevalence and management of COPD and heart failure comorbidity in the general practitioner setting

BACKGROUND

COPD frequently coexists with HF with which shares several risk factors. A greater collaboration is required between cardiologists and pulmonologists to better identify and manage concurrent HF and COPD. This observational, retrospective study provides new data regarding the management of these patients.

METHODS

from the Health Search Database which collects information generated by the routine activity of general practitioners, we selected 803 patients suffering from COPD or HF alone or combined analyzing similarities and differences regarding risk factors, diagnostic workup and therapeutic approaches.

MAIN RESULTS

Statistical analyses have evidenced significant differences regarding exposure to cigarette smoke and the prevalence of diabetes and hypertension in the three groups of patients. As regard to the diagnostic workup, it has been found that the 63,9% of COPD patients and the 57,1% of COPD + HF patients performed a spirometry vs the 95,4% of HF patients and the 95,2% of COPD + HF patients that performed an ECG. Regarding the pharmacologic treatment, the 47% of COPD patients was treated with an ICS/LABA association and the 22% with ICS/LABA + LAMA. In the COPD + HF group, 47% of patients were treated with ICS/LABA association, while 32% of these patients were treated with ICS/LABA + LAMA. The pharmacologic treatment most prescribed in HF was β-blockers (68%), diuretics (92.8%), antiplatelet therapy (55.6%) and ACE inhibitors (38.1%). In the COPD + HF group, β-blockers (40.1%), diuretics (89.8%), antiplatelet therapy (57.1%) and ACE inhibitors (44.9%) were prescribed.

CONCLUSION

this study has evidenced a disparity in performing instrumental diagnosis between COPD and HF groups that persists when both conditions coexist. Moreover, the pharmacological treatment of the two conditions shows a consistent under treatment with bronchodilators in COPD patients and with β-blockers in HF patients.

Chronotropic incompetence can limit exercise tolerance in COPD patients with lung hyperinflation

Purpose

Metabolic-chronotropic relationship is the only concept that assesses the entire chronotropic function during exercise, as it takes into account individual fitness. To better understand interrelationships between chronotropic incompetence (CI), dynamic hyperinflation (DH) and exercise limitation among Global initiative for chronic Obstructive Lung Disease (GOLD) stages of chronic obstructive pulmonary disease (COPD) disease severity, we evaluated cardiopulmonary responses to symptom-limited cycle exercise in stable patients.

Patients and methods

We prospectively studied 47 COPD patients classified by GOLD stage severity. Pulmonary function tests and cardiopulmonary responses to symptom-limited incremental exercise were studied. CI was defined by regression line between percent heart rate (HR) reserve and percent oxygen uptake (V’O₂) reserve, ie, chronotropic-metabolic index (CMI). DH was defined from the knot resulting from the nonlinear regressions of inspiratory capacity changes from rest to peak (dynamic inspiratory capacity (IC_dyn)) with percentage of maximal HR and CMI.

Results

Aerobic capacity (median interquartile ranges) peak V’O₂, 24.3 (23.6; 25.2), 18.5 (15.5; 21.8), 17.5 (15.4; 19.1) mL·kg⁻¹·min⁻¹ and CMI worsened according to GOLD severity. The optimal knot of IC_dyn was equal to −0.34 L. The multivariate logistic regression showed a strong relationship between CI (outcome) and DH (odds ratio [confidence interval 95]) 25 (3.5; 191.6).

Conclusion

COPD patients with DH have a poor cardiovascular response to exercise, which may be attributed to CI.

Pulmonary hypertension and right heart dysfunction in chronic lung disease

Group 3 pulmonary hypertension (PH) is a common complication of chronic lung disease (CLD), including chronic obstructive pulmonary disease (COPD), interstitial lung disease, and sleep-disordered breathing. Development of PH is associated with poor prognosis and may progress to right heart failure, however, in the majority of the patients with CLD, PH is mild to moderate and only a small number of patients develop severe PH. The pathophysiology of PH in CLD is multifactorial and includes hypoxic pulmonary vasoconstriction, pulmonary vascular remodeling, small vessel destruction, and fibrosis. The effects of PH on the right ventricle (RV) range between early RV remodeling, hypertrophy, dilatation, and eventual failure with associated increased mortality. The golden standard for diagnosis of PH is right heart catheterization, however, evidence of PH can be appreciated on clinical examination, serology, radiological imaging, and Doppler echocardiography. Treatment of PH in CLD focuses on management of the underlying lung disorder and hypoxia. There is, however, limited evidence to suggest that PH-specific vasodilators such as phosphodiesterase-type 5 inhibitors, endothelin receptor antagonists, and prostanoids may have a role in the treatment of patients with CLD and moderate-to-severe PH.

Maximal exercise in obese patients with COPD: the role of fat free mass

Background

Obese patients (OB) with COPD may better tolerate exercise as compared to normal weight (NW) COPD patients, even if the reason for this is not yet fully understood. We investigated the interactions between obesity, lung hyperinflation, fat-free mass (FFM) and exercise capacity in COPD.

Methods

Forty-four patients (16 females; age 65 ± 8 yrs) were assessed by resting lung function and body composition and exercised on a cycle-ergometer to exhaustion.

Results

Twenty-two OB and 22 NW patients did not differ in age, gender and airflow obstruction degree, but in FFM (p < 0.05). OB had significantly higher values in inspiratory capacity/total lung capacity ratio (IC/TLC) at rest (p < 0.01), but not at peak of exercise and showed significantly higher values in peak workload (p < 0.05) and in peak oxygen uptake (VO₂), when expressed as absolute value (p < 0.05), but not when corrected by FFM. OB compared to NW experienced lower leg fatigue (p < 0.05), but similar dyspnea on exertion. In all patients, the regression equation by stepwise multiple regression analysis for peak workload and VO₂, as dependent variables included both FFM and IC/TLC at rest, as independent variables (r² = 0.43 and 0.37, respectively).

Conclusions

OB with COPD, as compared to NW patients matched for age, gender and airflow obstruction, had greater FFM and less resting lung hyperinflation and showed greater maximal exercise capacity. Pulmonary and non-pulmonary factors may explain the preservation of exercise tolerance in patients with COPD associated with obesity.