NAMA INSTANSI

Lahir Lulus dokter Lulus Spesialis

: Agus Subagjo : LAB / SMF KARDIOLOGI DAN KEDOKTERAN VASKULAR FK Unair RSU Dr. SOETOMO : Kediri, 14 Agustus 1956 : FK Unair 1984 : Ilmu Penyakit Jantung dan Pembuluh Darah 1996

CARDIOVASCULAR COMPLICATIONS IN COPD AND ITS MANAGEMENT

AGUS SUBAGJO

Cardiology and Vascular Medicine Departement Medical Faculty of Airlangga University - Soetomo General Hospital Surabaya November 04, 2007

INTRODUCTION

COPD (Chronic Obstructive Pulmonary Disease) is a major 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

INTRODUCTION

The inter-relationship can be of two types: 1. An association between pathologies, which share similar risks and substrate (such as: CAD, COPD and cigarette smoking)

2. Dysfunction of the heart from primary lung disease (such as: pulmonary hypertension and right ventricular dysfunction)

INTRODUCTION

COPD: More than a lung disease A systemic disease Cause of hospitalization & mortality is cardiovascular in nature Some cardiovascular complications which are often occurs: 1. Secondary Pulmonary Hypertension (SPH) 2. Cor Pulmonale (CP) 3. Ischemic Heart Disease 4. Arrhythmia

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 and extrathoraxic conditions
At autopsy, in up to 40 % patient with COPD

Pathophysiology of SPH

Regardless of the underlying cause leads to right ventricular failure. PH can expand to exceed of COPD itself can impaired morbidity and mortality Alveolar hypoxia, acidosis and hypercarbia can increase pulmonary arterial pressure.

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

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

MANAGEMENT OF SPH

Treatment of the underlying disease and correction of hypoxemia. Long-term oxygen therapy Diet of low salt and diuretic Pharmacological therapy: Endothelin antagonist HP primer Prostacycline therapy Inhaled NO (Nitric Oxide) Lung transplantation if no respond to medical management

2. COR PULMONALE

Cor pulmonale: PH dilatation and hypertrofi RV resulting from disorders of the pulmonary parenchyma, the thoraxic cage, or the neuromuscular system, excluding congenital heart disease and disorders of the left side of the heart Cor pulmonale can occur: 1. Acutely 2. Chronically PH resulting lung disease

Pathophysiology of CP

6 - 7% of all adult heart diseases in the US Half cases of chronic CP is due to COPD If untreated: overload the right ventricle 1st response: expand the size of the RV muscle compensated cor pulmonale Decompensated cor pulmonale (elevated neck veins, congestive liver, and peripheral edema)

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 In advanced PH stages, the RV pressure increased elevated JVP, hepatomegaly, cardiac cirrhosis, jaundice, ascites, and etc)

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

MANAGEMENT OF COR PULMONALE I. Medical therapy : The underlying pulmonary disease Improvement of oxygenation and right ventricular function

If right heart failure is already occurred : 1. Reduce of pulmonary hypertension 2. Improvement heart failure

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 and reduce hypoxia.

Management of cor pulmonale

Pulmonary vasodilator: FDA: prostanoid, be careful monitor oxygen saturation prostacycline analogues; phosphodiesterase-5inhibitor ~ inhaled NO Cardiac glycosides, such as digitalis controversial Vasodilator be careful (fatal hypotension) Phlebotomy Diuretics

Management of cor pulmonale

Diuretics Improvement of the function RV & LV Reduce mean blood circulation pressure, CO and renal blood flow Hypokalemic & metabolic acidosis: - Arrhythmia - Diminish respiratory stimulation

Management of cor pulmonale

2. Improvement heart failure: vasodilator, diuretic, digitalis, and etc.

II. Surgical treatment: Single-lung, double-lung, and heart-lung transplantation

3. ISCHEMIA HEART DISEASE COPD increases the risk of cardiovascular disease by two to three fold Smoking: a major cause of chronic obstructive pulmonary disease (COPD) and cardiovascular disorders, including coronary heart disease (CHD) and peripheral arterial disease.

PATHOFISIOLOGY OF ISCHEMIA HEART DISEASE

Cigarette smoking, other environmental irritants and infectious 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

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 to produce leukocytes and platelets

Conjunction with traditional risk factors promote atherogenesis and cardiovascular disease.

Management of ischemic heart disease

Similar with treatment conventional ischemic heart disease. COPD + Ischemic heart disease

be careful to use beta blocker and ACE inhibitor in sensitive patient!!!

4. Arrhythmia

Supraventricular and ventricular arrhythmias are common among patients with COPD
The most frequent arrhythmias in COPD MAT= Multifocal Atrial Tachycardia

Arrhythmia

Multiple factors contribute to the development of arrhythmias in 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

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, unifocal and multifocal atrial tachycardia, and ventricular arrhythmias.

Arrhythmia

Beta-Agonist therapy: Tachycardia Acceleration of atrioventricular nodes Long Q-T syndrome Shorten atrioventricular nodes refractory periods Slow repolarization Can leads spontaneous arrhythmias

Arrhythmia

Attention in handling arrhythmias in COPD: Correction of precipitated factors (hypoxemia, hypercapnea, acid-base and metabolic disorder, abnormality of electrolyte, and acute ischemia myocard)

Avoiding usage drugs which may prolonged Q-T

The reduction of arrhythmogenic drugs

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 them Electrical cardioversion

Stable tachyarrhytmias: Vagal manouver Anti arrhytmogenic drugs (adenosine, CCB, amiodarone,etc)

Arrhythmias

Things to be considered in using antiarrhytmogenic drugs: Beta blocker contraindication in bronchospam and wheezing patients. Adenosine induced bronchospasm Long treatment Amiodarone 15% lung toxicity.

SUMMARY

The anatomical & functional relationship between the lungs & the heart is very strong COPD is more than a lung disease, it is a systemic disease with effects in the cardiovascular system.

Some cardiac complications which is often occurs in COPD patients are 1. Secondary Pulmonary Hypertension; 2. Cor Pulmonale; 3. Ischemia Heart Disease; 4. Arrhythmia SPH is a pulmonary artery systolic pressure >30 mm Hg or a pulmonary artery mean pressure > 20 mm Hg, as complication of many pulmonary, cardiac and extrathoracic conditions

SUMMARY

Cor pulmonale is a PH resulting from disorders of the pulmonary parenchyma, the thoracic cage, or the neuromuscular system, excluding congenital heart disease and disorders of the left side of the heart Medical treatment of CP is generally focused on treatment of the underlying pulmonary disease & improving oxygenation and right ventricular function COPD increases the risk of cardiovascular disease by two to three fold

SUMMARY

Smoking is a major cause of COPD and cardiovascular disorders, including CHD and peripheral arterial disease Cigarette smoking, etc, may activate alveolar macrophages and than promote atherogenesis and cardiovascular disease. Supraventricular and ventricular arrhythmias are common among patients with COPD, the most frequent arrhythmias in COPD is MAT (Multifocal Atrial Tachycardia)

ECG

signs of right ventricular hypertrophy (tall right precordial R waves, right axis deviation and right ventricular strain)