Noninvasive assessment of left ventricular performance in patients with chronic obstructive pulmonary disease

Heart failure and COPD: partners in crime?

Chronic obstructive pulmonary disease (COPD) and heart failure (HF) are both common diseases with major impact and seem to coexist more frequently than expected from their separate population prevalences. However, estimates of combined prevalence must be interpreted carefully because of imperfections and difficulties in assessment of both diseases. This review aims to highlight HF prevalence in patients with COPD and vice versa, with a critical analysis of studies performed. First, definition, diagnosis, and prevalence of COPD and of HF will be discussed. Subsequently, an overview of important studies concerning combined prevalence with their limitations will be presented. Finally, pathogenic mechanisms and diagnostic considerations in clinical practice will be discussed.

Percent emphysema, airflow obstruction, and impaired left ventricular filling

BACKGROUND

Very severe chronic obstructive pulmonary disease causes cor pulmonale with elevated pulmonary vascular resistance and secondary reductions in left ventricular filling, stroke volume, and cardiac output. We hypothesized that emphysema, as detected on computed tomography (CT), and airflow obstruction are inversely related to left ventricular end-diastolic volume, stroke volume, and cardiac output among persons without very severe lung disease.

METHODS

We measured left ventricular structure and function with the use of magnetic resonance imaging in 2816 persons who were 45 to 84 years of age. The extent of emphysema (expressed as percent emphysema) was defined as the percentage of voxels below -910 Hounsfield units in the lung windows on cardiac computed tomographic scans. Spirometry was performed according to American Thoracic Society guidelines. Generalized additive models were used to test for threshold effects.

RESULTS

Of the study participants, 13% were current smokers, 38% were former smokers, and 49% had never smoked. A 10-point increase in percent emphysema was linearly related to reductions in left ventricular end-diastolic volume (-4.1 ml; 95% confidence interval [CI], -3.3 to -4.9; P<0.001), stroke volume (-2.7 ml; 95% CI, -2.2 to -3.3; P<0.001), and cardiac output (-0.19 liters per minute; 95% CI, -0.14 to -0.23; P<0.001). These associations were of greater magnitude among current smokers than among former smokers and those who had never smoked. The extent of airflow obstruction was similarly associated with left ventricular structure and function, and smoking status had similar modifying effects on these associations. Percent emphysema and airflow obstruction were not associated with the left ventricular ejection fraction.

CONCLUSIONS

In a population-based study, a greater extent of emphysema on CT scanning and more severe airflow obstruction were linearly related to impaired left ventricular filling, reduced stroke volume, and lower cardiac output without changes in the ejection fraction.

Heart failure and chronic obstructive pulmonary disease: An ignored combination?

AIMS

To quantify the prevalence of heart failure and left ventricular systolic dysfunction (LVSD) in chronic obstructive pulmonary disease (COPD) patients and vice versa. Further, to discuss diagnostic and therapeutic implications of the co-existence of both syndromes.

METHODS AND RESULTS

We performed a Medline search from 1966 to March 2005. The reported prevalence of LVSD among COPD patients varied considerably, with the highest prevalence (10-46%) among those with an exacerbation. One single study assessed the prevalence of heart failure in COPD patients. A prevalence of 21% of previously unknown heart failure was reported in patients with a history of COPD or asthma. We did not find any report on COPD in heart failure or LVSD patients. Diagnosing heart failure in COPD patients or vice versa is complicated by overlap in signs and symptoms, and diminished diagnostic value of additional investigations. In general, pulmonary and heart failure 'drug cocktails' can be administered safely to patients with concomitant COPD and heart failure, although (short acting) beta2-adrenoreceptor agonists and digitalis have potentially deleterious effects on cardiac and pulmonary function, respectively.

CONCLUSION

Although knowledge about the prevalence of concomitant heart failure in COPD patients and vice versa is scarce, it seems that the combined presence is rather common. In view of diagnostic and therapeutic implications, more attention should be paid to the concomitant presence of both syndromes in clinical practice and research.

Importance of chronic obstructive pulmonary disease for prognosis and diagnosis of congestive heart failure in patients with acute myocardial infarction

AIMS

To evaluate the importance of chronic obstructive pulmonary disease for prognosis and diagnosis of congestive heart failure in patients with acute myocardial infarction.

METHOD AND RESULTS

Prospective registration of 6669 consecutive patients admitted with infarction and screened for a randomised controlled trial. A history of COPD was present in 765 (11.5%) patients. Thirty-day and 5-year survival in patients with chronic obstructive pulmonary disease was 86.3 and 42.9%. In patients without pulmonary disease the figures were 87.7 and 57.5%, respectively, giving a relative risk of 1.49 (1.35-1.65). In multivariate analysis the relative risk was 1.15 (1.04-1.28). The prevalence of congestive heart failure was 65.9% in patients with chronic obstructive pulmonary disease and 52.0% in patients without. This difference was most distinct in patients with normal or only slightly decreased left ventricular systolic function. In patients without congestive heart failure, chronic obstructive pulmonary disease was of prognostic importance [RR=1.44 (1.17-1.78)], but not in patients with congestive heart failure [RR=1.09 (0.96-1.23)].

CONCLUSION

Chronic obstructive pulmonary disease is a predictor of long-term mortality in patients with acute myocardial infarction without congestive heart failure, but is also a confounding factor for the diagnosis of congestive heart failure.

Cardiac troponin I in patients with severe exacerbation of chronic obstructive pulmonary disease

OBJECTIVES

Co-morbid conditions including risk factors for cardiovascular diseases and left ventricular dysfunction are common in patients with chronic obstructive pulmonary disease (COPD). This study assessed the incidence of cardiac troponin I (cTnI) elevation, a specific marker for cardiac injury, and its prognostic significance during severe exacerbation of COPD.

DESIGN

Prospective cohort study.

SETTING

Two intensive care units.

PARTICIPANTS

Seventy-one consecutive patients admitted for severe exacerbation of COPD.

INTERVENTION

None.

MEASUREMENTS AND RESULTS

Cardiac troponin I was assayed in blood samples obtained on admission and 24 h later (Stratus II immunoassay analyser, Dade International). Levels above 0.5 ng/ml were considered positive. The following data were recorded prospectively: clinical symptoms, co-morbidities, cause of the exacerbation, diagnostic procedures and treatment, general severity score (SAPS II) and in-hospital outcome. CTnI was positive in 18% of patients (95% confidence interval (CI(95)), 11-29%), with a median value at 1.00 ng/ml; CI(95 )(0.60-1.70). Eighteen patients died in the hospital (25%; CI(95), 17-37%). Only cTnI (adjusted odds ratio (ORa), 6.52; CI(95),1.23-34.47) and SAPS II 24 h after admission (ORa, 1.07; CI(95), 1.01-1.13) were independent predictors of in-hospital mortality.

CONCLUSION

Elevated cTnI is a strong and independent predictor of in-hospital death in patients admitted for acutely exacerbated COPD.

Limitations of radionuclide angiographic assessment of left ventricular systolic function before lung transplantation

To evaluate the influence of increased right ventricular afterload on radionuclide assessment of the left ventricular ejection fraction (LVEF), we compared the preoperative and postoperative value of isotopic LVEF in 11 patients who underwent lung transplantation and had a preoperative LVEF value below 55% (normal value: 68 +/- 8%). The underlying disease conditions were obstructive lung disease (n = 7) and pulmonary fibrosis (n = 4). The transplantation procedure was unilateral in 10 patients and bilateral in one. The mean value of isotopic LVEF prior to transplantation was 51 +/- 3% (range: 49% to 55%). At 42 +/- 13 mo postoperatively, isotopic LVEF increased significantly, to 65 +/- 10% (p = 0.001), suggesting that intrinsic left ventricular systolic function was in fact normal in these patients. We hypothesize that the low preoperative isotopic LEVF was not related to intrinsic dysfunction of the left ventricle, but rather to right ventricular pressure overload, leading to bulging of the interventricular septum into the left ventricle and to subsequent geometric distortion of the left ventricle. We conclude that isotopic LVEF may underestimate intrinsic left-ventricular systolic function in patients with severe chronic lung disease. Candidates for lung transplantation should not be rejected on the basis of a low isotopic LVEF, provided echocardiographic examination does show apparently normal left ventricular contraction.

Right ventricular function at rest and during exercise in chronic obstructive pulmonary disease. Comparison of two radionuclide techniques

Right ventricular function was assessed in 24 patients with COPD, at rest and during submaximal exercise, using both technetium-99m (99mTc) blood-pool and krypton-81m (81mKr) equilibrium ventriculography. Technetium-99m right ventricular ejection fraction (RVEF) at rest was lower than 81mKr RVEF (0.39 +/- 0.12 and 0.54 +/- 0.08, respectively; p < 0.001). During submaximal exercise, there was no increase in RVEF using either imaging technique. This observation contrasted with an increase in RVEF in a group of age-comparable normal subjects during modest submaximal exercise. An inability to obtain spatial separation of right heart structures using 99mTc imaging leads to a value for RVEF that is consistently lower than that measured using 81mKr ventriculography. Resting RVEF is well preserved at rest in most patients with COPD. In contrast to normal subjects, many show an inability to augment right ventricular function during exercise that may contribute to the reduced exercise capacity observed in these patients.

Cor pulmonale. Treatment implications of right versus left ventricular impairment

Diagnosing cor pulmonale and detecting left ventricular dysfunction in patients with advanced lung disease are difficult challenges. Usually, routine clinical assessment (history, physical examination, chest radiography, and electrocardiography) is inadequate and additional cardiac diagnostic techniques (eg, two-dimensional echocardiography, first-pass radionuclide angiography) are required for definitive documentation. Diagnosis of cor pulmonale and evaluation of cardiac function in patients with advanced lung disease are of more than academic interest. Long-term oxygen therapy, the main treatment option, improves survival rate in these patients. Establishing the coexistence of left ventricular dysfunction is important, because management of congestive heart failure offers little benefit and may even be harmful in patients with cor pulmonale.

Exercise limitation and pulmonary rehabilitation in chronic obstructive pulmonary disease

Impairment of exercise tolerance is a common problem in patients with severe chronic obstructive pulmonary disease. The cause of exercise intolerance in patients with severe chronic obstructive pulmonary disease is multifactorial and includes impaired lung mechanics, fatigue of inspiratory muscles, impaired gas exchange, right ventricular dysfunction, malnutrition, occult cardiac disease, deconditioning, and psychologic problems; however, impaired lung mechanics and gas exchange abnormalities seem to be the major limiting factors. Recently, the approach to management of pulmonary rehabilitation in patients with chronic obstructive pulmonary disease has changed because improvement in exercise tolerance has been demonstrated after pulmonary rehabilitation. Other adjunctive measures that have been shown to contribute to the observed improvement in exercise tolerance include administration of oxygen, nutritional support, cessation of smoking, and psychosocial support. The roles of ventilatory muscle endurance training, respiratory muscle rest therapy, nasally administered continuous positive airway pressure, and training of the muscles of the upper extremities are less clearly defined.

Cardiovascular-pulmonary interaction in chronic obstructive pulmonary disease with special reference to the pathogenesis and management of cor pulmonale

Chronic obstructive pulmonary disease (COPD), which here refers to a group of diseases that have in common the physiologic defect of airway obstruction, is often associated with severe hemodynamic consequences. This article provides an overview of cardiovascular function in COPD with emphasis on recent advances in detecting, quantifying, and treating pulmonary hypertension and its major cardiac complication, cor pulmonale.

Interdependence of the left and right ventricles in health and disease

Since the publication of Bernheim's report it has been clear that the anatomic and functional integrity of each ventricle is an important determinant of the functional characteristics of the other ventricle. How the ventricles interact in health and disease has been of interest to many investigators. This article reviews and considers the structure and function of each ventricle as an independent subunit and as a unified pumping system in the healthy state and in various disease states.

Improved recognition of cor pulmonale in patients with severe chronic obstructive pulmonary disease

To compare sensitivity of clinical methods (physical examination, electrocardiogram, and chest radiograph) to echocardiography in the detection of cor pulmonale, and to determine the role of nocturnal oxygen desaturation in its development, 33 non-hypoxemic patients who had severe chronic obstructive pulmonary disease (COPD) were evaluated by clinical methods, echocardiography, and overnight ear oximetry. Compared to 25 age-matched control subjects, COPD patients had higher peak pulmonary systolic pressures by contrast-enhanced Doppler (40 +/- 13 versus 22 +/- 5 mm Hg, or 5.3 +/- 1.7 versus 2.9 +/- 0.7 kPa) and ratios of right to left ventricular volume (1.1 +/- 0.6 versus 0.6 +/- 0.1, both p less than 0.05). Defining cor pulmonale as pulmonary hypertension, right ventricular enlargement, or right ventricular hypertrophy, 25 COPD patients (75 percent) had cor pulmonale by echocardiography and 13 (39 percent) by clinical methods (p less than 0.05). Nocturnal desaturation was present in only 21 percent of patients. Echocardiographic measurements were similar between patients with emphysema and patients with bronchitis, and between patients with and without sleep desaturation. In patients who have severe COPD without waking hypoxemia, cor pulmonale is detected nearly twice as often by echocardiography as by clinical methods, but is usually not associated with sleep desaturation.

The role of oesophageal electrocardiography in the diagnosis of right ventricular hypertrophy in chronic obstructive pulmonary disease

Oesophageal electrocardiograms were recorded in 25 normal persons, 20 patients with chronic bronchitis and predominant emphysema without right ventricular hypertrophy and 25 patients with chronic cor pulmonale as an end result of chronic obstructive pulmonary disease. At ventricular level, patients with chronic cor pulmonale had higher P wave height, lower Q wave depth, lower R wave height, deeper S waves and lower R/S ratio as compared to the group with emphysema. In terms of the transitional zone, patients with cor pulmonale had smaller Q waves and a lower Q/R ratio. At atrial level, the patients with cor pulmonale had higher heights of the P and R waves and a lower Q/R ratio. All these differences were highly significant statistically (P less than 0.001). An R/S ratio of less than 2.5 at ventricular level had high sensitivity (96.0%), specificity (100%) and accuracy (98%) in diagnosing right ventricular hypertrophy in cases of chronic obstructive pulmonary disease. This criterion obtained from the oesophageal electrocardiogram is much more sensitive and accurate than those obtained routinely from the surface electrocardiogram in diagnosing right ventricular hypertrophy in cases of chronic obstructive pulmonary disease.

Cardiac function in patients with cystic fibrosis: evaluation by two-dimensional and Doppler echocardiography

Two-dimensional and Doppler echocardiography were performed in 17 consecutive hospitalized patients with cystic fibrosis aged 6 to 38 years (mean 21 +/- 9) and in 10 normal subjects aged 24 +/- 7 years. Left ventricular and right ventricular ejection fraction were measured by a computerized light pen system and Simpson's rule from two-dimensional echocardiographic apical four and two chamber views. Right ventricular wall thickness, inferior vena cava size and the presence of tricuspid regurgitation by Doppler recording were also assessed. National Institutes of Health (NIH) score of clinical severity ranged from 22 to 72 (mean 51 +/- 15) (100 = excellent, 0 = poor). Four patients, all with an NIH score of 40 or less, died of respiratory failure within 1 year of the echocardiographic study. There was no significant difference between patients with cystic fibrosis and normal subjects with regard to right ventricular ejection fraction (59 +/- 11 versus 61 +/- 10%), left ventricular ejection fraction (67 +/- 8 versus 70 +/- 8%) and right ventricular systolic (5 +/- 1 versus 5 +/- 0.5 mm) and diastolic (2.4 +/- 0.5 versus 2.5 +/- 0.5 mm) wall thicknesses. A dilated inferior vena cava and mild tricuspid regurgitation by Doppler recording were detected in only one patient. A poor correlation was found between right ventricular ejection fraction and NIH clinical score (r = 0.26), chest X-ray score (r = 0.29) and pulmonary function tests. It is concluded that right and left ventricular systolic function is preserved in patients with moderately severe cystic fibrosis; clinical status in these patients is probably determined by the pulmonary rather than cardiac involvement.

Dyspnea: the heart or the lungs? Differentiation at bedside by use of the simple Valsalva maneuver

Thirty-seven patients with dyspnea, clinical chronic obstructive pulmonary disease and abnormal pulmonary function tests demonstrating an obstructive airways pattern underwent six-foot posteroanterior chest radiography, radionuclide ventriculography and sphygmomanometer-monitored arterial pressure response during a bedside Valsalva maneuver. Patients could be separated into three groups (square wave, absent overshoot, sinusoidal) on the basis of their Valsalva response which corresponded to left ventricular ejection fractions on radionuclide ventriculography of 0.19 +/- 0.05, 0.42 +/- 0.20, 0.64 +/- 0.13 (p less than 0.005 for differences between all group means). Pulmonary function test results and a detailed patient history could not accurately separate patients with primary pulmonary dyspnea from those with concomitant left ventricular dysfunction (ejection fraction less than 0.50). In this population of patients, however, both the sensitivity (88 percent) and predictive value (88 percent) for the presence of left ventricular dysfunction of an abnormal (square wave or absent overshoot) systolic arterial pressure response during Valsalva maneuver were high. Thus, in dyspneic subjects with clinical evidence of chronic obstructive airways disease, concomitant left ventricular dysfunction can be accurately diagnosed using the simple Valsalva maneuver without sophisticated equipment or highly trained personnel.

Assessment by radionuclide angiography of right and left ventricular function in chronic bronchitis and emphysema

Non-invasive measurements of right and left ventricular ejection fraction (RVEF, LVEF) by multiple-gated equilibrium radionuclide ventriculography were performed in 18 control subjects, 16 patients with angina pectoris, and 45 patients with hypoxic chronic bronchitis and emphysema. The mean RVEF in the control subjects was 0.62 +/- 0.09 (SD), which was not significantly different from the mean RVEF in the patients with angina (0.60 +/- 0.09), but was significantly higher (p less than 0.01) than the mean value in patients with chronic bronchitis and emphysema (0.45 +/- 0.11). LVEF was not significantly different in the groups studied. There was a significant correlation between LVEF and RVEF only in patients with chronic bronchitis and emphysema (p less than 0.001). Those patients with chronic bronchitis and emphysema who had clinical evidence of cor pulmonale at the time of the study had significantly lower values of RVEF and LVEF (p less than 0.001) than patients with no previous cor pulmonale or those who had had cor pulmonale in the past. There was a significant correlation between RVEF and arterial oxygen (p less than 0.01) and carbon dioxide tensions (p less than 0.05). Reduced RVEF in patients with chronic bronchitis and emphysema may be an early indicator of the development of cor pulmonale and may be useful as a non-invasive method of assessing the effects of therapeutic interventions.

Subcostal M-mode computerised echocardiography. An alternative or complementary approach to parasternal echocardiography?

Subcostal M-mode echocardiography has been suggested as a method for assessment of left ventricular size and function. Parasternal and subcostal measurements (direct and derived) of left ventricular function were compared in 30 healthy young subjects. We calculated instantaneous left ventricular diameter and wall thickness every 10 ms for both the subcostal and parasternal approaches using a computer program for echocardiographic digitisation and compensation. All variables were filtered to calculate instantaneous first derivative (velocity) and logarithmic derivative (normalised velocity). The program provided normal values for computerised variables of left ventricular function from the subcostal approach. It was found that there was no identity and no correlation or a poor one between subcostal and parasternal left ventricular internal diameters and volumes. The parietal wall thickness was significantly greater using the subcostal approach, and the comparative velocities study showed striking variations between the two approaches, especially in diastole, where the peak lateral wall thinning rate was 20% lower than the posterior thinning rate. We conclude that for a normal and young population, the subcostal and standard parasternal data cannot be used interchangeably for precise studies of left ventricular function. The subcostal approach, however, provides useful complementary information about lateral wall motion.

Simultaneous assessment of right ventricular ejection fraction and central haemodynamics at rest and during exercise in patients with pulmonary hypertension

In 10 patients, aged 55-73, with pulmonary hypertension, right ventricular ejection fraction (RVEF) was measured simultaneously with central haemodynamics twice, at rest and during exercise. In the first investigation, RVEF was measured with first pass (FP) radionuclide angiocardiography using 133Xe and 99Tcm as tracers. In the second investigation after 1 h's rest, RVEF was measured with equilibrium (EQ) radionuclide angiocardiography. Significant correlations were found between RVEF and pulmonary artery pressure (r = -0.76 to -0.88) and between RVEF and right arterial pressure (r = -0.76 to -0.84) at rest and during exercise. RVEF was low or decreased during exercise in all patients with haemodynamic signs of right ventricular failure. Good correlations were found between the FP and EQ techniques for measuring RVEF both at rest, r = 0.86, and during exercise, r = 0.91. RVEF, measured with the FP technique, showed better reproducibility and better correlation to haemodynamic variables and to history of right ventricular failure than the EQ technique. Thus, the FP technique seemed to be the method of choice for assessment of RVEF.

Nocturnal hypoxemia and associated electrocardiographic changes in patients with chronic obstructive airways disease

To study the direct effects of nocturnal hypoxemia on the heart, we recorded electrocardiographic tracings and arterial oxygen saturation (SaO2) during the night in patients with chronic obstructive airways disease. In seven "blue-bloater" patients the mean basal SaO2 was less than 80 per cent, and it fell by more than 10 per cent during 29 episodes of transient hypoxemia. Only five such episodes occurred in three of five "pink-puffer" patients. All "blue bloaters" with low basal mean SaO2 had multiple atrial and ventricular premature contractions and a high heart rate at rest; six patients has a prolonged QTc, three had ST-T depression, and one had right-bundle-branch block. Oxygen therapy increased basal mean SaO2, reduced ectopic activity, abolished ST-T changes and bundle-branch block, significantly reduced the resting heart rate and the amplitude of the R and S waves, and shortened the QTc in four nonsmokers. These results suggest that sustained hypoxemia contributes to myocardial dysfunction and heart failure in "blue-bloater" patients.

Exercise performance in chronic obstructive pulmonary diseases

Patients with chronic obstructive pulmonary diseases demonstrate exercise limitation as a consequence of both an increased ventilatory requirement and a decreased ventilatory capacity. The increased ventilatory requirement arises from the elevated wasted ventilation fraction of each breath (VD/VT) and hypoxemia secondary to ventilation-perfusion mismatching, both of which stimulate minute ventilation of increase. The reduced ventilatory capacity is primarily the result of airflow obstruction, which causes an increased work of breathing. Respiratory muscle fatigue may also play a role in reducing ventilatory capacity. The differentiation of heart failure from chronic obstructive pulmonary diseases as a cause of dyspnea can be accomplished using a variety of noninvasive and invasive techniques during exercise, including measurements of minute ventilation, the expiratory airflow pattern, ventilatory reserve (VEmax/MVV), ventilatory efficiency (VD/VT), arterial blood gases, the anaerobic threshold, heart rate, cardiac output, pulmonary hemodynamics and ventricular ejection fraction. Exercise training of patients with chronic obstructive pulmonary diseases improves exercise intolerance but appears to have little effect on pulmonary function tests, arterial blood gases and pulmonary hemodynamics. Supplemental oxygen during exercise training may be a useful adjunct for improving exercise tolerance in patients with chronic obstructive pulmonary diseases.

Noninvasive radiographic assessment of cardiovascular function in acute and chronic respiratory failure

Noninvasive radiographic techniques have provided a means of studying the natural history and pathogenesis of cardiovascular performance in acute and chronic respiratory failure. Chest radiography, radionuclide angiocardiography and thallium-201 imaging, and M mode and cross-sectional echocardiography have been employed. Each of these techniques has specific uses, attributes and limitations. For example, measurement of descending pulmonary arterial diameters on the plain chest radiograph allows determination of the presence or absence of pulmonary arterial hypertension. Right and left ventricular performance can be evaluated at rest and during exercise using radionuclide angiocardiography. The biventricular response to exercise and to therapeutic interventions also can be assessed with this approach. Evaluation of the pulmonary valve echogram and echocardiographic right ventricular dimensions have been shown to reflect right ventricular hemodynamics and size. Each of these noninvasive techniques has been applied to the study of patients with respiratory failure and has provided important physiologic data.

Evaluation of left ventricular function in chronic pulmonary disease by exercise gated equilibrium radionuclide angiography

To assess left ventricular (LV) response to supine bicycle exercise, we studied 10 normal (group 1). 10 patients with coronary artery disease (CAD) (group 2), 12 patients with severe obstructive lung disease (COPD) (group 3), and eight patients with both CAD and COPD (group 4) by gated equilibrium radionuclide angiography. Most individuals in all groups also had pulmonary catheter-obtained measurements of LV filling pressures during exercise. Normal individuals increased their ejection fraction (EF) during exercise by increasing stroke volume (SV) and reducing end-systolic volume (ESV) without changing end-diastolic volume (EDV); pulmonary artery (PAP) and wedge (PAW) pressures were unaltered. CAD patients (group 2) showed no change in EF with increased EDV, ESV, SV, and PAW. COPD patients (group 3) exhibited decreases in EDV, ESV, and SV, accounting for abnormal EF responses in 6 of 12; PAW was unchanged and the marked elevation of PAP correlated with reduced EDV. Group 4 patients (CAD plus COPD) had abnormal EF responses with increased EDV and ESV without change in SV. Thus an abnormal LV function response to exercise in COPD patients may be multifactorial, thereby indicating the possible need for therapeutic modalities in addition to those employed in alleviating pulmonary parenchymal disease.

First pass radionuclide assessment of right and left ventricular ejection fraction in chronic pulmonary disease. Effect of oxygen upon exercise response

Right and left ventricular ejection fraction (RVEF; LVEF) were determined in patients with severe chronic pulmonary disease (mean +/- SEM [FEV1 percent predicted 36 +/- 3%; PaO2: 64 +/- 3 mm Hg]), utilizing first pass radionuclide angiocardiography. RVEF and LVEF were measured at rest and again during upright bicycle exercise while patients breathed room air, and again during low flow oxygen (O2) administration. Mean RVEF was abnormal (less than 45%) at rest and did not increase with exercise while subjects breathed room air (44 +/- 2 percent vs 44 +/- 3 percent, P = ns), but improved significantly during exercise while patients breathed O2 (45 +/- 5 percent vs 51 +/- 3 percent, P less than .05). Breathing room air, RV exercise ejection fraction was abnormal (less than 5 percent increase in absolute RVEF) in 15 of 18 patients, but only 5 of 10 patients were abnormal during O2 administration. LVEF at rest was normal in all subjects. These data suggest: 1) RV exercise ejection fraction is abnormal in most patients with chronic pulmonary disease; 2) while low flow O2 does not alter RV performance at rest, it improves RV exercise ejection fraction in some patients.

Right and left ventricular dysfunction in patients with chronic obstructive lung disease. Assessment by first-pass radionuclide angiography

To evaluate the relationship between right and left ventricular function in patients with obstructive lund disease, we studied 10 normal subjects (group 1) and 37 patients with chronic obstructive pulmonary disease by first pass radionuclide angiography. These 37 patients were divided into three groups: nine with mild chronic obstructive pulmonary disease (group 2), 20 with severe chronic obstructive pulmonary disease (group 3) and eight with severe chronic obstructive pulmonary disease and primary left ventricular disease (group 4). In each subject right ventricular ejection fraction (RVEF), left ventricular ejection fraction (LVEF) and ejection fraction during first third of systole (first third LVEF) were calculated. (For table: see text.) p less than 0.05 versus 1. All subjects in group 2 had normal left ventricular and right ventricular function. In group 3, 11 of 10 (55 per cent) had a low RVEF and three of 20 (15 per cent) a low LVEF. However eight of 20 in this group (40 per cent) had a depressed first-third LVEF. The correlation between decline in RVEF and first-third LVEF was good r = 0.73. We conclude that (1) certain indices of early systolic left ventricular ejection are abnormal in many patients with chronic obstructive pulmonary disease and correlate with the decline in right ventricular function; (2) this is not seen in patients with mild chronic obstructive pulmonary disease and is worse in patients with underlying left-sided heart disease.

First-pass radionuclide assessment of right and left ventricular performance in patients with cardiac and pulmonary disease

First-pass radionuclide angiocardiography allows noninvasive determination of right and left ventricular performance from a single study. Analysis is made from the high frequency components of the regional radionuclide time-activity curves. Both regional and global ventricular performance can be assessed at rest and during exercise. Sequential studies can be performed to evaluate therapeutic interventions. This technique has been applied in a broad spectrum of patients with cardiac and pulmonary disease and has been shown to have major clinical impact.

Left ventricular function in chronic obstructive pulmonary disease

The presence or absence of left ventricular dysfunction in chronic obstructive pulmonary disease has been debated for decades. I have reviewed the following evidence pertaining to this topic: (1) left ventricular pathologic abnormalities; (2) the methods used to determine left ventricular performance; (3) specific abnormalities of left ventricular function as revealed by systolic time intervals, left ventricular end-diastolic pressure, ejection fraction, isovolumic indices, and left ventricular function curves; and (4) pertinent experimental data. The bulk of the evidence indicates that the clinical symtoms of left-sided failure are unreliable in those with obstructive disease of the airways and that the great majority of patients have normal left ventricular function, once other causes are excluded. A small group of patients have some abnormalities in left ventricular performance, but these have not been clinically significant. The ultimate importance of such abnormalities awaits future investigation.