ECHOCARDIOGRAPHIC EVALUATION OF PATIENTS WITH CHRONIC OBSTRUCTIVE PULMONARY DISEASE AND ITS CORRELATION WITH THE SEVERITY OF THE

DISEASE

• NAME :DR. AMARDIP K. RAJPUT

INTRODUCTION• Chronic Obstructive Pulmonary Disease (COPD) is a major cause of

health care burden worldwide and the only leading cause of death that is increasing in prevalence. It is the fourth leading cause of death, and by 2020, is expected to rise to the 3rd position as a cause of death. [1]

• Pulmonary hypertension is a serious complication of COPD and is associated with poor prognosis. In general pulmonary hypertension is said to be present when Mean pulmonary artery pressure (MPAP) is more than 30 mmHg. Pulmonary hypertension associated with COPD is usually mild to moderate, and in <5% patients it is severe. Pulmonary artery pressure is known to increase to a great extent during REM sleep, exercise, acute exacerbations which, eventually leads to right heart failure. Thus, early detection and treatment of pulmonary hypertension becomes important to prevent right heart failure. [2]

• This study was undertaken to assess the cardiac changes secondary to COPD by echocardiography, and to find out the correlation between echocardiographic findings and the severity of COPD.

AIMS AND OBJECTIVES AIMS:• Assessment of severity of chronic obstructive

pulmonary disease.• Echocardiographic assessment of systolic function,

diastolic function and pulmonary artery pressure. OBJECTIVES:• To assess the cardiac changes secondary to chronic

obstructive pulmonary disease by echocardiography and to find out the correlation between echocardiography findings and the severity of chronic obstructive pulmonary disease, if there is any.

MATERIALS AND METHODS Study design This was a hospital based prospective, observational case

control study. Sample size Total 50 subjects from case and control group each were

included in this study. Study duration November 2013 to June 2015 METHOD OF COLLECTION OF DATA Total 50 patients with COPD were selected after history

taking and physical examination supported by laboratory evidence, ECG, Echo and PFT to assess the clinical severity and complications.

Inclusion criteria Adult males and females of age ≥18 years and ≤60 years

with history of COPD were selected for the study. Exclusion criteria Patients with primary diagnosis of-• Bronchial asthma.• Known sleep apnea.• Lung cancer.• Known left ventricular dysfunction. • Poorly controlled hypertension.• Valvular heart disease.• Known coronary artery disease.• patients with poor echo window.

STUDY DETAILS Total 50 patients with COPD were selected. Confirmed with clinical history and pulmonary function tests. All patients were subjected to routine investigations.I. complete blood countII. Lipid profileIII. Blood sugarIV. Blood ureaV. Serum creatinineVI. Chest radiographyVII. Electrocardiography

STUDY DETAILSAll patients were investigated and by

spirometry and classified according to GOLD guidelines as follows.

FEV1/FVC ratio <0.7o Mild: FEV1 >80% predicted.o Moderate: FEV1 80-50% predicted.o Severe: FEV1 50-30% predicted.o Very severe FEV1 <30% predicted.

STUDY DETAILSAll patients were subjected to 2-dimentional transthorasic

Doppler echocardiography and following parameters were assessed.

Tricuspid regurgitant flow.Right ventricular systolic pressure.Systolic pulmonary artery pressure.Right ventricular dimensions.Ejection fraction.Right ventricular diastolic dysfunction.Left ventricular systolic and diastolic function.

STUDY DETAILS

Echocardiographic parameters were correlated with spirometric variables to find out the correlation of severity of COPD with echocardiographic findings.

RESULTS

COPD grade FEV1 % Predicted

males M [%] Females F [%] No. of Cases Percentage

Mild ≥80 0 0 0 0% 0 0%

Moderate 50-79 3 37.5 5 62.5 8 16%

Severe 30-49 17 56.67 13 43.33 30 60%

Very severe ≤30 6 50 6 50 12 24%

•Severity of COPD by pulmonary function tests- Of total 50 patients in case group 8 (16%) patients had moderate grade COPD (FEV1 50-79%) [3: M; 5: F]. 30 (60%) patients had severe grade COPD (FEV1 30-49%) [17: M; 13: F]. 12 (24%) had very severe grade COPD (FEV1 ≤30%) [6: M; 6: F] The mean FEV1 was 36.80±9.93 and the mean FEV1/FVC was 57.99±10.23.Table : Severity of COPD

SEVERITY OF COPD BY PULMONARY FUNCTION TESTS

Mild Moderate Severe Very severe0

5

10

15

20

25

30

0

8

30

12

No. of Cases

Pulmonary hypertension

COPD severity grading

Grade-2 moderate Grade -3severe Grade-4 very severe Total

Mild 6 14 2 22

Moderate+severe 2 16 10 28

Total 8 30 12 50

•Pulmonary hypertension correlation with COPD - Total 8 (16%) patients in our study had moderate grade COPD out of which 6 patients had mild pulmonary hypertension (sPAP 30-50), and 2 patients had moderate to severe pulmonary hypertension (sPAP 50-70, >70). 30 (60%) patients had severe grade COPD out of which 14 patients had mild pulmonary hypertension (sPAP 30-50) and 16 patients had moderate to severe pulmonary hypertension (sPAP 50-70, >70). 12 (24%)patients had very severe grade COPD out of which 2 patients had mild pulmonary hypertension (sPAP 30-50) and 10 patients had moderate to severe pulmonary hypertension (sPAP 50-70, >70). Pulmonary hypertension was strongly associated with severity of COPD. [chi square value: 6.8452; DF: 2; ‘p’ value: 0.0326]Table : Pulmonary hypertension correlation with COPD

PULMONARY HYPERTENSION CORRELATION WITH COPD

Grade-2 moderate Grade -3severe Grade-4 very severe0

2

4

6

8

10

12

14

16

6

14

22

16

10Mild Moderate+severe

Diastolic dysfunction

COPD severity grading

Grade-2 moderate Grade -3 severe Grade-4 very severe Total

Present 8 27 11 46

Absent 0 3 1 4

Total 8 30 12 50

•Diastolic dysfunction correlation with COPD - Total 30 (60%) patients had severe grade COPD out of which 27 patients had diastolic dysfunction. 12(24%) patients had very severe grade COPD out of which 11 had diastolic dysfunction. Diastolic dysfunction was statistically not associated with severity of COPD. [chi square value: 0.806; DF: 2; ‘p’ value :0.650]Table : Diastolic dysfunction correlation with COPD

DIASTOLIC DYSFUNCTION CORRELATION WITH COPD

Grade-2 moderate Grade -3 severe Grade-4 very severeCOPD severity grading

0

5

10

15

20

25

30

8

27

11

0 3 1

PresentAbsent

Diastolic dysfunction Present Percent (%) Absent Percent (%) Total

Patients with COPD 46 92 4 30 50

Control cases 15 8 35 70 50

Diastolic dysfunction of case group compared with control group: we compared the diastolic dysfunction of patients having COPD with control group and found out that diastolic dysfunction was significantly pravalent in patients with COPD than control population. [Chi square value 7.86; DF 1; ‘p’ value 0.005]

DIASTOLIC DYSFUNCTION OF CASE GROUP COMPARED WITH CONTROL GROUP

Present Absent 0

5

10

15

20

25

30

35

40

45

50

46

415

35

Patients with COPDControl cases

Systolic dysfunction COPD severity grading

Grade-2 moderate Grade -3 severe Grade-4 very severe Total

Present 0 6 1 7

Absent 8 24 11 43

Total 8 30 12 50

•Systolic dysfunction and correlation with COPD - Total 30 (60%) patients had severe grade COPD out of which 6 patients had systolic dysfunction. Total 12 patients had very severe grade COPD out of which 1 patient had systolic dysfunction. Systolic dysfunction was statistically not associated with severity of COPD. [chi square value : 2.519; DF:2; ‘p’ value: 0.283]Table : Systolic dysfunction correlation with COPD

SYSTOLIC DYSFUNCTION AND CORRELATION WITH COPD

Grade-2 moderate Grade -3 severe Grade-4 very severeCOPD severity grading

0

5

10

15

20

25

0

61

8

24

11

PresentAbsent

CORRELATION OF ECHOCARDIOGRAPHC VALUES WITH PFT PARAMETERS.

Pearson correlation coefficientFEV1 FVC FEV1/FVC PEFR

RV 0.038 0.089 0.030 0.005FS% -0.053 -0.057 -0.019 -0.423EF% 0.063 -0.020 0.107 -0.320

E 0.088 0.015 0.092 -0.176A 0.142 0.053 0.135 -0.205

E/A 0.075 0.054 0.001 -0.235TRvmax 0.105 0.096 0.014 -0.245

TR 0.167 0.138 0.054 -0.277RVSP -0.19 0.217 -0.51 -0.197Ea(m) -0.019 -1.98 -0.020 -0.288Aa(M) 0.020 0.030 -0.031 -0.174Sa(m) 0.027 -0.093 0.08 -0.132Ea(l) 0.043 -0.089 0.169 -0.199Aa(l) 0.069 0.007 0.097 0.174Sa(l) 0.095 -0.027 0.135 -0.141Ea/

Aa(m)-0.017 -0.017 0.017 -0.102

E/Ea(m) 0.195 0.119 0.116 0.139Ea/Aa(l) 0.015 -0.059 0.081 -0.111E/Ea(l) -0.103 -0.052 -0.096 -0.177

CORRELATION OF FEV1% WITH ECHOCARDIOGRAPHIC PARAMETERS.

• FEV1 [%] was positively correlated with RV diameter (0.038), ejection fraction [EF] (0.063), early mitral inflow velocity [E] (0.088), late mitral inflow velocity [A] (0.142), E/A ratio (0.075).

• FEV1 [%] was positively correlated with TR max jet velocity [TRvmax] (0.105), tricuspid regurgitant velocity [TR] (0.167), mitral annular velocity during late diastole [Aa(m)] (0.020), peak systolic mitral annular velocity [Sa(m)] (0.027), early diastolic velocity of the lateral motion of the mitral annulus [Ea(l)] (0.043), late diastolic velocity of the lateral motion of the mitral annulus [Aa(l)] (0.069), peak systolic velocity of the lateral motion of the mitral annulus [Sa(l)] (0.095),

• FEV1 [%] was positively correlated with transmitral to basal septal mitral early diastolic velocity ratio [E/Ea(m)] (0.195), early diastolic velocity of the lateral motion of the mitral annulus to late diastolic velocity of the lateral motion of the mitral annulus ratio [Ea/Aa(l)] (0.015)

• FEV1 [%] was negatively correlated with fractional shortening (-0.053), right ventricular systolic pressure [RVSP] (-0.19), mitral annular velocity during early diastole [Ea(m)] (-0.019), mitral annular velocity during early diastole to mitral annular velocity during late diastole ratio [Ea/Aa(m)] (-0.017), transmitral to mitral annular early diastolic velocity ratio [E/Ea(l)] (-0.103).

CORRELATION OF FVC% WITH ECHOCARDIOGRAPHIC PARAMETERS

• FVC [%] was positively correlated with RV diameter (0.089), early mitral inflow velocity [E] (0.015), late mitral inflow velocity [A] (0.053), E/A ratio (0.054),

• FVC [%] was positively correlated with TR max jet velocity [TRvmax] (0.096), tricuspid regurgitant

velocity [TR] (0.138), right ventricular systolic pressure [RVSP] (0.217), mitral annular velocity during late diastole [Aa(m)] (0.030), late diastolic velocity of the lateral motion of the mitral annulus [Aa(l)] (0.007), transmitral to basal septal mitral early diastolic velocity ratio [E/Ea(m)] (0.119),

• FVC [%] was negatively correlated with fractional shortening (-0.057),ejection fraction [EF] (-0.020),

mitral annular velocity during early diastole [Ea(m)] (-0.198), peak systolic mitral annular velocity [Sa(m)] (-0.093), early diastolic velocity of the lateral motion of the mitral annulus [Ea(l)] (-0.089), peak systolic velocity of the lateral motion of the mitral annulus [Sa(l)] (-0.027),

• FVC [%] was negatively correlated with mitral annular velocity during early diastole to mitral annular

velocity during late diastole ratio [Ea/Aa(m)] (-0.017), early diastolic velocity of the lateral motion of the mitral annulus to late diastolic velocity of the lateral motion of the mitral annulus ratio [Ea/Aa(l)] (-0.059), transmitral to mitral annular early diastolic velocity ratio [E/Ea(l)].(-0.052)

CORRELATION OF FEV1/FVC WITH ECHOCARDIOGRAPHIC PARAMETERS

• FEV1/FVC [%] was positively correlated with RV diameter (0.030), ejection fraction [EF] (0.107), early mitral inflow velocity [E] (0.092), late mitral inflow velocity [A] (0.135) E/A ratio (0.001).

• FEV1/FVC [%] was positively correlated with TR max jet velocity [TRvmax] (0.014), tricuspid regurgitant velocity [TR] (0.054), early diastolic velocity of the lateral motion of the mitral annulus [Ea(l)] (0.169), late diastolic velocity of the lateral motion of the mitral annulus [Aa(l)] (0.097), peak systolic velocity of the lateral motion of the mitral annulus [Sa(l)] (0.135).

• FEV1/FVC [%] was positively correlated with mitral annular velocity during early diastole to mitral annular velocity during late diastole ratio [Ea/Aa(m)] (0.017), transmitral to basal septal mitral early diastolic velocity ratio [E/Ea(m)] (0.116), early diastolic velocity of the lateral motion of the mitral annulus to late diastolic velocity of the lateral motion of the mitral annulus ratio [Ea/Aa(l)] (0.081),

• FEV1/FVC percent was negatively correlated with fractional shortening (-0.019), right ventricular systolic pressure [RVSP] (-0.51), mitral annular velocity during early diastole [Ea(m)] (-0.020), mitral annular velocity during late diastole [Aa(m)] (-0.031), peak systolic mitral annular velocity [Sa(m)] (-0.08), transmitral to mitral annular early diastolic velocity ratio [E/Ea(l)] (-0.096)

CORRELATION OF PEFR% WITH ECHOCARDIOGRAPHIC PARAMETERS

• PEFR [%] was positively correlated with RV diameter (0.005), late diastolic velocity of the lateral motion of the mitral annulus [Aa(l)] (0.174), transmitral to basal septal mitral early diastolic velocity ratio [E/Ea(m)] (0.139),

• PEFR [%] was negatively correlated with fractional shortening [FS%] (-0.423), ejection fraction[EF] (-0.320), early mitral inflow velocity [E] (-0.176), late mitral inflow velocity [A] (-0.205), E/A ratio (-0.235),

• PEFR [%] was negatively correlated with TR max jet velocity [TRvmax] (-0.245), tricuspid regurgitant velocity [TR] (-0.277), right ventricular systolic pressure [RVSP] (-0.197), mitral annular velocity during early diastole [Ea(m)] (-0.288), mitral annular velocity during late diastole [Aa(m)] (-0.174), peak systolic mitral annular velocity [Sa(m)] (-0.132), early diastolic velocity of the lateral motion of the mitral annulus [Ea(l)] (-0.199), peak systolic velocity of the lateral motion of the mitral annulus [Sa(l)] (-0.141),

• PEFR [%] was negatively correlated with mitral annular velocity during early diastole to mitral annular velocity during late diastole ratio [Ea/Aa(m)] (-0.102), early diastolic velocity of the lateral motion of the mitral annulus to late diastolic velocity of the lateral motion of the mitral annulus ratio [Ea/Aa(l)] (-0.111), transmitral to mitral annular early diastolic velocity ratio [E/Ea(l)] (-0.177).

TABLE : THE MEAN AND STANDARD DEVIATION OF PFT AND ECHOCARDIOGRAPHIC PARAMETERS IN CASES VS CONTROLParameters` Control Case Mean difference 95% CI of difference

SBP 117.92 ± 8.93 128.24 ± 9.63 10.32 6.63 – 14.0DBP 78.28 ± 4.55 79.68 ± 7.67 1.40 -3.90 – 1.10BMI 25.99 ± 5.36 20.58 ± 4.42 5.41 3.46 – 7.36HB 11.69 ± 1.80 12.47 ± 1.61 0.78 0.09 – 1.45PCV 33.46 ± 6.58 36.68 ± 4.82 3.23 0.93 – 5.52FEV1 86.24 ± 12.64 36.80 ± 9.93 49.44 44.93 – 53.95FVC 97.32 ± 9.32 63.80 ± 14.66 33.52 28.64 – 38.39FEV1/FVC 88.53 ± 9.13 57.99 ± 10.23 30.53 26.68 – 34.37PEFR 1.88 ± 0.40 2.72 ± 2.0 0.85 0.27 – 1.42RV 15.22 ± 3.74 29.09 ± 5.07 13.87 12.10 – 15.64FS 37.22 ± 4.66 36.04 ± 12.86 1.18 -2.65 – 5.02EF 57.97 ± 5.76 60.35 ± 10.61 2.37 -5.79 – 1.04E 0.73 ± 0.06 0.50 ± 0.15 0.23 0.18 – 0.27A 0.73 ± 0.05 0.71 ± 0.14 0.02 -0.02 – 0.06E/A 1.0 ± 0.05 0.73 ± 0.14 0.27 0.24 – 0.31TRV max 0.58 ± 0.10 2.03 ± 0.82 1.45 1.22 – 1.68TR 6.37 ± 1.41 16.87 ± 13.59 10.50 6.67 – 14.34RVSP 11.39 ± 0.45 29.11 ± 17.32 17.72 12.86 – 22.59Ea(m) 0.08 ± 0.01 0.07 ± 0.01 0.009 0.003 - 0.01Aa(m) 0.09 ± 0.02 0.094 ± 0.02 0.007 0.001 – 0.015Sa(m) 0.093 ± 0.02 0.07 ± 0.02 0.02 0.014 – 0.027Ea(I) 0.14 ± 0.02 0.07 ± 0.03 0.065 0.056 – 0.074Aa(I) 0.12 ± 0.02 0.11 ± 0.02 0.015 0.006 – 0.023Sa(I) 0.10 ± 0.02 0.08 ± 0.02 0.027 0.019 – 0.035Ea/Aa(m) 0.93 ± 0.26 0.75 ± 0.27 0.17 0.065 – 0.28E/Ea (m) 9.72 ± 1.55 7.64 ± 2.90 2.08 1.16 – 3.0Ea/Aa(I) 1.17 ± 0.26 0.68 ± 0.32 0.49 0.37 – 0.60E/Ea (I) 5.46 ± 0.79 7.97 ± 3.01 2.52 1.64 – 3.39

• The mean and standard deviation for systolic blood pressure [SBP] was 128.24(±9.63) and 117.92 (±8.93), for diastolic blood pressure [DBP] was 79.68(±7.67) and 78.28 (±4.55) for case and control group respectively.

• The mean and standard deviation for body mass index [BMI] was 20.58(±4.42) and 25.99 (±5.36) for case and control group respectively.

• The mean and standard deviation for hemoglobin [Hb%] was 12.47(±1.61) and 11.69 (±1.80), for packed cell volume [PCV] was 36.68(±4.82) and 33.46 (±6.58) for case and control group respectively.

• The mean and standard deviation for forced expiratory volume in 1 second [FEV1%] was 36.80(±9.93) and 86.24 (±12.64), for forced vital capacity [FVC] was 63.80(±14.66) and 97.32 (±9.32), for FEV1/FVC was 57.99(±10.23) and 88.53 (±9.13), for peak expiratory flow rate was 2.72(±2.0) and 1.88 (±0.40) for case and control group respectively.

• The mean and standard deviation for RV diameter [RV] was 29.09(±5.07) and 15.22 (±3.74), for fractional shortening [FS%] was 36.04(±12.86) and 37.22 (±4.66) for ejection fraction [EF%] was 60.35(±10.61) and 57.97(±5.76) for case and control group respectively.

• The mean and standard deviation for early mitral inflow velocity [E] was 0.50(±0.15) and 0.73(±0.06), for late mitral inflow velocity [A] was 0.71(±0.14) and 0.73(±0.05), for E/A ratio was 0.73(±0.14) and 1.0(±0.05) for case and control group respectively.

• The mean and standard deviation for TR max jet velocity [TRvmax] was 2.03(±0.82) and 0.58(±0.10), for tricuspid regurgitant velocity [TR] was 16.86(±13.59) and 6.37(±1.41), for right ventricular systolic pressure [RVSP] was 29.11(±17.32) and 11.39(±0.45) for case and control group respectively.

• The mean and standard deviation for mitral annular velocity during early diastole [Ea(m)] was 0.07(±0.01) and 0.08(±0.01), for mitral annular velocity during late diastole [Aa(m)] was 0.094(±0.02) and 0.09(±0.02),for peak systolic mitral annular velocity [Sa(m)] was 0.07(±0.02) and 0.093(±0.02) for case and control group respectively.

• The mean and standard deviation for early diastolic velocity of the lateral motion of the mitral annulus [Ea(l)] was 0.07(±0.03) and 0.14(±0.02), for late diastolic velocity of the lateral motion of the mitral annulus [Aa(l)] was 0.11(±0.02) and 0.12(±0.02) ,for peak systolic velocity of the lateral motion of the mitral annulus [Sa(l)] was 0.08(±0.02) and 0.10(±0.02) for case and control group respectively.

• The mean and standard deviation for mitral annular velocity during early diastole to mitral annular velocity during late diastole ratio [Ea/Aa(m)] was 0.75(±0.27) and 0.93(±0.26), for early diastolic velocity of the lateral motion of the mitral annulus to late diastolic velocity of the lateral motion of the mitral annulus ratio [Ea/Aa(l)] was 0.68(±0.32) and 1.17 (±0.26) for case and control group respectively.

• The mean and standard deviation for transmitral to basal septal mitral early diastolic velocity ratio [E/Ea(m)] was 7.64(±2.90) and 9.72(±1.55), for transmitral to mitral annular early diastolic velocity ratio [E/Ea(l)] was 7.97(±3.01) and 5.46(±0.79) for case and control group respectively.

TABLE : CORRELATION OF PFT AND ECHOCARDIOGRAPHIC PARAMETERS OF CASES AND CONTROL SUBJECTS

Parameter Pearson Correlation coefficient FEV1 0.096FVC -0.072

FEV1/FVC 0.0415PEFR 0.146

RV -0.032FS% 0.111EF% 0.210

E 0.193A 0.233

E/A -0.270TRvmax 0.063

TR 0.096RVSP 0.095Ea(m) -0.241Aa(m) -0.121Sa(m) -0.106Ea(l) -0.031Aa(l) 0.055Sa(l) 0.077

Ea/Aa(m) -0.038E/Ea(m) -0.106Ea/Aa(l) -0.072E/Ea(l) 0.007

• PEFR of case group was positively correlated with that of control group (0.146)• Fractional shortening [FS%] of case group was positively correlated with control

group.(0.111)• Ejection fraction [EF%] of case group was positively correlated with control group.

(0.210)• Eearly mitral inflow velocity [E] of case group was positively correlated with control

group. (0.193)• Late mitral inflow velocity [A] for the case group was positively correlated with that

of control group. (0.233) • The E/A ratio for case group was negatively correlated with that of control group. (-

0.270)• Mitral annular velocity during early diastole [Ea(m)] of the case group was

negatively correlated with that of control group.(-0.241)• Mitral annular velocity during late diastole [Aa(m)] for the case group was

negatively correlated with that of control group.(-0.121)• Peak systolic mitral annular velocity [Sa(m)] of the case group was negatively

correlated with that of control group.(-0.106)

• Transmitral to basal septal mitral early diastolic velocity ratio [E/Ea(m)] of case group was negatively correlated with that of control group.(-0.106)

DISCUSSION

Studies Mean FEV1 Mean FEV1/FVC

Prasanta Mohapatra et al[3] 42.5±14 54.86±4.04

Present study 36.80 ± 9.93 57.99 ± 10.23

FEV1 and FEV1/FVC Table : Spirometeric parameters compared with other studies In the present study the mean FEV1 and FEV1/FVC was comparable to Prasanta R Mohapatra et al study.

Distribution of patients according to COPD severity gradingIn our study it was found that of total 50 patients in case group 8 (16%) patients had moderate grade COPD (FEV1 50-79%) [3 M; 5: F]. 30 (60%) patients had severe grade COPD (FEV1 30-49%) [17: M; 13: F]. 12 (24%) had very severe grade COPD (FEV1 ≤30%) [6: M; 6: F]In study conducted by Jain B.K. et al out of 80 patients 42 (52.5%) patients had moderate grade COPD, 26 (32.5%) patients had severe grade COPD, and 12 (15%) patients had very severe grade COPD.[6]

COPD severity grading in our study was statistically correlated with the study by Jain B.K. et al [P-value- 0.0001]

• Pulmonary artery pressure and correlation with COPD

• Gupta N. K. et al shown that severe PAH is present in severe or very severe COPD and the incidence of PAH is directly proportional to severity of disease.[7] In a study by Higham MA et al. 25% patients had mild pulmonary hypertension while 75% patients had moderate to severe pulmonary hypertension.[5]

• In our study pulmonary hypertension was strongly associated with COPD severity [‘p’ value-0.0326], which is in accordance with previous studies

DIASTOLIC DYSFUNCTION

• Caram LM et al showed that chronic obstructive pulmonary disease (COPD) patients have a high prevalence of diastolic dysfunction according to disease severity. [8]

• Sanchez LM et al showed that the prevalence of LVDD in patients with severe COPD was high, as assessed by standard echocardiographic measurements, even in the younger patients group and regardless of lack of systemic hypertension. [9]

• In our study diastolic dysfunction was statistically not correlated with COPD severity [‘p’ value-0.650] which is not in accordance with previous studies.

SYSTOLIC DYSFUNCTION

• Rabab A. EL Wahsh et al showed that left ventricular diastolic function and LV systolic function are affected in COPD patients especially with progression of the disease. [10] COPD patients with pulmonary hypertension are more liable to LV diastolic and systolic dysfunction than normal pulmonary pressure COPD patients.

• In our study systolic dysfunction was statistically not correlated with COPD severity [‘p’ value: 0.283]

COMPARISON OF TISSUE DOPPLER IMAGING PARAMETERS WITH OTHER STUDIES

• In a study conducted by Ozben B. et al they found out that COPD severity has a negative impact on RV function, and TDI derived variables for RV function may be used in the assessment of subclinical RV dysfunction in patients with severe COPD.[11]

• Ugurlu A.O. et al in another study concluded that RV diastolic dysfunction, which may not be detected by conventional echocardiography techniques including M-mode, two-dimensional and spectral Doppler, can be determined by TDI from different segmental levels in patients with COPD even in the absence of PHT.[12]

• Necla Özer et al reported that with COPD, the development of pulmonary hypertension leads to right ventricular dilation, right ventricular systolic and diastolic dysfunction, and left ventricular diastolic dysfunction, whereas the patients without pulmonary hypertension are spared from right and left ventricular dysfunction.[13]

• We have compared the data of tissue doppler imaging (TDI) with these studies and found out that tissue doppler imaging (TDI) parameters from our study were fairly correlated with previous studies

TABLE : TDI PARAMETERS COMPARED WITH OTHER STUDIES

TDI parameters Present study Necla Özer et al[13]

A.O. Ugurlu et al[12]

Beste Ozben et al[11]

RV 29.09±5.07 40.4±11.2 32.0±3.0 38.0±7.8FS% 36.04±12.86 NM 37.7±5.7 NMEF% 60.35±10.61 NM 55.6±5.5 58.4±10.02

E 0.50±0.15 0.31±0.50 0.61±0.12 0.70±0.24A 0.71±0.14 0.54±0.15 0.78±0.18 0.82±0.19

E/A 0.73±0.14 0.61±0.16 NM 0.85±0.39TRvmax 2.03±0.82 NM NM NM

RVSP 29.11±17.32 NM NM 40.0±13Ea(m) 0.08±0.11 NM 0.19±0.92 0.10±0.30Aa(m) 0.09±0.02 NM 0.26±0.69 0.16±0.39Sa(m) 0.09±0.02 NM 0.23±0.92 0.12±0.27Ea(l) 0.14±0.02 NM 0.13±0.46 NMAa(l) 0.12±0.02 NM 0.17±0.56 NMSa(l) 0.10±0.02 NM 0.15±0.31 NM

Ea/Aa(m) 0.93±0.26 NM NM 0.71±0.27E/Ea(l) 9.72±1.55 NM NM NM

Ea/Aa(l) 1.17±0.26 NM NM NME/Ea(l) 5.46±0.79 NM NM NM

COMPARISON OF SPIROMETRIC PARAMETERS WITH ECHOCARDIOGRAPHY

• Das M et al in their study found that there was strong negative correlation of Systolic Pulmonary Artery Pressure (SPAP) with FEV1/FVC ratio (r = -0.5553) and PEFR (r = - 0.4604). They concluded that tissue Doppler imaging can be a vital prognostic sign to predict RV dysfunction and predict morbidity in COPD.[14]

• In our study There was negative correlation between pulmonary artery pressure and FEV1 (-0.19), FEV1/FVC ratio (-0.51), and PEFR (-0.197).

CONCLUSIONS• Pulmonary function tests namely FEV1, FVC,

FEV1/FVC were significantly deranged in case group as compared with control group.

• Lung function parameters namely FEV1, FVC, FEV1/FVC and PEFR have significant inverse correlation with the severity of COPD.

• RV diameter and RVSP were significantly increased in patients with COPD as compared with control group.

CONCLUSIONS• RV wall thickness was positively correlated with

duration and severity of COPD.• Significant number of patients with COPD had

diastolic dysfunction.• Early detection of pulmonary hypertension is

important for therapeutic and prognostic purposes.• Echocardiography helps in early detection of cardiac

changes secondary to COPD providing time for early intervention.

• Tissue Doppler imaging is an important tool for diagnosis of subclinical RV and LV dysfunction. (systolic and diastolic dysfunction)

BIBLIOGRAPHY1. World Health Report. Geneva: World Health Organization. Available from URL:

http://www.who.int/whr/2000/en/statistics.htm; 2000.2. Thomas L Petty. The history of COPD. International Journal of COPD 2006; 1(1):3-

14.3. Prasanta R Mohapatra, Ashok K Janmeja. Factors associated with hospital

admission in patients with acute exacerbation of COPD. CHEST 2011; 52:203-6.4. Migueres M. Pulsed Doppler echocardiography in diagnosis of pulmonary

hypertension in COPD. CHEST 1990;98:280-5.5. Higham MA. Utility of echocardiography in assessment of pulmonary hypertension

secondary to COPD. European Respiratory Journal 2001; 17:350-5.

6. Jain B. K, Pasari N., Bajpai A, Songara A. “Evaluation of Right Ventricular Dysfunction and Pulmonary Artery Hypertension Secondary to COPD Severity by Electrocardiogram and Echocardiography”. Journal of Evolution of Medical and Dental Sciences 2015; 4(42); 7275-7281.

7. Gupta NK. Echocardiographic evaluation of heart in COPD patient and its correlation with severity of disease. Lung India 2011 Apr-Jun;28(2):105-9.

8. De Oliveira Caram LM, Ferrari R, Naves CR, et al. Association between left ventricular diastolic dysfunction and severity of chronic obstructive pulmonary disease. Clinics. 2013;68(6):772-776.doi:10.6061/clinics/2013(06)08.

9. M. López-Sánchez, M. Muñz-Esquerre, D. Huertas, J. Gonzalez-Costello, J. Ribas, F. Manresa, J. Dorca, S. Santos: High prevalence of left ventricle diastolic dysfunction in severe COPD associated with a low exercise capacity: a cross-sectional study. PLOS ONE 8 (6) (2013) e68034.

10. Rabab A. El Wahsh , Mahmoud K. Ahmed , Rehab I. Yaseen: Evaluation of left ventricular function in patients with chronic obstructive pulmonary disease with or without pulmonary hypertension. Egyptian Journal of Chest Diseases and Tuberculosis (2013) 62, 575–582.

11. Beste Ozben, Emel Eryuksel, Azra Meryem Tanrikulu, Nurdan Papila,Tolga Ozyigit, Turgay Celikel, Yelda Basaran Acute exacerbation impairs right ventricular function in COPD patients hellenic j cardiol 2015; 56: 324-331.

12. Aylin Ozsancak Ugurlu, Asli I Atar, Ilyas Atar, Oyku Gulmez, Serife Savas Bozbas, Haldun Muderrisoglu, Fusun Oner Eyuboglu, Evaluation of right ventricular diastolic function in patients with chronic obstructive pulmonary disease using pulsed doppler tissue imaging JAMPS 2015; 36: 1-12.

13. Necla Özer, Lale Tokgözoˇglu, Lütfü Çöplü, Sırrı Kes Echocardiographic evaluation of left and right ventricular diastolic function in patients with chronic obstructive pulmonary disease J Am Soc Echocardiogr 2001;14:557-61.

14. Das M, Tapadar SR, Mahapatra ABS, Chowdhury SP, Basu S. Assessment of RV Function in Patients of (COPD). Journal of Clinical and Diagnostic Research : JCDR. 2014;8(3):11-13. doi:10.7860/JCDR/2014/6440.4090.

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