Chronic Obstructive Pulmonary Disease (COPD) is a prevalent condition that has a significant impact on individuals. The quality of life is significantly impacted by this condition, which also has a high death rate worldwide. COPD is characterized by persistent respiratory symptoms and reduced airflow caused by injury to the airways or alveoli, usually as a result of extended contact with detrimental particles or gases.[1]. The systemic effects of COPD extend beyond the lungs, with cardiovascular complications being among the most critical extrapulmonary manifestations. Pulmonary Artery Hypertension (PAH) and Left Ventricular Dysfunction (LVD) are notable cardiovascular conditions that frequently complicate the course of COPD. The echocardiographic evaluation of these conditions in COPD patients provides valuable insights into their prevalence, progression, and association with the level of disease severity, shaping the management and therapeutic strategies to improve patient outcomes.

Pulmonary arterial hypertension (PAH) is defined as having a mean pulmonary arterial pressure of 25 mmHg or above at rest. Pulmonary hypertension, often diagnosed by right heart catheterization, is a common consequence of COPD [2]. It results from pulmonary vascular remodelling, hypoxic vasoconstriction, and inflammation, which results in elevated pulmonary vascular resistance and, subsequently, PAH. The onset of PAH in COPD patients greatly worsens their prognosis by placing additional strain on the right ventricle, which can potentially result in right heart failure.

Conversely, in COPD patients, left ventricular diastolic dysfunction (LVD) arises from elevated left ventricular filling pressures. This condition is frequently overlooked but plays a significant role in the morbidity and mortality of COPD patients.[3]. The interaction between lung dysfunction and cardiac impairment in COPD is intricate and involves multiple factors, including systemic inflammation, hypoxia, and the use of cardiotoxic medications, among others.

Echocardiography stands as a cornerstone in the non-invasive evaluation of cardiac function and structure, offering a detailed assessment of ventricular dysfunction, pulmonary hypertension, and their impact on the heart's chambers. Techniques like Doppler echocardiography can accurately estimate cardiac dimensions and pulmonary artery pressures, aiding in the timely identification of cardiac involvement in individuals with chronic obstructive pulmonary disease (COPD). [4]. This Early detection is vital for the prompt management of PAH. and LVD, potentially mitigating their progression and improving patient prognosis.

The relationship between COPD severity and the development of PAH and LVD highlights a critical aspect of the disease's systemic nature. Numerous studies have shown that the degree of airflow restriction in chronic obstructive pulmonary disease (COPD) is connected to the level of PAH and the presence of LVD, indicating that echocardiographic screening among those diagnosed with moderate to severe chronic obstructive pulmonary disease (COPD) may be valuable for the early detection and management of these cardiac conditions. [5],[6].

Given the significant overlap in the clinical presentation of COPD and heart failure, distinguishing between respiratory and cardiac dysfunctions can be challenging. However, echocardiographic parameters provide a unique insight into the cardiac status of COPD patients, enabling clinicians to tailor treatments that address both pulmonary and cardiovascular constituents of the illness.

AIMS AND OBJECTIVES OF THE STUDY

1. To evaluate the prevalence of pulmonary artery hypertension and left ventricular dysfunction in COPD patients
2. To evaluate the early signs of heart failure in COPD patients.

Study Design and Venue this study was designed as a cross-sectional observational study conducted at the Department of General Medicine and the Department of Respiratory Medicine at Hassan Institute of Medical Sciences (HIMS), Hassan on sample size on 135 patients. The study aimed to evaluate the prevalence of pulmonary artery hypertension (PAH) and left ventricular dysfunction (LVD) among chronic obstructive pulmonary disease (COPD) patients, assessing their correlation with the severity of the disease.

Source of Data Collection Data were collected from both inpatient and outpatient COPD patients presenting to the departments, who met the inclusion and exclusion criteria specified for the study.

Study Period The study was conducted over a period of one year.

Estimation of sample size:   According to previous study by Gupta et al.,[7] prevalence of abnormal findings in

ECHO among COPD cases was 50%.

Estimated sample size = 135

Inclusion criteria

All COPD patients above 30 years of age, diagnosed clinically and satisfying the spirometric criteria will be included in the study.

 A diagnosis of COPD will be considered in any patient who has symptoms of

1. Chronic cough –

                             - Present intermittently or everyday

                             - Often present throughout the day

                             - Seldom or only nocturnal

1. Chronic sputum production

                            - Any pattern of Chronic sputum production may indicate COPD

1. Dyspnea that is

                           - Progressive (worsens over time)

                            - Persistent (present everyday)

                           - Worse on exercise

                          - Worsens during respiratory infections

1. Spirometric criteria: The diagnosis is confirmed by spirometry. The presence of a post bronchodilator FEV 1 < 80% of the predicted value in combination with an FEV 1 / FVC < 70% confirms the presence of air flow limitation that is not fully reversible

Exclusion criteria

Patients with other diagnosed respiratory diseases like:

• Asthma
• Tuberculosis
• Bronchiectasis
• Lung malignancy will be excluded from the study.

Patients with:

• Valvular heart diseases
• Coronary heart diseases
• Systemic hypertension • Cardiomyopathies
• Congenital heart disease
• AIDS [20]
• Thyroid disorders

METHODOLOGY:

Patients fulfilling the inclusion criteria will be taken into the study. The aims and objectives of the intended study will be explained to the patients and written informed consent will be taken. Socio-demographic data will be collected using proforma sheet. Data with respect to demographic profile will be taken from COPD patients after determining them by clinical history, radiology of chest, and pulmonary function test. Severity of disease will be determined by using GOLD criteria. All the clinically suspected COPD patients will be subjected to chest radiography and PFT.

Evaluation of cardiac morphology will be done by using Echocardiography to assess the pericardium, valvular anatomy and function, left and right-side chamber size and cardiac function. It's also done to evaluate the early signs of heart failure like hepato-jugular reflux, paroxysmal nocturnal dyspnea in COPD patients.

• Pulmonary hypertension (PH) will be defined in this study as Systolic Pulmonary Artery Pressure (sPAP) ≥ 30 mmHg. This value will be chosen according to the definition of pulmonary hypertension. PH was classified into mild, moderate, and severe category as sPAP 30–50, 50–70, >70 mmHg, respectively (using Chemla formula, mean pulmonary arterial pressure (MPAP) =0.61 PASP + 2 mmHg and putting value of 25–35, 35–45, and >45 mmHg of MPAP for mild, moderate, and severe pulmonary hypertension, respectively).[74]• Left ventricular function will be also assessed by using the following parameters: EF (ejection fraction) = measure of how much end-diastolic value is ejected from LV with each contraction.
• E/A = diastolic filling of left ventricles usually classified initially on the basis of the peak mitral flow velocity of the early rapid filling wave, peak velocity of the late filling wave caused by atrial contraction (A).
• E/A = diastolic filling of left ventricles usually classified initially on the basis of the peak mitral flow velocity of the early rapid filling wave, peak velocity of the late filling wave caused by atrial contraction (A).

GOLD CRITERIA for severity of COPD

Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: 2021 report

Investigations

• Complete blood count • Renal function test, • Liver Function Test • Serum Electrolytes • Random Blood Sugar • Thyroid Function Test • HIV, HBSAG, HCV, PT/APTT, INR • Chest Xray, ECG • PFT(Spirometry) • Echocardiography

Echocardiographic Evaluation

Echocardiography was utilized to evaluate the morphology of the pericardium, valvular anatomy, and function, as well as the size of the left and right sides of the heart. Pulmonary hypertension was defined in this study as systolic pulmonary artery pressure (sPAP) ≥ 30 mmHg. The severity of PH was classified into mild, moderate, and severe categories based on sPAP values of 30–50 mmHg, 50–70 mmHg, and >70 mmHg, respectively. Left ventricular function was assessed through parameters such as ejection fraction (EF), and diastolic filling of the left ventricles was classified based on the E/A ratio, with specific cut-offs adjusted for age groups to identify left ventricular diastolic dysfunction (LVDD).

Statistical Analysis:

Data were analyzed using SPSS version 20 and Microsoft Excel. Descriptive statistics were used to summarize mean, standard deviation, frequency, and percentage. Inferential statistics, including the Chi-square test and one-way ANOVA with post-hoc tests, were employed to examine the associations between variables.

Table 1: Echocardiographic Findings in COPD Patients

Table 2: Prevalence of PAH and LVD in COPD Patients

Table 3: Correlation between COPD Severity and PAH

Table 4: Correlation between COPD Severity and LVD

Table 5: Early Signs of Heart Failure in COPD Patients

The present cross-sectional observational study aimed to evaluate the prevalence of pulmonary artery hypertension (PAH) and left ventricular dysfunction (LVD) in chronic obstructive pulmonary disease (COPD) patients and to assess the early signs of heart failure and their correlations with the severity of the disease. The study found a high prevalence of both PAH (71.1%) and LVD (74.8%) among COPD patients, with significant correlations between COPD severity and the severity of PAH and LVD. used a lower age threshold of thirty years for my estimation since this age was often utilized in the published research. Furthermore, the prevalence of this condition is quite low in those below this age.

Obstructive airway disease has been observed to be more prevalent in middle and elderly age. This is due to

• The chance of developing COPD is positively correlated with advancing age due to the cumulative impact of exposure to environmental stressors, in addition to the influence of smoking pack years.
• Typically, patients often disregard the first symptoms and as they become older, the symptoms worse and they only seek medical attention at this point.
• As life expectancy rises due to advancements in medical treatment, COPD will become a more pressing issue as people age.

Prevalence of PAH and LVD in COPD Patients

Our findings are consistent with several studies that have reported a high prevalence of cardiovascular comorbidities in COPD patients. A study by Gupta et al. reported a Page 84 prevalence of 42.5% for PAH and 47.5% for LVD in COPD patients, which is lower than the prevalence found in our study (71.1% for PAH and 74.8% for LVD). Another study by Sharma et al. found a prevalence of 48% for PAH and 32% for LVD in COPD patients.[8] The higher prevalence rates in our study may be attributed to differences in the study population, severity of COPD, and diagnostic criteria used for PAH and LVD.

A meta-analysis by Zhyvotovska et al. reported a pooled prevalence of 35% for PAH in COPD patients, with a higher prevalence in severe COPD (48%) compared to mild-to- moderate COPD (24%).  This finding supports our study's results, which showed a significant correlation between COPD severity and the severity of PAH (p=0.027). The high prevalence of PAH in COPD patients can be attributed to various mechanisms, including chronic hypoxemia, pulmonary vascular remodeling, and endothelial dysfunction.[9]

Regarding LVD, a study by López-Sánchez et al. found a prevalence of 53.1% for left ventricular diastolic dysfunction (LVDD) in COPD patients, which is lower than the prevalence of LVD (74.8%) in our study. The difference may be due to the inclusion of both systolic and diastolic dysfunction in our definition of LVD, while the study by López-Sánchez et al. focused only on LVDD. The high prevalence of LVD in COPD patients may be explained by shared risk factors, such as smoking, systemic inflammation, and oxidative stress, which can lead to myocardial damage and dysfunction.[10]

Correlation between COPD Severity and PAH/LVD

Our study demonstrated a significant correlation between COPD severity (GOLD stage) and the severity of PAH (p=0.027) and LVD (p=0.048). These findings are Page 85 consistent with several studies that have reported an association between COPD severity and the presence of cardiovascular comorbidities. A study by Cuttica et al. found a significant association between COPD severity and the presence of PAH (p<0.001) and LVD (p=0.002). Similarly, a study by Hilde et al. reported that the prevalence of PAH increased with increasing COPD severity (p<0.001).

The correlation between COPD severity and PAH/LVD can be explained by several pathophysiological mechanisms. As COPD progresses, chronic hypoxemia and inflammation can lead to pulmonary vascular remodeling and increased pulmonary vascular resistance, resulting in the development of PAH.[11] Additionally, the increased work of breathing and hyperinflation in severe COPD can lead to reduced left ventricular filling and diastolic dysfunction.[12] These findings highlight the importance of early screening and management of cardiovascular comorbidities in COPD patients, particularly those with more severe disease.

Correlation between PAH and LVD

Our study found a significant correlation between PAH severity and LVD severity (p=0.003), suggesting that the presence of one condition may increase the risk of developing the other. This finding is consistent with a study by Freixa et al., which reported a significant association between the presence of PAH and LVD in COPD patients (p<0.001). The coexistence of PAH and LVD in COPD patients may be attributed to shared pathophysiological mechanisms, such as chronic hypoxemia, systemic inflammation, and endothelial dysfunction.

The interaction between PAH and LVD in COPD patients can lead to a vicious cycle of cardiovascular deterioration. PAH can cause right ventricular dysfunction and dilation, which can lead to interventricular septal displacement and impaired left Page 86 ventricular filling, resulting in LVD.[13] Conversely, LVD can cause pulmonary venous congestion and increased pulmonary vascular resistance, contributing to the development of PAH.[14] This complex interplay between PAH and LVD in COPD patients underscores the importance of comprehensive cardiovascular assessment and management in this population.

Early Signs of Heart Failure in COPD Patients

 Our study found that early signs of heart failure were present in 34.8% of COPD patients and were significantly associated with COPD severity (p=0.042), PAH (p<0.001), and LVD (p<0.001). These findings are consistent with a study by Houben-Wilke et al., which reported a high prevalence of unrecognized heart failure (20.5%) in COPD patients and a significant association with COPD severity (p<0.001).

The high prevalence of early signs of heart failure in COPD patients may be due to the overlapping symptoms and risk factors between the two conditions.[15] Symptoms such as dyspnea, fatigue, and exercise intolerance are common in both COPD and heart failure, making it challenging to distinguish between the two conditions based on clinical presentation alone. Additionally, shared risk factors such as smoking, obesity, and aging can contribute to the development of both COPD and heart failure.

Early detection and management of heart failure in COPD patients are crucial, as the presence of heart failure is associated with increased morbidity, mortality, and healthcare utilization. A study by Boudestein et al. found that COPD patients with unrecognized heart failure had a significantly higher risk of mortality (hazard ratio: 1.7; 95% CI: 1.2-2.3) compared to those without heart failure. These findings underscore the importance of routine screening for heart failure in COPD patients, particularly those with more severe disease or the presence of PAH or LVD[16].

Impact of Comorbidities on PAH and LVD

 In our study, the presence of comorbidities was significantly associated with LVD severity (p=0.026) but not with PAH severity (p=0.189). This finding is partially consistent with a study by Patel et al., which reported a significant association between comorbidities and the presence of both PAH (p=0.001) and LVD (p<0.001) in COPD patients.

The discrepancy in the association between comorbidities and PAH severity in our study may be due to differences in the types and severity of comorbidities assessed[17]. A study by Divo et al. found that specific comorbidities, such as congestive heart failure, coronary artery disease, and peripheral vascular disease, were significantly associated with the presence of PAH in COPD patients (p<0.001). Future studies should evaluate the impact of specific comorbidities on the development and progression of PAH and LVD in COPD patients.

Exacerbations and Hospitalizations

Patients with PAH in our study experienced significantly more exacerbations (p=0.024) and hospitalizations (p=0.007) compared to those without PAH. This finding is consistent with a study by Adir et al., which reported a higher rate of exacerbations (p=0.002) and hospitalizations (p<0.001) in COPD patients with PAH compared to those without PAH. The presence of PAH in COPD patients may contribute to increased airway inflammation, mucus hypersecretion, and airway obstruction, leading to more frequent exacerbations and hospitalizations. Interestingly, our study did not find significant differences in exacerbations (p=0.091) or hospitalizations (p=0.118) between patients with and without LVD. This finding contrasts with a study by Agarwal et al., which reported a significant association between the presence of LVD and increased exacerbations (p=0.003) and hospitalizations (p=0.001) in COPD patients. The discrepancy may be attributed to differences in the severity of LVD, sample size, and other confounding factors.

A study by Westerik et al. found that the presence of both PAH and LVD in COPD patients was associated with a significantly higher risk of exacerbations (incidence rate ratio: 2.5; 95% CI: 1.3-4.8) compared to those with only one or neither condition. This finding suggests that the coexistence of PAH and LVD in COPD patients may have a synergistic effect on the risk of exacerbations and hospitalizations

In conclusion, this cross-sectional observational study demonstrates a high prevalence of pulmonary artery hypertension (PAH) and left ventricular dysfunction (LVD) among COPD patients, with significant correlations between COPD severity and the severity of these cardiovascular comorbidities. The presence of early signs of heart failure was also common and associated with COPD severity, PAH, and LVD. Furthermore, patients with PAH experienced significantly more exacerbations and hospitalizations compared to those without PAH.

These findings underscore the importance of routine echocardiographic screening in COPD patients, particularly those with more severe disease, to facilitate early detection and management of cardiovascular comorbidities. The significant association between PAH severity and LVD severity highlights the complex interplay between these conditions in COPD patients and the need for comprehensive cardiovascular assessment and management.

The study also identified several factors, such as smoking history, occupational exposure, and comorbidities, that may contribute to the development of PAH and LVD in COPD patients. These factors should be considered when assessing the risk of cardiovascular complications in this population.

Future research should focus on developing standardized screening protocols for PAH and LVD in COPD patients, investigating the impact of early interventions on the progression of these comorbidities, and exploring the underlying pathophysiological mechanisms linking COPD and cardiovascular diseases. A multidisciplinary approach involving pulmonologists, cardiologists, and primary care physicians is essential for the optimal management of COPD patients with cardiovascular comorbidities.

In summary, this study highlights the high prevalence of PAH and LVD in COPD patients and the significant correlations with disease severity. The findings emphasize the importance of routine echocardiographic evaluation and early intervention to improve patient outcomes and quality of life.

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