Impaired Left Ventricular Filling in COPD and Emphysema: Is It the Heart or the Lungs?

Abstract

1143C hronic lower respiratory disease is the third-leading cause of death in the United States. 1 The most morbid components of chronic lower respiratory dis ease are COPD, defi ned by spirometry as airfl ow obstruction that is not fully reversible, and pulmonary emphysema, defi ned by morphology as permanent enlargement of airspaces accompanied by destruction of their walls. 2,3 Emphysema on CT imaging is present in approximately one-half of patients with COPD, 4-7 and an estimated 2% of the general population aged . 50 years has emphysema without spirometry-defi ned COPD. 8 The number of Americans with a diagnosis of heart failure was 5.7 million in 2008, and approximately one-half of prevalent heart failure cases are characterized by preserved ejection fraction. 9,10 By comparison, 12 million Americans have a diagnosis of COPD and an additional 12 million may have undiagnosed COPD and emphysema. 11Background: COPD and heart failure with preserved ejection fraction overlap clinically, and impaired left ventricular (LV) fi lling is commonly reported in COPD. The mechanism underlying these observations is uncertain, but may include upstream pulmonary dysfunction causing low LV preload or intrinsic LV dysfunction causing high LV preload. The objective of this study is to determine if COPD and emphysema are associated with reduced pulmonary vein dimensions suggestive of low LV preload. Methods: The population-based Multi-Ethnic Study of Atherosclerosis (MESA) COPD Study recruited smokers aged 50 to 79 years who were free of clinical cardiovascular disease. COPD was defi ned by spirometry. Percent emphysema was defi ned as regions , 2 910 Hounsfi eld units on full-lung CT scan. Ostial pulmonary vein cross-sectional area was measured by contrast-enhanced cardiac magnetic resonance and expressed as the sum of all pulmonary vein areas. Linear regression was used to adjust for age, sex, race/ethnicity, body size, and smoking. Results: Among 165 participants, the mean ( Ϯ SD) total pulmonary vein area was 558 Ϯ 159 mm 2 in patients with COPD and 623 Ϯ 145 mm 2 in control subjects. Total pulmonary vein area was smaller in patients with COPD ( 2 57 mm 2 ; 95% CI, 2 106 to 2 7 mm 2 ; P 5 .03) and inversely associated with percent emphysema ( P , .001) in fully adjusted models. Signifi cant decrements in total pulmonary vein area were observed among participants with COPD alone, COPD with emphysema on CT scan, and emphysema without spirometrically defi ned COPD. Conclusions: Pulmonary vein dimensions were reduced in COPD and emphysema. These fi ndings support a mechanism of upstream pulmonary causes of underfi lling of the LV in COPD and in patients with emphysema on CT scan. CHEST 2013; 144(4):1143-1151Abbreviations: E/A ratio 5 ratio of peak fi lling rates during early phase diastole and atrial contraction; E/A ratioMR 5 ratio of peak fi lling rates during early phase diastole and atrial contraction estimated by magnetic resonance; EDV 5 end-diastolic volume; LV 5 left ventricle; MESA 5 Multi-Ethnic Study of Atherosclero...

Loss of Lung Health from Young Adulthood and Cardiac Phenotypes in Middle Age

“…Our observation that a greater decline in the FEV 1 /FVC ratio is associated with an underfilled/low-output cardiac phenotype at Year 25 is compatible with the findings of early vascular changes seen in the animal model. Reduced pulmonary vein area has been described in individuals with established COPD suggesting an "upstream" obstruction to blood flow as the cause of reduced LV preload (32). Our findings indicate that the development of an under-filled left heart occurs concurrent with the decline in lung (33,34).…”

Airflow limitation in COPD is associated with increased left ventricular wall stress in coincident heart failure

“…Particularly, a higher vascular resistance in COPD leads to increased right heart load [21] that usually considered as cor pulmonale and impaired filling of the LV [22,23]. In turn, structural pulmonary changes occur in chronic left heart failure.…”

Very Small Left Atrial Volume as a Marker for Mortality in Patients Undergoing Nongated Computed Tomography Pulmonary Angiography

“…Underfilling of the LA has also been shown in patients with COPD [19]. Moreover, it was previously demonstrated via magnetic resonance angiography that the pulmonic vein area of patients with COPD is smaller, suggesting underfilling of their LA [20]. Proposed mechanisms for decreased left side filling in patients with COPD include an altered intrathoracic pressure, increased pulmonary veins resistance, compression of alveolar vessels [20], increased heart rate [19], systemic vasodilation [21], and bulging of the septum due to right heart dilatation [22,23].…”

“…Moreover, it was previously demonstrated via magnetic resonance angiography that the pulmonic vein area of patients with COPD is smaller, suggesting underfilling of their LA [20]. Proposed mechanisms for decreased left side filling in patients with COPD include an altered intrathoracic pressure, increased pulmonary veins resistance, compression of alveolar vessels [20], increased heart rate [19], systemic vasodilation [21], and bulging of the septum due to right heart dilatation [22,23]. Investigating the etiologies of small LA size on CT, Cassagnes et al [6] reported that patients with emphysema had an inverse correlation between LA volume and the severity of emphysema.…”