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P.R. Herych, R.I. Yatsyshyn
SHEI "Ivano-Frankivsk National Medical University "
UDC 616-071+616.24+616-005.4+616.12
STATE OF THE PULMONARY VENTILATION FUNCTION, INTRA-CARDIAC AND PULMONARY HEMODYNAMICS DURING EXACERBATION OF COPD OF THE IIIRD DEGREE OF SEVERITY COMBINED WITH STABLE ISCHEMIC
HEART DISEASE
Abstract. The peculiarities of clinical signs, ventilation violations, structural and hemodynamic parameters heart using echocardiography (EchoCG) and doppler echocardiogram (DpEchoCG) were analyzed in 72 patients with chronic obstructive pulmonary disease (COPD) of the IIIrd degree, who were divided into two groups - patients with an isolated course of COPD and patients with concomitant or combined cardiorespiratory pathology (CRP). The last group consisted of 44 patients with COPD of the IIIrd degree, clinical course of which was complicated by a combination of related and comorbid stable ischemic heart disease (SIHD).
Keywords: chronic obstructive pulmonary disease, comorbid and concomitant stable ischemic heart disease, indicators of echocardio- and doppler echocardiography.
Introduction. The high incidence of COPD is now mainly stated during clinically significant process in the presence of complications and the presence of combined diseases, generating high disability and mortality [1, 2]. It is believed that over the past two decades the mortality of patients with COPD will be at the peak. Experts of WHO predict that in 2020 COPD will come to third place among all causes of mortality and cause the death of about 4.5 million people per year [3].
The peak of COPD incidence occurs usually in 5565 years. It is known that this age population is characterized by polymorbidity and comorbidity. COPD is usually not the only disease for the elderly people. In older and senile age COPD can run in conjunction with underlying chronic diseases. Often this disease is accompanied by cardiogenic complications (angina pec-toris attacks, myocardial infarction), which significantly worsen the prognosis of the disease [1, 2, 5, 6].
Causes and course of ischemic heart disease in patients with COPD are not studied enough. Mechanisms of their combined course are complex and continue to be actively studied. To date, there is no doubt that is-chemic heart disease, which develops against the back-
ground of COPD, is comorbid disease that requires special treatment in terms of diagnostic and therapeutic plan [7]. The above-mentioned demonstrates the urgent need to consider the problems in pulmonological and cardiological practice in a large number of specific clinical situations in a single block [8].
The aim of research is to study the clinical characteristics, functional parameters of pulmonary ventilation function and structural-functional state of the heart during exacerbation of COPD of the IIIrd degree of severity, groups C and D combined with SIHD, stable angina pectoris (SAP) of I-II FC.
Materials and methods. The study involved 72 patients with verified diagnosis of COPD exacerbation of the IIIrd degree of severity, groups C and D. The study included 60 (83.33%) men and 12 (16.66%) women with isolated course of COPD of the IIIrd degree of severity and combined with SIHD, SAP of I-II FC. The average age of studied patients was - 56.9±6.8 years.
According to the results of clinical-laboratory and functional examinations there were formed two groups of patients. I (control) group consisted of 28 (38.88%)
u
patients with isolated course of COPD of the IIIrd degree of severity, groups C and D. The second group included 44 patients with COPD combined with SIHD, SAP of I-II FC. 24 patients were revealed SAP of I FC, 20 patients - SAP of II FC, 7 patients had MI in anamnesis.
Patients of the second group by randomization method were divided into two subgroups. The main sub-group (26 patients) consisted of patients with COPD of the IIIrd degree in conjunction with the accompanying SIHD of the I-II FC; comparison subgroup (18 patients) included patients with comorbid ischemic heart disease that has developed against the background of COPD of the IIIrd degree. In the subgroup of comparison the duration of COPD disease was 1.3-1.5 times higher than the SIHD duration.
The study of external respiration function (ERF) with characteristic of parameters (forced vital capacity of lungs (FVCL), forced expiratory volume in 1 second (FEVi), Tiffeneau index (FEV1/VCL), the maximum volume rate of 25-75% (MVRate25-75%), was performed in the spirography on the unit "SPIROKOM". Complex research to study the structural-functional characteristics of the heart, included ECG in 12 leads, daily monitoring (DM) of ECG, stress test - bicycle ergometry (BEM), EchoCG and DpEchoCG with the study protocol of the right ventricle (RV), LV and other indicators according to the developed protocol.
Coronaroventriculography according to the method of M. P. Judkins (1967) was performed in 24 patients. The average pressure in the pulmonary artery (APPA) was assessed using the time parameters of systolic flow in the pulmonary artery (PA). The ratio of the time flow acceleration (A/T) in RV outflow tract to the time of emission (E/T) was determined. Later according to the table APPA was calculated. PH was treated by the level of systolic pressure in the PA above 30 mmHg.
Diagnostics of concomitant ischemic heart disease was based on the previous MI (extract from history, characteristic changes in the ECG), results of coronaroventriculography in patients with combined CRP, as well as on the typical clinical manifestations of angina pectoris, which were confirmed by instrumental methods.
Diagnosis of comorbid IHD was made in patients in previous stages of treatment and confirmed in the dynamic, clinical, laboratory and instrumental examination in hospital.
Statistical analyses of the results and data calculations were performed using SPSS 10.0 for Windows.
The results of the study and their discussion. In the analysis of clinical symptoms in 40 (90.90%) patients with marked CRP there is cough, shortness of breath, increase of the sputum amount, palpitation and typical anginal pain. Pain syndrome was found in 17 (38.63%) patients, while in 75.0% of cases there was typical pressing chest pain that was irradiating into the left hand.
During the initial examination of patients in both subgroups cough intensity exceeded the output level (remission phase). In 23 (88.46±8.2%) patients of the main subgroup and in 21 (80.76±9.2%) patients of
comparison subgroup the cough was severe, in the rest of the patients in both subgroups - it was moderate.
Exacerbation of COPD in all of the patients led to an increase of sputum. In most patients, sputum volume was within 60-90 ml per day. During exacerbation an increase of sputum purulency was observed - in 19 (73.07±9.9%) patients of the main subgroup and in 23 (8846±10.3%) patients of comparison subgroup.
One of the main features of COPD exacerbation in all of the examined patients was an increase of manifestations of dyspnea, which was a problem in small exertion for significant majority of patients - in 24 (85.71%) patients with isolated course of COPD and in 39 (88.63%) patients with CRP. In other patients in both groups dyspnea was manifested at rest.
In patients with isolated course of COPD the obstruction of moderate severity was diagnosed in 18 (64.28%) patients, severe - in 10 (35.71%) patients. In the group with combined CRP obstructive bronchial patency of medial degree was detected in 16 (36.36%) patients, and severe - in 28 (63.54%). In most of the patients with combined CRP, the rate of FEV1 was in the range of 40-55% of the relevant values.
Thus, the combination of COPD and SIHD deepens the bronchial patency, as evidenced by credible distinction between ERF data in patients of two subgroups of and the control group.
These data indicate that the development and progression of SIHD took place against the background of the IIIrd degree of severity of COPD. The direct relationship between the severity of COPD and the presence of IHD was confirmed during the correlation analysis between indicators of severity of broncho-obstructive violations - FEV1 and SAP of the I-II FC, which formed (r=+0.32, r=+0.28), respectively (p<0.05 for both indicators).
Respiratory failure (RF) of the Ist degree was observed in 13 (46.42%) patients with isolated course of COPD and in 21 (47.72%) patients with combined CRP. RF of the IInd degree was observed in 15 (53.57%) patients of the control group and in 13 (46.42%) patients with COPD combined with concomitant and comorbid coronary disease.
Signs of chronic cor pulmonale (CCP) of the I-II FC were recorded only in 5 (17.85%) patients with isolated course of COPD, whereas such violations of diastolic heart function were found in 19 (43.18%) patients with combined CRP.
The study of heart rate (HR) at the time of admission to the hospital showed that despite receiving chrono-negative drugs (P-blockers, calcium channel blockers) in 40 (90.90%) patients with CRP there was tachycardia and on the background of therapy there were attacks of angina pectoris. The average heart rate in both subgroups of the study was collated and amounted to 79.8±5.2 and 81.4±3.6 beats/min. respectively (p>0.05).
The results of our research in the original DM ECG daily duration of myocardial ischemia (DDMI) in both subgroups did not exceed 40 min. of its value and the total number of painful episodes of myocardial ischemia (PEMI) and episodes of silent myocardial ischemia (ESMI) was collated.
Analysis of indexes of block structure and functional state of the left and right parts of the heart in combined course of COPD and IHD showed that in patients
with CRP test results were significantly different from those who are practically healthy individuals (PHI) and from patients with isolated course of COPD (Table 1).
Table 1
Indicators of echocardiography studies in patients with isolated
Trd .
PHI Control group Main subgroup Subgroup of
Indicators (n=28) (n=28) (n=26) comparison (n=18)
TDS LV, mm 48.1±0.03 49.65±0.03 53.05±0.03 51.17±0.03#
TSS LV, mm 34.4±0.02 35.6±0.03 42.36±0.02 37.28±0.02#
TDV LV, ml 118.6±4.69* 12L3±6.34A 136.0±5.09 125.1±4.94#
TSV LV, ml 61.0±4.01* 62.3±5.88A 75.9±3.98 68.5±4.24#
IMM LV, g/m2 130.33±4.32* 138.23±6.22A 146.4±9.4 142.3±11.3
IVST, mm 10.2±0.03* 10.6±0.04A 12.94±0.03 11.64±0.03#
TPW LV, mm 9.11±0.03* 9.17±0.03A 11.91±0.039 10.12±0.039#
LA, mm 33.2±0.07* 36.8±0.11A 40.1±3.2 41.8±4.1
HI, l/min/m2 3.12±0.08 3.00±0.07 2.69±0.04 2.85±0.05
RA, mm 37.1±0.07 38.0±0.1 39.2±0.08 38.3+0.08
TAW RV, mm 0.40±0.04 0.45±0.07 0.58±0.040 0.51±0.04
TDS RV, cm 2.30±0.06 2.36±0.08 2.79±0.05 2.49±0.06
RF LV, % 58.5±1.62 56.2±2.28 49.4±1.63 53.2±1.81
Vcf, st.un. 0.32±0.003 0.41±0.005 0.46±0.004 0.41±0.005
AS, % 34.10±0.22 32.10±0.32 24.12±0.29 29.23±0.32
HR, min. 72.2±2.1 78.5±2.3 88.3±2.2 85.8±2.2
SAP, mm Hg 122.0±1.9 152.3±3.8 151.5±3.9 148.2±4.2
DAP, mm Hg 78.4±2.1 87.8±1.3 91.2±1.4 88.8±1.9
Note. * - p<0.05 - between indicators of PHI and main group; A - p<0.05 - between indicators of the control and the main groups; # - p<0.05 - between indicators of the main subgroup and subgroup of comparison.
In patients with CRP against the background of severe course of COPD structural and geometric heart condition is significantly changed. In particular, dilatation of LA of slight and moderate degree was found in 24 (92.30%) patients with concomitant IHD and in 16 (80.0%) patients with comorbid SIHD. In comparative evaluation of parameters of the block structure of the heart, a significant increase in the size of LA in patients with mixed pathology compared with the control group and PHI (p<0.05) was observed, that indirectly showed an increase of pressure in the system of PA and reduction of pumping function of the left ventricle. It should be noted that these data point to the development of not only LA dilatation in patients with combined CRP, but also in patients with isolated course of COPD.
In comparative perspective in patients of the main subgroup there was noted an increase of TDS in left ventricle to 8.2±0.2% and TSS LV to 11.6±0.3% relative to those data in patients of the subgroup of comparison (p<0.05), which is accompanied by a decrease of indexes in left ventricular systolic function. Such correlations are traced in comparison of the terminal-systolic volume (TSV) and terminal-diastolic volume (TDV) of the left ventricle, and this difference was more significant in 7 patients with the presence of wave Q, which was proof of the previous IM.
TSV index in COPD patients with concomitant IHD was - 75.9±3.98 ml, which is 19.64% higher (p<0.05) than in PHI and 18.32% higher (p<0. 05) than in patients with isolated course of COPD. The value index of TSV in patients with COPD and comorbid IHD was 7.4 less (8.75%) ml relative to patients of the main
subgroup (p<0.05). TDV index in COPD patients with concomitant IHD was - 136.0±5.09 ml that is 8.02%, 10.81% and 12.80% higher in relation to patients with COPD and comorbid IHD, with isolated course of COPD and PHI respectively (p<0.05).
Thus, an analysis of the structural-functional state of left heart departments showed that in patients with isolated course of COPD indexes of TDS, TSS, TDV, TSV of LV were close to normal, while in patients with mixed pathology they were increased, indicating the development of hypertrophy and dilatation of LV. In addition, the development of pronounced maladaptive cardiac remodeling was confirmed by a tendency to increase of relative wall thickness of the myocardium in patients with both COPD with concomitant SIHD and COPD with comorbid SIHD. In patients with isolated course the IVST was - 10.6±0.04 mm, that is 3.78% more than in PHI group (p>0.05). The value of this indicator in patients with COPD with concomitant SIHD was - 12.94±0.03 mm, that is 21.28%, 18.09% and 11.05% respectively higher than the rate of PHI, of patients in the control group and patients with COPD with comorbid SIHD (p<0.05).
In patients with isolated COPD course posterior wall thickness (TPW) LV was - 10.17±0.03 mm, that is 11.63% higher than in the PHI group (p>0.05). At the same time the value of this indicator in patients with COPD with concomitant SIHD amounted - 13.2±0.039 mm, that is 31.0%, 22.45% and 15.76% respectively higher than the rate of PHI, patients with isolated course of COPD and patients with COPD with comor-bid SIHD (p<0.05).
y
In assessing changes in LV geometry there were revealed an increase in myocardial mass (MM) and my-ocardial mass index (IMM) LV. IMM LV in patients with COPD in conjunction with the accompanying SIHD was 5.59% higher (p<0.05) than in patients with isolated course of COPD and 2.81% higher (p>0.05) in relation to patients with COPD in combination with comorbid SIHD. As a result of echocardiography study of the block structure of left heart departments there was LV hypertrophy in 80.76% of patients with COPD with concomitant SIHD and in 60.0% of patients with COPD with comorbid SIHD.
In patients of the control group the ejection fraction (EF) of LV (formula "area-length") amounted -56.2±2.28%, and AS% - 32.10±1.98%, which was seen as state of relatively preserved contractile myocardial ability and inotropic cardiac function. In patients of the main subgroup the value of EF LV was significantly lower than the rate of EF in patients with isolated COPD course in 1.13 times (p<0.05) and 1.07 times (p>0.05) lower than in patients of subgroup of comparison. In patients with mixed pathology and reduced EF LV (<49.4±1.69%) heart failure was only of the IInd FC. As a whole, systolic dysfunction of LV (ejection fraction^0/«) was found in 10 (38.46%) patients of the main subgroup, in 7 (35.0%) patients of the subgroup of comparison and only in 3 (15.0%) patients of the control group.
Index of shortening degree of the anteroposterior size in patients of the main subgroup was 29.27% lower than the in PHI group (p<0.05), 14.23% lower than in patients with isolated COPD course (p<0.05) and 5.87% lower (p<0.05) than in patients in the subgroup of comparison, that, in accordance with generally accepted diagnostic criteria of SIHD, shows a decrease of pumping and inotropic functions of the heart. In addition, in 8 (17.39%) patients with combined CRP violations of local reduction in LV myocardium according to the type of hypokinesia and akinesia were found.
A correlation of indices of echocardiography study of the left and right departments of the heart with age and duration of COPD disease and SIHD was performed. There was a weak negative correlation between the duration of COPD and TDS and TSS LV (CK=-0.30-0.28, respectively), between SIHD duration and indicators of myocardial contractile ability - EF LV and %AS (CK=- 31 and -0.36), respectively with duration of the disease with accompanying SIHD and anterior-posterior size of LA and TDS LV, which directly correlates moderately (CK=+0.55, +0.50) respectively. We found a positive correlation between TAW RV and the duration of COPD disease (CK=+0.28) and APPA (CK=+0.44).
In patients with obstructive disorders of ventilation, correlation between echocardiography parameters and ERF indexes had a number of peculiarities. In obstructive disorders a strong negative relationship between TPW LV and MVRate50-75% (CK=-0.38; p<0.05 for both parameters), and between EF and MVRate50-75 % (CK=-0.35; p<0.05) respectively, was found.
Comparative analysis of cardiorespiratory relationships in patients with COPD showed that there are a number of peculiarities that depend on the form of
SIHD and degree of ventilation violations. In patients with COPD of the IIIrd degree and concomitant SIHD, correlation coefficient between the size of the right atrium (RA) and VCL is - 0.28, in patients with COPD of the IIIrd degree with concomitant SIHD correlation coefficient increases up to - 0.32, while in patients with comorbid SIHD indexes of correlation were - 0.18 and - 0.39, respectively. Similar character has the dependence between size of RA and FEVi, RA and PP and MVRate25% (CK=-0.31 and -0.38) respectively.
The relationship between the size of the left atrium (LA) and VCL parameters, FEVi, MVRate25% depended on the version of SIHD (CK=-0.31-0.41, 0.22-0.36, 0.20-0. 23; p<0.05), according to the accompanying and comorbid SIHD. In addition, correlation of size of LA with the MVRate50-75% was expressed somewhat weaker (CK=-0.19-0.23). Correlations between RV parameters and indices of ventilation lung function in patients with COPD combined with SIHD had no distinct patterns of either option of SIHD. However, in patients with COPD of the IIIrd degree there is high dependence of RV parameters on VCL, FEV1, MVRate25% (CK=-0.09-0.26; -0.82-0.87; -0.70-0.79; p<0.05 for all indicators).
Among the indices of diastolic heart function size of LA moderately correlates with indicators of TDS and TSS LV (CK=+0.52 and +0.56) respectively, and shows moderate negative correlation with indices of myocardial contractile capacity, including EF LV and %AS (CK=-0.52 and -0.49; p<0.01-0.05) respectively.
These data are consistent with the DpEchoCG study that was manifested by signs of DD LV (E/T=-0.83), which pointed to a weakening of contractile myocardial ability of the left ventricle in patients with concomitant IHD and, to a lesser extent, in patients with comorbid SIHD, strengthening of its diastolic dysfunction due to its dilatation and LA dilatation.
Thus, the study of parameters of echocardiography of the heart showed that contractile function of the left departments of the heart is mostly kept in patients with isolated course of COPD and in patients with COPD in combination with comorbid SIHD, and to a lesser extent, in patients with COPD with concomitant SIHD. In patients with combined CRP there was noted probable deviation from the norm for most indicators of echocardiography in the form of an increase in their size (TDS LV, TSS LV, TDV LV, TSV LV, IMM LV, IVST, TPW LV, Vcf) as well as reduction of such parameters as EF, HI, AS%. Comparative according to the value of an increase in post-load in patients with COPD with concomitant and comorbid SIHD was accompanied by the development of various types of compensatory my-ocardial hypertrophy.
Therefore, the performed analysis of clinical symptoms, ventilatory lung function and echocardio-graphic study demonstrates the fundamental differences in the proportions of ventilation violations and structural-functional characteristics of the heart in patients with isolated course of COPD of the IIIrd degree and in accession of concomitant or comorbid SIHS to the COPD. This transformation of the geometry of the heart, thickening of its walls are directly dependent on
the ventilation violations. Definition of structural-geometric model of the heart in patients with COPD with concomitant or comorbid SIHD is due to significant differences not only in geometry and thickness of the walls of the heart, but also to significant differences in the functional state of the heart, which are mainly determined by the indices of contractile function of the heart. In comparative perspective with regard to ventilation violations and morpho-functional characteristics of blood flow of the heart, the progress of COPD in combination with comorbid SIHD is more favourable, unlike COPD with concomitant SIHD and, to some extent, given the other factors of development and progress of the discussed pathology causes a positive outlook. Structural-functional characteristics and hemodynamics of the heart and lungs in patients with exacerbation of COPD of the IIIrd degree depend on the version of the course of SIHD and is a manifestation not only of ischemic changes of myocardium caused by atherosclerotic lesions of the coronary arteries, but, as shown by further research, are the result of immunolog-ical reactivity and activation of certain parts of inflammation in both bronchopulmonary complex and in the vessels of the lungs and heart.
Conclusions. All patients with acute exacerbation
tency of varying degrees of expression. Clinical peculiarities of SAP in conjunction with COPD are the simultaneous occurrence along with typical pain complaints of shortness of breath, palpitations, and different kinds of arrhythmias.
Comparative analysis of the structural-functional condition of the heart showed that in patients with isolated course of COPD indices of TDS LV, TSS LV, TDV LV, TSV LV were close to normal, while in patients with mixed pathology they were increased, indicating development of LV hypertrophy and dilation.
Study of echocardiography parameters of the heart showed that mostly the contractile function of the left departments of the heart is kept in patients with isolated course of COPD and in patients with COPD in combination with comorbid SIHD, and to a lesser extent, in patients with COPD with concomitant SIHD.
The presence of concomitant or comorbid SIHD in patients with COPD of the IIIrd degree makes a significant contribution to the remodeling of the left and the right ventricles, which leads to lowering of pumping and inotropic functions of the heart. Development of LA dilatation may indirectly indicate the presence of PH and also the raising of filling pressure and reduction of pumping function of the left ventricle.
of COPD had obstructive disorders of bronchial pa-
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Лiвiнський Володимир Григорович,
старший науковий cniepo6imHUK, Укратська втськово-медична академiя Livinskyi Vladimir G.,
Senior Research Fellow, Ukrainian Military Medical A cademy
ФОРМУВАННЯ ЕДИНОГО МЕДИЧНОГО ПРОСТОРУ ДЕРЖАВИ В 1НТЕРЕСАХ МЕДИЧНОГО ЗАБЕЗПЕЧЕННЯ ВШСЬКОВОСЛУЖБОВЩВ FORMATION OF A SINGLE MEDICAL SPACE IN THE INTERESTS STATE MEDICAL
SERVICE PERSONNEL SUPPORT
АНОТАЦ1Я: Опрацювання перспективних шляхiв реформування системи вшськово! охорони здо-ров'я потребуе нових оргашзацшних пiдходiв щодо ефективного i рацюнального використання наявних медичних ресурав. 1х розроблення здшснюеться з урахуванням досвщу збройних сил передових кран
