PDF herunterladen
Semin Respir Crit Care Med 2003; 24(3): 263-272
DOI: 10.1055/s-2003-41087
Copyright © 2003 by Thieme Medical Publishers, Inc., 333 Seventh Avenue, New York, NY 10001, USA. Tel.: +1(212) 584-4662

Pulmonary Hypertension and Cor Pulmonale in COPD

Teofilo L. Lee-Chiong Jr.1 , Richard A. Matthay2
  • 1Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Arkansas for Medical Sciences, Little Rock, Arkansas
  • 2Pulmonary and Critical Care Section, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
Weitere Informationen

Publikationsverlauf

Publikationsdatum:
01. August 2003 (online)

    Lizenzen und Reprints

ABSTRACT

Pulmonary artery hypertension (PAH) is the primary cardiovascular complication encountered in chronic obstructive pulmonary disease (COPD). Cor pulmonale can range clinically from mild changes in right ventricular function to frank right heart failure. The prevalence of PAH increases as COPD worsens, and the development of PAH and cor pulmonale appears to affect survival of patients with COPD. Potential causes proposed to explain the development of PAH in COPD include gas exchange abnormalities, destruction of the pulmonary vascular bed, alterations in respiratory mechanics, changes in intrinsic pulmonary vessel tone, and increased blood viscosity. Standard clinical evaluation, including history, physical examination, spirometry, electrocardiography, and chest radiography, is generally inadequate in identifying right ventricular dysfunction. Noninvasive techniques, such as echocardiography, radionuclide ventriculography, and magnetic resonance imaging, have largely replaced invasive pulmonary artery catheterization in the initial assessment of cor pulmonale. The goals of therapy consist of attenuation of PAH, enhancement of right ventricular function, alleviation of clinical symptoms, and improvement in survival. The agents that have been most extensively evaluated for these purposes include oxygen, vasodilators, theophylline, and inotropic medications.

KEYWORDS

Cor pulmonale - pulmonary artery hypertension - chronic obstructive pulmonary disease - right ventricle - left ventricle

REFERENCES

  • 1 Lee-Chiong T L, Matthay R A. The heart in the stable COPD patient. In: Similowski T, Whitelaw WA, Derenne JP, eds. Clinical Management of Chronic Obstructive Pulmonary Disease New York: Marcel Dekker 2002 : 475-532
    Suche in Google Scholar
  • 2 Lee-Chiong T L, Matthay R A. COPD and the left heart. In: Similowski T, Whitelaw WA, Derenne JP, eds. Clinical Management of Chronic Obstructive Pulmonary Disease New York: Marcel Dekker 2002 : 533-547
    Suche in Google Scholar
  • 3 MacNee W. Pathophysiology of cor pulmonale in chronic obstructive pulmonary disease, Part One.  Am J Respir Crit Care Med .
    PubMed
  • 4 MacNee W. Pathophysiology of cor pulmonale in chronic obstructive pulmonary disease, Part Two.  Am J Respir Crit Care Med . 1994;  150 1158-1168
    PubMedSuche in Google Scholar
  • 5 Wiedemann H P, Matthay R A. Cor pulmonale. In: Braunwald E, ed. Heart Disease. A Textbook of Cardiovascular Medicine 5th ed. Philadelphia: WB Saunders 1997: 1604-1625
    Suche in Google Scholar
  • 6 World Health Organization. Chronic cor pulmonale: a report of the expert committee.  Circulation . 1963;  27 594-598
    PubMedSuche in Google Scholar
  • 7 Ben J rad, Slimane M L, Boujnah M R, Ben Hamda K, Ameur Y. Prognosis and treatment of chronic cor pulmonale.  Tunis Med . 1993;  71 505-508
    PubMedSuche in Google Scholar
  • 8 Heath D, Brewer D, Hicken P. Mechanisms and pathology. In: Thomas CC, ed. Cor pulmonale in Emphysema Springfield: Thomas 1968: 1-37
    Suche in Google Scholar
  • 9 Mitchell R S, Vincent T N, Filley G F. Chronic obstructive bronchopulmonary disease, IV: The clinical and physiological differential of chronic bronchitis and emphysema.  Am J Med Sci . 1964;  247 513-517
    PubMedSuche in Google Scholar
  • 10 Renzetti Jr D A, McClement J H, Litt B D. The Veterans Administration cooperative study of pulmonary function, III: Mortality in relation to respiratory function in chronic obstructive pulmonary disease.  Am J Med . 1966;  41 115-119
    CrossrefPubMedSuche in Google Scholar
  • 11 Laks M M, Garner D, Swan H JC. Volumes and compliances measured simultaneously in the right and left ventricles of the dog.  Circ Res . 1967;  20 565-569
    PubMedSuche in Google Scholar
  • 12 Khaja F, Parker J O. Right and left ventricular performance in chronic obstructive lung disease.  Am Heart J . 1971;  82 319-327
    CrossrefPubMedSuche in Google Scholar
  • 13 MacNee W. Right ventricular function in cor pulmonale.  Cardiology . 1988 (suppl 1);  75 S30-S40
    PubMedSuche in Google Scholar
  • 14 Matthay R A, Arroliga A C, Wiedemann H P, Schulman D S, Mahler D A. Right ventricular function at rest and during exercise in chronic obstructive pulmonary disease.  Chest . 1992 (suppl 5);  S225-S262
    PubMedSuche in Google Scholar
  • 15 Mizushige K, Morita H, Senda S, Matsuo H. Influence of right ventricular pressure overload on left and right ventricular filling in cor pulmonale assessed with Doppler echocardiography.  Jpn Circ J . 1989;  53 1287-1296
    PubMedSuche in Google Scholar
  • 16 Heath D, Du Shane W J, Wood E H, Edwards J E. Structure of the pulmonary trunk at different ages and in cases of pulmonary hypertension and pulmonary stenosis.  J Pathol Bacteriol . 1959;  77 443-456
    CrossrefPubMedSuche in Google Scholar
  • 17 Weibel E R, Gomez D M. The architecture of the human lung.  Science . 1962;  137 577-585
    PubMedSuche in Google Scholar
  • 18 Harris P, Heath D. Normal variations in pressure and flow. In: Harris P, Heath D, eds. The Human Pulmonary Circulation 3rd ed. Edinburgh: Churchill Livingstone 1986: 149-160
    Suche in Google Scholar
  • 19 Riley R L, Himmelstein A, Morley H L, Motley H L, Weiner H M, Cournand A. Studies of the pulmonary circulation at rest and during exercise in normal individuals and in patients with chronic pulmonary disease.  Am J Physiol . 1948;  152 372-382
    PubMedSuche in Google Scholar
  • 20 Abel R L. Effects of alterations in peripheral resistance on left ventricular function.  Proc Soc Exp Biol Med . 1965;  120 52-56
    PubMedSuche in Google Scholar
  • 21 Murphy M L, Adamson J, Hutcheson F. Left ventricular hypertrophy in patients with chronic bronchitis and emphysema.  Ann Intern Med . 1974;  81 307-313
    PubMedSuche in Google Scholar
  • 22 Fluck D C, Chandrasekar R G, Gardner F V. Left ventricular hypertrophy in chronic bronchitis.  Br Heart J . 1966;  28 92-97
    PubMedSuche in Google Scholar
  • 23 Robotham J L, Lixfeld W, Holland L, MacGregor D, Bryan A C, Rabson J. Effects of respiration on cardiac performance.  J Appl Physiol . 1978;  44 703-709
    PubMedSuche in Google Scholar
  • 24 Harvey R M, Ferrer M I, Richards D W, Cournand A. Influence of chronic pulmonary disease on the heart and circulation.  Am J Med . 1951;  10 719-738
    CrossrefPubMedSuche in Google Scholar
  • 25 Dunnill M S. Fibrinoid necrosis in the branches of the pulmonary artery and chronic nonspecific lung disease.  Br J Dis Chest . 1960;  54 355-360
    CrossrefPubMedSuche in Google Scholar
  • 26 Harris P, Heath D. The pulmonary vasculature in emphysema. In: Harris P, Heath D, eds. The human pulmonary circulation Edinburgh: Churchill Livingstone 1986: 507-521
    Suche in Google Scholar
  • 27 Enson Y, Guintini C, Lewis M L, Morris T Q, Ferrer M I, Harvey R M. The influence of hydrogen ion concentration and hypoxia on the pulmonary circulation.  J Clin Invest . 1964;  43 1146-1162
    PubMedSuche in Google Scholar
  • 28 Durand J, Leroy-Ladurie M, Ransom-Bitker B. Effects of hypoxia and hypercapnia on the repartition of pulmonary blood flow in supine subjects.  Respir Res . 1970;  5 156-165
    PubMedSuche in Google Scholar
  • 29 Dinh-Xuan A T, Higenbottam T W, Wallwork J. Relationship between chronic hypoxia and in vitro pulmonary relaxation mediated by endothelium-derived relaxing factors in human chronic obstructive lung disease.  Angiology . 1992;  43 350-356
    PubMedSuche in Google Scholar
  • 30 Cargill R I, Kiely D G, Clark R A, Lipworth B J. Hypoxaemia and release of endothelin-1.  Thorax . 1995;  50 1308-1310
    PubMedSuche in Google Scholar
  • 31 Moncada S, Palmer R MJ, Higgs E A. Prostacyclin and endothelial-derived relaxing factor: biological interactions and significance. In: Verstraete M, Verrmylen J, Lijnen RH, eds. Thrombosis and Haemostasis Belgium: University Press Leuven, 1987: 597-618
    Suche in Google Scholar
  • 32 Clini E, Cremona G, Campana M. et al . Production of endogenous nitric oxide in chronic obstructive pulmonary disease and patients with cor pulmonale. Correlates with echo-Doppler assessment.  Am J Respir Crit Care Med . 2000;  162 446-450
    PubMedSuche in Google Scholar
  • 33 Segel N, Bishop J M. The circulation in patients with chronic bronchitis and emphysema at rest and during exercise with special reference to the influence of change in blood viscosity and blood volume on the pulmonary circulation.  J Clin Invest . 1966;  45 1555-1568
    PubMedSuche in Google Scholar
  • 34 Harris P, Segel N, Green J, Housley E. The influence of the airways resistance and alveolar pressure on the pulmonary resistance in chronic bronchitis.  Cardiovasc Res . 1968;  2 84-94
    PubMedSuche in Google Scholar
  • 35 Morpurgo M. Noninvasive assessment of pulmonary arterial hypertension in chronic lung disease (WHO study).  Eur Respir J . 1989;  2 S666-S668
    PubMedSuche in Google Scholar
  • 36 Hill N S. The cardiac exam in lung disease.  Clin Chest Med . 1987;  8 273-285
    PubMedSuche in Google Scholar
  • 37 Matthay R A, Schwarz M I, Ellis J H. et al . Pulmonary artery hypertension in chronic obstructive pulmonary disease: determination by chest radiography.  Invest Radiol . 1981;  16 95-100
    CrossrefPubMedSuche in Google Scholar
  • 38 Kilcoyne M M, Davis A L, Ferrer M I. A dynamic electrocardiographic concept useful in the diagnosis of cor pulmonale.  . 1970;  42 903
    PubMedSuche in Google Scholar
  • 39 Incalzi R A, Fuso L, De Rosa M. et al . Electrocardiographic signs of chronic cor pulmonale: a negative prognostic finding in chronic obstructive pulmonary disease.  Circulation . 1999;  99 1600-1605
    PubMedSuche in Google Scholar
  • 40 Himelman R B, Struve S N, Brown J K, Namnum P, Schiller N B. Improved recognition of cor pulmonale in patients with severe chronic obstructive pulmonary disease.  Am J Med . 1988;  84 891-898
    CrossrefPubMedSuche in Google Scholar
  • 41 Matthay R A, Berger H J. Noninvasive assessment of right and left ventricular function in acute and chronic respiratory failure.  Crit Care Med . 1983;  11 329-338
    PubMedSuche in Google Scholar
  • 42 Himelman R B, Stulbarg K, Kircher B. et al . Noninvasive evaluation of pulmonary arterial pressure during exercise by saline enhanced Doppler echocardiography in chronic pulmonary disease.  Circulation . 1989;  79 863-871
    CrossrefPubMedSuche in Google Scholar
  • 43 Starling M R, Crawford M H, Sorensen S G, O'Rourke R A. Two-dimensional echocardiographic technique evaluating right ventricular size and performance in patients with obstructive lung disease.  Circulation . 1982;  66 612-620
    PubMedSuche in Google Scholar
  • 44 Zompatori M, Battaglia M, Rimondi M R, Battista G, Stambazzi C. Hemodynamic estimation of chronic cor pulmonale by Doppler echocardiography: clinical value and comparison with other noninvasive imaging techniques.  Rays . 1997;  22 73-93
    PubMedSuche in Google Scholar
  • 45 Berger H J, Matthay R A, Loke J, Marshal R C, Gottschalk A, Zaret B L. Assessment of cardiac performance with quantitative radionuclide angiography: right ventricular ejection fraction with reference to findings in chronic obstructive pulmonary disease.  Am J Cardiol . 1978;  41 897-905
    CrossrefPubMedSuche in Google Scholar
  • 46 Maddahi J, Bermon D S, Matsuoka D T. et al . A new technique for assessing right ventricular ejection fraction using rapid multiple gated equilibrium cardiac blood pool scintigraphy.  Circulation . 1979;  60 581-589
    PubMedSuche in Google Scholar
  • 47 Kato H, Misawa T, Kutsumi Y. et al . Quantitative evaluation of right ventricular overload in cor pulmonale using 201TI myocardial SPECT.  J Cardiology . 1990;  20 167-175
    PubMedSuche in Google Scholar
  • 48 Longmore D B, Klipstein R H, Underwood S R. et al . Dimensional accuracy of magnetic resonance studies of the heart.  Lancet . 1985;  1 1360-1362
    PubMedSuche in Google Scholar
  • 49 Turnbull L W, Ridgeway J P, Biernacki W. et al . Assessment of the right ventricle by magnetic resonance imaging in chronic obstructive lung disease.  Thorax . 1990;  45 597-601
    CrossrefPubMedSuche in Google Scholar
  • 50 British Medical Research Council Working Party. Long-term domiciliary oxygen therapy in chronic hypoxic cor pulmonale complicating bronchitis and emphysema.  Lancet . 1981;  1 681-685
    PubMedSuche in Google Scholar
  • 51 Nocturnal Oxygen Therapy Trial Group. Continuous or nocturnal oxygen therapy in hypoxemic chronic obstructive lung disease.  Ann Intern Med . 1980;  93 391-398
    PubMedSuche in Google Scholar
  • 52 Timms R M, Khaja F U, Williams G W. Hemodynamic response to oxygen therapy in chronic obstructive pulmonary disease.  Ann Intern Med . 1985;  102 29-36
    CrossrefPubMedSuche in Google Scholar
  • 53 Weitzenblum E, Sautegeau A, Ehrhart M, Mammosser M, Pelletier A. Long-term oxygen therapy can reverse the progression of pulmonary hypertension in patients with chronic obstructive pulmonary disease.  Am Rev Respir Dis . 1985;  131 493-498
    PubMedSuche in Google Scholar
  • 54 Ashutosh K, Mead G, Dunsky M. Early effects of oxygen administration and prognosis in chronic obstructive pulmonary disease and cor pulmonale.  Am Rev Respir Dis . 1983;  127 399-404
    PubMedSuche in Google Scholar
  • 55 MacNee W, Wathen C G, Flenley D C, Muir A D. The effects of controlled oxygen therapy on ventricular function in patients with stable and decompensated cor pulmonale.  Am Rev Respir Dis . 1988;  137 1289-1295
    PubMedSuche in Google Scholar
  • 56 Wiedemann H P, Matthay R A. Cor pulmonale in chronic obstructive pulmonary disease: circulatory pathophysiology and new concepts of therapy. In: Simmons DH, ed. Current Pulmonology Vol 8. Chicago: Year Book Medical Publishers 1987: 127-162
    Suche in Google Scholar
  • 57 Bardsley P A, Tweney J, Morgan N, Howard P. Oral almitrine in treatment of acute respiratory failure and cor pulmonale in patients with an exacerbation of chronic obstructive airways disease.  Thorax . 1991;  46 493-498
    PubMedSuche in Google Scholar
  • 58 Melot C, Naeije R, Rothschild T, Mertens P, Mols P, Hallemans R. Improvement in ventilation-perfusion matching by almitrine in COPD.  Chest . 1983;  83 528-533
    PubMedSuche in Google Scholar
  • 59 Connaughton J J, Douglas N J, Morgan A D. et al . Almitrine improves oxygenation when both awake and asleep in patients with hypoxia and carbon dioxide retention caused by chronic bronchitis and emphysema.  Am Rev Respir Dis . 1985;  132 206-210
    PubMedSuche in Google Scholar
  • 60 Adnot S, Samoyeau R, Weitzenblum E. Treatment of pulmonary hypertension in patients with chronic obstructive pulmonary disease: position of vasodilators with special focus on urapidil.  Blood Press . 1995;  3 47-57
    PubMedSuche in Google Scholar
  • 61 Van Mieghem W, De Backer G, De Wispelaere B, Billiet L, Cosemans J. Phentolamine infusion in cor pulmonale due to chronic obstructive pulmonary disease.  Acta Cardiologica . 1978;  33 253-262
    PubMedSuche in Google Scholar
  • 62 Vik-Mo H, Walde N, Jentoft H, Halvorsen F J. Improved haemodynamics but reduced arterial blood oxygenation, at rest and during exercise after long-term oral prazosin therapy in chronic cor pulmonale.  Eur Heart J . 1985;  6 1047-1053
    PubMedSuche in Google Scholar
  • 63 Van Mieghem W, Van den Brande P, De Waele R, Meirghaeghe J, Arens M, Demedts M. Evaluation of the safety and efficacy of amrinone in chronic obstructive lung disease with cor pulmonale.  Acta Cardiologica . 1990;  1 57-64
    PubMedSuche in Google Scholar
  • 64 Stockley R A, Finnegan P, Bishop J M. Effect of intravenous terbutaline on arterial blood gas tensions, ventilation, and pulmonary circulation in patients with chronic bronchitis and cor pulmonale.  Thorax . 1977;  32 601-605
    PubMedSuche in Google Scholar
  • 65 Chan C K, Loke J, Snyder P E, Wackers F, Mattera J, Matthay R A. Oral terbutaline augments cardiac performance in chronic obstructive pulmonary disease.  Am J Med Sci . 1988;  296 33-38
    PubMedSuche in Google Scholar
  • 66 Mols P, Ham H, Naeije N. et al . How does salbutamol improve the ventricular performance in patients with chronic obstructive pulmonary disease?.  J Cardiovasc Pharmacol . 1988;  12 127-133
    PubMedSuche in Google Scholar
  • 67 Mathur P N, Powles A C, Pugsley S O, McEwan M P, Campbell E J. Effect of long-term administration of digoxin on exercise performance in chronic airflow limitation.  Eur J Respir Dis . 1985;  66 273-283
    PubMedSuche in Google Scholar
  • 68 Heinman H O. Right-sided heart failure and the use of diuretics.  Am J Med . 1978;  64 357-370
    PubMedSuche in Google Scholar
  • 69 Evans T W, Waterhouse J, Finlay M, Suggett A J, Howard P. The effects of long-term methyldopa in patients with hypoxic cor pulmonale.  Br J Dis Chest . 1988;  82 405-413
    CrossrefPubMedSuche in Google Scholar
  • 70 Germann P, Ziesche R, Leitner C. et al . Addition of nitric oxide to oxygen improves cardiopulmonary function in patients with severe COPD.  Chest . 1998;  114 29-35
    PubMedSuche in Google Scholar
  • 71 Naeije R, Melot C, Mols P, Hallemans R. Reduction in pulmonary hypertension by prostaglandin E1 in decompensated chronic obstructive pulmonary disease.  Am Rev Respir Dis . 1982;  125 1-5
    PubMedSuche in Google Scholar
  • 72 Jones K, Higgenbottam T, Wallwork J. Pulmonary vasodilation and prostacyclin in primary and secondary pulmonary hypertension.  Chest . 1989;  96 784-789
    PubMedSuche in Google Scholar
  • 73 Matthay R A. Favorable cardiovascular effects of theophylline in COPD.  Chest . 1987;  92 (suppl 1) S22-S26
    PubMedSuche in Google Scholar
  • 74 Matthay R A. Effects of theophylline on cardiovascular performance in chronic obstructive pulmonary disease.  Chest . 1985;  88 (suppl 2) S112-S117
    PubMedSuche in Google Scholar
  • 75 Matthay R A, Berger H J, Davies R, Gottschalk A, Zaret B L. Improvement in cardiac performance by oral long-acting theophylline in chronic obstructive pulmonary disease.  Am Heart J . 1982;  104 1022-1026
    CrossrefPubMedSuche in Google Scholar
  • 76 Howard P. Vasodilator drugs in chronic obstructive airways disease.  Eur Respir J . 1989;  7 678-681
    PubMedSuche in Google Scholar
  • 77 Saadjian A, Philip-Joet F, Arnaud A. Hemodynamic and oxygen delivery responses to nifedipine in pulmonary hypertension secondary to chronic obstructive lung disease.  Cardiology . 1987;  74 196-204
    PubMedSuche in Google Scholar
  • 78 Mookherjee S, Ashutosh K, Dunsky M. et al . Nifedipine in chronic cor pulmonale: acute and relatively long-term effects.  Clin Pharmacol Ther . 1988;  44 289-296
    PubMedSuche in Google Scholar
  • 79 Konietzko N, Schlehe H, Harich B, Matthys H. Effect of isosorbide dinitrate on hemodynamics and respiration of patients with coronary artery disease and of patients with chronic cor pulmonale.  Respiration . 1975;  32 368-377
    PubMedSuche in Google Scholar
  • 80 McGoon M D, Seward J B, Vlietstra R E, Choo M H, Moyer T P, Reeder G S. Haemodynamic response to intravenous hydralazine in patients with pulmonary hypertension.  Br Heart J . 1983;  50 579-585
    PubMedSuche in Google Scholar
  • 81 Zielinski J, Hawrylkiewicz I, Gorecka D, Gluskowski J, Koscinska M. Captopril effects on pulmonary and systemic hemodynamics in chronic cor pulmonale.  Chest . 1986;  90 562-565
    PubMedSuche in Google Scholar
  • 82 Weisse A B, Mochos C B, Frank M J, Levinson G E, Canilla J E, Regan T J. Hemodynamic effect of staged hematocrit reduction in patients with stable cor pulmonale and severely elevated hematocrit levels.  Am J Med . 1975;  58 92-98
    CrossrefPubMedSuche in Google Scholar
  • 83 Borst M M, Leschke M, Konig U, Worth H. Repetitive hemodilution in chronic obstructive pulmonary disease and pulmonary hypertension: effects on pulmonary hemodynamics, gas exchange, and exercise capacity.  Respiration . 1999;  66 225-232
    CrossrefPubMedSuche in Google Scholar
  • 84 Bishop J M, Cross K W. Physiological variables and mortality in patients with various categories of chronic respiratory disease: WHO multicenter study.  Bull Eur Physiopathol Respir . 1984;  20 495-500
    PubMedSuche in Google Scholar
  • 85 Weitzenblum E, Sautejeau A, Ehrhart M, Mammosser M, Pettetier A. Long-term course of pulmonary arterial pressure in chronic obstructive pulmonary disease.  Am Rev Respir Dis . 1984;  130 993-998
    PubMedSuche in Google Scholar
  • 86 Medical Research Council Working Party. Long-term domiciliary oxygen therapy in chronic hypoxic cor pulmonale complicating chronic bronchitis and emphysema.  Lancet . 1981;  1 681-686
    PubMedSuche in Google Scholar
  • 87 Schrijen F, Uffholtz H, Polu J M, Poincelot F. Pulmonary and systemic hemodynamic evaluation in chronic bronchitis.  Am Rev Respir Dis . 1978;  117 25-31
    PubMedSuche in Google Scholar
  • 88 Weitzenblum E, Hirth C, Duculone A, Mirhom R, Rasaholinjanahary J, Ehrhart M. Prognostic value of pulmonary artery pressure in chronic obstructive pulmonary disease.  Thorax . 1981;  36 752-758
    CrossrefPubMedSuche in Google Scholar
  • 89 Finlay M, Middleton H C, Peake M D, Howard P. Cardiac output, pulmonary hypertension, hypoxaemia and survival in patients with chronic obstructive airways disease.  Eur J Respir Dis . 1983;  64 252-263
    PubMedSuche in Google Scholar