Chest
Volume 137, Issue 6, Supplement, June 2010, Pages 39S-51S
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PULMONARY VASCULAR DISEASE: THE GLOBAL PERSPECTIVE
Pulmonary Hypertension in COPD: Epidemiology, Significance, and Management: Pulmonary Vascular Disease: The Global Perspective

https://doi.org/10.1378/chest.10-0087Get rights and content

Pulmonary hypertension (PH) associated with parenchymal lung diseases is one of the most common forms of PH. Studies in patients with advanced COPD and hypoxemia have shown a very high prevalence of PH; however, prevalence in mild and moderate COPD is not known. Typical hemodynamic abnormalities include mild-to-moderate elevations in pulmonary artery pressure (PAP) and pulmonary vascular resistance with a preserved cardiac output. A small proportion (< 5%) of patients may have significant elevations in PAP (mean PAP > 35-40 mm Hg) in the presence of mild airflow limitation and are believed to have disproportionate PH. COPD-associated PH has significant clinical implications because it can produce functional limitation and has a negative impact on prognosis. Doppler echocardiography is the best noninvasive test, but noninvasive methods used for diagnosis are prone to error and cannot be relied on when making or refuting the diagnosis of PH. All patients require right-sided heart catheterization if treatment with PH-specific medications is contemplated. The most important steps in managing these patients are: (1) confirm the diagnosis; (2) optimize COPD management; (3) rule out comorbidities; (4) assess and treat hypoxemia; and (5) enroll the patient in pulmonary rehabilitation, if indicated. In patients with PH and advanced airflow limitation, lung transplantation offers the best opportunity for long-term benefit. The role of PH-specific medications remains poorly defined and requires further study but may be considered in patients with disproportionate PH

Section snippets

Pulmonary Hemodynamics in COPD

The literature on the prevalence of PH in COPD is confounded by several limiting factors. Estimates of the prevalence of PH in patients with COPD vary widely (Table 1) based on the definition of PH, the physiologic characteristics of the underlying lung disease, and the methods used to determine pulmonary pressures. The true prevalence of PH in patients with mild or moderate COPD is not known because of the absence of large-scale epidemiologic studies. Most studies have reported a prevalence of

Diagnosis

It is unclear whether screening for PH is feasible in patients with COPD and, if so, which population should be screened. As discussed, patients with advanced compromise in pulmonary function often have PH, but the prevalence, etiology, and significance of PH in patients with mild COPD is unclear (Table 4).

PH should be suspected in patients with COPD and declining functional capacity or increasing shortness of breath in the presence of stable airflow obstruction and the lack of an alternative

Treatment

Investigators have attempted to study the role of various treatment modalities in patients with COPD, given its frequency and profound impact on both functional capacity and survival (Table 5). The goals of treatment remain alleviation of clinical symptoms, improvement in hemodynamics and RV performance, and improved functional parameters and survival. It is important to first rule out treatable comorbid conditions, such as pulmonary embolism, left-sided cardiac disease, and obstructive sleep

Acknowledgments

Financial/nonfinancial disclosures: The authors have reported to CHEST the following conflicts of interest: Dr Minai is a member of the scientific advisory board and speakers bureau for Actelion, United Therapeutics, and Gilead and a member of the scientific advisory board for Pfizer. Drs Adnot and Chaouat have reported that no potential conflicts exist with any companies/organizations whose products or services may be discussed in this article.

References (90)

  • MW Sims et al.

    Impact of pulmonary artery pressure on exercise function in severe COPD

    Chest

    (2009)
  • F Khaja et al.

    Right and left ventricular performance in chronic obstructive lung disease

    Am Heart J

    (1971)
  • A Vonk-Noordegraaf et al.

    Early changes of cardiac structure and function in COPD patients with mild hypoxemia

    Chest

    (2005)
  • M Jessup et al.

    The effect of chronic pulmonary hypertension on left ventricular size, function, and interventricular septal motion

    Am Heart J

    (1987)
  • A Vonk Noordegraaf et al.

    The effect of right ventricular hypertrophy on left ventricular ejection fraction in pulmonary emphysema

    Chest

    (1997)
  • AD Renzetti et al.

    The Veterans Administration cooperative study of pulmonary function. 3. Mortality in relation to respiratory function in COPD

    Am J Med

    (1966)
  • RT Tan et al.

    Utility of CT scan evaluation for predicting pulmonary hypertension in patients with parenchymal lung disease

    Chest

    (1998)
  • MI Burgess et al.

    Comparison of echocardiographic markers of right ventricular function in determining prognosis in chronic pulmonary disease

    J Am Soc Echocardiogr

    (2002)
  • SK Olvey et al.

    First pass radionuclide assessment of right and left ventricular ejection fraction in chronic pulmonary disease. Effect of oxygen upon exercise response

    Chest

    (1980)
  • J Zielinski et al.

    Effects of long-term oxygen therapy on pulmonary hemodynamics in COPD patients: a 6-year prospective study

    Chest

    (1998)
  • OA Minai et al.

    Predictors of nocturnal oxygen desaturation in pulmonary arterial hypertension

    Chest

    (2007)
  • AJ Block et al.

    The origins of cor pulmonale; a hypothesis

    Chest

    (1979)
  • P Germann et al.

    Addition of nitric oxide to oxygen improves cardiopulmonary function in patients with severe COPD

    Chest

    (1998)
  • S Alp et al.

    Sildenafil improves hemodynamic parameters in COPD—an investigation of six patients

    Pulm Pharmacol Ther

    (2006)
  • BP Madden et al.

    A potential role for sildenafil in the management of pulmonary hypertension in patients with parenchymal lung disease

    Vascul Pharmacol

    (2006)
  • S Holverda et al.

    Acute effects of sildenafil on exercise pulmonary hemodynamics and capacity in patients with COPD

    Pulm Pharmacol Ther

    (2008)
  • K Jones et al.

    Pulmonary vasodilation with prostacyclin in primary and secondary pulmonary hypertension

    Chest

    (1989)
  • SL Archer et al.

    A placebo-controlled trial of prostacyclin in acute respiratory failure in COPD

    Chest

    (1996)
  • WM Chatila et al.

    Comorbidities in chronic obstructive pulmonary disease

    Proc Am Thorac Soc

    (2008)
  • JA Falk et al.

    Cardiac disease in chronic obstructive pulmonary disease

    Proc Am Thorac Soc

    (2008)
  • A Chaouat et al.

    Pulmonary hypertension in COPD

    Eur Respir J

    (2008)
  • A Hyduk et al.

    Pulmonary hypertension surveillance—United States, 1980-2002

    MMWR Surveill Summ

    (2005)
  • B Burrows et al.

    Patterns of cardiovascular dysfunction in chronic obstructive lung disease

    N Engl J Med

    (1972)
  • E Weitzenblum et al.

    Prognostic value of pulmonary artery pressure in chronic obstructive pulmonary disease

    Thorax

    (1981)
  • E Weitzenblum et al.

    Long-term course of pulmonary arterial pressure in chronic obstructive pulmonary disease

    Am Rev Respir Dis

    (1984)
  • M Oswald-Mammosser et al.

    Non-invasive diagnosis of pulmonary hypertension in chronic obstructive pulmonary disease. Comparison of ECG, radiological measurement, echocardiography, and myocardial scintigraphy

    Eur Respir J

    (1987)
  • SM Scharf et al.

    Hemodynamic characterization of patients with severe emphysema

    Am J Respir Crit Care Med

    (2002)
  • V Cottin et al.

    Combined pulmonary fibrosis and emphysema: a distinct underrecognised entity

    Eur Respir J

    (2005)
  • D Stevens et al.

    Severe pulmonary hypertension associated with COPD

    Ann Transplant

    (2000)
  • A Chaouat et al.

    Severe pulmonary hypertension and chronic obstructive pulmonary disease

    Am J Respir Crit Care Med

    (2005)
  • RM Timms et al.

    Hemodynamic response to oxygen therapy in chronic obstructive pulmonary disease

    Ann Intern Med

    (1985)
  • JL Wright et al.

    Analysis of the structure of the muscular pulmonary arteries in patients with pulmonary hypertension and COPD: National Institutes of Health nocturnal oxygen therapy trial

    Lung

    (1992)
  • S Santos et al.

    Characterization of pulmonary vascular remodelling in smokers and patients with mild COPD

    Eur Respir J

    (2002)
  • R Kessler et al.

    “Natural history” of pulmonary hypertension in a series of 131 patients with chronic obstructive lung disease

    Am J Respir Crit Care Med

    (2001)
  • E Weitzenblum et al.

    Long-term oxygen therapy can reverse the progression of pulmonary hypertension in patients with chronic obstructive pulmonary disease

    Am Rev Respir Dis

    (1985)
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