ΑΛΛΗΛΕΠΙΔΡΑΗ ΚΑΡΔΙΑ ΚΑΙ ΠΝΕΥΜΟΝΩΝ

Transcription

1 ΕΜΙΝΑΡΙΟ ΕΠΙΣΗΜΟΝΙΚΩΝ ΕΝΩΕΩΝ ΕΛΛΗΝΙΚΟΤ ΚΟΛΛΕΓΙΟΤ ΚΑΡΔΙΟΛΟΓΙΑ ΑΛΛΗΛΕΠΙΔΡΑΗ ΚΑΡΔΙΑ ΚΑΙ ΠΝΕΥΜΟΝΩΝ Ιωάννησ Αλεξανιάν Καρδιολόγοσ, Επιμελητήσ Β Γενικό Νοςοκομείο Νοςημάτων Θώρακα Αθηνών «Η ωτηρία» Αθήνα 2-4 Οκτωβρίου 2015

2 HEART - LUNG CROSSTALK

3 CARDIOPULMONARY PATHOPHYSIOLOGY AND INTERACTIONS IN PATIENTS WITH HEART FAILURE AND PULMONARY DISEASE European Heart Journal (2013) 34,

4 Cardio-Pulmonary-Renal Interactions Faeq Husain-Syed et al. J Am Coll Cardiol 2015;65:

5 Prevalence and prognosis of heart failure and COPD The prevalence of GOLD stage II or higher COPD is 5 10% of adults. One-year mortality in the community is relatively low (around 3%), but higher following hospitalization (25%). HF is less common, affecting 1 3% of the general population, but carries a worse prognosis. Annual mortality in stable community patients approximates 5 7%, while median survival following hospitalization remains just 2 years. COPD occurs in 30% of elderly patient with stable HF, estimated by spirometry. Concurrent COPD independently predicts mortality in patients with reduced and preserved ejection fraction. The prevalence of unrecognized HF was 20.9% in patients with COPD or asthma presenting to the emergency department, 20.5 and 17% in community patients with stable COPD. HF doubles the mortality of patients with COPD without HF over a mean follow-up of 4.2 years. European Heart Journal (2013) 34,

6 THE LUNGS AFFECT THE HEART

7 Airflow obstruction, lung function, and risk of incident heart failure: the Atherosclerosis Risk in Communities (ARIC) study N=15792 FU=14.9 yrs FEV1 quartiles Adjusted for age, gender, race, height, height height, prevalent chronic heart disease, diabetes, hypertension, cigarette smoking status, cigarette-years of smoking, LDL, HDL and BMI. European Journal of Heart Failure (2012) 14,

8 Myocardial infarction and other co-morbidities in patients with COPD - A Danish Nationwide Study of 7.4 million individuals European Heart Journal (2011) 32,

9 Chronic obstructive pulmonary disease and sudden cardiac death the Rotterdam study N= subjects, aged >45 years, FU=up to 24yrs European Heart Journal (2015) 36,

10 Differences in clinical characteristics, management and short-term outcome between acute heart failure patients COPD and those without this co-morbidity COPD patients (n = 1,143, 24.8 %) were older and more frequently men when compared to non- COPD patients and more frequently presented with acutely decompensated heart failure. A worse cardiovascular profile was observed in the COPD group, including more AF/flutter, diabetes, hypertension, obesity, PAD. Notably, b-blockers were less prescribed before admission (21.1 vs %, p = 0.055) in COPD patients, and remained underutilized at discharge (p<0.001). Correcting for baseline differences, all-cause in-hospital mortality did not differ between COPD and non-copd groups (10.1 vs %, p = 0.085). Clin Res Cardiol (2014) 103:

11 The Pathophysiology of Heart Failure N Engl J Med 341: , 1999

12 Mechanisms by Which High-Output or Low-Output HF leads to the Activation of Neurohormonal Vasoconstrictor Systems and Renal Sodium and Water Retention N Engl J Med 341: , 1999

13 Neurohumoral Activation as a Link to Systemic Manifestations of Chronic Lung Disease Evidence of Neurohumoral Activation in COPD Peripheral Sympathetic Activation Cardiac Sympathetic Activation Systemic Neurohumoral Activation - elevated catecholamines, and activated RAAS Possible Mechanisms of Neurohumoral Activation in COPD Hypoxemia and Hypercapnia The Muscle Metaboreflex Lung Inflation Reflex The Baroreflex Potential Implications of Neurohumoral Activation in COPD Skeletal and Respiratory Muscle Dysfunction Cachexia, Systemic Inflammation, and Leptin Pulmonary Blood Flow and Bronchoconstriction CHEST 2005; 128:

14 OXIDATIVE STRESS IN COPD CHEST 2013; 144 ( 1 ):

15 Inflammatory pathways involved in the cardiopulmonary continuum European Heart Journal (2013) 34,

16 Arterial Stiffness in COPD CHEST 2014; 145(4):

17 Hypercarbia Hyperinflation (COPD, mechanical ventilation) Lung damage Parenchyma Vascular surface area Hypoxia Hyperventilation Pulmonary vasocontriction Pulmonary vascular remodeling Renal blood flow Renal Na/H 2 0 retention Edema RV-PA INTERACTION Rate of rise in PVR Absolute rise in PVR Degree of RV adaptation Activation of Sympathetic NS RAAS Peripheral chemoreceptors Systemic vasoconstriction and coronary and celebral vasodilation Hyperventilation Pulmonary stretch receptors Systemic vasodilation PHD1 PHD2 P. Forfia et al. Pulmonary Circulation 2013

18 Pulmonary heart disease type I and II Pulm Circ 2013 Jan;3(1):5-19

19 Cardiac and Non-Cardiac Dysfunction as Precursors of Heart Failure with Reduced and Preserved Ejection Fraction in the Community The most prominent non-cardiac predictor of incident HFPEF was airflow obstruction. This observation is supported by large epidemiologic studies showing a high prevalence of pulmonary disease in patients with HFPEF, the frequent co-existence of HF in patients with chronic obstructive lung disease, as well as a recent study in the Multi-Ethnic Study of Atherosclerosis (MESA) cohort demonstrating an association between airflow obstruction and abnormal LV filling.

20 Noncardiac Comorbidities in Patients With HFpEF vs. Those With HFrEF

21 W. Paulus et al. J Am Coll Cardiol 2013;62:263 71

22 PERCENT EMPHYSEMA, AIRFLOW OBSTRUCTION, AND IMPAIRED LEFT VENTRICULAR FILLING A greater extent of emphysema on CT scanning and more severe airflow obstruction were linearly related to impaired left ventricular filling, reduced stroke volume, and lower cardiac output without changes in the LVEF N Engl J Med January 21; 362(3):

23 Cor Pulmonale Parvus in COPD and Emphysema Reduced RV volumes contradict the classic paradigm of cor pulmonale in COPD RV volumes are lower without significant alterations in RV mass and ejection fraction in contemporary COPD, and this reduction is related to the greater percentage of emphysema on computed tomography J Am Coll Cardiol 2014;64:2000 9

24 Right Ventricular Dysfunction and Remodeling in COPD Without Pulmonary Hypertension The present study showed that impaired RV systolic function, hypertrophy, and dilation were present even at a slight increase of mpap, which indicates an early impact on RV function and structure in patients with COPD. RV isovolumic acceleration, performance index, and strain could detect subclinical disease and separate controls from those with no PH. J Am Coll Cardiol 2013;62:

25 Peripheral Chemoreceptor Hypersensitivity An Ominous Sign in Patients With Chronic Heart Failure Hypersensitivity of the peripheral chemoreceptors independently predicts adverse prognosis in ambulatory patients with CHF. This hyperactive excitatory reflex, through its inhibitory effect on the baroreflex, may be the reason for the previously observed prognostic association of the latter Circulation. 2001;104: )

26 Enhanced Sympathetic and Ventilatory Responses to Central Chemoreflex Activation in Heart Failure Chronic heart failure is characterized by a potentiation of ventilatory and sympathetic responses to hypercapnia. In contrast, responses to hypoxia and to the excitatory cold pressor stimulus are not altered. This selective potentiation of central chemoreflex sensitivity may be implicated in the pathophysiology of CHF Circulation. 1999;100:

27 Does impaired O 2 delivery during exercise accentuate central and peripheral fatigue in patients with coexistent COPD-CHF Potential negative cardiopulmonary interactions in moderate to severe COPD Potential implications of abnormal pulmonary gas exchange and central hemodynamics on CNS(brain) and peripheral skeletal muscle function during exercise in combined COPD-CHF Front Physiol Jan 7;5:514

28 Electrocardiographic abnormalities and cardiac arrhythmias in COPD International Journal of Cardiology 199 (2015)

29 Beta-Blockers Reduced the Risk of Mortality and Exacerbation in Patients with COPD: A Meta-Analysis of Observational Studies Beta-blockers use and mortality risk in COPD Beta-blockers use and exacerbation of COPD risk in COPD PLoS One Nov 26;9(11):e113048

30 Reduction of Morbidity and Mortality by Statins, ACEI, and ARBs in Patients With COPD J Am Coll Cardiol 2006;47:2554 6

31 THE HEART AFFECTS THE LUNGS

32 Pulmonary function tests in HF Airflow obstruction is typical in decompensated acute pulmonary oedema. Both misdiagnosis and overestimation of COPD severity may ensue. FEV1 improves by 11 34% with diuresis and often normalizes. Restrictive ventilation is the hallmark of chronic stable HF, reflecting cardiomegaly, respiratory muscle weakness and interstitial fibrosis.

33 Pathophysiology and Clinical Relevance of Pulmonary Remodelling in Pulmonary Hypertension due to Left Heart Diseases Lung injury and repair in left heart disease Respiratory modifications in left heart disease Canadian Journal of Cardiology 31 (2015) 416e429

34 Resolution of Pulmonary Edema Normal alveolar fluid clearance pathways Up-regulated clearance pathways Impaired alveolar fluid clearance Am J Respir Crit Care Med Vol 189, Iss 11, pp

35 Alveolar-capillary membrane conductance is the best pulmonary function correlate of exercise ventilation efficiency in HF The European Journal of Heart Failure 7 (2005)

36 Exhaled Breath Condensate in Acute and Chronic HF New Insights into the Role of Lung Injury and Barrier Dysfunction Overall, inflammatory and oxidative insult to the lungs may play a crucial pathophysiological role in heart failure decompensation by further damaging the alveolar capillary barrier and increasing its permeability. As a consequence, pulmonary capillary hydrostatic pressure threshold for pulmonary edema formation decreases, which may account for the vulnerability of heart failure patients to recurrences Pappas L,,Filippatos G. Am J Respir Crit Care Med Aug 1;190(3):342-5

37 Alveolar-Capillary Membrane Dysfunction in Heart Failure CHEST 2003; 124:

38 Cardiopulmonary interactions in patients with heart failure Beneficial effects of cardiopulmonary interactions: mechanical ventilation in acute cardiogenic pulmonary edema Deleterious effect of cardiopulmonary interactions: acute cardiogenic pulmonary edema during weaning from mechanical ventilation Current Opinion in Critical Care 2007, 13:6

39 Heart lung interactions during mechanical ventilation Ventilation-induced dynamic changes in arterial pulse pressure and stroke volume variation (PPV>13% and SVV>10%, respectively) identify volume responsiveness. The cause of PPV and SVV are due to intrathoracic pressure induced variations in right atrial pressure changing intrathoracic blood volume over the ventilatory cycle. Curr Opin Crit Care 2012, 18:

40 SLEEP APNEA Lancet 2009; 373: Circulation. 2008;118:

41 TAKE HOME MESSAGES Organ injury is the consequence of maladaptive neurohormonal activation, oxidative stress, abnormal immune cell signaling, and a host of other mechanisms that precipitate adverse functional and structural changes. The presentation of interorgan crosstalk may include an acute, chronic, or acute on chronic timeframe. Assessment of organ (cardiac and pulmonary) functional reserve is a valuable clinical strategy to screen and detect disease, assist in diagnosis, assess prognosis, and predict recovery or progression to chronic disease.

42 ΕΤΥΑΡΙΣΩ ΠΟΛΤ