Characteristics of concomitant cardiovascular diseases in patients with chronic obstructive pulmonary disease

Journal of military pharmaco-medicine n 0 1-2020 181 CHARACTERISTICS OF CONCOMITANT CARDIOVASCULAR DISEASES IN PATIENTS WITH CHRONIC OBSTRUCTIVE PULMONARY DISEASE Bui Mai Huong1; Nguyen Dinh Tien2 SUMMARY Objectives: To examine the characteristics of concomitant cardiovascular diseases in patients with chronic obstructive pulmonary disease. Subjects and methods: A cross-sectional descriptive study was conducted on 162 patients who had a confirmed diagnosis of chronic obstructive pulmonary disease from January 2016 to October 2018. Results and conclusions: The average age of our study patient group was 72.3 ± 9.8. The majority of patients was > 60 years old, accounting for 89.4%. The male/female ratio was 3/1. The rate of cardiovascular diseases: valvular heart disease encountered in 100% of patients with chronic obstructive pulmonary disease, hypertension accounted for 84%, arrhythmia accounted for 65.4%, the proportion of patients with ischemic heart disease and right heart failure syndrome was 57.49% and 36.4%. Only 2.5% of the patients had peripheral vascular disease. Characteristics of heart failure: the proportion of patients with chronic obstructive pulmonary disease with heart failure accounted for 50.6%: right heart failure accounted for 36.4%, left heart failure accounted for 0.6% and two-side heart failure accounted for 13.9%. The relationship between cardiovascular disease characteristics and the stages of chronic obstructive pulmonary disease: the patients with stage III chronic obstructive pulmonary disease had the highest rate of chronic cor pulmonale, heart failure, ischemic heart disease (48.6%; 53.6%; 52.9%; 46.2% and 75.0%). * Keywords: Chronic obstructive pulmonary disease; Cardiovascular disease. INTRODUCTION Chronic obstructive pulmonary disease (COPD) is one of the leading causes of morbidity and mortality worldwide resulting in increasing serious economic and social burden. Although COPD affects mainly the lungs, it also causes many systemic diseases, especially cardiovascular diseases: the disease not only damages the right heart, but also the left heart, arrhythmias, myocardial ischemia, atherosclerosis, embolism, etc. The incidence of COPD is often directly related to smoking rate although in many countries, air pollution outdoors, at work and indoors are the main risk factors for COPD. Smoking is also a risk factor for cardiovascular disease. Therefore, in patients with COPD, there are many accompanying other cardiovascular diseases and clinical manifestations of COPD are enriched. The effects of cardiovascular disease caused by COPD and .the .combination of cardiovascular 1. Saint Paul Hospital 2. 108 Military Central Hospital Corresponding author: Bui Mai Huong (huongkorea07@gmail.com) Date received: 21/12/2019 Date accepted: 15/01/2020 Journal of military pharmaco-medicine n 0 1-2020 182 diseases with COPD exacerbate the severity of the disease, increase complications and increase mortality rate. We conducted this study: To analyse the characteristics of concomitant cardiovascular diseases in patients with COPD SUBJECTS AND METHODS 1. Subjects. 162 patients with COPD were treated at the Department of Internal Medicine - Pulmonary Division, Department of Internal Medicine - Cardiology and the Department of Internal Medicine, Emergency Resuscitation - Saint Paul Hospital. The study duration was from January 2016 to October 2018. * Selection criteria: - Patients with a confirmed diagnosis of COPD according to GOLD (2016). - Patients with a confirmed diagnosis of the Hypertension Clinical Practice Guidelines (2017) and JNC 7. - Patients with a confirmed diagnosis of the ESC Guidelines (2016). - Patients with a confirmed diagnosis of chronic cor-pulmonale an expert committee of the Word Health Organization (1998). - Patients agreed to participate in the study. * Exclusion criteria: - Patients who were impossible to measure pulmonary ventilation function and did not take an electrocardiogram (ECG), echocardiography. - Patients did not agree to cooperate. - Patients who were re-hospitalized during the study. 2. Methods. A cross-sectional descriptive study. * Information needed to collect: - General information: Age, gender, occupation, living region, reasons for admission to the hospital. - History, medical history. - Clinical examination. - Classification of disease stage according to GOLD (2016). - Laboratory testing: + Measurement of pulmonary function was done at the Pulmonary Department, Saint Paul Hospital. + Echocardiography and pulse measurements were made in the echocardiography room - Saint Paul Hospital. Clinical and paraclinical results were compared with echocardiography. + Electrocardiography was made in the Department of Internal Medicine - Pulmonary Division, Department of Internal Medicine - Cardiology, Saint Paul Hospital. Clinical and paraclinical results were compared with electrocardiography. Journal of military pharmaco-medicine n 0 1-2020 183 RESULTS AND DISCUSSION 1. Age and gender characteristics. Table 1: Distribution of the study patients by age and gender. The study results showed that the average age of patients in the study was 72.3 ± 9.8. The average age of our patients was higher than that of some domestic authors such as Nguyen Chinh Dien (68.1 ± 9.3) [1]; Nguyen Thi Kim Oanh (67.06 ± 10.3) [2] and also higher than some foreign authors such as Abroug et al [6]; Mailsel A.S (64 ± 17) [7]. The age of male patients was mainly in the age of 60 - 69 years and 70 - 79 years old (47.6%). Meanwhile, the age of female patients was the most common in the age of 70 - 79 (9.9%) and there were no female patients aged < 50. 2. Rate of cardiovascular diseases in the study patients. Table 2: Rate of types of cardiovascular disease in patients with COPD. Types of cardiovascular disease n Rate (%) Arrhythmia 106 65.4 Right atrial hypertrophy on ECG 74 45.7 Right heart failure syndrome 59 36.4 Chronic cor pulmonale Systolic pulmonary hypertension 69 42.6 Valvular heart disease 162 100.0 Hypertension 136 84.0 Heart failure 82 50.6 Ischemic heart disease 93 57.4 Peripheral vascular disease 4 2.5 Common Male Female Age group n Rate (%) n Rate (%) n Rate (%) p < 50 1 0.6 1 0.8 0 0.0 50 - 59 16 9.9 13 10.7 3 7.3 60 - 69 49 30.2 39 24.1 10 6.2 70 - 79 54 33.3 38 23.5 16 9.9 ≥ 80 42 25.9 30 18.5 12 7.4 > 0.05 Average age 72.3 ± 9.8 71.7 ± 9.9 74.3 ± 9.2 n 162 121 41 Journal of military pharmaco-medicine n 0 1-2020 184 In cardiovascular diseases, valvular heart disease in the elderly encountered in 100% of patients with COPD. Among cardiovascular diseases, valvular heart disease in the elderly was the most common in 100% of patients with COPD. The rate of hypertension in our study was higher than that in Nguyen Thi Kim Oanh’s findings with 37/100 patients (37%) [2], because atherosclerosis and overweight are now common causes and more and more increasing. The rate of arrhythmia in our study was lower than in Nguyen Thi Kim Oanh’s with 76/100 patients (76%) [2] and the study results by the General Cardiology Department of Nhan Dan Gia Dinh Hospital (n = 96): arrhythmia 70.8% [3]. The proportion of patients with chronic cor pulmonale in our study by assessing pulmonary hypertension through echocardiography was lower than in Ngo Quy Chau’s and Nguyen Chinh Dien’s findings (70.6%) [1], Chu Thi Hanh and Nguyen Thi Kim Oanh (75%) [2]. This relatively high proportion can be explained by the fact that currently, echocardiography can detect early systolic pulmonary hypertension, helping to diagnose early chronic cor pulmonale while there is no clinical manifestation. Another reason is that patients with COPD in the above authors’ findings were all in the Respiratory Center, Bachmai Hospital which is at the central level, so these patients at admission were often severe and very severe, thus the rate of right heart failure of these patients was more frequent than in our study. The proportion of patients with chronic cor pulmonale diagnosed with right atrial thickness manifestations on electrocardiogram was 45.7%, our results were similar to Nguyen Thi Thuy Nga’s findings (35.8%) [4]; with 36.4% of the patients suffering from right heart failure syndrome. Our result was higher than Nguyen Thi Kim Oanh’s (19%) [2]. The rate of heart failure in our study was similar to that in Ngo Quy Chau’s and Nguyen Chinh Dien’s (40.1%) [1], higher than the study results by Nguyen Thi Kim Oanh (22%) [2] and Nhan Dan Gia Dinh Hospital (18.8%) [3]. The incidence of ischemic heart disease in our study was higher than that in Nguyen Thi Kim Oanh’s (12%) [2]. In this study, we found that 100% of the study patients had concomitant cardiovascular diseases, which was also noted in some other studies on COPD. Table 3: Characteristics of heart failure in patients with COPD. Manifestation n Rate (%) Right heart failure 59 36.4 Left heart failure (EF < 50%) 1 0.6 Heart failure Total heart failure 22 13.6 Without heart failure 80 49.4 Journal of military pharmaco-medicine n 0 1-2020 185 Thus, heart failure in our study was both a consequence of right heart failure of COPD and a combination of left heart failure and COPD. Previous studies had shown that about 10% of patients hospitalized for heart failure with COPD, recent reports showed that this proportion increased to about 20 - 30% and also about 30% of patients with COPD accompanied by left ventricular function failure. In the study by Nguyen Chinh Dien, there were 41/102 patients with heart failure (40.1%) [1] and in the study by Hoang Duc Bach there were 26/81 patients (32.1%) with heart failure (with a BNP concentration > 100 pg/mL) [5]. 3. Relationship between cardiovascular disease and clinical characteristics in COPD. Table 4: Relationship between cardiovascular disease in coronary artery disease and the stages of COPD. Stages of disease II III IV Cardiovascular disease n Rate (%) n Rate (%) n Rate (%) p Arrhythmia (n = 106) 48 45.3 46 43.4 12 11.3 > 0.05 Right atrial thickness on ECG (n = 74) 29 39.2 36 48.6 9 12.2 < 0.05 Chronic cor pulmonale Systolic pulmonary hypertension (n = 69) 24 34.8 37 53.6 8 11.6 > 0.05 Valvular heart disease (n = 162) 80 49.4 67 41.4 15 9.3 > 0.05 Hypertension (n = 136) 69 50.7 54 39.7 13 9.6 > 0.05 Heart failure (n = 82) 30 36.6 43 52.9 9 11 < 0.01 Ischemic heart disease (n = 93) 41 44.1 43 46.2 9 9.7 > 0.05 Peripheral vascular disease (n = 4) 1 25.0 3 75.0 0 0 > 0.05 The proportion of patients with arrhythmia decreased with the severity of the disease, in stage II the proportion of patients with arrhythmia was 45.3%. In stage III, it was 43.4% and in stage IV it was 11.3%. However, the difference was not statistically significant with p > 0.05. The results were the same for patients with hypertension (p > 0.05). The proportion of patients with COPD with the right atrial thickness on ECG, systolic pulmonary hypertension, heart failure and ischemic heart disease were the highest in stage III. Stage IV had the lowest proportion. However, the difference was statistically significant only in patients with the right atrial thickness on ECG with Journal of military pharmaco-medicine n 0 1-2020 186 p < 0.05 and heart failure with p < 0.01. This is explanable because most cardiovascular disease is associated with COPD, rather than as a consequence of the disease. Particularly, chronic cor pulmonale as a consequence of the disease on the right heart, there were stages but the incidence did not increase gradually with the stage of the disease as many authors have commented [1, 8], that it was highest in stage III (53.6%) and the lowest in stage IV (11.6%), because patients in stage IV were treated primarily at the intensive care unit, therefore in our study the number of patients in stage IV was small, so it was difficult to exactly assess the rate of chronic cor pulmonale. The proportion of patients with COPD with a peripheral vascular disease was the highest in stage III (75%) and none of the patients in stage IV had peripheral vascular disease. The difference was not statistically significant with p > 0.05. CONCLUSIONS The average age of our study patients group was 72.3 ± 9.8. The majority of patients was > 60 years old, accounting for 89.4%, this is also the age at risk of COPD and concomitant cardiovascular disease. The male/female ratio was 3/1. In cardiovascular diseases, valvular heart disease in the elderly encountered 100% of patients with COPD. Hypertension accounted for 84%. Patients with COPD with arrhythmia accounted for 65.4%. The proportion of patients with ischemic heart disease and right heart failure syndrome was 57.49% and 36.4%. Only 2.5% of patients had peripheral vascular disease. The proportion of patients with COPD with heart failure accounted for 50.6%, of which right heart failure accounted for 36.4%, left heart failure accounted for 0.6% and whole heart failure accounted for 13.9%. The patients with stage III COPD had the highest rate of chronic cor pulmonale, heart failure, ischemic heart disease (48.6%; 53.6%; 52.9%; 46.2% and 75%). REFERENCES 1. Ngo Quy Chau, Nguyen Chinh Dien. Research on some concomitant cardiovascular diseases in patients with acute obstructive pulmonary disease treated at the Respiratory Center, Bach Mai Hospital. Specialty II Thesis. Hanoi Medical University. 2010. 2. Nguyen Thi Kim Oanh. Research on some cardiovascular diseases in patients with chronic obstructive pulmonary disease treated at the Respiratory Center, Bach Mai Hospital. Master Thesis. 2013. 3. Survey on the rate of types of concomitant cardiovascular diseases in patients with chronic obstructive pulmonary disease at the General Cardiology Department of Nhan Dan Gia Dinh Hospital from February 2010 to August 2011. 4. Nguyen Thi Thuy Nga. Research on changes in morphology and right ventricular diastolic function by Doppler echocardiography in patients with chronic obstructive pulmonary Journal of military pharmaco-medicine n 0 1-2020 187 disease and bronchial asthma. Military Medical University. 2007. 5. Hoang Duc Bach. Clinical and paraclinical characteristics and BNP concentration in patients with chronic obstructive pulmonary disease treated at the Respiratory Department, Bach Mai Hospital. Master of Medicine Thesis. 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