The impact and treatment of cardiac morbidity in COPD patients and its effect on weaning

The impact and treatment of cardiac morbidity in COPD patients and

its effect on weaning

Gökhan M. Mutlu, M.D.Pulmonary and Critical Care Medicine

Northwestern University Feinberg School of Medicine

Turkish Thoracic Society MeetingAntalya, Turkey

April 2008

Financial Disclosure: Nothing to disclose

COPD and Cardiovascular disease

• Ischemic heart disease

• Pulmonary hypertension and right heart failure

• Congestive heart failure

• Atrial fibrillation

COPD and cardiovascular disease

Large population based studies• Patients with COPD are 2-3 times more at risk for

CVD and associated mortality• One of the leading but under-recognized cause of

death in COPD is ischemic heart disease• Patients with lower FEV1 are more likely to have

CV disease and related mortality• FEV1 <2L is associated with up to 5-fold increase

for CV mortality

Camilli AE, et al. Am J Epidemiol 1991:133:795-800Jousilahti P, et al. Lancet 1996;348:567-72Janssens, JP, et al. J Am Geriatr Soc 2001;49:571=6

FEV1 and cardiovascular disease

Sin DD and Man SFP. Proc Am Thorac Soc 2005;2:8-11


Tucson epidemiologic study of obstructive airways disease

• CV disease related mortality is the leading cause of death in COPD patients.

• Only 8% of patients with airway obstruction died directly from their airway disease as the cause of death.

• Even those with severe obstructive disease (FEV1<50% of predicted), only less than 25% died from respiratory failure

Camilli AE, et al. Am J Epidemiol 1991:133:795-800


Newman et al. Circulation 2001:104:2679-84

• 614 subjects, >65 years old• Electron beam tomography for coronary calcium

• Prevalence of self reported COPD was 77 to 91% higher in the highest quartile of coronary artery calcium compared to the lowest quartile.


Jousilahti et al. Lancet 1996;348:567-72

• 9,342 men and 10,102 women• 50% increase in risk of death from CAD in those who had a positive response to the question “Do you cough on most days and nights as much as 3 months each year?”

• This effect was independent of other risk factors for CAD (i.e., hypercholesterolemia) and was adjusted for age.


Sidney S, et al. Chest 2005:128;2068-75• 45,966 patients with COPD • 45,966 control subjects without COPD• Cardiovascular endpoints studied• Younger (<65 yo) and female patients had a higher risk


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The Lung Health Study*• 5,887 smokers, ages between 35 and 60 years• Mild to moderate airways obstruction• 2.5% of population died within the initial 5-year follow-up• 25% of the patients died of a cardiovascular event.• 13% required at least one hospitalization• CV events accounted for 42% of the first and 48% of the

second hospitalization• Rate of hospitalization for lower respiratory tract infection

was only 1/3

*Anthonisen NR, et al. AJRCCM 2002;166:333-9


The Lung Health Study*• For every 10% decrease in FEV1

*Anthonisen NR, et al. AJRCCM 2002;166:333-9

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Non-fatalCoronary event

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Myocardial ischemia in ICU patients

• Several small studies suggest that myocardial ischemia or injury are common in critically ill patients.

Guest TM, et al. JAMA 1995;273:1945-9Hurford WE, et al. Anesthesiology 1991;74:1007-16Lemaire F, et al. Anesthesiology 1988;69:171-9Hurford WE, et al. Crit Care Med 1995;23:1475-80 Chatila W, et al. Chest 1996;109:1577-83

Problems: small sample size and few examined the impact of myocardial ischemia


Booker, KJ, et al. Am J Crit Care 2003;12:508-1776 consecutive patientsST segment monitoring with 12-lead EKGSerum troponin I within 8-12 hours of admission

Results: 8 patients (10.5%) had ischemic events


Booker, KJ, et al. Am J Crit Care 2003;12:508-17

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• Demand ischemia is more common that acute coronary syndrome (ACS)

• Differentiating demand ischemia from ACSDemand ischemia- ST-segment depressionACS- ST-segment elevation

SBT

• Used to assess readiness of mechanically ventilated patients to sustain spontaneous ventilation.

• Spontaneous ventilation increases basal metabolism and O2 consumption (VO2) compared to that on full mechanical ventilatory support.

• SBT increases cardiopulmonary demand• In patients with CAD, this increment in VO2 and the

increase in cardiac loads imposed by the transition to spontaneous ventilation could lead cardiac ischemia

Cardiovascular changes during SBT

Increased venous returnIncreased RV and LV preload

Increased LV afterload Increased catecholamines

Increased heart rateIncreased contractility

Increased total body oxygen consumption

VO2 increases by 15-25%Comparison

Walking 3 mph- 100% increaseFever (from 37 to 39C)- 20% increase

Myocardial ischemia

MyocardialO2 supply

MyocardialO2 demand

Myocardialischemia

Myocardial ischemia during SBT

• Demand ischemia occurs during weaning and is associated with adverse hospital outcomes

Abalos et al. Am J Crit Care 1992;1:32-6• 62 patients• EKG- ST segment monitoring• 19.3%- ischemia during weaning


Rasanen et al. Chest 1984;85:21-8• 12 patients• 5 patients developed ischemia during weaning• PAOP increased significantly with spontaneous

respiration

Hurford et al. Anesthesiology 1991;74:1007-16• Thallium scintigraphy• 5/15 patients (33%) - ischemia• 7/15 patients (47%) - acute LV dilation


Hurford and Favorito. Crit Care Med 1995;23:1475-80• EKG- ST segment monitoring• 6/17 patients (35%)• All these patients had weaning failure• Survival was 17% (1/6) vs. 73%


Chatila W, et al. Chest 1996;109:1577-83• Prospective study• 93 patients

• EKG monitoring (I, II, and V2) during SBT for 1 hour• ST segment measured continuously and analyzed

• SBT: T-piece, CPAP with or without low level PS• SBT outcomes

Pre-SBT During SBT

Chatila W, et al. Chest 1996;109:1577-83


Chatila W, et al. Chest 1996;109:1577-83• Results

6 developed ischemia3 symptomatic (distress and chest pain)All patients except one had known history of CAD

ST segment changes occurred in10% of patients with CAD2% of patients without CAD22% in those with CAD and failed extubationChanges occurred within 10-15 minutes

Hemodynamic changes during SBT

Lemaire F, et al. Anesthesiology 1988;69:171-9• 15 patients with COPD and cardiovascular disease• Hemodynamic effects of weaning

• ResultsDecreased esophageal pressureDecreased cardiac indexIncreased systemic blood pressureIncreased PAOP (from 8 to 25 mmHg)Development of pulmonary edema

9 out of 15 were successfully extubated after optimization of cardiac status


• Increased PAOP and pulmonary edema in these patients were thought to be due to:– Increased venous return due to

• abrupt shift from positive to negative intrathoracic pressure and

• to the increased sympathetic activity– Reduction in LV compliance secondary to

• weaning induced myocardial ischemia and/or • ventricular interdependence due to increased RV

afterload– Abrupt increase in LV afterload secondary to

• the negativation of intrathoracic pressure


Jubran A, et al. AJRCCM 1998;158:1763-9• Hemodynamic data from patients who failed SBT and those

who did not• 8 patients failed while 11 patients had successful SBT• SvO2

– Not different in the beginning– Fell progressively in the SBT failure group– No change in the SBT success group


Failure group

• SvO2 fell after MV is discontinued

• No increase in CI or O2 transport

• Increased O2 extraction

• LV and RV afterload increased

Success group

• SvO2 did not change after MV is discontinued

• Increased CI and O2 transport

LV function during weaning in COPD

Richard C, et al. Intensive Care Med 1994;20:181-6

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Pre-SBT During SBT

• Prospective study• 12 patients with no documented CAD• Increased inspiratory pressure decreased the reduction in LVEF

Conclusion

• Ischemia and decompensation of CHF may occur during SBT particularly in patients with underlying CAD and CHF

• Detection of ischemia during mechanical ventilation and SBTs is difficult

• Monitoring of ST segment is not easy

• Fluid status has to be optimized before SBT

Documents

The impact and treatment of cardiac morbidity in COPD patients and its effect on weaning