European Journal of Cardiovascular Medicine

Chronic Obstructive Pulmonary Disease (COPD) is a progressive lung disorder characterized by airflow limitation that is not fully reversible and is often associated with an enhanced inflammatory response of the lungs to noxious particles or gases. It remains a major cause of morbidity and mortality worldwide, ranking as the third leading cause of death globally according to the World Health Organization [1]. In addition to its pulmonary effects, COPD has well-documented systemic manifestations, among which cardiovascular complications are particularly significant due to their impact on patient outcomes [2].

Cardiac involvement in COPD patients commonly includes right ventricular dysfunction, pulmonary hypertension (PH), and cor pulmonale, although left ventricular dysfunction is also increasingly recognized [3]. The interplay between the pulmonary and cardiovascular systems in COPD is complex, involving hypoxic vasoconstriction, vascular remodeling, and systemic inflammation, which may collectively lead to cardiac structural and functional alterations [4]. These cardiac manifestations often remain underdiagnosed until they become clinically significant, thereby contributing to exacerbations, increased hospitalizations, and premature death [5].

Echocardiography (ECHO) serves as a non-invasive, accessible, and highly informative diagnostic tool for assessing both right and left heart function, as well as estimating pulmonary artery pressures. It is particularly valuable in the COPD population, where symptoms of cardiac dysfunction may overlap with or be masked by pulmonary symptoms [6]. Studies have shown that echocardiographic abnormalities are prevalent in COPD patients and may be correlated with disease severity as classified by GOLD (Global Initiative for Chronic Obstructive Lung Disease) staging [7]. Furthermore, echocardiographic findings such as right ventricular dilation, decreased ejection fraction, and increased pulmonary artery pressure have been associated with poor prognosis [8].

Identifying cardiac involvement early in the course of COPD through echocardiography could facilitate timely interventions, including pharmacologic therapy, pulmonary rehabilitation, and oxygen supplementation, all of which could potentially slow disease progression and improve quality of life [9]. Moreover, integrating echocardiographic evaluation into routine COPD management may reduce both cardiovascular and all-cause mortality by enabling a more holistic and initiative-taking approach to patient care [10].

Therefore, this study aims to evaluate the diagnostic value of echocardiographic findings among COPD patients to identify cardiac manifestations and explore their relationship with disease severity. Such an approach could lead to earlier interventions, ultimately reducing morbidity and mortality and enhancing the quality of life in this vulnerable population.

This was a hospital-based, observational, cross-sectional study conducted in the Department of Pulmonary Medicine and Cardiology at a tertiary care hospital. The study was conducted over a period of one year, from January 2023 to December 2023. The study included 44 patients diagnosed with Chronic Obstructive Pulmonary Disease (COPD), attending the outpatient or inpatient departments during the study period. All patients were diagnosed based on clinical history, physical examination, and spirometry findings in accordance with the GOLD (Global Initiative for Chronic Obstructive Lung Disease) criteria.

Inclusion Criteria

• Patients aged ≥40 years.
• Clinically and spirometrically confirmed cases of COPD (FEV1/FVC < 0.70 post-bronchodilator).
• Patients willing to give informed written consent.

Exclusion Criteria

• Patients with known congenital or valvular heart disease.
• Patients with a history of ischemic heart disease, myocardial infarction, or heart failure of known non-pulmonary etiology.
• Patients with significant renal or hepatic impairment.
• Patients with active pulmonary infections such as tuberculosis.

Sample Size

A total of 100 COPD patients were selected using a convenience sampling technique.

Data Collection

After obtaining written informed consent, demographic details, smoking history, clinical symptoms, and comorbidities were recorded. Each patient underwent a thorough clinical examination followed by spirometry to classify the severity of COPD based on GOLD staging.

Echocardiographic Assessment

All patients underwent transthoracic 2D echocardiography performed by an experienced cardiologist using a standardized protocol. The following parameters were evaluated:

• Right atrial and ventricular dimensions
• Pulmonary artery pressure
• Right ventricular systolic pressure (RVSP)
• Left ventricular ejection fraction (LVEF)
• Presence of pulmonary hypertension or cor pulmonale
• Any valvular abnormalities

Echocardiographic findings were documented and correlated with the severity of COPD.

Data Analysis

Data were compiled and analyzed using appropriate statistical software (e.g., SPSS version XX). Descriptive statistics were used for baseline characteristics. Chi-square tests and Pearson correlation coefficients were applied to determine the relationship between ECHO findings and COPD severity. A p-value of <0.05 was considered statistically significant.

Table 1 shows the distribution of pulmonary arterial hypertension (PAH) among COPD patients according to disease severity. The prevalence of PAH increases with advancing COPD stage, with the highest occurrence seen in Stage IV patients (88.9%) and the lowest in Stage I (16.7%). This suggests a strong correlation between COPD severity and the presence of PAH.

Table 2 shows the distribution of right ventricular (RV) size on echocardiography according to COPD severity. It demonstrates a progressive increase in RV enlargement with advancing stages of COPD. While all patients in Stage I had normal RV size, 100% of Stage IV patients exhibited RV enlargement. This indicates a strong association between disease severity and structural cardiac changes, particularly right ventricular dilation.

Table shows the comparison of right ventricular (RV) size with COPD severity. RV enlargement increases with disease severity, being absent in Stage I and present in all Stage IV patients, indicating a clear trend of worsening cardiac involvement in advanced COPD.

Table 1: Comparison of PAH in echo according to severity of disease.

Table 2: Comparison of RV size in ECHO according to severity of disease.

Table 3: Comparison of RA size in ECHO according to severity of disease.

This study highlights the significant cardiac manifestations observed in COPD patients, particularly the increasing prevalence of pulmonary arterial hypertension (PAH) and right ventricular (RV) enlargement with advancing disease severity. Our findings align with previous reports suggesting that cardiovascular involvement, especially right heart changes, are common but underrecognized complications of COPD [11].

The presence of PAH in over half of the study population reinforces the growing concern that chronic hypoxia and pulmonary vascular remodeling in COPD contribute substantially to increased pulmonary pressures [12]. In our study, PAH was most frequent in GOLD Stage IV patients, mirroring results from earlier studies which established that more severe airway obstruction correlates with elevated pulmonary artery pressure [13].

Similarly, right ventricular enlargement was more prominent among patients in the higher GOLD stages, particularly Stage IV. This observation supports the concept of cor pulmonale as a key consequence of long-standing pulmonary hypertension and increased afterload on the right heart, leading to structural adaptations and functional decline [14].

Early identification of these cardiac complications through echocardiography is critical, as it allows for timely interventions such as long-term oxygen therapy, pulmonary vasodilators, or tailored cardiac care, which may improve overall outcomes [15]. Our study underscores the need for routine echocardiographic screening in moderate-to-severe COPD patients to reduce the burden of morbidity and mortality.

This study highlights the significant prevalence of cardiac manifestations such as pulmonary arterial hypertension and right ventricular enlargement among COPD patients, particularly as disease severity increases. Echocardiography proved to be a valuable, non-invasive tool for early detection of these complications. Incorporating routine cardiac evaluation in COPD management can facilitate timely interventions, potentially improving quality of life and reducing morbidity and mortality in this population.

1. World Health Organization. Chronic obstructive pulmonary disease (COPD) [Internet]. 2023 [cited 2025 Mar 24]. Available from: https://www.who.int
2. Fabbri LM, Rabe KF. From COPD to chronic systemic inflammatory syndrome? Lancet. 2007;370(9589):797–9.
3. Barr RG, Bluemke DA, Ahmed FS, et al. Percent emphysema, airflow obstruction, and impaired left ventricular filling. N Engl J Med. 2010;362(3):217–27.
4. MacNee W. Pathophysiology of cor pulmonale in chronic obstructive pulmonary disease. Part Two. Am J Respir Crit Care Med. 2005;172(2):144–60.
5. Feary JR, Rodrigues LC, Smith CJP, et al. Prevalence of major comorbidities in subjects with COPD and incidence of myocardial infarction and stroke. Thorax. 2010;65(11):956–62.
6. Jörgensen K, Müller MF, Nel J, et al. Echocardiographic findings in patients with COPD. Chest. 1997;111(1):144–50.
7. Gürdal A, Yildiz BS, Arslan S, et al. Evaluation of right ventricular function with echocardiography in COPD. Multidiscip Respir Med. 2014;9(1):49.
8. Vonk-Noordegraaf A, Marcus JT, Holverda S, et al. Early changes of cardiac structure and function in COPD patients with mild hypoxemia. Chest. 2005;127(6):1898–903.
9. Smith MC, Wrobel JP. Epidemiology and clinical impact of major comorbidities in patients with COPD. Int J Chron Obstruct Pulmon Dis. 2014;9:871–88.
10. Hawkins NM, Petrie MC, Jhund PS, et al. Heart failure and chronic obstructive pulmonary disease: diagnostic pitfalls and epidemiology. Eur J Heart Fail. 2009;11(2):130–9.
11. Minai OA, Gudavalli R, Moser B, et al. Cardiac comorbidities in patients with chronic obstructive pulmonary disease. Proc Am Thorac Soc. 2008;5(4):543–8.
12. Chaouat A, Bugnet AS, Kadaoui N, et al. Severe pulmonary hypertension and chronic obstructive pulmonary disease. Am J Respir Crit Care Med. 2005;172(2):189–94.
13. Oswald-Mammosser M, Weitzenblum E, Quoix E, et al. Prognostic factors in COPD patients receiving long-term oxygen therapy. Chest. 1995;107(5):1193–8.
14. Arcasoy SM, Christie JD, Ferrari VA, et al. Echocardiographic assessment of pulmonary hypertension in patients with advanced lung disease. Am J Respir Crit Care Med. 2003;167(5):735–40.
15. Weitzenblum E, Chaouat A. Cor pulmonale. Chronobiol Int. 2001;18(6):1041–63.