European Journal of Cardiovascular Medicine

Chronic obstructive pulmonary disease (COPD) is a progressive respiratory disorder characterized by persistent airflow limitation and associated with significant extrapulmonary complications¹. The Global Initiative for Chronic Obstructive Lung Disease (GOLD) defines COPD as a preventable and treatable disease with systemic consequences, including substantial cardiovascular involvement^2,3. Cardiovascular disease is one of the leading causes of morbidity and mortality in COPD patients, with conditions such as pulmonary hypertension, right ventricular hypertrophy, and left ventricular dysfunction being commonly observed⁴.

COPD and cardiovascular diseases share common risk factors, including smoking, systemic inflammation, oxidative stress, and hypoxia-induced vascular remodeling. Chronic hypoxia in COPD leads to increased pulmonary arterial pressure, contributing to the development of pulmonary hypertension and cor pulmonale⁵. Additionally, left ventricular dysfunction may result from increased pulmonary vascular resistance and right ventricular overload, further exacerbating the disease burden⁶.

Echocardiography serves as a valuable, non-invasive diagnostic tool for assessing cardiac abnormalities in COPD patients. It provides real-time imaging of cardiac structure and function, allowing for the early detection of pulmonary hypertension, right ventricular hypertrophy, and left ventricular diastolic dysfunction⁷. Understanding these cardiographic findings and their correlation with COPD severity can aid in risk stratification and the implementation of appropriate management strategies.

This study aims to evaluate the cardiac alterations associated with COPD using echocardiography and to establish a correlation between echocardiographic findings and the severity of COPD as classified by GOLD staging. Identifying cardiovascular involvement in COPD patients can facilitate timely intervention and improve overall prognosis.

Study Design and Setting

The prospective observational study was conducted over a 16-month period, from June 2023 to November 2024, in the Department of Respiratory Medicine at Maharajahs Institute of Medical Sciences (MIMS), Vizianagaram, Andhra Pradesh, India.

Study Population

A total of 50 patients diagnosed with chronic obstructive pulmonary disease (COPD) were included in the study. COPD diagnosis was confirmed based on the GOLD (Global Initiative for Chronic Obstructive Lung Disease) criteria.

Inclusion Criteria

Patients aged above 40 years

Any gender

Patients diagnosed with COPD

Patients willing to participate in the study and provide informed consent

Exclusion Criteria

Patients with active tuberculosis, HIV, terminal cancer

Pregnant and lactating women

Patients with hepatic or renal conditions and immunocompromised status

Patients with a history suggestive of asthma

Patients with lung disorders that contribute to decreased lung function

Patients with poor echocardiographic window

Patients with acute exacerbation of COPD within two weeks before enrollment

Patients with conditions that contraindicate forced expiratory maneuvers

Data Collection and Investigations

After obtaining informed consent, all patients underwent a detailed medical history assessment, including smoking habits and clinical examination. The following investigations were performed:

Spirometry: To assess lung function and determine the severity of COPD based on GOLD staging.

Electrocardiography (ECG): To detect arrhythmias, right ventricular hypertrophy, or ischemic changes.

Arterial Blood Gas (ABG) Analysis: Performed in patients with severe COPD to assess oxygenation and acid-base status.

Echocardiography: Conducted following the guidelines of the American Society of Echocardiography to assess cardiac function, right ventricular (RV) thickness, left ventricular diastolic dysfunction (LVDD), pulmonary hypertension, and ejection fraction. A cardiologist reviewed all echocardiographic findings for accuracy.

GOLD Grading for COPD Severity

The severity of COPD was classified according to the Global Initiative for Chronic Obstructive Lung Disease (GOLD) criteria based on post-bronchodilator FEV₁ as follows:

The classification was used to assess disease severity and correlate it with echocardiographic findings in COPD patients. This grading helped determine the impact of disease progression on cardiovascular alterations observed in the study

Statistical Analysis

The collected data were tabulated and analyzed using descriptive statistics. Frequencies and percentages were calculated for categorical variables. Mean ejection fraction was compared between patients with and without pulmonary hypertension. The association between echocardiographic findings and COPD severity was evaluated.

Ethical Considerations

The study was conducted after obtaining approval from the Institutional Ethics Committee, Maharajahs Institute of Medical Sciences, Vizianagaram. All procedures followed ethical guidelines, ensuring patient confidentiality and safety.

A total of 50 patients diagnosed with chronic obstructive pulmonary disease (COPD) were included in this study. Echocardiographic evaluation revealed significant cardiac alterations associated with COPD severity as per GOLD staging.

Smoking Status

Among the study participants, 64% (32) were smokers, while 36% (18) had a smoking history of less than 20 pack-years or were non-smokers (Table 1 & Figure :1).

Table 1: Smoking Status in COPD Patients

Figure No:1. Smoking Status in COPD Patients

Pulmonary Hypertension

Pulmonary hypertension was observed in 24% (12) of the patients (Table 2 & Figure :2). The presence of pulmonary hypertension correlated with the severity of COPD, indicating a higher prevalence in patients with advanced disease stages.

Table 2: Prevalence of Pulmonary Hypertension in COPD Patients

Figure No:2. Prevalence of Pulmonary Hypertension in COPD Patients

Right Ventricular (RV) Thickness

Increased RV thickness (>0.5 mm) was noted in 24% (12) of patients (Table 3 & Figure :3), suggesting right ventricular hypertrophy as a consequence of chronic pulmonary hypertension and increased pulmonary vascular resistance.

Table 3: Distribution of Right Ventricular (RV) Thickness in COPD Patients

Figure No:3. Distribution of Right Ventricular (RV) Thickness in COPD Patients

Left Ventricular Diastolic Dysfunction (LVDD)

Left ventricular diastolic dysfunction was identified in 20% (10) of patients (Table 4 & Figure :4). This finding supports the presence of left ventricular impairment in COPD patients, potentially due to chronic hypoxia and increased pulmonary arterial pressures.

Table 4: Left Ventricular Diastolic Dysfunction (LVDD)

Figure No:4. Prevalence of Left Ventricular Diastolic Dysfunction (LVDD) in COPD Patients

Ejection Fraction (%)

The mean ejection fraction did not show a statistically significant difference between patients with and without pulmonary hypertension. Patients without pulmonary hypertension had a mean ejection fraction of 61.6%, whereas those with pulmonary hypertension had a slightly lower mean ejection fraction of 60.5% (Table 5 & Figure :5 ).

Table 5: Ejection Fraction (%)

Figure No:5. Comparision of Ejection Fraction in COPD Patients

Association with COPD Severity

The echocardiographic abnormalities, including pulmonary hypertension, increased RV thickness, and LVDD, were more frequently observed in patients with severe and very severe COPD as per GOLD classification. These findings highlight the need for routine cardiovascular assessment in COPD patients to detect early cardiac dysfunction and optimize clinical management.

Chronic obstructive pulmonary disease (COPD) is not only a respiratory disorder but also a systemic condition with significant cardiovascular implications. The present study aimed to evaluate echocardiographic changes in COPD patients and establish a correlation with disease severity. The findings highlight the high prevalence of cardiovascular abnormalities in COPD patients, reinforcing the importance of routine cardiovascular assessment in disease management.

Smoking and Cardiovascular Complications in COPD

Smoking is a well-established risk factor for both COPD and cardiovascular diseases. In this study, a majority of the participants were smokers, which is consistent with previous findings that highlight smoking-induced systemic inflammation, oxidative stress, and endothelial dysfunction as key contributors to pulmonary vascular remodeling and increased right ventricular afterload (Gupta et al⁸., 2011; Kaushal et al¹⁰., 2016). Smoking also accelerates COPD progression, leading to higher rates of cardiovascular comorbidities.

Pulmonary Hypertension in COPD

Pulmonary hypertension was observed in a significant proportion of patients, supporting earlier studies that report increased pulmonary arterial pressures in COPD due to chronic hypoxia-induced vasoconstriction and vascular remodeling (Bhat et al⁹., 2024; Falk et al¹¹., 2008). Pulmonary hypertension is a key contributor to right ventricular dysfunction and cor pulmonale in COPD, ultimately affecting exercise capacity and overall prognosis. Bhat et al⁹. (2024) further demonstrated that pulmonary hypertension is linked to higher mortality rates in COPD patients, emphasizing the need for early detection and management.

Right Ventricular Hypertrophy and Pulmonary Pressure Overload

Right ventricular (RV) thickness greater than 0.5 mm was noted in a considerable number of patients, suggesting hypertrophic changes in response to increased pulmonary artery pressures. Previous studies have identified right ventricular hypertrophy as a common finding in COPD patients with pulmonary hypertension (Nasir et al., 2020; Mohammed et al¹³., 2023). Chronic hypoxia and pulmonary hypertension result in right ventricular remodeling, which may eventually lead to right heart failure if left unaddressed. Buklioska-Ilievska et al¹². (2019) reported that increased RV thickness is strongly associated with airflow limitation and disease severity, highlighting the role of echocardiography in disease monitoring.

Left Ventricular Diastolic Dysfunction (LVDD) in COPD

Left ventricular diastolic dysfunction (LVDD) was detected in a notable proportion of patients, which aligns with prior studies demonstrating the impact of COPD on left ventricular function (Kaushal et al¹⁰., 2016; Buklioska-Ilievska et al¹²., 2019). COPD is often associated with LVDD due to systemic inflammation, arterial stiffness, and increased afterload from pulmonary hypertension. Studies have reported a significant association between COPD severity and LVDD, which may contribute to exercise intolerance and worsening dyspnea (Falk et al¹¹., 2008). Gupta et al⁸. (2011) suggested that LVDD in COPD patients is an important predictor of cardiovascular morbidity and should be routinely assessed using echocardiography.

Ejection Fraction and Cardiac Function in COPD

The mean ejection fraction was similar between patients with and without pulmonary hypertension. This finding suggests that COPD predominantly affects diastolic rather than systolic function. Previous studies have reported that in COPD patients, systolic function is generally preserved unless there is concomitant ischemic heart disease (Mohammed et al¹³., 2023). However, Bhat et al⁹. (2024) and Nasir et al¹⁴. (2020) found that in advanced COPD cases with significant pulmonary hypertension, ejection fraction may eventually decline due to chronic RV strain. The lack of a significant difference in ejection fraction in the present study may be attributed to the relatively small sample size.

Clinical Implications

The echocardiographic findings in this study underscore the need for routine cardiovascular screening in COPD patients. Pulmonary hypertension, right ventricular hypertrophy, and left ventricular dysfunction are common in COPD and contribute to increased morbidity and mortality. Buklioska-Ilievska et al¹². (2019) and Falk et al¹¹. (2008) emphasized that echocardiography is a critical tool for early detection of cardiac abnormalities in COPD patients, allowing for timely intervention. Early detection through echocardiography can facilitate pulmonary rehabilitation, optimized pharmacotherapy, and lifestyle modifications, ultimately improving patient outcomes.

Limitations of the Study

This study has certain limitations, including a relatively small sample size and the lack of long-term follow-up to assess cardiovascular outcomes. Additionally, the study was conducted at a single center, which may limit the generalizability of the findings. Future studies with larger sample sizes and longitudinal follow-up are warranted to further explore the impact of COPD on cardiac function.

The present study highlights the significant cardiac alterations in COPD patients, with pulmonary hypertension, right ventricular hypertrophy, and left ventricular diastolic dysfunction (LVDD) being common findings. These echocardiographic abnormalities demonstrate a strong correlation with COPD severity, highlighting the need for routine cardiovascular assessment. Echocardiography serves as a valuable tool for early detection of cardiac complications in COPD patients. Given the increased prevalence of pulmonary hypertension and structural cardiac changes, regular screening every six months is recommended to facilitate timely intervention and reduce morbidity. Early diagnosis and appropriate management can significantly improve clinical outcomes and quality of life in COPD patients, preventing further cardiac deterioration.

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