European Journal of Cardiovascular Medicine

Chronic obstructive pulmonary disease (COPD) is a progressive, debilitating respiratory disorder characterized by persistent airflow limitation and chronic inflammatory responses in the airways and lungs, usually caused by significant exposure to noxious particles or gases, most commonly tobacco smoke ⁽¹⁾. It remains a major public health concern worldwide, ranking as the third leading cause of death globally, and is associated with considerable morbidity, mortality, and healthcare burden ⁽²⁾. Beyond its impact on pulmonary function, COPD is increasingly recognized as a systemic disease with significant extrapulmonary manifestations, particularly affecting the cardiovascular system ⁽³⁾.

The intricate interplay between pulmonary pathology and cardiovascular complications in COPD has been a subject of growing interest. Chronic hypoxemia, pulmonary hypertension, and right ventricular dysfunction, often termed “cor pulmonale,” are well-documented sequelae that profoundly influence the prognosis of these patients ^(4,5). Electrocardiography (ECG) and echocardiography (ECHO) are valuable, non-invasive tools that can detect early cardiac changes in COPD, including right atrial enlargement, right ventricular hypertrophy, altered ventricular filling, and pulmonary arterial pressure elevation ^(6,7).

Several studies have shown that ECG findings, such as P pulmonale, right axis deviation, and evidence of right ventricular strain, are frequently observed in patients with moderate to severe COPD, often correlating with the degree of pulmonary hypertension ⁽⁸⁾. Echocardiographic assessment provides complementary insights, allowing direct evaluation of chamber dimensions, wall thickness, systolic and diastolic function, and estimation of pulmonary arterial pressure, thereby helping in the early recognition of right heart involvement before overt clinical manifestations appear ^(9,10).

Given the substantial overlap between pulmonary and cardiac morbidity in COPD, systematic evaluation of electrocardiographic and echocardiographic changes is essential for comprehensive disease management. Understanding these patterns not only aids in early diagnosis of cardiovascular complications but also has important implications for prognosis and therapeutic interventions.

Aim and Objectives

Aim

To evaluate the electrocardiographic and echocardiographic changes in patients with chronic obstructive pulmonary disease (COPD) and to explore their association with disease severity.

Objectives

1. a) To identify common electrocardiographic abnormalities in COPD patients, such as P pulmonale, right axis deviation, right ventricular hypertrophy, and conduction disturbances.
2. b) To assess echocardiographic parameters including right ventricular dimensions, systolic and diastolic function, pulmonary artery pressure, and left ventricular involvement.
3. c)To correlate electrocardiographic and echocardiographic findings with the clinical severity of COPD, as classified by spirometric indices and GOLD criteria.
4. d)To highlight the importance of early recognition of cardiac involvement in COPD for improving prognosis and guiding therapeutic strategies.

Study Design and Setting

This was a hospital-based, cross-sectional observational study conducted in the Department of Medicine, pharmacology and Pulmonology at Konaseema institute of medical sciences Amalapuram AP, a tertiary care centre, over a period of January 2024 to July 2025. Ethical clearance was obtained from the Institutional Ethics Committee prior to initiation of the study, and written informed consent was taken from all participants in accordance with the Declaration of Helsinki ⁽¹¹⁾.

Study Population

Patients aged ≥40 years, diagnosed with chronic obstructive pulmonary disease (COPD) based on clinical features and spirometry according to Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines ⁽¹²⁾, were enrolled. Diagnosis was confirmed by post-bronchodilator FEV1/FVC ratio <0.70 on spirometry.

Inclusion criteria

Clinically and spirometrically confirmed COPD patients.

Stable cases without acute exacerbation for at least 4 weeks before enrolment.

Exclusion criteria

Patients with known primary cardiac diseases (e.g., ischemic heart disease, congenital heart disease, valvular heart disease).

History of systemic hypertension, diabetes mellitus, or other chronic systemic illnesses affecting cardiovascular status.

Patients with poor echocardiographic window or uninterpretable ECG.

Clinical and Laboratory Evaluation

Detailed history including smoking status, biomass fuel exposure, occupational history, and comorbidities was obtained. Physical examination included general, respiratory, and cardiovascular system assessment. COPD severity was classified according to GOLD stages ⁽¹²⁾. Routine laboratory investigations were done to rule out associated systemic illness.

Electrocardiographic Evaluation

A standard 12-lead electrocardiogram (ECG) was performed on all patients at rest using [Machine Model, Manufacturer]. ECG parameters studied included P-wave morphology (P pulmonale), QRS axis, right ventricular hypertrophy (RVH), right atrial enlargement, right bundle branch block (RBBB), and evidence of right ventricular strain, as per established criteria ^(13,14).

Echocardiographic Evaluation

Two-dimensional echocardiography with Doppler was performed using [ECHO machine model, Manufacturer]. Parameters assessed included:

Right atrial and right ventricular dimensions.

Right ventricular systolic pressure (RVSP) estimated from tricuspid regurgitation jet velocity.

pulmonary artery systolic pressure (PASP).

Left ventricular ejection fraction (LVEF), interventricular septal motion, and diastolic function.

Echocardiography was performed in accordance with the recommendations of the American Society of Echocardiography ⁽¹⁵⁾.

Statistical Analysis

Data were entered in Microsoft Excel and analyzed using [SPSS version 13 software]. Continuous variables were expressed as mean ± standard deviation (SD) and categorical variables as percentages. Chi-square test was applied for categorical data and Student’s t-test/ANOVA for continuous data. Correlation between echocardiographic and electrocardiographic findings with COPD severity was evaluated using Pearson’s correlation coefficient. A p-value <0.05 was considered statistically significant

A total of 60 patients with COPD were studied. The mean age was 58.4 ± 9.2 years, and the majority were male (46 males, 14 females; M:F = 3.3:1). Most patients (78.3%) had a history of smoking, while 21.7% were exposed to biomass fuel.

Clinical and Spirometric Characteristics

Based on GOLD criteria, 20 patients (33.3%) were in stage II (moderate), 26 patients (43.3%) in stage III (severe), and 14 patients (23.3%) in stage IV (very severe). The mean post-bronchodilator FEV1 was 1.18 ± 0.4 L (46.5% predicted).

Table 1. Baseline demographic and spirometric characteristics of study population (n = 60)

Electrocardiographic Findings: -

Electrocardiographic abnormalities were noted in 42 of 60 patients (70%). The most frequent abnormality was P pulmonale, observed in 24 patients (40%). Right axis deviation was present in 18 patients (30%), while right ventricular hypertrophy (RVH) was found in 16 patients (26.7%). Right bundle branch block (RBBB) occurred in 8 patients (13.3%), and right ventricular strain pattern in 10 patients (16.7%). The prevalence of abnormalities was higher in patients with GOLD stage III and IV compared to stage II.

Table 2. Distribution of ECG abnormalities in COPD patients (n = 60)

Echocardiographic Findings: - Echocardiographic abnormalities were present in 36 patients (60%). Right atrial enlargement was found in 18 patients (30%), while right ventricular dilatation was seen in 20 patients (33.3%). Pulmonary hypertension was detected in 28 patients (46.7%), with a mean estimated right ventricular systolic pressure (RVSP) of 47.5 ± 8.6 mmHg.

Left ventricular systolic dysfunction was noted in only 6 patients (10%), but diastolic dysfunction was present in 12 patients (20%), predominantly in severe and very severe COPD cases. Interventricular septal motion abnormalities were seen in 8 patients (13.3%).

Table 3. Echocardiographic abnormalities in COPD patients (n = 60)

Correlation with Disease Severity

Both electrocardiographic and echocardiographic abnormalities increased with COPD severity. P pulmonale and RVH were observed in 60–70% of GOLD stage IV patients, compared to 15–20% of stage II. Similarly, pulmonary hypertension was present in 71.4% of stage IV patients, 50% of stage III, and only 25% of stage II.

Pearson’s correlation analysis demonstrated a significant negative correlation between FEV1 and pulmonary artery systolic pressure (r = –0.46, p < 0.01).

In this hospital-based cross-sectional study of 60 COPD patients, we observed a high prevalence of both electrocardiographic and echocardiographic abnormalities. These findings highlight the significant cardiovascular burden associated with COPD, particularly in advanced stages of the disease. Our observations are in agreement with previous reports demonstrating the effect of chronic hypoxemia and pulmonary vascular remodeling on right heart structure and function ^(16,17).

Electrocardiographic Findings: -

Electrocardiographic abnormalities were present in 70% of our study population. P pulmonale was the most frequent finding (40%), followed by right axis deviation (30%) and right ventricular hypertrophy (26.7%). Similar trends have been reported in earlier Indian and international studies, where P pulmonale and RVH were found in up to 35–45% of COPD patients ^(18,19). Right bundle branch block (13.3%) and RV strain pattern (16.7%) were less common but were predominantly associated with GOLD stage III and IV disease, a pattern also described in earlier literature ⁽²⁰⁾.

Echocardiographic Findings: -

Echocardiographic evaluation revealed cardiac changes in 60% of patients. Pulmonary hypertension was detected in 46.7% of cases, with a mean RVSP of 47.5 ± 8.6 mmHg. This prevalence aligns with earlier reports, where pulmonary hypertension was seen in 40–65% of COPD patients ^(21,22). Right ventricular dilatation (33.3%) and right atrial enlargement (30%) were also consistent with findings by Hilde et al. ⁽²³⁾.

Left ventricular systolic dysfunction was less frequent (10%), but diastolic dysfunction (20%) and septal motion abnormalities (13.3%) were notable. These findings are supported by Vonk-Noordegraaf et al. ⁽²⁴⁾, who demonstrated that right ventricular pressure overload in COPD can impair left ventricular filling through ventricular interdependence.

Correlation with COPD Severity

A clear relationship was noted between disease severity and cardiac abnormalities. In our study, pulmonary hypertension was present in 71.4% of GOLD stage IV patients, compared to 25% in stage II. Similarly, P pulmonale and RVH were more frequent in severe and very severe COPD. A significant negative correlation was observed between FEV1 and PASP (r = –0.46, p < 0.01), consistent with findings from Oswald-Mammosser et al. ⁽²⁵⁾.

These results reaffirm that cardiovascular involvement progresses with worsening COPD and underline the prognostic value of cardiopulmonary interaction in these patients.

Clinical Implications: -

The coexistence of COPD and cardiac dysfunction poses significant challenges in patient management. Cardiac abnormalities contribute to exercise intolerance, recurrent hospitalizations, and increased mortality. Early identification of ECG and echocardiographic changes is therefore crucial for timely intervention. Incorporating routine cardiac evaluation into COPD care pathways may improve outcomes, particularly in those with severe disease ⁽²⁶⁾.

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