Edema nelle fasi avanzate della BPCO: cuore polmonare cronico o scompenso cardiaco? Stefano Carlone Direttore UOC Malattie Apparato Respiratorio Roma

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Valentina Gatto
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1 Edema nelle fasi avanzate della BPCO: cuore polmonare cronico o scompenso cardiaco? Stefano Carlone Direttore UOC Malattie Apparato Respiratorio Roma

2 Caso clinico A Paziente di 65 anni, con diagnosi certa di BPCO Dispnea di 3-4 grado Ortopnea Turgore delle giugulari Epatomegalia Edema agli arti inferiori Insufficienza respiratoria ipossiemica po2 48 pco2 34 mmhg ph 7.47 PFR = Deficit ventilatorio di tipo misto ECG = FA ad alta frequenza segni di ischemia antero-laterale BNP = 1350 pg/ml

3 Diagnosi: Scompenso cardiaco congestizio in cardiopatia dilatativa ischemica in paziente affetto da BPCO

4 Caso clinico B Paziente di 71 anni con diagnosi certa di BPCO Dispnea di 4 grado Turgore delle giugulari Epatomegalia Edema agli arti inferiori Insufficienza respiratoria ipossiemica e ipercapnica po2 44 pco2 78 mmhg ph 7.31 PFR = Deficit ventilatorio di tipo ostruttivo di grado severo (VEMS 40% del valore teorico, Indice di Tiffenau 60%) ECG = Tachicardia sinusale, P polmonare BNP = 285 pg/ml

5 Diagnosi: Cuore polmonare in paziente affetto da BPCO

6 COPD: a multi-component airway disease Inflammation Muco-ciliary dysfunction Loss of elastic recoil (emphysema) Airway remodelling (chronic bronchitis) Hyperinflation Dyspnea Reduced exercise tolerance Systemic effects

8 Eventi cardiovascolari prevalenti nella BPCO Coronaropatie 15.2% Aritmie 25-30% FA e fibrillo-flutter Extrasistolia sopra e ventricolare Tachicardia sinusale Tachiaritmie Fibrillazione ventricolare Ipertensione arteriosa 39.6% Scompenso cardiaco 20% Ipertensione polmonare 90% al III stadio Edema (cuore polmonare) 48% al III stadio

9 INDACO Study Comorbidity prevalence in 547 COPD pts 51.3 Cardiovascular comorbidities Metabolic syndrome 18,5 8.4 Diabetes Cardiac ischemia 12.2 Anxiety Depression Hypertension Cancers (All) Heart failure Lung cancer None

10 Ageing of the population increases the prevalence of chronic diseases, including cardiovascular diseases, cancer, chronic respiratory diseases and metabolic syndrome in developed countries with a substantial economic and social burden. Almost half of all elderly people (> 65 yrs) have at least three chronic medical conditions and one fifth have five or more.

11 Comorbidities affect health outcomes in COPD Patients with COPD mainly die of nonrespiratory diseases such as cardiovascular diseases (25%), cancer (mainly lung cancer, 20-33%) and other causes (30%). Respiratory diseases (mainly respiratory failure due to COPD excerbations) account for 4-35% of deaths.

12 COPD e CV risk In mild to moderate COPD three times as many hospital admissions in this patient group are for cardiovascular than for pulmonary causes. In the Lung Health Study, 25% of deaths were due to CV disease In the TORCH study the proportion was 27% In a systematic review of the literature (> pts) reduced FEV1 nearly doubles the risk for CV mortality independent of confounders as age, smoking, etc For every 10% decrease of FEV1, CV mortality increased by 28%, and nonfatal coronary event increased by almost 20%, after adjustments for confounders as age, sex, smoking status, cholesterol and hypertension Sin Proc Am Thor Soc 2005 Anthonisen AJCRCM 2002

13 COPD is frequently associated with chronic heart failure (CHF) (> 20%) and metabolic syndrome (hypertension, diabetes, dyslipidemia, obesity, insulin resistance, proinflammatory state ( CRP) and a prothrombotic state

14 Major risk factors for chronic disease expecially COPD and CHF: Cigarette smoking Obesity Cigarette smoking is associated with: Lung and systemic inflammation Systemic oxidative stress Marked changes of vasomotor and endothelial function Enhanced circulating concentrations of several procoagulant factors Obesity is associated with: Insulin resistance Oxidative stress Increased concentrations of various (adipo) cytokines and inflammatory markers (CRP) Endothelial dysfunction

15 Eur Respir J 2009

21 Caso B: Terapia Broncodilatazione: beta agonisti short acting e long acting, anticolinergici (riduzione della CO 2 ) Ossigeno terapia Diuretici? Digitale? Riabilitazione

22 Adverse cardiovascular events by b 2 agonist use in COPD patients Myocardial infarction Congestive hearth failure Cardiac arrest and acute cardiac death Increase of heart rate and decrease of potassium concentration, associated with other effect of b-adrenergic stimulation may precipitate ischemia, congestive heart failure, arrythmias and sudden death S.R. Salpeter, Chest 2004, 125:

23 Caso A: Terapia Diuretici Digitale? ACE inibitori Ossigeno terapia Beta bloccanti cardioselettivi

24 β-blockers The ßB has traditionally been contraindicated in COPD mainly because of anecdotal evidence and case reports citing acute bronchospasm after their administration

26 Assessing the effects (mortality, hospital admissions, and COPD exacerbations) of BB therapy on 5977 COPD patients on top of standard therapy with a mean follow-up of 4.35 years. BMJ 2011;342:d2549

27 Kaplan-Meier survival curves among patients with COPD by use of β blockers 22% overall reduction in all cause mortality for COPD patients taking BB in addition to standard therapy for COPD. BMJ 2011;342:d2549

29 Why BB may improve outcomes in HF and COPD patients? Up-regulation of β2 adrenoceptors by chronic β blockade may improve the effectiveness of β2 agonists (cardioselective β blockers such as bisoprolol, have been shown to exert significant β2 adrenoceptor antagonism, resulting in β2 adrenoceptor upregulation). Cardioprotective effects of β blockade (decrease in oxygen consuption, increase diastolic filling, antioxidant properties)

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