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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. Turkish Thoracic Society Meeting Antalya, Turkey April 2008. Gökhan M. Mutlu, M.D. Pulmonary and Critical Care Medicine Northwestern University Feinberg School of Medicine.

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

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  1. The impact and treatment of cardiac morbidity in COPD patients and its effect on weaning Turkish Thoracic Society Meeting Antalya, Turkey April 2008 Gökhan M. Mutlu, M.D. Pulmonary and Critical Care Medicine Northwestern University Feinberg School of Medicine Financial Disclosure: Nothing to disclose

  2. COPD and Cardiovascular disease • Ischemic heart disease • Pulmonary hypertension and right heart failure • Congestive heart failure • Atrial fibrillation

  3. 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 1991:133:795-800 Jousilahti P, et al. Lancet 1996;348:567-72Janssens, JP, et al. J Am Geriatr Soc 2001;49:571=6

  4. FEV1 and cardiovascular disease Sin DD and Man SFP. Proc Am Thorac Soc 2005;2:8-11

  5. COPD and cardiovascular disease 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

  6. COPD and cardiovascular disease 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.

  7. COPD and cardiovascular disease 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.

  8. COPD and cardiovascular disease 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

  9. COPD and cardiovascular disease Relative risk 2.09 2.32 2.14 3.75 1.33 CHF Stroke Angina Acute MI Any CVD

  10. COPD and cardiovascular disease 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

  11. COPD and cardiovascular disease The Lung Health Study* • For every 10% decrease in FEV1 % increase 20 14 28 All cause mortality CV mortality Non-fatal Coronary event *Anthonisen NR, et al. AJRCCM 2002;166:333-9

  12. 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;273:1945-9 Hurford WE, et al. Anesthesiology 1991;74:1007-16 Lemaire F, et al. Anesthesiology 1988;69:171-9 Hurford 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

  13. Myocardial ischemia in ICU patients Booker, KJ, et al. Am J Crit Care 2003;12:508-17 76 consecutive patients ST segment monitoring with 12-lead EKG Serum troponin I within 8-12 hours of admission Results: 8 patients (10.5%) had ischemic events

  14. Myocardial ischemia in ICU patients Booker, KJ, et al. Am J Crit Care 2003;12:508-17 Events 32 37 35 12 Silent ST changes Ischemic events Troponin-I

  15. Myocardial ischemia in ICU patients • Demand ischemia is more common that acute coronary syndrome (ACS) • Differentiating demand ischemia from ACS Demand ischemia- ST-segment depression ACS- ST-segment elevation

  16. 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

  17. Cardiovascular changes during SBT • Increased venous return Increased RV and LV preload • Increased LV afterload • Increased catecholamines Increased heart rate Increased contractility • Increased total body oxygen consumption VO2 increases by 15-25% Comparison Walking 3 mph- 100% increase Fever (from 37 to 39C)- 20% increase

  18. Myocardial ischemia Myocardial O2 supply Myocardial O2 demand Myocardial ischemia

  19. 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

  20. Myocardial ischemia during SBT 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

  21. Myocardial ischemia during SBT 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%

  22. Myocardial ischemia during SBT 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

  23. Pre-SBT During SBT Chatila W, et al. Chest 1996;109:1577-83

  24. Myocardial ischemia during SBT Chatila W, et al. Chest 1996;109:1577-83 • Results 6 developed ischemia 3 symptomatic (distress and chest pain) All patients except one had known history of CAD ST segment changes occurred in 10% of patients with CAD 2% of patients without CAD 22% in those with CAD and failed extubation Changes occurred within 10-15 minutes

  25. 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 pressure Decreased cardiac index Increased systemic blood pressure Increased PAOP (from 8 to 25 mmHg) Development of pulmonary edema 9 out of 15 were successfully extubated after optimization of cardiac status

  26. Hemodynamic changes during SBT • 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

  27. Hemodynamic changes during SBT 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

  28. Hemodynamic changes during SBT • Success group • SvO2 did not change after MV is discontinued • Increased CI and O2 transport Failure group • SvO2 fell after MV is discontinued • No increase in CI or O2 transport • Increased O2 extraction • LV and RV afterload increased

  29. LV function during weaning in COPD • Prospective study • 12 patients with no documented CAD • Increased inspiratory pressure decreased the reduction in LVEF Richard C, et al. Intensive Care Med 1994;20:181-6 LVEF (%) Pre-SBT During SBT

  30. 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

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