Subclinical impairment of lung function is related to mild cardiac dysfunction and manifest heart failure in the general population
Introduction
Lung and heart diseases share common risk factors. Chronic obstructive pulmonary disease (COPD) and heart failure are common comorbidities [1]. In both, dyspnea is the main clinical symptom. Impairment of lung function may cause symptoms of heart failure (HF), although no cardiovascular or structural heart disease is present. In patients with COPD, diastolic dysfunction seems to be frequent. It has been explained by shortened diastolic filling due to medication-induced elevated heart rate (β2 agonists, theophylline), hypoxemia and reduced preload [2]. In severe COPD, parenchymal destruction and hypoxic vasoconstriction cause elevated pulmonary vascular resistance leading to right heart failure and consequently to a reduction of left ventricular filling, stroke volume and cardiac output [3], [4]. In addition, the left ventricle may be directly compromised. Hyperinflation with consequent elevated intrathoracic pressure, as seen with increasing severity of COPD, is associated with decreasing cardiac chamber size [5]. Even in mild pulmonary impairment, an affection of left ventricular performance can be observed, e.g. a linear association of decreasing FEV1/FVC ratio and increasing emphysema with left ventricular end-diastolic volume (LVEDV), stroke volume (SV) and cardiac output has been shown [6].
Little is known about the relation of mild or subclinical lung function impairment with left ventricular measurements and heart failure. Some studies have reported, that moderately reduced FEV1 was associated with an increased incidence of HF in middle aged men [7], in older [8] and middle aged community-based individuals [9]. Impaired pulmonary function in young adulthood precedes left ventricular dysfunction in later life [10].
Since the cardio-pulmonary interplay is a continuum, we hypothesized that mild impairment of pulmonary function is related to echocardiographic measures of left ventricular systolic and diastolic dysfunction and heart failure in the general population. We further hypothesized that the associations would not change after exclusion of individuals with manifest COPD.
Section snippets
Study participants
The Gutenberg Health Study (N = 15010) started in 2007 as a population-based, prospective, single-center cohort study in the Rhine-Main region in western mid Germany [11]. Individuals between 35 and 74 years were randomly selected from the governmental local registry offices and equally stratified by sex and residence for each age decade and invited to take part in a five-hour study visit at the University Medical Center of the Johannes Gutenberg-University Mainz. Standardized interviews were
Results
The baseline characteristics of the study are presented in Table 1. The median age was 55 years (25th/75th percentile 46/65 years), 50.5% males. Current smoking was observed in 19.4%, the median FEV1/FVC ratio was 78.9% and COPD occurred in 8.1%. The median left ventricular ejection fraction (EF) was 63.4%, 3.7% of the study participants had heart failure. According to the definition of Paulus et al. 2007 [12], 468 individuals had HFpEF. Of them, 59 had mild, 166 moderate and 1 severe diastolic
Discussion
In our large population-based cohort in middle-aged individuals we could demonstrate an association of pulmonary function variables with echocardiographically determined cardiac structure and performance. %pred. FEV1, FVC and FEV1/FVC ratio showed significant correlations with left ventricular end-diastolic dimensions, stroke volume and left ventricular ejection fraction. Strong associations were observed for manifest heart failure, HFpEF as well as HFrEF.
Negative effects of chronic pulmonary
Conclusion
In conclusion, the impact of COPD on the heart has repeatedly been published in the past. Associations at the population level are less well established. With our data we can extend prior observations towards associations with mild diastolic and systolic dysfunction and heart failure with good power at the upper and lower limits of normal pulmonary and cardiac function. In the middle-aged general population mild alterations in lung function are related to measurable echocardiographic changes
Funding sources
The Gutenberg Health Study is funded through the government of Rhineland-Palatinate (“Stiftung Rheinland-Pfalz für Innovation”, contract AZ 961-386261/733), the research programs “Wissen schafft Zukunft” and “Center for Translational Vascular Biology (CTVB)” of the Johannes Gutenberg-University of Mainz, and its contract with Boehringer Ingelheim and PHILIPS Medical Systems, including an unrestricted grant for the Gutenberg Health Study. Philipp S. Wild is funded by the Federal Ministry of
Conflicts of interest
None declared.
Acknowledgements
We thank the participants and dedicated study staff of the Gutenberg Health Study for their generous contribution of time and efforts.
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- 1
DZHK (German Center for Cardiovascular Research), partner site Hamburg/Kiel/Lübeck, Germany.
- 2
DZHK (German Center for Cardiovascular Research), partner site RhineMain, Mainz, Germany.