| Abstract | Plućna hipertenzija utječe na klinički tijek pacijenata sa kroničnom opstruktivnom bolesti jer smanjuje funkcijski kapacitet, povećava rizik egzacerbacija i mortalitet.
Najčešće korištena i najdostupnija metoda za procjenu postojanja plućne hipertenzije jest ehokardiografija, no, u ove skupine pacijenata, ona je često netočna ili onemogućena neadekvatnim ehokardiografskim prozorom uslijed hiperinflacije plućnog parenhima.
Cilj ovog istraživanja bio je utvrditi omjer širine plućne arterije i aorte u bolesnika sa KOPB-om stadija C i D, te ispitati korelaciju između omjera PA/A i stupnja težine kronične opstruktivne plućne bolesti. U ispitivanju smo ispitali korelaciju omjera širine plućne arterije i aorte sa učestalošću plućne hipertenzije, te procjenili odnos omjera širine plućne arterije i aorte s ehokardiografski utvrđenim parametrima disfunkcije desne klijetke.
U ovo prospektivno istraživanje uključeno je inicijalno 100 pacijenata, no, nakon isključivanja zbog nepravodobno učinjene obrade, te dodatnom redukcijom zbog isključnih kriterija istraživanja, u ispitivanje je uključeno 66 pacijenata koji su hospitalizirani na Klinici za plućne bolesti Jordanovac, KBC-a Zagreb. Skupinu bolesnika činili su bolesnici sa dijagnozom kronične opstruktivne plućne bolesti (prema GOLD-u stupnja C i D) koji su u kontroli Ambulante za opstruktivne plućne bolesti Klinike za plućne bolesti Jordanovac, KBC Zagreb.
Medijan životne dobi pacijenata iznosio je 58.5 (48-66) godina, a 54 % (36/66) pacijenata bilo je muškog spola.
U skupini bolesnika s PH, FEV1 je iznosio 32,5 ± 15 %, a u kontrolnoj skupini 33.7 ± 19 %.
Nakon provedene kateterizacije desnog srca i određivanja tlakova u plućnoj cirkulaciji, bolesnici su razvrstani u dvije skupine, ovisno o vrijednostima srednjeg tlaka u plućnoj arteriji.
Između ispitivanih skupina nije nađeno značajniih razlika u sociodemografskim i kliničkim plućnim karakteristikama (broj egzacerbacija KOPB-a, stupanj opstrukcije, pušački status, CAT upitnik). Značajne razlike utvrđene su u određivanju stupnja zaduhe mMRC upitnikom i oodređivanjem BODE indeksa, te difuzije (p=0.043, p=0.006, p=0.09).
Testiranje funkcionalnog statusa šest-minutnim testom hoda ukazalo je na slabiji funkcionalni kapacitet ispitanika sa plućnom hipertenzijom (125 m ± 349 m) u usporedbi sa skupinom bez plućne hipertenzije (180 m ±230 m), no bez dostizanja statističke značajnosti.
Procjenom širine plućne arterije kompjuteriziranom tomografijom utvrdili smo prosječnu širinu plućne arterije 27.5 ± 10.5 mm u kontrolnoj skupini, a 36.1 ± 27 mm u skupini pacijenata sa PH.
U širini same aorte nije bilo statistički značajnih razlika među skupinama.
Omjer širine plućne arterije i aorte iznosio je 0.80 ± 0.21 u kontrolnoj skupini, a 1.06 ± 0.61 u skupini pacijenata sa PH (p<0.001). U podskupinama bolesnika klasificiranih prema GOLD-u u skupine C i D, nismo našli statistički značajne razlike u omjerima PA/A u ove dvije grupe pacijenata.
Utvrdili smo da omjer širine plućne arterije i aorte veći od 0.95, a dobiven neinvazinim oslikavanjem kompjuteriziranom tomografijom jest neovisni predskazatelj postojanja plućne hipertenzije u bolesnika sa višim stupnjevima KOPB-a (ROC 0.88, 95 % CI, 0.78 do 0.95, p<.001).
Usporedbom omjera širine plućne arterije i aorte s ehokardiogarfski utvrđenim parametrima disfunkcije desne klijetke nađeni su značajni pozitivni korelacijski koeficijenti sa vrijednostima sPAP-a, RA, RAVI, RVs, RVOTprox, Rvbas, MPI, a značajni negativni koeficijenti dobiveni su za PVAccT, RVOT-SF, RVFAC, RVS', te IVA.
Primjenom univarijantne binarne logističke regresije pokazano je da je najjači pozitivni prediktor plućne hipertenzije postojanje hipertrofije slobodnog zida desne klijetke uz OR=33.03; 95% CI=3.66 – 298.15; p=0.002, a da je upravo IVA najznačajniji negativni prediktor plućne hipertenzije (OR=0.003, 95% CI = 0.001-0.06, p<0.001).
Utvrđivanjem omjera širine plućne arterijei aorte većeg od 0.95 mjerenog kompjuteriziranom tomografijom u pacijenata sa KOPB-om, a uz upotrebu ehokardiografskih parametara koji pokazuju dobru korelaciju sa povišenim srednjim tlakom u plućnoj arteriji, omogućava se pravovremeno postavljanje indikacije za kateterizaciju desnog srca jer je vjerojatnost postojanja plućne hipertenzije dovoljno visoka da opravda nastavak obrade invazivnim metodama. |
| Abstract (english) | Pulmonary hypertension affects the clinical course in patients with chronic obstructive disease because it lowers functional capacity, increases the risk of exacerbation and mortality.
Most commonly used and available method for the assessment of the existence of pulmonary hypertension is echocardiography, but for this patient group it is often inaccurate or impeded by inadequate echocardiographic window due to hyperinflation of pulmonary parenchyma.
The goal of this research was to establish the ratio between the diameter of the pulmonary artery and that of the aorta in patients with COPD in stages C and D and to assess the correlation between the PA/A ratio and the severity of the chronic obstructive pulmonary disease. The research examined the correlation between the ratio of the diameter of the pulmonary artery to the diameter of the aorta and the frequency of pulmonary hypertension and assessed the relation of the ratio between the diameter of the pulmonary artery and that of the aorta with echocardiographic parameters of the dysfunction of the right ventricle.
This prospective research initially included 100 patients, but after exclusion due to untimely treatment and an additional reduction due to excluded research criteria, research included 66 patients who were hospitalized in the Clinical Center for Pulmonary Diseases Jordanovac of the University Hospital Center Zagreb. Patient group comprised those diagnosed with chronic obstructive pulmonary disease (GOLD stages C and D), treated in the Department for Obstructive Pulmonary Disease of the Clinical Center for Pulmonary Diseases Jordanovac of the University Hospital Center Zagreb.
Median patient age was 58.5 (48-66) years, and 54% (36/66) were male.
FEV1 was 32.5 ± 15% in the PH patient group, and 33.7 ± 19% in the control group.
After right heart catheterization and measurement of pressure in pulmonary circulation, patients were classified in two groups according to mean pulmonary artery pressure. No significant differences were found between examined groups in terms of socio-demographic and clinical pulmonary characteristics (COPD exacerbation count, level of obstruction, smoking status, CAT questionnaire). Significant differences were found in determining the degree of dyspnea using the mMRC scale and establishing the BODE index and diffusion (p=0.043, p=0.006, p=0.09).
Functional testing using six-minute walk test indicated the weaker functional capacity in subjects with pulmonary hypertension (125 m ± 349 m) versus those without pulmonary hypertension (180 m ± 230 m), but without reaching statistical relevance.
By assessing the diameter of pulmonary artery using computed tomography, we established the average diameter of the pulmonary artery 27.5 ± 10.5 mm in the control group, and 36.1 ± 27 mm in the PH patient group.
There were no statistically relevant differences between groups in terms of aorta diameter.
The ratio of the pulmonary artery diameter to that of aorta was 0.80 ± 0.21 in the control group, and 1.06 ± 0.61 in the PH patient group (p<0.001). In subgroups of patients classified using GOLD stages C and D, no statistically relevant differences in the PA/A ratios were found in these two patient groups.
We have established that the ratio of the pulmonary artery diameter to that of aorta higher than 0.95, obtained using non-invasive computed tomography imaging, is an independent indicator of the existence of pulmonary hypertension in patients with COPD in higher stages (ROC 0.88, 95 % CI, 0.78 to 0.95, p<.001).
Comparison of the ratio of the pulmonary artery diameter to that of aorta with echocardiographic parameters of the dysfunction of the right ventricle showed significant positive correlation coefficients with sPAP, RA, RAVI, RVs, RVOTprox, Rvbas, and MPI values, and significant negative coefficients were obtained for PVAccT, RVOT-SF, RVFAC, RVS', and IVA.
Univariate binary logistic regression showed that the strongest positive predictor of the pulmonary hypertension is the existence of hypertrophy of the right ventricular free wall with OR=33.03; 95% CI=3.66 – 298.15; p=0.002, and that IVA is the most relevant negative predictor of the pulmonary hypertension (OR=0.003, 95% CI = 0.001-0.06, p<0.001).
Establishment of the ratio of the pulmonary artery diameter to that of aorta higher than 0.95 using computed tomography in patients with COPD and using echocardiographic parameters showing good correlation with increased mean pressure in pulmonary artery allow for timely indication for right heart catheterization because the probability of the existence of pulmonary hypertension is high enough to justify further treatment with invasive methods. |
