Cardiac Considerations in Chronic Lung Disease 2020

Respiratory Medicine
Series Editors: Sharon I.S. Rounds · Anne Dixon · Lynn M. Schnapp
Surya P. Bhatt Editor
Cardiac
Considerations
in Chronic
Lung Disease
Series Editors
Sharon I.S. Rounds
Alpert Medical School of Brown University
Providence, RI, USA
Anne Dixon
University of Vermont, Larner College of Medicine
Burlington, VT, USA
Lynn M. Schnapp
University of Wisconsin - Madison
Madison, WI, USA
More information about this series at http://www.springer.com/series/7665

Surya P. Bhatt
Editor
Cardiac Considerations
in Chronic Lung Disease
Editor
Surya P. Bhatt
Division of Pulmonary, Allergy and Critical Care Medicine
University of Alabama at Birmingham
Birmingham, AL
USA
ISSN 2197-7372 ISSN 2197-7380 (electronic)

ISBN 978-3-030-43434-2 ISBN 978-3-030-43435-9 (eBook)
https://doi.org/10.1007/978-3-030-43435-9
© Springer Nature Switzerland AG 2020

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Preface
With the reduction in mortality attributable to cardiovascular disease in the devel-

oped world, the burden of chronic lung disease is becoming increasingly apparent.
Globally, respiratory diseases are amongst the leading causes of mortality.
Significant challenges exist in the prevention, diagnosis, and treatment of chronic
lung disease. There is now growing awareness that chronic lung disease is a distinct
risk factor for cardiovascular disease, akin to immunologic diseases such as rheu-
matoid arthritis and systemic lupus erythematosus. Given the overlapping symp-
toms and signs, considerable challenges exist in the recognition of cardiovascular
disease in the presence of chronic lung disease. This book aims to increase aware-
ness of this important comorbidity in individuals with chronic lung disease. The
individual chapters address important issues including the epidemiology of cardio-
vascular disease in the presence of chronic lung disease, as well as factors to con-
sider when diagnosing one in the presence of the other (Chap. 1). Peak lung function
is usually attained in the third decade of life, and there is now growing awareness
that a substantial number of individuals never reach optimal lung function. Chapter
2 discusses the early life origins of both cardiac and pulmonary diseases and their
interactions. There appear to be substantial gender differences in both lung and
heart diseases, and these are discussed in Chap. 3. The pathophysiologic mecha-
nisms of increased risk for coronary artery disease and left ventricular dysfunction
are not fully understood and are discussed in Chap. 4. Chapter 5 addresses the
pathophysiology of right heart dysfunction in the presence of chronic lung disease.
A substantial number of individuals with chronic lung disease develop pulmonary
hypertension for which there are no disease-modifying therapies at present. Chapter
6 addresses treatment considerations for these individuals with secondary pulmo-
nary hypertension. Chapter 7 describes imaging modalities for the lung and the
heart. When both cardiac and lung diseases are present in the same individual, it can
be difficult to identify the predominant contributor to symptoms as well as their
relative contributions. Chapter 8 discusses the nuances of cardiopulmonary exercise
testing to help discern these aspects. Chapter 9 addresses heart-lung interactions
and how physiologic changes in one organ system affect the other. Most guidelines
recommend treating chronic lung disease and cardiac disease as they would usually
v
vi Preface
be treated regardless of the presence of heart-lung comorbidity. A number of cardiac

and pulmonary medications interact with each other and can result in adverse con-
sequences. Chapter 10 addresses medication safety. Chapter 11 addresses non-phar-
macologic therapy with exercise training and considerations involved in exercise
prescription. The course of chronic lung disease is frequently punctuated by acute
exacerbations, and a number of these are closely associated with cardiovascular
derangements. Chapter 12 addresses cardiac considerations in acute exacerbations
of chronic lung disease. Finally, when chronic lung disease is far advanced, lung
transplantation becomes the only remaining option. Chapter 13 addresses cardiac
considerations in individuals who are candidates for lung transplantation. We hope
that this broad range of topics addressing cardiac manifestations and considerations
in chronic lung disease will be helpful for both cardiologists and pulmonologists, as
well as primary care practitioners, who treat patients with these common diseases
that frequently coexist.
Birmingham, AL, USA Surya P. Bhatt, MD

Contents
1 Cardiovascular Comorbidity in Chronic Lung Disease:

Epidemiology, Clinical Manifestations, and Diagnosis�� 1
Surya P. Bhatt
2 Origins of Cardiopulmonary Disease in Early Life�� 17
Michael J. Cuttica and Ravi Kalhan
Gender Differences�� 25
Christine Jenkins
4 Pathophysiology of Cardiovascular Disease in Chronic
Lung Disease�� 45
Trisha M. Parekh and Mark T. Dransfield
5 Pathophysiology of Right Heart Disease in Chronic
Lung Disease�� 59
Indranee Rajapreyar and Deepak Acharya
6 Pulmonary Hypertension Associated with Chronic
Lung Diseases: Treatment Considerations�� 79
Jason Weatherald, David Montani, and Olivier Sitbon
7 Imaging in Chronic Lung Disease: Cardiac Considerations �� 97
Firdaus A. A. Mohamed Hoesein
The Role of Cardiopulmonary Exercise Testing �� 115
J. Alberto Neder, Alcides Rocha, Flavio F. Arbex, Mayron Oliveira,
Maria Clara N. Alencar, and Denis E. O’Donnell
9 Physiology of Heart-Lung Interactions�� 149
Alicia K. Gerke and Gregory A. Schmidt
vii
viii Contents
10 Medication Safety in Chronic Lung Disease with Cardiac

Comorbidity�� 161
Roy Pleasants
11 Cardiovascular Co-Morbidity in Chronic Lung Disease:
Exercise Training �� 213
Rachael A. Evans
12 Acute Exacerbations of Chronic Lung Disease:
Cardiac Considerations �� 229
Kate Milne and Don D. Sin
13 Lung Transplantation for Chronic Lung Disease:
Cardiac Considerations �� 247
Keith M. Wille, Tyler R. Reynolds, and Victoria Rusanov
Index�� 267
Contributors
Deepak Acharya, MD, MSPH Division of Cardiovascular Diseases, Sarver Heart

Center, University of Arizona, Tucson, AZ, USA
Maria Clara N. Alencar, PhD Pulmonary Function and Clinical Exercise
Physiology Unit (SEFICE), Division of Respirology, Federal University of Sao
Paulo, Sao Paulo, Brazil
Flavio F. Arbex, MD Pulmonary Function and Clinical Exercise Physiology Unit
(SEFICE), Division of Respirology, Federal University of Sao Paulo, Sao
Paulo, Brazil
Surya P. Bhatt, MD, MSPH Division of Pulmonary, Allergy and Critical Care
Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
Michael J. Cuttica, MD, MS Northwestern University, Feinberg School of
Medicine, Division of Pulmonary and Critical Care Medicine, Chicago, IL, USA
Mark T. Dransfield, MD Lung Health Center, Division of Pulmonary, Allergy,
and Critical Care, University of Alabama at Birmingham, Birmingham, AL, USA
Birmingham VA Medical Center, Birmingham, AL, USA
Rachael A. Evans, PhD National Institute of Health Research Biomedical
Research Centre, Respiratory Sciences, University of Leicester, Leicester, UK
Department of Respiratory Medicine, Thoracic Surgery and Allergy, Glenfield
Hospital, University Hospitals of Leicester NHS Trust, Leicester, UK
Alicia K. Gerke, MD University of Iowa, Department of Internal Medicine,
Division of Pulmonary Diseases, Critical Care, and Occupational Medicine, Iowa
City, IA, USA
Christine Jenkins, MD, FRACP Concord Hospital Sydney, Concord, NSW,
Australia
The George Institute for Global Health, Sydney, NSW, Australia
ix
x Contributors
Faculty of Medicine, UNSW Sydney, Sydney, NSW, Australia

University of Sydney, Sydney, NSW, Australia
Ravi Kalhan, MD, MS Northwestern University, Feinberg School of Medicine,
Division of Pulmonary and Critical Care Medicine, Chicago, IL, USA
Kate Milne, MD University of British Columbia (UBC) Division of Respiratory
Medicine (Department of Medicine) and Centre for Heart Lung Innovation, St.
Paul’s Hospital, Vancouver, BC, Canada
Firdaus A. A. Mohamed Hoesein, MD, PhD Department of Radiology, University
Medical Center Utrecht, University Utrecht, Utrecht, The Netherlands
David Montani, MD, PhD Université Paris-Sud, Faculté de Médecine, Université
Paris-Saclay, Le Kremlin-Bicêtre, France
Service de Pneumologie, Hôpital Bicêtre, AP-HP, Le Kremlin-Bicêtre, France
INSERM UMR_S 999, Hôpital Marie Lannelongue, Le Plessis Robinson, France
J. Alberto Neder, MD Laboratory of Clinical Exercise Physiology (LACEP),
Queen’s University & Kingston General Hospital, Kingston, ON, Canada
Respiratory Investigation UniT (RIU), Queen’s University & Kingston General
Hospital, Kingston, ON, Canada
Denis E. O’Donnell, MD Laboratory of Clinical Exercise Physiology (LACEP),
Queen’s University & Kingston General Hospital, Kingston, ON, Canada
Respiratory Investigation UniT (RIU), Queen’s University & Kingston General
Hospital, Kingston, ON, Canada
Mayron Oliveira, PT Pulmonary Function and Clinical Exercise Physiology Unit
Paulo, Brazil
Trisha M. Parekh, DO Lung Health Center, Division of Pulmonary, Allergy, and
Critical Care, University of Alabama at Birmingham, Birmingham, AL, USA
Roy Pleasants, PharmD Division of Pulmonary Diseases and Critical Care
Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
Pulmonary Department, Durham VA Medical Center, Durham, NC, USA
Indranee Rajapreyar, MD Section of Advanced Heart Failure, Pulmonary
Vascular Disease, Heart Transplantation, and Mechanical Circulatory Support,
Division of Cardiovascular Diseases, University of Alabama at Birmingham,
Birmingham, AL, USA
Tyler R. Reynolds Louisiana State University, Baton Rouge, LA, USA
Alcides Rocha, MD Pulmonary Function and Clinical Exercise Physiology Unit
Paulo, Brazil
Contributors xi
Victoria Rusanov, MD Department of Medicine, University of Alabama at

Birmingham, Birmingham, AL, USA
Gregory A. Schmidt, MD University of Iowa, Department of Internal Medicine,
Division of Pulmonary Diseases, Critical Care, and Occupational Medicine, Iowa
City, IA, USA
Don D. Sin, MD MPH University of British Columbia (UBC) Division of
Respiratory Medicine (Department of Medicine) and Centre for Heart Lung
Innovation, St. Paul’s Hospital, Vancouver, BC, Canada
Olivier Sitbon, MD, PhD Université Paris-Sud, Faculté de Médecine, Université
Paris-Saclay, Le Kremlin-Bicêtre, France
Jason Weatherald, MD University of Calgary, Department of Medicine, Division
of Respiratory Medicine, Calgary, AB, Canada
Libin Cardiovascular Institute of Alberta, Calgary, AB, Canada
Keith M. Wille, MD Department of Medicine, University of Alabama at
Birmingham, Birmingham, AL, USA
Chapter 1
Cardiovascular Comorbidity in Chronic
Lung Disease: Epidemiology, Clinical
Manifestations, and Diagnosis
Surya P. Bhatt
Clinical Pearls
• Strong epidemiologic data exist for the association between chronic lung
disease, especially chronic obstructive pulmonary disease, and the occur-
rence of cardiovascular disease, including atherosclerosis, coronary artery
disease, cerebrovascular disease, peripheral vascular disease, heart failure,
and cardiac arrhythmias.
• Chronic lung diseases and cardiovascular disease are both very prevalent,
but their coexistence is not explained by chance but by the risk of athero-
sclerosis and deranged cardiopulmonary interactions conferred by the
presence of chronic lung disease.
• A low index of suspicion should be maintained to evaluate for chronic lung
or cardiovascular disease when one of these is present, especially when
symptoms and functional impairment are deemed to be out of proportion
for the existing diagnosis.
Epidemiology
Chronic lung diseases account for a substantial amount of morbidity and dis-
ability. They are, however, frequently under-recognized and remain undiag-
nosed in a significant proportion of the population. The most common chronic
S. P. Bhatt (*)
Division of Pulmonary, Allergy and Critical Care Medicine,
University of Alabama at Birmingham, Birmingham, AL, USA
e-mail: sbhatt@uabmc.edu
© Springer Nature Switzerland AG 2020 1

S. P. Bhatt (ed.), Cardiac Considerations in Chronic Lung Disease,
Respiratory Medicine, https://doi.org/10.1007/978-3-030-43435-9_1
2 S. P. Bhatt
lung diseases include chronic obstructive pulmonary disease (COPD), bronchial

asthma, and interstitial lung diseases. With significant advances made in the
reduction of mortality from cancer and cardiovascular disease, mortality attrib-
utable to chronic lung disease continues to rise [1]. Between 1969 and 2013, the
largest decreases in mortality were for stroke (77%) and heart disease (68%) [1].
The mortality for all cancers combined decreased by 18%. There was however
a 100% increase in mortality from COPD in the same time interval [1]. Similarly,
the age-standardized years of potential life lost decreased by 75% for stroke,
68% for heart disease, and 41% for cancer but without any change over this time
interval for COPD [1]. The reduction in mortality due to heart disease is likely
due to improvement in the detection and control of risk factors such as hyperten-
sion and hyperlipidemia, smoking cessation efforts, and improvements in medi-
cal care. The decrease in cancer deaths is also likely due to smoking cessation
efforts and due to advances in screening and early detection as well as advances
in therapy. The increase in COPD-related mortality is likely due to a multitude
of factors: the lag between improved smoking cessation rates and disease inci-
dence that would correspond with a decrease in the occurrence of chronic lung
disease, limited efforts in tackling causes other than cigarette smoking such as
environmental pollution and biomass fuel exposure, limited advances in thera-
pies that affect the course of the disease, a direct effect of reduction in mortality
due to the other chronic diseases, and a higher rate of diagnosis of these chronic
lung diseases.
Both chronic lung disease and cardiovascular disease are highly prevalent.
The prevalence of COPD in the United States is approximately 6.5%; 14 million
adults have COPD, and approximately 10 million adults who meet criteria for
airflow obstruction have not been diagnosed with COPD [2, 3]. COPD also
accounted for 133,575 deaths in 2010 [3]. In 2016, approximately 19 million
(8.4%) of adults in the United States had an active diagnosis of asthma. 8.4 mil-
lion reported an asthma attack including 7.3 million office visits, 1.2 million
emergency room visits, and 108,505 hospitalizations [4]. In the United States,
92.1 million individuals have some form of cardiovascular disease; 16.5 million
adults older than 20 years have coronary artery disease (CAD), and 6.5 million
have heart failure [5]. It is therefore not surprising that these conditions fre-
quently coexist. Although math suggests that these interactions could happen by
chance in 1% of the general population, multiple cohort studies suggest that the
frequency of coexistence of these chronic diseases is considerably higher,
underscoring the overlapping pathophysiologic links. Most of the epidemio-
logic data available for chronic lung disease is regarding COPD (Fig. 1.1).
Recent data suggest similar associations between other chronic lung diseases
and cardiovascular disease, including for atherosclerosis, coronary artery dis-
ease, cerebrovascular disease, peripheral vascular disease, heart failure, and car-
diac arrhythmias. This chapter is not meant to be a systematic review or
meta-analysis but will include large studies and results of meta-analyses to
highlight these associations.
1 Cardiovascular Comorbidity in Chronic Lung Disease: Epidemiology, Clinical… 3
CVD categories
Unspecified CVD 2.46
Ischaemic heart disease 2.28
Coronary heart disease 1.86
Myocardial infarction 2.71
Angina pectoris 8.16
Cardiac dysrhythmia 1.94
Cerebrovascular disease 1.32
Heart failure 2.57
Diseases of pulmonary circulation 5.14
Diseases of the arteries 2.35
Cardiovascular risk factors

Diabetes 1.36
Hypertension 1.33
Dyslipidaemia 1.03
Obesity 1.40
Ever smoked 4.25
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22
Weighted-pooled summary estimates of odds ratios
Fig. 1.1 Forest plot showing the weighted-pooled summary estimates of odds ratio (meta-OR)
with 95% CI for cardiovascular disease in COPD compared with individuals without COPD. The
meta-odds ratio is indicated with a black diamond, and the 95% CI are indicated by the error bars.
The dash vertical line indicates threshold for significance. CVD cardiovascular disease,
COPD chronic obstructive pulmonary disease. (Reproduced, with permission of the publisher,
from Chen et al. [8])
Coronary Artery Disease (CAD)
There are a number of overlapping risk factors for chronic lung disease and CAD;
these include cigarette smoking, environmental pollutants, advancing age, gender,
and diet [6, 7]. These risk factors, however, do not fully explain the frequent coex-
istence of these chronic diseases. A substantial number of observational studies in
the past two decades have demonstrated that CAD occurs much more frequently in
individuals with COPD than is explained by the risk factors [6, 7].
Low forced expiratory volume in the first second (FEV1) and low forced vital
capacity (FVC) are both associated with poor cardiovascular outcomes. Multiple
cohort studies have shown a relationship between low FEV1 and cardiovascular
mortality, even after adjustment for age, gender, and smoking burden [8]. Data from
the Renfrew and Paisley population-based study (n = 15,411) showed that the haz-
ard ratio (HR) for mortality in the lowest quintile of FEV1 was 1.92 in males and
1.89 in females, compared with healthy controls after adjustment for age, cigarette
smoking, serum cholesterol, diastolic blood pressure, body mass index, and social
class [9]. There appears to be a dose-response relationship between the degree of
lung function impairment and the occurrence of CAD. Data from the Lung Health
Study showed that cardiovascular mortality rose by 28% for every 10% decrease in
FEV1 [10]. The Renfrew and Paisley study suggested that one-fourth of the attribut-
able risk from ischemic heart disease was due to low FEV1 [9]. In a more recent
community-based international cohort study of 126,359 adults followed for a
4 S. P. Bhatt
median duration of 7.8 years, the population attributable risk from mild to moderate
reduction in FEV1 was 17.3% for cardiovascular disease and 24.7% for all-cause
mortality [11]. These studies suggest that a low FEV1 is second only to hypertension
when attributable risk factors for cardiac disease are ranked. Despite these findings,
lung function is not included in risk scores for cardiovascular outcomes.
Although low FEV1 is often used as a reflector of airflow obstruction, this can be
due to either obstructive or restrictive lung disease. Multiple studies have also evalu-
ated the association between airflow obstruction (low FEV1/FVC ratio, either <0.70
or less than the lower limit of normal derived from normative population data) and
cardiovascular morbidity and mortality. In a large population-based study of 341,329
individuals registered in the Health Search Database in Italy, the prevalence of CAD
was 6.9% in general population and 13.6% in those with COPD [12]. In a retrospec-
tive study of 11,493 subjects, the presence of airflow obstruction was associated
with a 1.61-fold higher odds of angina and myocardial infarction, and a relative risk
of 2.07 for cardiovascular mortality, even after adjusting for other known risk fac-
tors [13]. In a very large retrospective cross-sectional study involving 1,204,100
subjects, Feary et al. found that the prevalence of cardiovascular disease (including
CAD, congestive heart failure, peripheral arterial disease, and aortic aneurysm) was
28% in those with COPD and 7.2% in those without COPD (odds ratio 4.98, 95%
CI 4.85–5.81) [14]. Mannino et al. analyzed data from 20,296 subjects enrolled in
the Atherosclerosis Risk in Communities (ARIC) Study and the Cardiovascular
Health Study (CHS) and found that the prevalence of cardiovascular disease was
19.7–22.1% across the range of disease severity in COPD compared with 9% in
those with normal spirometry (overall odds ratio 2.4, 95% CI 1.9–3.0) [15]. In the
Danish Nationwide Study of 7.4 million individuals, Sode et al. found that individu-
als with COPD had a higher lifetime age-standardized incidence of myocardial
infarction compared to those without COPD (27.2 vs. 17.7 events per 10,000
person-years) [16].
Low FVC is also associated with cardiac disease. Results from the Framingham
study of 5209 individuals aged 45–74 years, followed for approximately 20 years,
suggested that there was a graded inverse relationship between FVC and cardiovas-
cular mortality as well as for incident CAD, heart failure, intermittent claudication
and stroke [17]. FVC ranked high on the list of risk factors for cardiac mortality, and
these associations were seen even in those without established pulmonary disease
[17]. More recent data from the ARIC study showed that individuals in the lowest
FVC quartile had HR of 5.64 for incident CAD compared with the highest FVC
quartile, after adjustment for age, race, study center, height, height [2], and smoking
status [18].
Data from subjects referred for lung transplantation suggest that fibrotic lung
diseases are associated with a greater risk of CAD than non-fibrotic lung diseases;
these studies are however biased due to the variation in disease severity required for
referral for transplantation [19, 20]. In the Health Improvement Network, a longitu-
dinal primary care dataset from the United Kingdom, Hubbard et al. found a higher
prevalence of history of acute coronary syndrome (8% vs. 5%) and angina (16% vs.
9%) in those with idiopathic pulmonary fibrosis (IPF) than in age- and sex-matched
controls without pulmonary fibrosis [21]. On follow-up over approximately

3–4 years, the incidence of acute coronary syndrome was higher in IPF than in con-
trols (19.3 vs. 8.5 per 1000 person-years) [21]. There are few epidemiologic studies
of CAD in asthma. A large meta-analyses of 495,025 individuals enrolled in asthma
cohorts revealed a higher risk of CAD in those with asthma than in those without the
disease (HR 1.42, 95% CI 1.30–1.57) [22].
In summation, these studies indicate that CAD is very common in individuals
with spirometric impairment, and the data is especially robust for the association of
CAD with COPD. There are also similar reports of a high prevalence of COPD in
studies of CAD. Although COPD frequently remains undiagnosed, its prevalence in
CAD ranges from 7% to 34% [23, 24].
Cerebrovascular Disease
Given the similarities in pathophysiologic processes between CAD and ischemic

cerebrovascular disease, it is to be expected that chronic lung disease would be
associated with a higher prevalence of and risk for incident cerebrovascular disease.
Most of the available data is for COPD; high-quality prevalence data from popula-
tion studies are, however, limited. Curkendall et al. analyzed data from a longitudi-
nal healthcare database in the Saskatchewan region of Canada and found that the
prevalence of stroke in individuals with COPD was 1.47-fold higher than in those
without COPD (4.8% vs. 3.3%) [13]. In 18,342 adults from the 2002 National
Health Interview Survey (NHIS), Finkelstein and colleagues found that the preva-
lence of stroke in those with COPD was 8.6%, compared with 3.6% in those without
COPD and 4.1% in smokers that did not have COPD [25]. In the National Health
and Nutrition Examination Survey (NHANES), Schnell et al. analyzed 14,828 par-
ticipants for prevalent comorbidities in physician-diagnosed COPD and reported
that individuals with COPD had twice the risk of stroke than individuals without
COPD (8.9% vs. 4.6%) [26]. In a UK primary care data study of 1,204,100 mem-
bers of the general population aged ≥35 years, the presence of COPD was associ-
ated with a 3.3-fold higher odds of stroke after adjustment for age, sex, and smoking
burden; the prevalence of stroke in those with COPD was 9.9% compared with
3.2% in those without COPD [14].
A number of longitudinal studies have demonstrated a relationship between the
presence of airflow obstruction and incident stroke. In a study of 18,403 males fol-
lowed for 18 years, individuals with FEV1 less than 3 L had a 1.9-fold increase in
HR for fatal cerebrovascular disease, compared with those with higher FEV1 [27].
Wannamethee et al. prospectively studied 7,735 men and found that the relative risk
of stroke in the lowest FEV1 tertile was 1.4 times that in the highest tertile [28]. In
the Renfrew and Paisley study (n = 15,411), those in the lowest FEV1 quintile had a
1.6-fold higher mortality due to stroke compared with the highest quintile, after
adjustment for age, cigarette smoking, serum cholesterol, diastolic blood pressure,
body mass index, and social class [9]. In the Copenhagen City Heart Study of
6 S. P. Bhatt
12,878 individuals, the relative risk of stroke increased by 5% for every 10%
decrease in FEV1 percent predicted [29]. The risk of fatal stroke followed a similar
pattern; there was an 11% increase in relative risk for each 10% decrease in FEV1
percent predicted [29]. In the Bergen Clinical Blood Pressure Survey of 5,617 par-
ticipants followed for approximately four decades, there was an inverse relationship
between FEV1 and fatal stroke (HR 1.38 in men and 1.62 in women), adjusted for
age and height [30]. In the Rotterdam study, 13,115 participants were followed for
approximately 9.6 years, and the risk of stroke was 1.2-fold higher in those with
COPD compared to those without COPD [31].
Studies of stroke in individuals with asthma are sparse. A meta-analysis of
524,637 participants found that asthma was associated with an increased risk of
stroke (HR 1.32) [32]. A more recent analysis of the Korean Health Insurance
Review and Assessment Service-National Sample Cohort that included 111,364
individuals with asthma and 111,364 controls found that there was no elevated risk
for hemorrhagic or ischemic stroke in asthma [33]. A large study of 446,346
Taiwanese adults however showed that asthma is associated with a 1.23-fold higher
risk of fatal stroke [34]. No robust data are available for the prevalence of ischemic
stroke in pulmonary fibrosis and other chronic lung diseases, but it is expected to
be high.
Peripheral Arterial Disease
Given the high prevalence of atherosclerotic disease and COPD, it is not surprising
that peripheral arterial disease is also frequently observed in individuals with
COPD. The true prevalence of peripheral arterial disease in COPD is not known and
varies widely between studies. In 2,741 individuals enrolled in the German
COSYCONET (COPD and Systemic Consequences–Comorbidities Network)
cohort study, and evaluated for peripheral arterial disease using the ankle-brachial
index, 8.8% had peripheral arterial disease [35]. The prevalence of peripheral arte-
rial disease increased with increasing lung disease severity, and individuals with
peripheral arterial disease had a worse disease-specific health status with higher
SGRQ (St. George’s Respiratory Questionnaire) scores and CAT (COPD Assessment
Test) scores [35]. Of those with evidence of peripheral arterial disease, 55% did not
report this in their medical history [35]. This prevalence rate is consistent with a
cross-sectional study from Taiwan in which 8% of 427 individuals with COPD were
found to have peripheral arterial disease [36]. In a large case-control study of claims
data from Taiwan, 6% of individuals with COPD had peripheral arterial disease, and
COPD was associated with a 1.23-fold higher prevalence of peripheral arterial dis-
ease compared with those without COPD [37]. Analysis of 3,123 participants from
the population-based Rotterdam study showed that the presence of COPD was asso-
ciated with a 1.9-fold increase in incident peripheral arterial disease [38].
The reported prevalence of peripheral arterial disease has generally been higher
in smaller cohorts of special populations such as hospitalized patients or outpatients
with COPD. In a Swiss study of hospitalized COPD patients who were assessed for
peripheral arterial disease using the ankle-brachial index and the toe-brachial index,
43% of those with spirometry-confirmed COPD had evidence of peripheral arterial
disease [39]; in comparison, 24% of individuals without COPD had peripheral arte-
rial disease. A smaller outpatient study of 412 individuals with COPD found a prev-
alence rate of 28% [36]. In a small cross-sectional study of 246 subjects, 36.8% of
COPD patients had peripheral arterial disease [40].
There are no population-based studies of peripheral arterial disease in other
chronic lung diseases such as bronchial asthma and idiopathic pulmonary fibrosis.
In a large insurance claims study in Taiwan, 28,158 adults with newly diagnosed
asthma were compared with 56,316 individuals without asthma [41]. The preva-
lence of peripheral arterial disease was 1.46 times higher in those with asthma than
in controls [41]. The prevalence of peripheral arterial disease in pulmonary fibrosis
remains unknown but is expected to be high based on features of inflammation and
high risk of atherosclerosis similar to that seen in COPD.
Heart Failure
Heart failure, both with reduced and preserved ejection fraction, is common in
chronic lung disease, especially with COPD. The mechanisms for this increased
risk are described in Chap. 5. The epidemiologic data supporting this association is
sparse. In a retrospective analysis of longitudinal healthcare databases maintained
by the government of Saskatchewan in Canada, Curkendall and colleagues found
that congestive heart failure was reported in 19% of individuals with COPD com-
pared with 3.7% of those without COPD [13]. In a cross-sectional study of 405
elderly patients (age >65 years) with COPD, Rutten et al. found that 20.5% had
presence of previously undiagnosed heart failure [42].
Lower lung function is also associated with a greater risk of incident heart fail-
ure. In the Health ABC study, in 2,125 participants without known lung disease or
heart failure, FEV1 was inversely associated with incident heart failure over the
median follow-up of 9.4 years (HR 1.18) [43]. In the population-based Malmö
Preventive Project that included 20,998 males with no prior myocardial infarction
or stroke and with a median of 23 years of follow-up, lower FEV1 was associated
with an increased incidence of hospitalization due to heart failure (HR 1.25 in non-
smokers and 1.32 in smokers) [44]. In the retrospective Saskatchewan cohort, the
risk ratio for developing congestive heart failure was 4.5 in COPD compared with
age-matched controls without COPD, after adjustment for other cardiovascular risk
factors [13].
There is growing awareness that COPD is also associated with diastolic dysfunc-
tion and heart failure with preserved ejection fraction. Population data for this asso-
ciation is again sparse; prevalence rates are mostly informed by small studies that
used different diagnostic approaches, and hence the prevalence varies widely. In
615 individuals with COPD in the COSYCONET cohort, 4.1% had evidence of
8 S. P. Bhatt
diastolic dysfunction [45]. In a nested case-control study of 115 individuals with

COPD and 115 age- and sex-matched controls, the prevalence of diastolic dysfunc-
tion was 10.5% in those with COPD compared to 9.1% in those without COPD [46].
Reflecting the high variability in small studies, a frequency of diastolic dysfunction
up to 71% has been reported [47–51]. Independent of airflow obstruction, the pres-
ence of emphysema also appears to be associated with impaired left ventricular
filling. Barr and colleagues used magnetic resonance imaging (MRI) in 2,816 sub-
jects and showed that the percentage emphysema on CT was associated with
impaired left ventricular filling; the study however did not provide prevalence esti-
mates for diastolic dysfunction [52]. There are no population-based estimates of
prevalence of diastolic dysfunction and heart failure with preserved ejection frac-
tion in other chronic lung diseases.
Cardiac Arrhythmias
COPD is associated with cardiac arrhythmias, both atrial and ventricular, and these
arrhythmias are found in higher frequencies in COPD than in individuals without
COPD. In the retrospective Saskatchewan cohort data, Curkendall et al. found that
the prevalence of cardiac arrhythmia was 11.3% in COPD compared with 5.2% in
age- and sex-matched controls without COPD [13]. Multifocal atrial tachycardia
(MAT) is often seen in COPD, especially at the time of an exacerbation [53]. In one
review, COPD was present in 55% of individuals with MAT [53]. MAT is also asso-
ciated with the use of theophylline, a phosphodiesterase inhibitor used in the treat-
ment of COPD [54]. Other arrhythmias are less specific to COPD but more
frequently seen and include premature ventricular complexes, atrial flutter, atrial
fibrillation, and ventricular tachycardia [6]. In stable but hypoxemic COPD sub-
jects, 24-hour ambulatory electrocardiography showed a high incidence of arrhyth-
mias: ventricular premature complexes were noted in 83%, supraventricular
tachycardia in 69%, ventricular bigeminy in 68%, and non-sustained ventricular
tachycardia in 22% [55]. In the Copenhagen City Heart Study, 13,430 individuals
without known cardiac disease were followed for approximately 13 years. A low
FEV1 was independently associated with the incidence of atrial fibrillation, inde-
pendent of age, gender, smoking burden, blood pressure, and body mass index [56].
In the ARIC study, after adjustment for traditional cardiovascular risk factors, the
lowest quartile of FEV1 was associated with an increased likelihood of atrial fibril-
lation compared with the highest FEV1 quartile (HR ranging from 1.37 in white
women to 2.36 in black men) [57]. In a retrospective analysis of 7,441 individuals
with COPD who underwent 24-hour Holter monitoring, COPD was associated with
a higher rate of atrial flutter/fibrillation (23.3% vs. 11%), and non-sustained ven-
tricular tachycardia (13% vs. 5.9%), but a lower rate of sustained ventricular tachy-
cardia (0.9% vs. 1.6%), compared to those without COPD [58].
Many arrhythmias are paroxysmal and may not be detected on routine monitor-
ing but confer similar cardiac risk for adverse outcomes. Using surface
electrocardiographic surrogates for arrhythmias, Tutek et al. found that the disper-
sion of P waves, a surrogate for atrial arrhythmias, is greater in those with COPD
compared to age- and sex-matched controls without COPD [59]. P-wave dispersion
was also significantly greater in COPD patients who had paroxysmal atrial fibrilla-
tion compared with COPD without paroxysmal atrial fibrillation [59]. P-wave dis-
persion is also greater in COPD patients with frequent exacerbations [60].
Susceptibility to ventricular arrhythmias is also higher in COPD as evidenced by
greater QTc dispersion than in age-matched controls without COPD [61].
Although prevalence of sudden cardiac death in COPD is hard to determine, the
presence of COPD is associated with 1.4-fold greater odds of sudden cardiac death
[62, 63]. Both prolonged and abnormally short QTc interval are known risk factors
for sudden cardiac death. The association between a prolonged QTc interval and
COPD has been inconsistent in previous studies [64]. In a large cross-sectional
study of 6.4 million electrocardiographs in 1.7 million individuals, the presence of
COPD was associated with 2.4-fold greater odds of a short QTc interval [65]. Heart
rate variability is also a risk factor for sudden cardiac death and has been found to
be reduced in COPD, a reflection of the high sympathetic tone observed in
COPD [66].
Clinical Manifestations and Diagnosis
The symptoms and signs of most chronic lung and cardiac diseases have substantial
overlap and hence lack specificity for either diagnosis [67]. The most common
symptoms of chronic lung disease include dyspnea and cough that is either dry or
productive of phlegm. Wheezing is often a symptom of airway diseases including
asthma and COPD, but it can also be seen in heart failure and pulmonary edema
with bronchovascular congestion where it is referred to as “cardiac asthma.” Chest
pain related to lung disease is pleuritic in nature as the lungs themselves do not have
pain fibers. Orthopnea and paroxysmal nocturnal dyspnea, although more frequently
observed with heart failure and pulmonary edema, are not specific to cardiac disease
and are often noted in individuals with asthma and COPD.
Physical examination is also frequently not sufficient to distinguish heart from
lung disease although there are certain pointers for each organ involvement.
Inspection of the chest can reveal a barrel-shaped chest in cases of severe asthma or
COPD. These individuals may also have hyper-resonant notes on percussion.
Polyphonic rhonchi on auscultation indicate airway disease but are again not spe-
cific as bronchovascular congestion can result in airway narrowing. Rales on exami-
nation are also nonspecific, but “Velcro-like” crackles, especially in the bases, can
point toward interstitial lung disease. Jugular venous distention and pedal edema are
frequently signs of volume overload from cardiac disease but can also be seen with
cor pulmonale in the presence of severe lung disease.
In individuals already diagnosed with either a cardiac or lung disease, the symp-
toms are frequently ascribed to the existing diagnosis [42, 68]. Although the
10 S. P. Bhatt
correlation between reported symptoms and objective findings (either on clinical

examination or on diagnostic testing) is not linear, efforts should be made to note
whether these are reasonably proportionate. Symptoms that are disproportionate to
objective findings should alert the clinician to the presence of an additional disease.
In the context of chronic lung disease, out-of-proportion dyspnea is frequently due
to cardiovascular disease and deconditioning. In the majority, differentiation of
chronic lung disease and cardiovascular disease can be made if history and physical
examination findings are complemented by appropriate laboratory tests and imag-
ing. These include serum markers (troponin, brain natriuretic peptide, or BNP),
spirometry, chest radiography, 2D echocardiography, and computed tomography
(CT) imaging. Sometimes, more advanced testing is needed including right heart
catheterization and cardiopulmonary exercise testing. These aspects are discussed
in greater detail in Chap. 8.
Laboratory tests are frequently useful, but caution should be exercised in their
interpretation. For instance, an elevated BNP can be seen in both heart failure with
reduced ejection fraction as well as with cor pulmonale and right ventricular failure.
Spirometry is useful for the diagnosis of lung disease and also for narrowing the
differential diagnoses to predominantly obstructive or restrictive patterns. However
fluid accumulation in the lungs in stable heart failure with reduced ejection fraction
can result in low forced vital capacity (FVC) and normal or elevated FEV1/FVC
ratio, thus resulting in a restrictive ventilatory defect [69]. Alternatively, peribron-
chial edema can result in airflow obstruction [70]. The resulting airflow obstruction
can also confound severity grading of airflow obstruction [71]. For these reasons,
spirometry should be performed after every attempt has been made to achieve
euvolemia. Lung volumes are either normal or elevated in obstructive lung disease
and decreased in restrictive lung disease. The variable influence of pulmonary
edema on lung parenchyma and the airways can result in a mixed obstructive and
restrictive pattern, wherein spirometry shows an obstructive pattern and total lung
capacity is low on lung volume testing. The diffusing capacity of carbon monoxide
(DLCO) is frequently low in the case of emphysema and interstitial lung disease,
whereas it can be normal or mildly low in cases of heart failure.
Additional tests with lung imaging may be required to differentiate cardiac and
lung disease. Chest X-ray may show signs of hyperinflation with flattening of hemi-
diaphragms and obstructive lung disease and small lung volumes and restrictive lung
disease. Idiopathic pulmonary fibrosis is associated with interstitial opacities that
are frequently bilaterally symmetric, basal, and peripheral. Widened mediastinum,
bilateral pleural effusions, and fluid in the horizontal fissures point toward a diagno-
sis of pulmonary edema. With diffuse interstitial markings, it can be difficult to dif-
ferentiate fluid overload from interstitial lung disease. A widened vascular pedicle
points toward volume overload [72, 73]. In acute care settings, lung ultrasound can
be used to differentiate obstructive airway disease from congestive heart failure as
pulmonary edema is frequently associated with B-lines [74]. CT of the chest with
prone positioning may be required to differentiate basal fluid accumulation and
Kerley B-lines from reticular opacities due to interstitial lung disease [75, 76].
Pulmonary hypertension can result from both chronic lung disease and cardio-
vascular disease. Differentiation frequently requires right heart catheterization, and
a disproportionate increase (>12 mmHg) in pulmonary artery diastolic pressure
over the wedge pressure indicates the presence of a secondary cause of pulmonary
hypertension that is not purely due to left ventricular dysfunction [77]. The diagno-
sis and characterization of pulmonary hypertension are discussed in greater detail in
Chap. 6.
All of the above-described tests are performed at rest and may not indicate the
predominant pathophysiology contributing to an individual’s dyspnea. The role of
cardiopulmonary exercise testing (CPET) in determining the predominant cause of
dyspnea is discussed in Chap. 8.
Conclusions
In summary, chronic lung diseases and cardiovascular disease are both very preva-
lent, and their coexistence is not explained by chance but by the risk of atheroscle-
rosis and deranged cardiopulmonary interactions conferred by the presence of
chronic lung disease. A low index of suspicion should be maintained to evaluate for
chronic lung or cardiovascular disease when one of these is present.
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Chapter 2
Origins of Cardiopulmonary Disease
in Early Life
Michael J. Cuttica and Ravi Kalhan
Pearls
• Approaching the concept of lung health by focusing on the identification
of early-life risk factors that drive the evolution of disease states later in
life rather than defining disease and health by a dichotomized spirometric
value will allow for more robust preventative health strategies targeted at
lung disease.
• Understanding heart-lung interactions early in life and the pathophysio-
logic mechanisms underlying them will allow a better understanding of the
co-evolution of cardiopulmonary disease.
Lung Disease and Cardiovascular Disease
The association between lung disease and cardiovascular disease later in life has
been well described. Both obstructive and restrictive lung physiology as measured
with spirometry have been associated with cardiovascular disease and poor health
outcomes [1–8]. In an aging population, it is not surprising that there would be over-
laps between common lung diseases like COPD and common cardiovascular dis-
eases like coronary artery disease especially considering that many of these diseases
share common risk factors like tobacco use and aging. It is these common risk fac-
tors that give rise to the hypothesis that lung disease and heart disease are separate
entities that evolve in parallel with the idea that environmental exposures such as
tobacco smoke through direct injury to the lung and activation of inflammatory path-
ways lead to decline in lung function and eventually to COPD, while at the same
time the activated inflammatory pathways also activate atherosclerotic pathways and
M. J. Cuttica · R. Kalhan (*)

Northwestern University, Feinberg School of Medicine,
Division of Pulmonary and Critical Care Medicine, Chicago, IL, USA
e-mail: micuttic@nm.org; r-kalhan@northwestern.edu

18 M. J. Cuttica and R. Kalhan
eventually lead to coronary artery disease. However, there is growing data that sug-
gests that the association between diseases like COPD and cardiovascular disease
occurs independent of these common risk factors [5]. As we see more evidence that
lung and heart disease occur in individuals later in life, it raises an important ques-
tion: are the processes that affect lung and heart function through life intertwined in
such a way that they are actually causally linked in the development of shared dis-
ease states? Perhaps, instead of parallel development of lung disease and cardiac
disease as individuals’ age, these processes co-evolve into shared cardiopulmonary
disease. If this is the case, then it becomes imperative that we look to the origins of
this co-evolution early in life before disease is established to determine if we can
intervene to delay or prevent these cardiopulmonary disease processes.
The Paradigm: Identification of Pre-cardiovascular Disease
No field in medicine has done a better job in the past than cardiovascular medicine
in realizing the importance of identifying risk factors early in life that both predict
the development of future disease and can be treated to modify and prevent devel-
opment of disease. The paradigm in the cardiovascular community has been to
conceptualize “ideal cardiovascular health” to include a set of factors, several situ-
ated directly along the causal pathway of transitions from health to disease, which
protect against the development of cardiac disease. Considering cardiovascular
health along such a continuum has facilitated identification of risk factors for loss
of health, delineated intermediate endotypes which are deployed in clinical practice
as screening tools, and, historically, has led to increasingly effective preventive
health measures. Although a full review of the broad literature base related to car-
diovascular disease prevention is beyond the focus of this chapter, one example to
highlight the importance of approaching cardiovascular health along a continuum
from health to disease is worth exploring. Probably one of the best examples of this
are the guidelines on lipid management for the reduction of atherosclerotic cardio-
vascular disease events. The INTERHEART study, a large international case-con-
trol study, identified abnormal lipid levels as being associated with the highest
population attributable risk for the occurrence of acute myocardial infarction com-
pared to other modifiable risk factors [9]. This highlights one of many studies
which identified cholesterol as not only an important risk factor in the development
of coronary artery disease but via reduction of cholesterol levels through lifestyle
and pharmacologic means as a major modifiable risk factor to prevent disease [10–
13]. These epidemiologic studies looking at population-based effects of cholesterol
on heart health along with multiple interventional studies exploring the direct effect
of lipid-lowering interventions have allowed for the development of guidelines tar-
geted at very specific patient groups [14–17]. For example, guidelines recommend
statin therapy for individuals without atherosclerotic cardiovascular disease but
with low density lipoprotein (LDL) cholesterol levels >190 mg/dL and for indi-
viduals aged 40–75 years old again without atherosclerotic cardiovascular disease
2 Origins of Cardiopulmonary Disease in Early Life 19
but who have diabetes and LDL cholesterol levels in the range of 70–189 mg/dL
[18]. Again, this does not mean to serve as a primary review of cholesterol based
preventive health strategies for cardiovascular disease. Rather, it is as an excellent
example of an approach where the focus lies on identifying and intervening on a
continuum of health rather than awaiting intervention after the disease state has
presented.
he Paradigm Shift: Loss of Lung Health and Identification

T
of Pre-lung Disease
Although significant attention has been paid to the clinical manifestations of chronic
lung disease, less is known about the evolution of respiratory conditions across the
lifespan. Pulmonary physicians and respiratory researchers have traditionally
defined lung health exclusively as the absence of lung disease. This simplistic defi-
nition has limited the development of a robust approach to lung disease prevention.
Contrary to the experience of our cardiovascular colleagues who as outlined above
have focused on the defining and intervening on the continuum of cardiovascular
health as people age, there has been a distinct absence of life-course studies focused
primarily on understanding the evolution of lung health as we age. As a result of
this, it is a challenge to conceptualize how an individual might progress from ideal
lung health to an intermediate phenotype of impaired respiratory health to chronic
lung disease [19]. In the current paradigm, simple spirometry thresholds singularly
delineate respiratory health from lung disease [20]. This simplistic approach does
not acknowledge that the transition from health to chronic lung disease develops
over years, a period of time when disease interception may be most efficacious. As
a consequence, there are limited primary prevention strategies for chronic lung dis-
ease that are analogous to those implemented for cardiovascular conditions.
In recent years, there has been better identification of this gap in our knowledge
base and the beginning of an increased focus on understanding the evolution of lung
health. For instance, in an analysis of three independent primarily cardiovascular
disease-focused cohorts in both the United States and Europe (the Framingham
Offspring Cohort, the Copenhagen City Heart Study, and the Lovelace Smokers
Cohort), participants with lower lung function (defined as an FEV1 less than 80% of
predicted) at cohort inception were at greater risk of chronic obstructive pulmonary
disease (COPD) after 22 years of observation than those who had normal lung func-
tion at baseline [21]. This is an important study which shows that factors that impact
an individual’s peak lung function early in life have important implications for an
individual’s risk of developing obstructive lung disease as they age. This means
lung function in early adulthood is an important risk factor for the development of
lung disease later in life. One limitation of this study was that the mean age at cohort
inception was about 40 years, ranging from 21 to 75 years across all three cohorts.
This mean age is well beyond when most people attain peak lung function and pre-
sumably results in capturing people who have already accumulated environmental
exposures that impact the risk of developing lung disease. However, these findings
actually reinforced a prior report from the Coronary Artery Risk Development in
Young Adults (CARDIA) cohort, which revealed that low baselineFEV1 and FEV1/
forced vital capacity (FVC) between 18 and 30 years of age predicted airflow
obstruction 20 years later independent of smoking status [22]. Of even more inter-
est, most of the individuals in the CARDIA study with lower baseline lung function
still had lung function values that would be considered in the “normal” range (i.e.,
FEV1 greater than 80% of predicted and FEV1/FVC greater than the lower limit of
normal), did not report a diagnosis of any underlying lung disease, and typically
would not have undergone spirometric testing in the context of routine clinical care.
These again highlight the importance of approaching the idea of lung health as a
continuum that evolves as we age rather than the traditional hard cut-off lung func-
tion value that separates “healthy” from “disease.”
Our group has investigated the predictors and consequences of lung function
decline in the CARDIA study [23], a longitudinal cohort aged 18–30 years at incep-
tion in 1985. We have identified features of impaired respiratory health that precede
the development of chronic lung disease. These include: lower peak lung function
in young adulthood [22], accelerated age-related decline in lung function, elevations
in systemic inflammatory biomarkers [24], and the presence of respiratory symp-
toms [25]. We have shown the clinical relevance of impaired respiratory health [22,
25, 26], but our work to date does not provide a set of targets for the interception of
chronic lung disease.
o-evolution of Lung and Heart Disease: The Birth

C
of Cardiopulmonary Disease
As more attention seems to be focused on trying to better define lung health, and
where loss of lung health is on the path to the development of lung disease, there is
an opportunity to explore how heart and lung disease coevolve as we age. It has long
been recognized that measures of lung function are associated with cardiovascular
outcomes. In the Framingham Heart Study, FVC measured at a mean age of
40–45 years was noted to be associated with risk of subsequent cardiovascular dis-
ease [27]. This finding reproduced similar associations noted in several older stud-
ies between lung function and cardiovascular outcomes but like its predecessors
also failed to define a strong theory on the mechanism underlying the association
[28–30]. As with the transgenerational cohort analysis discussed above [21], one
limitation to the Framingham study is that the age range captured at the time of lung
function testing (40–45 years old) is older than when most people attain peak lung
function (typically around age 25–35 years) [31] and at an age when lung disease
starts to become clinically apparent [21, 32, 33]. Occult coronary disease, smoking
impacts on health, and hypoxic effects are presented as potential mechanisms driv-
ing the association even as the authors note that the associations in the statistical
models are independent of these general risk factors [27]. This highlights the
importance of being able to evaluate this association starting even earlier in life
before the onset of disease and before common risk factors start to accumulate.
The CARDIA study again through its ability to look at measurements of lung
function in early adulthood (ages 18–30 years) and link it to a robust cardiovascular
outcomes database has provided a unique insight into the coevolution of heart and
lung disease. Like the Framingham study before it, the CARDIA study was able to
show an association independent of sex, race, smoking, BMI, total cholesterol,
blood pressure, and diabetes between baseline lung function measured at mean age
of 25 years and cardiovascular disease events over 29 years of follow-up. Unlike the
Framingham study though, CARDIA captures an association occurring at a time
when tobacco smoke exposure is low, lung function is at or near its peak, and, in
almost all participants, the measurements of lung function are in the “normal” range
[34]. The obvious implication of these findings is that lung function testing in early
adulthood may provide an early window into cardiovascular health at a time when
the evolution of potential heart and lung disease are in their initial stages.
These findings of links between peak lung function measurements in early adult-
hood and cardiovascular outcomes do not answer the questions related to the mech-
anisms that drive this association. It is intriguing that this study from CARDIA also
showed that lung function was associated specifically with heart failure and cere-
brovascular events and not coronary artery disease events like myocardial infarction
or with indicators of atherosclerotic disease like coronary calcium scores. This is
particularly interesting given the known association between lung disease like
COPD and coronary artery disease events later in life [4, 35] and perhaps gives a
window into different mechanistic pathways that may be present early in life versus
pathways that develop through environmental exposure as we age. These early-life
mechanistic pathways may lie more with metabolic changes linked to lung and car-
diovascular function that impact overall vascular health. One example pointing
toward this would be the evidence of associations between lung function and risk of
diabetes, a disease with clear negative effects on both cardiac and vascular health
outcomes [36–38]. How lung function is linked with diabetes risk is unclear, and
exploring the roles of the interplay of physical fitness and common inflammatory
pathways may lead to insights into the development of cardiopulmonary disease. It
has also been shown in CARDIA that there is an association between FVC decline
and incident hypertension. Although the mechanisms underlying this link remain to
be understood, this association may provide a common pathway linking lung func-
tion to cardiovascular outcomes [39]. To help better understand this relationship, we
further evaluated patterns of decline in lung health from peak lung function in young
adulthood and their associations with heart structure and function in middle age. We
found that patterns of loss of lung health are associated with distinct echocardio-
graphic phenotypes in middle age such that a decline in the FEV1/FVC ratio is
associated with a decrease in left heart chamber size and lower cardiac output,
whereas, a decline in the FVC but with a preserved FEV1/FVC ratio is associated
with left heart hypertrophy, increased cardiac output, and early diastolic dysfunc-
tion [26]. It is reasonable to hypothesize that as these divergent patterns of loss of
lung health develop into distinct heart-lung phenotypes in middle age, the
Peak lung
function Young
adulthood
Differential pattern of
lung function decline
Declining FEV1 (and FVC) Declining FVC (and FEV1)

Declining FEV1/FVC ratio Preserved FEV1/FVC ratio
Decreased left heart Increased LV wall thickness

Chamber size, decreased increased LV mass, increased
stroke volume, decreased cardiac output, diastolic
cardiac output dysfunction Middle
age
“Small heart, low output “Hypertrophic, high output

phenotype” phenotype”
Cardio pulmonary disease states
Later
Heart failure preserved ejection fraction Systolic heart failure life
Pulmonary hypertension
Fig. 2.1 Divergent patterns of loss of lung health and development of disease. Reproduced from
Cuttica et al. [26])
groundwork is being laid for the eventual development of distinct heart failure syn-
dromes seen later in life (Fig. 2.1).
Conclusion
All of these findings highlight the complexity of the early-life origins of the heart-
lung interactions that evolve as we age to lead to the development of shared cardio-
pulmonary disease states. Almost all the data available evaluating this come from
observational epidemiology studies which although providing interesting and
important insights into the links between heart and lung disease are limited in their
ability to explore mechanisms that drive this. Many intriguing findings have been
reported raising many interesting questions regarding the origins of cardiopulmo-
nary disease. Perhaps the next area of focus needs to be on interventional studies
allowing for the delineation of the pathways that link the co-evolution heart and
lung interactions. As our cardiovascular colleagues have shown, understanding
these pathways will eventually allow us to modify and prevent the development of
cardiopulmonary disease.
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Chapter 3
Lung Disease: Gender Differences
Christine Jenkins
Pearls
1. Asthma is associated with a higher probability of cardiovascular disease
(CVD). The association is stronger in women than in men, for both mor-
bidity and mortality.
2. Adult-onset asthma in women has the highest association with CVD, and
women with asthma and CVD receive fewer interventions when they are
admitted with myocardial infarction.
3. There are likely to be markedly different prevalence rates and clinical pre-
sentations between men and women with airway disease and CVD,
depending on the country and the causes of obstructive lung disease.
4. CVD in men and women with asthma and COPD is under-recognized and
treated differently, women tending to seek more healthcare interactions but
receive fewer medications and interventions.
5. Sex- and gender-based differences in chronic lung disease with CVD
urgently need further research to understand impact and to tailor better
management.
There are substantial gender differences in chronic respiratory diseases as well as

cardiovascular disease. In this chapter, gender differences in comorbid chronic lung
disease (CLD) and cardiovascular disease (CVD) will be examined. Data on this
C. Jenkins (*)
Concord Hospital Sydney, Concord, NSW, Australia
The George Institute for Global Health, Sydney, NSW, Australia
Faculty of Medicine, UNSW Sydney, Sydney, NSW, Australia
University of Sydney, Sydney, NSW, Australia
e-mail: christine.jenkins@sydney.edu.au

26 C. Jenkins
intersection are limited and are found mostly in literature focused on asthma and
chronic obstructive pulmonary disease (COPD). Interstitial lung disease (ILD) will
not be included in this chapter as there are too few studies to allow meaningful con-
clusions to be drawn.
What Do We Mean by Sex and Gender?
Throughout the chapter, the Institute of Medicine definitions of sex as the classifica-
tion of living things, generally as male or female according to their reproductive
organs and functions assigned by chromosomal complement, will be used. Gender
is a person’s self-representation as male or female, or how that person is responded
to by social institutions, on the basis of the individual’s gender presentation [1].
Asthma, Cardiovascular Disease, and Sex Differences
The sex-specific aspects of asthma that are well recognized include a higher preva-
lence of asthma among boys in childhood and higher occurrence of new cases
among girls, commencing around puberty and persisting through the life span. It is
well known that young adult females may suffer from menstrual cycle-related
asthma flare-ups, worsening asthma during pregnancy, and a higher risk of hospital
admissions. Later in life, women with asthma also outnumber men, in both preva-
lence and mortality [2].
Asthma has been associated with increased cardiovascular disease (CVD) mor-
bidity and mortality in multiple studies [3]. However, CVD is not a highly recog-
nized comorbidity of asthma, and there are some conflicting results from different
studies and populations. Very little is known about the impact of gender on CVD
comorbidity in asthma.
What Can We Learn from General Population Studies?
In a large population-based cohort of men and women in Northern California, with

a median follow-up 27 years [4], Iribarren et al. examined the sex-specific associa-
tion between asthma and non-fatal and fatal coronary artery disease (CAD). After
adjusting for age, ethnicity, education, occupational exposures, and several other
risk factors, a history of asthma was associated with a 1.22-fold (95% CI: 1.14,
1.31) increased hazard of CAD among women compared to men. This was observed
in never-smoking and ever-smoking women and in younger and older women. By
contrast, asthma was not associated with CAD among men (adjusted hazard
ratio = 0.99; 95% CI: 0.93, 1.05).
3 Cardiovascular Comorbidity in Chronic Lung Disease: Gender Differences 27
The Atherosclerosis Risk in Communities (ARIC) Study in four US communities

included 15,792 men and women aged 45–64, followed for 14 years for incidence of
CAD and stroke events to 2001 [5]. Compared with never having asthma, the adjusted
hazard ratio (HR) of stroke was 1.50 (95% CI 1.04–2.15) for those reporting ever hav-
ing asthma (prevalence 5.2%) and 1.55 (95% CI 0.95–2.52) for current asthma (preva-
lence 2.7%). Those reporting wheeze attacks with shortness of breath also had greater
risk for stroke (HR = 1.56, 95% CI 1.18–2.06) than participants without these symptoms.
In the same study population, women with adult-onset asthma (but not those with
child-onset asthma) experienced a twofold increase in incident CAD and stroke
which was independent of other known risk factors, and this increase persisted when
the analysis was restricted to never-smokers [6]. No significant association was
found among women with childhood-onset asthma or among men. The authors con-
cluded that adult-onset asthma may be a significant risk factor for CAD and stroke
among women but not men. Subsequently they found carotid artery intimal-medial
wall thickness (IMT) to be slightly greater for women with history of adult-onset
asthma than that of women without asthma, but mean IMT did not differ signifi-
cantly according to asthma history among men. The interaction between adult-onset
asthma and gender was significant, even after adjusting for age, race, body mass
index, smoking status, smoking pack-years, diabetes, hypertension, physical activ-
ity, education level, and high- and low-density lipoprotein levels. They concluded
that adult-onset asthma is associated with increased carotid atherosclerosis among
women but not among men, an observation that provides one possible contributory
mechanism for the higher probability of stroke and CAD in women.
By contrast, in the Canadian Community Health Survey [7], there was no clear
relationship between age of onset of asthma and CVD risk. Asthmatics were 43%
(odds ratio, OR = 1.43, 95% CI 1.19–1.72) more likely to have heart disease and
36% (OR = 1.36, 95% CI 1.21–1.53) more likely to have high blood pressure than
non-asthmatics. Males with adult-onset asthma (>20 years old) were 63% more
likely to have high blood pressure than males with early-onset asthma, but other-
wise there were no significant differences between males and females.
In a large Italian database, a diagnosis of asthma was modestly associated with
the diagnosis of different cardiovascular comorbidities although significantly less
strongly than for COPD [8]. In the whole population, cardiovascular comorbidities
affected minimally more women than men (male:female = 0.98). Among patients
with diagnosed asthma, the OR for angina and coronary disease was higher in
women compared to men, but no difference was seen for association with all cardio-
vascular diseases.
Asthma and CVD in Case-Control Studies
In a US cohort of 203,595 adults with asthma and a parallel asthma-free cohort

matched for age, sex, and ethnicity, asthma was associated with a 1.40-fold increased
hazard of CAD, a 1.20-fold hazard of cerebrovascular disease, a 2.14-fold hazard of
28 C. Jenkins
heart failure, and a 3.28-fold hazard of all-cause mortality after adjustment for mul-
tiple risk factors [4]. Stronger associations were noted among women. However,
only those using asthma medications (particularly those on oral corticosteroids
alone or in combination) were at enhanced risk of CVD. These data suggest that
severity of asthma is a determinant of CVD morbidity, and sex is a cofactor modify-
ing this.
Further exploring this, among 100 asthmatic patients and 129 COPD patients
consecutively recruited from an Italian university outpatient clinic, a high preva-
lence of CVD was found. On the basis of history, clinical, and echocardiographic
data, CVD was found in 81% of this population, 51% of these having COPD and
30% having asthma [9]. CVD was associated with older age and more severe air-
flow obstruction both in asthma and COPD. Distributions of pressure and volume
overload showed a clear increase with increasing severity of asthma, in contrast to
COPD where the prevalence of each type of CVD was similar across GOLD stages.
In a Danish study comparing mortality rates in asthma and COPD patients to the
general population over a mean follow-up of 13 years, and after adjustment for
predictors of survival (age, FEV1% predicted, body mass index, smoking status, oral
prednisolone, CAD, and cor pulmonale), the relative risk of death was 1.21 and
0.98 in females compared with males in asthma and COPD, respectively [10]. When
standardized mortality rates were used, the relationship was stronger with a rate
ratio of 1.24 (95% CI 0.82–1.84) in asthma. However, females and males with the
same level of obstructive lung disease appeared to have similar mortality rates.
ender Effects on Outcomes in Asthma

G
with CVD Comorbidity
A recent meta-analysis examined the relationship between asthma and CVD or all-
cause mortality in prospective and retrospective cohort studies, containing over
400,000 participants [11]. The summary relative risk for all-cause mortality in
patients with asthma and CVD was 1.33 (95% CI 1.15–1.53). For asthma and CVD
in women, the relative risk for mortality was 1.55 (95% CI 1.20–2.00), 1.20 (95%
CI 0.92–1.56) in men, and 1.36 (95% CI 1.01–1.83) for all-cause mortality in both
genders. Women with asthma experienced a higher risk of CVD than men with
asthma, these findings remaining consistent after sensitivity analysis.
In a study of myocardial infarction (MI) and post-MI outcomes in people with
asthma (who constituted 3% of the total database) compared to the general popula-
tion in the United Kingdom, analysis of over 300,000 people showed that people
with asthma were more likely to have adverse outcomes [12]. These included a
delay in their MI diagnosis following an ST-segment elevation myocardial infarc-
tion (STEMI), OR 1.38, and 95% CI 1.06–1.79, but not a non-STEMI, OR 1.04, and
95% CI 0.92–1.17, compared to people without asthma. They also experienced a
delay in reperfusion (OR 1.19, 95% CI 1.09–1.30) following a STEMI. People with
asthma were much less likely to be discharged on a beta-blocker following a
myocardial infarction (STEMI or non-STEMI), OR 0.24, 95% CI 0.21–0.28 and

OR 0.27, 95% CI 0.24–0.30. While this is not surprising, withholding highly effica-
cious medications such as beta-blockers which reduce post-MI mortality could be
one mechanism by which mortality from MI is increased in people with asthma.
On presentation with an MI, people with asthma were older than those without
(mean age 72.8 vs. 67.3) and more likely to be female (54.4% vs. 32.5%). Although
there was a higher prevalence of comorbid conditions such as chronic kidney dis-
ease, diabetes, and congestive cardiac failure among people with asthma, after con-
trolling for age, sex, smoking status, and comorbidities, there was no difference in
in-hospital mortality between people with and without asthma.
In another UK study of asthma deaths in hospital, ascertained through anony-
mized National Health Service (NHS) data from 2000 to 2005, respiratory infection
was the single most common comorbidity (25%), but CVD diagnoses (atrial fibril-
lation and flutter, hypertension, left ventricular failure, and CAD) accounted for
54% of all listed comorbidities [13]. Females and those over 45 years were at the
highest risk of death after a hospitalization for asthma. Conceivably, infection inter-
acts with other comorbidities such as heart disease to increase risk of admission or
death, such as is now known for pneumococcal infection.
ender-Related Factors Affect the Presentation

G
and Management of Asthma with CVD
In relation to the impact of CVD in asthma, an analysis of sex differences in health

service and medication use in the German statutory health insurance database of
over 26 million people [14] showed that men had on average 17.1% (95% CI
14.1–20.2) higher costs for inpatient care after adjusting for age and comorbidity.
On average women received more prescriptions than men, but costs per medication
for men were higher per prescription. Men and women received about the same
percentage of prescriptions for beta-2 agonists and inhaled steroids. While not
directly informing us about the impact of gender on the association between CVD
and asthma, this analysis indicates that in this population, men and women received
different treatments for similar diseases. This may result from different presentation
patterns and physician contacts as well as different prescribing behaviors.
Other studies confirm the different prescribing patterns for men and women with
asthma. In an analysis of over 11 million ambulatory visits in COPD patients in the
United States [15], there was a significantly lower bronchodilator treatment rate
among patients with comorbid CVD (32.3%) than among patients without CVD
(57.6%). There were significant interactions between CVD and gender, concomitant
beta-blocker drugs, and concomitant asthma. The presence of CVD diagnosis sig-
nificantly decreased the likelihood of bronchodilator prescribing by 97% for females
with asthma who were not taking beta-blockers and by 83% in males with similar
characteristics. De-prescribing was more pronounced for females than males, and
bronchodilator prescribing in females with CVD taking beta-blockers with
30 C. Jenkins
coexisting asthma was 79% less than those without CVD (OR = 0.21, 95% CI
0.14–0.30). In females who had asthma and did not use beta-blockers, there was
only a 3% chance of taking bronchodilators compared with the non-comorbid CVD
group. In males with no asthma and no beta-blocker use, there was a higher bron-
chodilator prescribing rate of 68% (OR = 0.32, 95% CI 0.25–0.40). CVD did not
affect the prescribing outcome in male beta-blocker users, regardless of asthma sta-
tus. The authors commented that the lower utilization rates in females suggest more
conservative prescribing practices for females than for males.
In many countries the female:male ratio for deaths in severe asthma is still very
high, even allowing for the fact that there is a greater proportion of females with
asthma. Since more older women than men die from asthma, and the majority of
deaths from asthma in older adults are associated with cardiac events [13], on the
basis of these data, the coexistence of CVD in asthma in women is a warning flag
for increased mortality risk from asthma.
Mechanisms for the Increased Prevalence of CVD in Asthma
There are several possible reasons for an increased risk of CVD among people
with asthma, but these mostly remain theoretical and unproven. Several investi-
gators propose that tobacco smoking is the main explanation of poor CV progno-
sis in some individuals with asthma. This is based on studies such as the
Copenhagen Heart Study [16], which found that the increased CVD risk in
patients with asthma was restricted to former and current smokers, and no differ-
ence in CVD risk existed between never-smokers with asthma and never-smokers
without asthma.
This contrasts however with other studies suggesting that the higher risk of CVD
in patients with asthma is the result of a causal or contributory effect of asthma on
CVD, potentially mediated by common inflammatory pathways, asthma medica-
tion, cardiopulmonary interactions, or other mechanisms and related in some stud-
ies to asthma severity. When the analysis is restricted to never-smokers and after an
adjustment for potential confounders, some studies have found no association
between asthma and CVD [16].
Although inflammation has been proposed as the common pathway in asthma
and CVD [17], this common mechanistic pathway has not been proven. Inflammation
in CVD and asthma may be driven by different etiologic factors, such as allergen
exposure or dietary fat intake, as well as some very similar factors, such as air pol-
lution, which significantly increases all-cause mortality and cardiorespiratory mor-
tality. Although these effects could be additive, this has yet to be demonstrated and
would be challenging.
Several studies have shown an association between allergic features (history or
high IgE) and risk of atherosclerosis [18, 19], although a sex difference has not been
shown. A positive skin prick test was associated with a 1.7 times (1.4–2.2) increased
risk of CVD mortality in one study [17], and others have shown a significant asso-
ciation (OR = 3.8, 95% CI 1.4–10.2) between allergic disorders, such as asthma and
allergic rhinitis, with atherosclerosis [19].
In a study of Hutterites, sex was a significant predictor trait value in a linear
regression model for 16 of 19 phenotypes characterizing different aspects of CVD,
DM, OA, and asthma [20]. For asthma, these included FEV1, the ratio of FEV1/
FVC, eosinophil count, and total immunoglobulin E (IgE) as well as more systemic
features such as body mass index and fat free mass. These could potentially interact
with CVD-associated traits such as HDL-cholesterol, lipoprotein A, triglycerides,
and diastolic and systolic blood pressure, with a female bias.
re There Sex Differences in the Mechanisms Underlying

A
the Association Between CVD and Asthma?
The observation that the association between asthma and cardiovascular disease
only occurs in women in most studies, and most strongly in those with adult-onset
asthma, leads to a consideration of hormonal influences as major contributors.
Estrogen levels increase at puberty, exactly the time when the higher male:female
ratio of prevalence switches, and over the life span, asthma is not only more preva-
lent in women but also more severe. In vitro, estrogen modulates the release of pro-
inflammatory cytokines from activated monocytes, macrophages, and vascular cells
and also regulates the production of leukotrienes from mast cells. It is speculated
that women who develop asthma after puberty may be particularly susceptible to
estrogen-modulated alterations in inflammatory cytokine and leukotriene regula-
tion [21].
The effects of estrogen on CVD however may be quite different [22]. The
heart contains receptors for sex hormones, including estrogen, and in animal
models, estrogen has been shown to improve cardiac function and reduce the
severity of ischemic injury. Estrogen can also act as an anti-oxidant [23]. Post
menopause, however, when estrogen levels drop markedly, the cardioprotective
effects are lost, and the prevalence of CVD in women increases dramatically.
When combined with the increased prevalence of asthma in women, this effect
may be additive or synergistic, helping to explain the significant risk of CVD in
women, particularly those with adult-onset asthma. Other comorbidities may
play some role in this also [24]. Diabetes is increased in asthma, and of the many
CVD risk factors, diabetes, high-density lipoprotein levels, and triglyceride lev-
els have a greater impact on CVD in women than men. Diabetic men have a two-
to threefold increased risk of CVD, whereas women have a three- to sevenfold
increased risk. It could be postulated that the risks of CVD in asthma is magni-
fied, when all three are combined in women – asthma, CVD, and diabetes. Given
the high prevalence of all these chronic diseases in the adult population, this
requires further research.
32 C. Jenkins
ex Differences in Chronic Obstructive Pulmonary Disease

S
(COPD) with Comorbid CVD
COPD is now the third most frequent cause of death in the world, behind ischemic
heart disease and stroke, the two major causes of death from CVD. Given the com-
mon risk factors of tobacco smoking, air pollution, deprivation, and early-life deter-
minants of CVD and lung health, it is not surprising that these two diseases occur
together and may interact in a significant proportion of cases [25]. Large population-
based studies suggest that patients with COPD are two to three times more at risk
for cardiovascular mortality, and COPD-related and CVD-related deaths account
for around 50% of total number of deaths [26]. All-cause mortality is related to the
presence of airflow obstruction, whether diagnosed or not, symptomatic or not [25].
Symptoms alone contribute to all-cause and CVD mortality risk in COPD. In
NHANES, having symptoms of chronic bronchitis alone increased the risk of coronary
death by 50% [27], and in two Scandinavian studies, having a mucus hypersecretion-
chronic bronchitic phenotype had a similar impact [28]. In some older studies, poor
lung function was as powerful a predictor of cardiac mortality as established risk fac-
tors such as total serum cholesterol [29]. Although the availability of statins and other
effective lipid-lowering medications has significantly ameliorated the consequences of
hypercholesterolemia, the impact of FEV1 on CVD and all-cause mortality may change
very slowly. This is because of the combined effect of the increasing global burden of
COPD; the continuing exposure to smoke, dusts, and fumes of many millions around
the world; the lack of effective detection of early COPD; and the inability of currently
available treatments to slow the rate of FEV1 decline.
Sex Differences in COPD Prevalence and Impact
It is becoming clear that COPD affects men and women differently, develops in
response to different exposures and doses, and presents differently clinically [30].
The prevalence of COPD in women is rapidly rising, and in some countries, mortal-
ity is equal to that in men. Women are therefore increasingly likely to be affected by
COPD comorbidities, but the sex differences of COPD comorbidities are a poorly
studied area, and little is known about their frequency and impact [31]. Patients with
COPD are frequently excluded from clinical trials of drugs which reduce cardiac
morbidity and mortality, and many studies show that CVD in COPD patients is
under-recognized and under-treated. Given the relative over-representation of men
in randomized controlled trials of COPD, and the exclusion of COPD patients from
CVD trials, where COPD and CVD coexist, it may be some time before the gender
differences in treatment outcomes are known.
In some contrast to COPD, increasingly important sex differences are known
to affect CVD pathophysiology [32], presentation, management, and outcomes
[33], even though women are also under-represented in CVD trials [34]. In rela-
tion to CVD in COPD, much of what is known pertains to tobacco-related COPD
and treatment effects derived from trials with a predominantly male population.
Although the interaction between CVD and COPD could have different manifes-
tations in men and women, there is a dearth of research addressing this specifi-
cally, although much can be gleaned from database studies and randomized
clinical trials.
isk of Developing COPD Differs by Dose and Type

R
of Exposure
There is increasing evidence that women are more susceptible to the effects of ciga-
rette smoke than men [35, 36], for a given number of cigarettes smoked per day and
total intake. There are many possible mechanisms for this, including different
molecular and metabolic responses to cigarette and biomass smoke, different air-
way geometry, patterns of inhalation, intensity and diversity of exposure, and cel-
lular vulnerability [37–41].
Multiple studies from different regions of the world have suggested both
increased risk and greater impact of COPD in women who smoke [42]. Two longi-
tudinal Danish studies [43], the Copenhagen City Heart Study and the Glostrup
Population Study combined, found that after adjusting for smoking, women had a
1.5 times greater probability of COPD-related hospitalizations than men, which
could not be accounted for by higher rates of hospitalization in women in general.
For each pack-year of smoking, women had greater excess loss of FEV1 in ml per
year. In another study, women were disproportionately represented in the subset of
patients with COPD with severe disease despite minimal tobacco smoke exposure
(defined as <20 pack-years) [44]. Women were also more likely to present with
COPD before the age of 60 years.
In a study from Nanjing China exploring the relationship between cigarette
smoking and COPD among urban and rural adults >35 years old, the overall preva-
lence of diagnosed COPD was significantly higher among men than in women [45].
However the relationship between prevalence of COPD and total cigarette smoking
was dose dependent in women, while only men with the highest cigarette smoking
rates were more likely to have COPD. This finding is similar to a Finnish analysis
of medical records of 844 COPD patients in which women reported significantly
fewer pack-years than men [46]. Compared to the men, women had less advanced
airflow obstruction but more severe gas transfer impairment. This cohort showed
several significant gender dependent differences in their clinical presentation includ-
ing women having a lower body mass index, and more psychiatric conditions, espe-
cially depression, and men being more likely to have cardiovascular diseases,
diabetes, and alcoholism.
34 C. Jenkins
I ncreased Susceptibility of Women to Tobacco and Biomass

Smoke Inhalation
The recently published study from the UK Biobank confirms the increased suscep-
tibility of women to cigarette smoke. In a very large database of approximately
500,000 subjects aged 40–69 years, the association of airflow obstruction and smok-
ing was stronger in women than in men [35]. There was a greater probability of
having airflow obstruction with a lower self-reported cigarette smoke exposure
among women, and women were at increased risk of airflow obstruction after only
15 years of smoking and five cigarettes per day.
In the BOLD study, the prevalence of stage II or higher COPD was 10.1%
overall, 11.8% for men, and 8.5% for women. Even allowing for a greater sus-
ceptibility to tobacco-related lung damage, and lower smoking rates than men,
this difference is not as great as might be expected. In countries where women
have much less tobacco exposure, factors other than cigarette smoking contrib-
ute to COPD prevalence. The prevalence of airway hyperresponsiveness in
women with COPD is greater than in men; hyperresponsiveness is an important
predictor of decline in lung function, which may, at least partially, account for
some of the variability between genders in symptoms such as dyspnea, and pos-
sibly FEV1, although further studies are required. Airway reactivity was more
strongly related to rates of FEV1 decline in women than in men in the Lung
Health Study [47].
In low- to middle-income countries, early-life nutritional deficiencies may con-
tribute to both CVD risk and poor lung growth, subsequently increasing COPD risk.
Women and men experience different domestic air pollution exposures, accounting
for the more equal prevalence of COPD despite the fact that women are usually not
tobacco smokers [48]. However, there is a strong cardiovascular risk associated with
secondhand smoke exposure, and studies demonstrate a consistent 25–30%
increased risk for coronary disease associated with secondhand smoke [49, 50]. The
best established mechanisms underlying this effect include endothelial dysfunction
and a prothrombotic effect.
Little is known about the sex differences in risk of CVD in settings where
COPD is not tobacco smoke related, such as biomass-related COPD [51]. A few
studies have shown increased risk of CVD in non-tobacco-related COPD [52, 53],
but a link between biomass or solid fuel exposure, COPD, and CVD has not been
demonstrated yet. Men and women may not only have different susceptibility but
also markedly different combined exposures, women usually not smoking but
working in unskilled jobs or cottage industries where smoke and dust exposure
are very high and men smoking and working unprotected in very dusty jobs.
Early-life exposures combined with nutritional deficiencies may combine to com-
pound vulnerability.
ifferent Symptom Profile and Burden in Men and Women

D
with COPD
Some studies have shown similar COPD symptoms between men and women [54,
55], but others report higher levels of dyspnea in women compared with men, higher
exacerbation rates and hospital admissions but lower mortality rates [56–58]. This
could conceivably relate to a lower risk of acute MI and CVD complications post
exacerbation. In a study detailing the under-diagnosis of acute MI in COPD, men
had slightly higher cardiac injury scores, but women and younger age groups were
less likely to have an established MI diagnosis despite electrocardiographic evi-
dence of a previous infarction [59].
The higher rate of exacerbations in women versus men with COPD, identified in
some studies, may contribute to the overall higher death rate in women in some
countries, such as the United States [57, 60]. In the Evaluation of COPD
Longitudinally to Identify Predictive Surrogate End-points (ECLIPSE) cohort
(n = 2164), the rate of exacerbations was found to be significantly higher in women
than men at each GOLD stage [56]. Similarly, in a post hoc analysis from the
Prevention of Exacerbations with Tiotropium in COPD (POET-COPD) trial, the
risk of first exacerbation was higher for women compared with men (HR 1.31, 95%
CI 1.19–1.43) [61]. Data from the TOwards a Revolution in COPD Health (TORCH)
study also showed that the time to first exacerbation was shorter and the rate of
exacerbations was 25% higher in women than in men (95% CI 16–34%; P < 0.001),
although the number of hospital admissions caused by exacerbations was similar in
both sexes [57].
Although several studies show that women are more likely to be admitted to
hospital for an exacerbation [43], they appear less likely to die in hospital [62]. In a
population of >40,000 participants in the Quebec Insurance databases, males had a
significantly increased risk of death (adjusted HR 1.45, 95% CI 1.42–1.49) and re-
hospitalization for COPD (adjusted HR 1.12, 95% CI 1.09–1.15) [63].
Men and women appear to experience a different spectrum and severity of symp-
toms for a given severity of spirometric abnormality [64]. In a Spanish study, women
were younger, smoked less, had better PaO2 and lower PaCO but more exacerba-
tions in the last year and fewer comorbidities. However they performed less well
than men in walking distance, had worse St. George Respiratory Questionnaire
(SGRQ) total, symptoms and activity scores, and had a higher degree of dyspnea
[65]. Several studies have shown a greater predominance of anxiety, depression,
osteoporosis, and sleep disturbance but a lower prevalence of cardiovascular diag-
noses among women [66, 67]. In combination, differences in dyspnea and exercise
capacity contribute to poorer prognostic scores such as the BODE (Body mass
index, airflow Obstruction, Dyspnea, and Exercise capacity) score in women com-
pared with men who are matched for lung function and age [58].
36 C. Jenkins
ifferent Responses of Clinicians to Men and Women

D
with COPD
Finally, it is well recognized that the responses of clinicians may also differ to men and
women, and this can markedly affect the rapidity of diagnosis. Women with COPD are
likely to have more frequent interactions with healthcare providers and use more
healthcare resources than men [56, 62]. However, there is a higher rate of misdiagno-
sis or delayed diagnosis in women with COPD compared with men, potentially lead-
ing to suboptimal treatment [31, 68]. Although the gender bias in diagnosis is reduced
by the use of spirometry, spirometry in general remains underused, particularly in
women. COPD patients with concurrent CVD were less likely to be prescribed bron-
chodilators, with the exception of males who were also prescribed beta-blockers.
otential Mechanisms for Sex Differences in Increased Risk

P
of CVD and COPD
Gender differences are especially prevalent in cardiovascular disease. Males tend to

suffer from myocardial infarctions earlier than females, and a woman’s risk of car-
diovascular disease increases after menopause reaching a similar prevalence to
males in the sixth decade. Several studies indicate that there is an apparent associa-
tion between gender and oxidative stress, where women seem to be less susceptible
to oxidative stress but lose this protection after menopause.
Multiple factors contribute to the risk of CVD, as they do in COPD, apart from
known environmental exposures such as tobacco smoking or hyperlipidemia. Many
studies show a strong association between childhood adversity and CVD. A study of
sex differences in vascular physiology and pathophysiology [22] in Canadians aged
18–49 years showed an OR of 2.14 (95% CI, 1.56–2.94) for 3+ childhood adversi-
ties. The association was stronger with increasing stressful events, and female
patients with 3+ stressful events exhibited the highest risk of CVD (OR 4.40, 95%
CI 1.98–9.75), indicating that the effect of childhood adverse events on CVD is
heightened among women, particularly women with stressful adulthoods. This dif-
ference was not mediated by depression, smoking, or poor diet. Such differences
however could interact with the increased vulnerability of women to smoking-related
airflow limitation, increasing their probability of having both COPD and CVD.
COPD, CVD Clinical Manifestations, and Sex Differences
COPD patients carry an excessive risk of cardiac disease beyond what would be
expected from a common initiating pathway such as cigarette smoking or atmo-
spheric pollution. In large population databases, there is a strong association
between COPD and vascular disease, which confers worse outcomes and is likely
to contribute to the high mortality of COPD. CVD accounts for around 30% of
deaths in COPD patients [69], and this is so even in younger patients and those
with milder COPD. This risk is particularly increased in the weeks immediately
following an acute exacerbation of COPD (AECOPD), although to date there is
no strong evidence of a sex difference. This may be due to the relatively small
numbers of patients in longitudinal COPD studies, and prospective studies will
be needed to ascertain whether sex differences in COPD-cardiac comorbid-
ity exist.
In a UK analysis of 18,342 subjects aged ≥40 years, COPD patients (n = 958)
were at higher risk of having CAD, angina, myocardial infarction, stroke, conges-
tive heart failure, poor lower limb circulation, and arrhythmia. Overall, the presence
of COPD increased the odds of having CVD by a factor of 2.7 (95% CI 2.3–3.2).
Older age, lower family income, underweight, smoking, drinking, diabetes, hyper-
tension, and high cholesterol were significantly associated with increased risk of
CVD. In gender-related differences, there was no significant difference between
ORs for CVD or any CVD category except for CAD, which was significantly greater
in females than in males.
In another UK study of >25,000 patients with COPD, there was a 2.27-fold (95%
CI, 1.1–4.7) increased risk of MI 1–5 days after exacerbation. The increased risk
diminished over time and was not significantly different from the baseline MI risk
at times longer than 5 days post MI. There was a slight preponderance of men who
experienced MI, a smaller difference than suggested by a recent analysis assessing
the burden of CVD, where around three times as many men had a MI compared with
women in the UK.
Large clinical trials, especially those with a longitudinal follow-up, have pro-
vided substantial information on CVD risk in COPD, but few have analyzed or
commented on sex differences in treatment effects. The Lung Health Study recruited
predominantly asymptomatic smokers aged 35–60 years old with mild, predomi-
nantly early GOLD stage II COPD patients [70]. Cardiovascular events accounted
for 42% of the first hospitalizations and 48% of the second hospitalizations in the
13% of the cohort who experienced at least one hospitalization during the 5-year
follow-up. Coronary artery disease accounted for approximately two-thirds of non-
fatal CVD. Baseline FEV1% predicted was inversely related to all-cause mortality
and to deaths from coronary artery disease and CVD. Mortality did not differ sig-
nificantly between groups by sex. Increased body mass index was a risk factor for
respiratory illnesses, as was female sex.
In this same study, among participants who quit smoking in the first year, FEV1%
predicted increased more in women (3.7%) than in men (1.6%) [47]. The relation-
ship between all-cause mortality, CVD mortality, and FEV1 raises the possibility
that women may gain more than men in reduced mortality from CVD when they
give up smoking.
Clinically, there is frequent uncertainty in determining whether worsening dys-
pnea is due to AECOPD, heart failure, or acute ischemia. Differentiating between
HF and AECOPD can be difficult, and both frequently coexist. CVD has been
38 C. Jenkins
detected in up to 55% of patients admitted with AECOPD, suggesting that up to

20% of AECOPD could be due to cardiac events.
In the Understanding Potential Long-term Impacts on Function with Tiotropium
(UPLIFT) trial, another large RCT of patients with GOLD stage II–IV disease, there
were >900 deaths, with 11% deaths due to CVD and 4.4% due to sudden cardiac
death. Interestingly, the panel and study investigators agreed closely on causes of
death except in the case of a threefold greater rate attributed to “cardiac disorders”
by study investigators compared to the adjudication panel. An analysis based on
gender was not reported.
In the TORCH study, an independent adjudication committee determined that
23% of participants who died did so from CVD causes [71]. At baseline, 7% of
patients reported a history of previous MI, 41% were taking CVD medications, and
during the study 17–20% and 10–12% of patients had cardiac adverse events or
severe adverse events, respectively. A history of MI doubled the probability of car-
diovascular adverse events, but the likelihood of experiencing a cardiovascular
adverse event was unaffected by gender and current smoking status.
A crucial question, given the high rate of cardiac comorbidity in COPD, is
whether treating COPD with medications that reduce exacerbations also reduces
cardiac comorbidity. In the Study to Understand Mortality and Morbidity in COPD
(SUMMIT) study [72], combination ICS-LABA therapy had no effect on composite
cardiovascular events, even though ICS and LABA alone or in combination reduced
the rate of moderate and severe AECOPD. As so often in randomized trials in
COPD, the statistical analysis model (in this case the Cox proportionate hazards
model) “allowed” for the covariates of age and sex. Any approach to RCT analysis
that makes adjustments for sex inevitably standardizes the treatment effect in men
and women and so does not report on sex differences – and is unlikely to show
differences.
otential Mechanisms for Sex Differences Affecting

P
the Increased Cardiovascular Risk Associated with COPD
The pathophysiologic mechanisms which contribute to the increased prevalence and

impact of CVD in patients with COPD, and vice versa, will be fully explored in
Chap. 6. Very briefly, these include but are not limited to increases in structural vas-
cular changes such as carotid intima-media thickness, plaques, and arterial stiffness,
which are more prevalent in patients with COPD compared to matched smokers
without COPD. Key COPD events such as exacerbations are associated with increases
in arterial stiffness, increased myocardial oxygen demand in a hypoxemic state, and
increased pulmonary vascular pressures. Additional demand occurs through medica-
tions such as beta-2 agonists, frequently administered at very high doses.
Changes in inflammatory parameters, such as C-reactive protein, vascular adhe-

sion molecules and fibrinogen levels, cytokines, and TNF-α, all contribute to the
higher CVD mortality and morbidity observed in frequent exacerbators. Increases
in BNP and troponin have been demonstrated in even moderate exacerbations of
COPD [73], and retrospective analyses show that undiagnosed ischemic damage is
common in hospitalized patients with AECOPD. Infection-related exacerbations
are especially related to greater increases in arterial stiffness which is consistent
with observations that lung infections are associated with increased acute and long
term risk of cardiovascular disease.
Even in the stable state, COPD is a disease associated with increased markers of
systemic inflammation, oxidative stress, physiological stress, and accelerated aging
[74], which are known to occur differently in men and women. However, there are
no robust data on the extent to which these inflammatory mechanisms operate simi-
larly or differently in men and women when COPD and CVD coexist. The different
impact of similar and dissimilar exposures, such as active and passive smoking,
dusty work environments, and domestic biomass fuel exposures, is likely to add
complexity to the interactions of inflammatory mechanisms, hormonal effects, and
physiologic responses in the CVD-COPD interaction.
ummary: Cardiovascular Comorbidity in Airway Disease:

S
Gender Differences
In summary, cardiovascular comorbidity in airway disease shows significant gender

differences. In asthma, there is an increased risk of CVD as a comorbidity and an
increased risk of CVD death in women, especially those with later-onset disease,
and in those who have been smokers. There is evidence of different prescribing pat-
terns for men and women, the latter receiving less medication targeted at both their
lung and heart diseases. A different pattern of comorbidities exists in men and
women with asthma that may further influence the risks of adverse outcomes for
those with asthma and CVD.
In COPD, the increased risk of CVD as a comorbidity is common, frequently
symptomatic but often undertreated, and appears to affect men and women equally
but increases mortality risk compared to COPD alone. CVD is a major contributor
to mortality in COPD, and research is needed to determine the optimal management
of patients with both diseases, particularly urgent because of the rising prevalence
of COPD globally. Although men and women present differently and receive differ-
ent management, in both diseases there are very limited data on the gender differ-
ences in treatment outcomes, despite the many opportunities available through large
randomized trials of asthma and COPD.
40 C. Jenkins
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Chapter 4
Pathophysiology of Cardiovascular Disease
Trisha M. Parekh and Mark T. Dransfield
Pearls
• Chronic lung diseases and cardiovascular diseases share many risk factors
and are common comorbid conditions.
• Impairment of lung function is associated with an increased risk of cardio-
vascular events.
• Arterial abnormalities, accelerated aging, systemic inflammation, and oxi-
dative stress play a role in the development of cardiovascular disease in
chronic lung diseases.
Introduction
Multiple factors contribute to the complex link between cardiovascular disease

(CVD) and chronic lung diseases (CLD). Despite having numerous shared risk fac-
tors including smoking and socioeconomic status, there is now growing evidence to
suggest potential causality between CLD and CVD rather than simple association.
In this chapter, we will review the pathobiologic processes that may drive the devel-
opment of CVD in patients with CLD. This chapter will focus primarily on the
T. M. Parekh
Lung Health Center, Division of Pulmonary, Allergy, and Critical Care, University
of Alabama at Birmingham, Birmingham, AL, USA
M. T. Dransfield (*)
Lung Health Center, Division of Pulmonary, Allergy, and Critical Care, University
of Alabama at Birmingham, Birmingham, AL, USA
Birmingham VA Medical Center, Birmingham, AL, USA
e-mail: mdransfield@uabmc.edu

46 T. M. Parekh and M. T. Dransfield
relationship between chronic obstructive pulmonary disease (COPD) and coronary

artery disease (CAD) but will also briefly examine the associations with congestive
heart failure, peripheral arterial disease, and cerebral vascular disease as well as the
relationship between other CLDs and CVD.
Epidemiology of COPD and CVD
COPD is the fourth leading cause of mortality worldwide [1]. The epidemiology of
COPD and CVD overlaps, with the two diseases sharing many risk factors, and the
presence of one worsens the prognosis and complicates the management of the
other. CVD is a leading cause of death in COPD [2], and the presence of COPD
predicts mortality in patients with heart disease [3]. COPD is associated with a sig-
nificantly increased risk of incident and recurrent myocardial infarction [4], while a
rise in troponin during a COPD exacerbation also predicts mortality [5]. The risk for
cardiovascular events increase in the period after COPD exacerbations [6–8], with
the risk highest in the first 30 days but lasting up to 1 year [9]. Patients with both
COPD and CVD also incur significantly greater morbidity and healthcare costs with
increased number of hospitalizations and prolonged exacerbations compared to
patients who have COPD alone [10–12]. In order to decrease the burden of CVD in
CLD patients, it is crucial to understand the mechanisms that underlie the relation-
ship between CLD and CVD.
Relationship Between Lung Function and CVD
There is a clear association between impaired lung function and the risk of cardio-
vascular disease as low baseline forced expiratory volume (FEV1), forced vital
capacity (FVC), and declines in FEV1 predict cardiovascular events independent of
traditional cardiac risk factors [2, 10, 11, 13]. The association of impaired lung
function and increased risk of cardiovascular events is evident across age groups,
including the young and elderly populations [12, 13]. A population-based study
found that individuals in the lowest FEV1 quintile had a fivefold increased risk of
cardiovascular mortality [14].
Pathobiologic Processes Underlying CVD Risk in COPD
Arterial Abnormalities
A number of vascular abnormalities have been described in patients with CVD

including arterial thickening, impaired vasodilation, stiffness, and calcification, and
these may be more prevalent or severe in patients with COPD.
4 Pathophysiology of Cardiovascular Disease in Chronic Lung Disease 47
Carotid intimal medial thickness (CIMT) is a surrogate indicator of atheroscle-

rotic heart disease, with an increased thickness of the intima or media associated
with an increased risk of CVD. In smokers with airflow obstruction compared to
smokers without airflow obstruction as well as non-smokers, CIMT is increased and
is independently associated with lower FEV1 [14]. COPD patients with an increased
CIMT also have a higher risk of mortality from CVD [15]. COPD is also an inde-
pendent predictor of carotid plaque development [16], including vulnerable
plaques [17].
Flow-mediated dilation (FMD) is another noninvasive tool used to assess endo-
thelial function and early development of atherosclerosis [18]. FMD is determined
by measuring the brachial artery diameter in response to hyperemia. FMD measure-
ments have been shown to correlate inversely with CIMT [19] as well as predict
future cardiovascular events [20]. After adjusting for cardiovascular risk factors and
age, FMD was found to correlate with percent predicted FEV1 [21], measurements
of which are reproducible over time [22]. In patients with AECOPD requiring hos-
pitalization, FMD was found to be lower during exacerbation and improved upon
resolution of exacerbation 3 months later [23]. Evidence supports the presence of
endothelial dysfunction in stable and exacerbating COPD patients and provides a
possible explanation for the increased risk of CVD, especially during
exacerbations.
Arterial stiffness occurs as a consequence of atherosclerosis and normal aging
and can be measured by pulse wave velocity (PWV) [24]. Independent of smoking
and prior myocardial infarction history, COPD patients are twice as likely to have
increased arterial stiffness compared to non-smoking controls [25]. PWV is
inversely related to FEV1 and FVC [26] as well as emphysema severity [27].
Systemic inflammation may be a mechanism for this relationship [28]. Elastin deg-
radation may be another mechanism for increased arterial stiffness in COPD. Skin
elastin degradation is increased in COPD, and this is associated with airflow obstruc-
tion, emphysema severity, and PWV [29].
Arterial calcification is also a predictor for CVD and coronary artery calcifica-
tion is increased in COPD patients and associated with mortality [30]. In the
National Lung Screening Trial, CT emphysema was also associated with increased
thoracic aortic calcification [31]. Some have suggested that individuals with COPD
should be screened for arterial stiffness and calcification; however, this is not yet
recommended by clinical guidelines [32].
Accelerated Aging
Both COPD and CVD are diseases that are associated with accelerated aging.
Shortened telomere length, increased apoptosis, and reductions of anti-aging pro-
teins are potential mediators of an increased CVD risk in COPD patients. Shortened
telomeres and increased cell senescence occur naturally with aging. However in
comparison to age-matched control smokers, telomere length was shortened in
COPD patients [33]. Markers of cellular senescence (p16 and p21) are also increased
in samples of lung tissue from patients with emphysema [34]. Evidence suggests
that telomere shortening and senescent pulmonary vascular endothelial cells pro-
mote the release of inflammatory cells [35], further perpetuating the vicious cycle
of inflammation and aging.
Accelerated aging may also contribute to the development of emphysema
through increased apoptosis. Cellular senescence and reduced levels of vascular
endothelial growth factor receptor-2 increase apoptosis in endothelial and epithelial
cells as a protective response to harmful exposures like smoke [36]. In the lung, this
can prevent regeneration of lung parenchyma, leading to loss of cells in the alveolar
walls causing emphysema [37].
Decreased levels of proteins including sirtuin-1 and Werner’s syndrome protein
may also contribute to accelerated aging in COPD patients. Sirtuin-1, an anti-aging
protein, plays a major role in cellular stress management, and, compared to non-
smoking controls, levels of sirtuin-1 were shown to be reduced in lung samples of
COPD patients [38]. Animal studies have shown that sirtuin-1 overexpression sup-
presses markers associated with aging (p21, p16, p53). A reduction in sirtuin-1 also
predated the development of emphysema in mice models [39]. Reductions of sir-
tuin-1 may be the result of increased levels of oxidative stress and inflammation,
both of which are prominent in COPD patients [40]. Suppression of Werner’s syn-
drome protein, which is associated with increased cell senescence in fibroblasts
isolated from patients with emphysema, has also been proposed as a mechanism of
accelerated aging in COPD patients [41].
Cellular senescence has an established association with CVD. Shortened telo-
mere length is associated with arterial stiffness [42] and is a predictor of future
cardiovascular events [43]. Senescent endothelial cells are found on plaque surfaces
and may be involved in the development of CVD [44].
Systemic Inflammation
Inflammation plays a major role in the pathophysiology of most CLD, including

COPD, ILD, and asthma. Inflammatory molecules, including C-reactive protein,
tumor necrosis factor alpha, fibrinogen, IL-6, and IL-8, are known to be elevated in
COPD [45, 46] and have all been evaluated as possible disease-related biomarkers.
Nuclear studies have also documented greater inflammation seen in the aorta of
COPD patients compared to ex-smoking controls [47]. The systemic effects of
inflammation in COPD also play a role in the development of comorbidities, includ-
ing diabetes, hypertension, and CVD [48]. Coronary artery disease is accepted as a
disease of inflammation [49, 50]. CRP, IL-6, and fibrinogen are involved in the
formation of plaque [51] and progression of atherosclerosis [52]. Elevated CRP in
the presence of airflow obstruction has been associated with increased risk of car-
diac injury [53]. CT findings of coronary artery calcification, presence of metabolic
syndrome, and elevated CRP were also associated with lower FEV1 [54]. Levels of
inflammatory markers are higher during AECOPD [55], a time when CV events are
known to occur [6]. This may be due to dysfunctional endothelial progenitor cells
that alter the vascular endothelium during AECOPD [56]. Systemic inflammation,
oxidative stress, and endothelial dysfunction are common in both COPD and CVD,
and their interrelationship mechanisms are complex.
Oxidative Stress
An imbalance between reactive oxygen species and antioxidants can produce a state
of oxidative stress which can lead to tissue damage in the lungs and systemic ves-
sels. Cigarette smoking and frequent exacerbations perpetuate the imbalance of free
radicals in COPD [57] which can lead to increased mucous secretion, direct injury
to lung cells, and protease/antiprotease imbalance [58]. Reactive oxygen species
can also upregulate pro-inflammatory cytokines in COPD [59] contributing to the
negative effects caused by chronic inflammation. Oxidative stress increases lipid
peroxidation, a mechanism that promotes atherosclerosis, specifically during
AECOPD [60], and levels of oxidized low-density lipoproteins are elevated in
COPD patients [61]. End products of lipid peroxidation induce apoptosis in multi-
ple cell lines. This can be combated by antioxidant enzymes like glutathione
s-transferase [62]. Evidence also points to increased prevalence of glutathione
s-transferase polymorphisms in COPD patients [63] which predisposes the indi-
vidual to increased damage from reactive oxygen species, including upregulation of
inflammation and development of atherosclerosis.
Protease/Antiprotease Imbalance
Proteases are enzymes that digest proteins in the connective tissues. They are the
primary culprit in the development of emphysema. Elevated neutrophil elastase,
matrix metalloproteases (MMP), and cathepsins are mechanisms that may contrib-
ute to both CLD and CVD. Unregulated neutrophil elastase promotes the develop-
ment of emphysema [64]. Elevated levels are also found in unstable angina and
myocardial infarction patients [65] as well as on the surface of fibrous and athero-
sclerotic plaques [66]. MMPs, specifically MMP-1, MMP-2, MMP-7, MMP-9, and
MMP-12, are involved in the degradation of various components of the matrix
framework, and their imbalance plays a key role in the development of COPD, ILD,
and asthma [67]. MMPs have also been involved in the development of CVD. MMP-9
is associated with aortic stiffness in patients with systolic hypertension and in
healthy individuals [68]. Polymorphisms of MMP-3 have also been associated with
plaque rupture and acute myocardial infarction [69]. Cathepsin K is an enzyme
primarily involved in bone resorption but also has implications for the development
of emphysema and atherosclerosis. Levels of cathepsin K have been shown to be
elevated in humans with emphysema and in animal models [70]. Cathepsin K levels
are also elevated in patients with coronary artery disease [71]. In animal models, the
knockout of cathepsin K is associated with a reduction in atherosclerosis [72] as
well as age-related cardiac dysfunction [73].
Renin-Angiotensin System
The renin-angiotensin system (RAS) functions to regulate the body’s systemic

blood pressure and electrolyte and fluid balance. The RAS also plays a role in the
development of CLD, including COPD and interstitial lung diseases. During peri-
ods of hypoxia, as is frequently seen in CLD patients, the RAS is activated [74], and
this has pro-inflammatory and pro-fibrotic effects that contribute to the development
of systemic inflammation and fibrosis in CLD [75]. Upregulation of the RAS is also
involved in the development of atherosclerosis through vascular inflammation,
plaque development, and cardiac remodeling [76, 77]. Animal models show that
instillation of angiotensin-II, a main effector molecule of the RAS, is associated
with increased plaque vulnerability [78]. The chronic hypoxia seen in CLD patients
can upregulate the RAS causing increased production of angiotensin II and increased
risk of a cardiovascular event.
Hypercoagulability
Abnormal blood clotting increases the body’s susceptibility to vascular events.

Fibrinogen is a protein that functions mainly to promote hemostasis but in excess
can cause infarctions in the heart, brain, and extremities. COPD patients have higher
levels of coagulation markers, including thrombin-antithrombin complex [79] and
fibrinogen [80], which are also associated with the development of acute coronary
syndrome [81]. COPD patients undergoing percutaneous stent placement are at
higher risk of major adverse cardiac events, stent thrombosis, and myocardial
infarction compared to patients without COPD [82]. Specific mechanisms underly-
ing the cause of hypercoagulability in COPD patients remain undetermined, and
this may be in part due to thrombocytosis [83].
Hypoxia and Sympathetic Nervous System Activation
Patients with severe CLD experience episodes of hypoxia frequently. Chronic

hypoxia has been associated with increased levels of inflammation, platelet
activation, cell apoptosis, RAS activation, and oxidative stress [84–88], the CVD-
related mechanisms of which are discussed above. Hypoxia can also cause signifi-
cant hemodynamic changes through activation of the sympathetic nervous system
[89]. In a study of healthy men, heart rate increased and systemic vascular resis-
tance decreased after 1 hour of hypoxia [90]. Muscle sympathetic nerve activity
increase in response to hypoxia and hypercapnia can persist up to 20 minutes after
return to room air breathing [91]. As a result, COPD patients frequently have an
elevated resting heart rate [92]. Autonomic dysregulation and tachycardia are both
risk factors for cardiovascular mortality [93, 94].
Heart Failure
COPD patients have a 4.5-fold higher risk of developing heart failure (HF) com-
pared to age-matched controls without COPD [95], and patients with both condi-
tions have worse outcomes [96]. Through mechanisms discussed earlier, COPD
increases the risk of ischemic coronary events, which predisposes patients to the
development of systolic heart failure. With a prevalence of 90% in one study of
stable severe COPD patients [97], diastolic heart failure can also develop in CLD
and occurs primarily from lung hyperinflation causing a reduction in left ventricu-
lar preload [98, 99]. In a cohort of 615 COPD participants, lung hyperinflation and
lower FEV1 were associated with echocardiographic markers of diastolic dysfunc-
tion [100]. These data also suggest that a reduction in hyperinflation could improve
diastolic filling, a hypothesis supported by several randomized trials of inhaled
treatments. Hohlfeld et al. found that use of dual bronchodilator therapy with a
long-acting muscarinic antagonist and long-acting beta-agonist over 14 days was
associated with a 10% increase in left ventricular end diastolic volume in the treat-
ment group compared to placebo group as well as a reduction in lung hyperinfla-
tion [101]. Similar improvements in left as well as right ventricular end diastolic
volume was also reported after 14 days of treatment with an inhaled steroid and
long acting beta-agonist combination as compared to placebo [102]. It is also pos-
sible that the improvement in ventricular filling after lung deflation could improve
cardiac performance as supported by the study by Come et al., who found improve-
ments in oxygen pulse in patients in the National Emphysema Treatment Trial who
achieved significant reductions in hyperinflation with lung volume reduction sur-
gery [103].
Right heart failure occurs secondary to the development of pulmonary hyper-
tension in patients with COPD. Mechanisms leading to the development of pul-
monary hypertension in COPD patients include hyperinflation, systemic
inflammation, and hypoxic vasoconstriction [104]. This topic is discussed sepa-
rately in Chap. 7.
Cerebrovascular and Peripheral Artery Disease
The evidence supporting a causal relationship between COPD and cerebrovascular

diseases is less compelling. Population-based studies have found COPD patients have
an up to 20% higher risk of stroke; however, the association is significantly weaker
after accounting for smoking status [7], indicating that this and perhaps other shared
risk factors may largely account for the risk. Peripheral artery disease (PAD) also
occurs in COPD patients and can have a significant impact on functional capacity and
quality of life. Similar to stroke and CAD, PAD risk is inversely associated with FEV1
(% predicted) [105]. Proposed mechanisms for development of stroke and PAD in
COPD patients are similar to the mechanisms involved in the pathogenesis of CAD.
Idiopathic Pulmonary Fibrosis and Asthma
Other chronic lung diseases including idiopathic pulmonary fibrosis (IPF) and
asthma are also associated with the development of cardiovascular diseases; how-
ever, they are much less researched. Similar to COPD, IPF patients have an increased
risk of cardiovascular disease that is not fully explained by shared risk factors [106,
107]. In a cohort of patients undergoing transplant evaluation, IPF patients had a
significantly increased prevalence of CAD compared to COPD patients as well as
worse survival outcomes [108]. In the Multiethnic Study of Atherosclerosis, persis-
tent asthmatic patients had a 1.6-fold increased risk of cardiovascular events com-
pared to age- and risk-matched non-asthmatic controls [109]. Many of the
mechanisms discussed previously that explain the relationship between COPD and
CVD, including systemic inflammation, hypoxia, and sympathetic activation, may
also underlie the relationship between other CLDs and CVD.
Conclusion
CVD is a common comorbidity in COPD independent of shared risk factors. A

variety of altered pathobiologic pathways have been described in patients with
COPD including increased systemic inflammation, accelerated aging, vascular
abnormalities, oxidative stress, hypoxia, sympathetic nervous system activation,
hypercoagulability, and protease/anti-protease imbalance, and these likely underlie
the increased risk for CVD. Though a definitive cause and effect pathway has not
been established and there is no COPD-specific marker of CVD risk, the presence
of COPD should raise suspicion for the presence of clinically overt and subclinical
CVD. More research is needed to further define the exact pathobiologic relationship
between COPD and CVD and to explore potential therapies for both. The mecha-
nisms underlying CVD development in other CLD including IPF and asthma also
warrant further studies.
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Chapter 5
Pathophysiology of Right Heart Disease
Indranee Rajapreyar and Deepak Acharya
Key Points/Pearls
• Right heart dysfunction is associated with many types of chronic lung
disease.
• Right heart dysfunction in chronic lung disease is often secondary to pul-
monary hypertension or hypoxia but may be independent of these factors.
• Pathophysiology of right heart dysfunction in chronic lung disease may be
specific to the underlying lung disease.
Introduction
Different chronic lung diseases (CLDs) are associated with varying degrees of right
heart dysfunction. The pathophysiology of right heart disease in chronic lung dis-
ease is complex, and mechanisms include pulmonary hypertension, hypoxia, neuro-
hormonal alterations, metabolic perturbations, endothelial dysfunction, ischemia,
and systemic inflammation. The right ventricle can develop adaptive or maladaptive
responses to these processes, and varying degrees of right heart dysfunction can
ensue. Clinical management is currently focused on management of underlying
I. Rajapreyar
Section of Advanced Heart Failure, Pulmonary Vascular Disease, Heart Transplantation, and
Mechanical Circulatory Support, Division of Cardiovascular Diseases, University of Alabama
at Birmingham, Birmingham, AL, USA
e-mail: irajapreyar@uabmc.edu
D. Acharya (*)
Division of Cardiovascular Diseases, Sarver Heart Center, University of Arizona,
Tucson, AZ, USA
e-mail: dacharya@shc.arizona.edu

60 I. Rajapreyar and D. Acharya
lung disease and pulmonary hypertension, but as pathophysiologic mechanisms

become better understood, new therapeutic targets, including those that focus
directly on the right ventricle, may emerge. In this chapter, we provide a compre-
hensive review of normal physiology as well as the pathophysiology of the right
heart and pulmonary circulation in chronic lung disease.
Normal Right Ventricular Anatomy and Physiology
The normal right ventricle (RV) is a crescent-shaped chamber with inlet, trabecular,
and outflow components (Fig. 5.1). It has approximately one-sixth the mass of the
Fig. 5.1 Normal anatomy of the right ventricle. (Reproduced with permission from Mcalpine WA,
Heart and Coronary Arteries: An anatomical atlas for clinical diagnosis, radiological investigation,
and surgical treatment. Springer 1975)
5 Pathophysiology of Right Heart Disease in Chronic Lung Disease 61
left ventricle and operates as a high-volume, low-pressure circulation [1]. The nor-
mally high capacitance and low afterload of the pulmonary circulation are illus-
trated by the triangular shape of the right ventricular pressure-volume loop, where
isovolumic contraction is not well defined, and ejection continues when RV pres-
sure is falling, with a significant proportion of stroke volume ejected after peak
systolic pressure [2] (Fig. 5.2). Right ventricular function is dependent on multiple
factors, including filling volumes (preload), pulmonary vascular resistance (after-
load), intrinsic RV contractility, interventricular septal contribution, right and left
ventricular interaction, and pericardial restraint.
Right Heart Dysfunction in Chronic Lung Disease
Right heart dysfunction associated with CLDs has been recognized since the
early 1800s. The World Health Organization (WHO) convened an expert meet-
ing in 1960 in an attempt to provide a more uniform language and consistent
classification scheme and defined the term chronic cor pulmonale as “hypertro-
phy of the right ventricle resulting from diseases affecting the function and/or
structure of the lung, except when these pulmonary alterations are the result of
diseases that primarily affect the left side of the heart or of congenital heart
disease” [3].
a b
30 12
25 10
Pressure (mmHg)( x10–1)
Pressure (mmHg)
20 8
15 6
10 4
5 2
0 0
2 4 6 8 10 12 14 4 6 8 10 12 14 16
Volume (cc x10–1) Volume (cc x10–1)
Fig. 5.2 (a) Right ventricular pressure-volume loop. (b) Left ventricular pressure-volume loop.
The right ventricle starts ejecting early in systole and does not have a well-defined isovolemic
contraction period. It continues to eject after peak pressure has been achieved, as illustrated by
decreasing pressure and volume. In contrast, the left ventricle has well-defined isovolemic contrac-
tion and relaxation, and ventricular volume does not decrease after peak systolic pressure.
(Reproduced with permission from Ref. [2])
Multiple mechanisms can account for right heart dysfunction in CLD. These
include (1) pulmonary hypertension (PH), (2) lung hyperinflation causing reduction
of intrathoracic volume, (3) mechanical compression of ventricles, (4) expiratory air-
flow limitation resulting in expiratory blood flow limitation in the pulmonary circula-
tion, (5) hypoxia in the setting of higher work and oxygen demands, (6) ischemia, (7)
activation of renin-angiotensin-aldosterone system due to hypoxia and/or hypercapnia
and resultant volume overload, (8) sympathetic nervous system activation, (9) endo-
thelial dysfunction, and (10) systemic inflammation [4–7]. The relative importance of
each of these mechanisms, either in patients with different types of lung disease or in
different individuals with the same underlying lung disease, is poorly understood, as
is the varying adaptation of the RV to the different forms of physiologic stress.
Pathophysiology of the Pulmonary Vasculature
ulmonary Vascular Remodeling in PH Due to Chronic

P
Lung Disease
Metabolic remodeling, inflammatory pathway activation, and neurohormonal dys-

regulation can occur in the pulmonary vasculature in response to the inciting pulmo-
nary insult and, consequently, in the right ventricle due to increased RV pressure
afterload. Mechanistic insights to the development and progression of PH are often
derived from animal models of PH due to hypoxia, vascular endothelial growth fac-
tor inhibitor, and monocrotaline. Pathophysiological mechanisms underlying devel-
opment of pulmonary hypertension and worsening right ventricular dysfunction in
CLD in humans have been extrapolated from animal models of hypoxia.
Pulmonary vascular remodeling was observed in patients with chronic obstruc-
tive pulmonary disease (COPD) and PH in varying degrees of severity [8, 9]. A
study examining the explanted lungs from patients with COPD who underwent lung
transplantation revealed plexiform lesions and medial and intimal fibrosis in small
muscular arteries in a subset of COPD patients with severe PH (mPAP >35 mmHg).
In the same study, patients with COPD and no PH did not exhibit extensive pulmo-
nary vascular remodeling [8]. Chronic pulmonary vascular remodeling and inability
to recruit blood flow during exercise in patients with COPD can result in PH with
exercise and progression of PH at rest [10].
ontribution of Inflammatory Pathways to PH in Chronic

C
Lung Disease
Lung injury promotes increased release of the signaling molecule adenosine from
inflammatory cells and breakdown of nucleotides like ATP and ADP by CD39 and
CD73, respectively, and promotes maladaptive tissue remodeling via adenosine
receptor signaling. Adenosine receptor signaling via A2BR stimulates release of

cytokines (IL-8, IL-4, IL-13, IL-6, IL-10, TGF-β) from effector cells and growth
factors like VEGF that promote angiogenesis and increased fibroblast differentia-
tion promoting fibrosis and progression of disease [11]. Hypoxia, as a result of
progressive lung damage, triggers airway inflammation by recruitment of macro-
phages, with differentiation to M2 phenotype under the influence of Th2 cytokines
(IL-4, IL-13), CCL2, and IL-6. Activated macrophages (M2 phenotype) express
Found in Inflammatory Zone-1 (Fizzl) and arginase 1, promoting pulmonary artery
vascular smooth proliferation and vascular remodeling [12]. Vascular inflammation
in PH is predominant in the pulmonary artery adventitia where resident fibroblasts
secrete IL −6 and activate STAT 3 signaling in macrophages with increased expres-
sion of CD163 + and CD 206+, thereby promoting vascular remodeling. IL-6/
STAT3/CEBPβ signaling plays a pivotal role in promoting vascular remodeling by
expression of genes that promote fibrosis (arginase-1), altered metabolism and
inflammation (HIF1), smooth muscle proliferation and resistance to apoptosis
(Pim1, NFAT), and angiogenesis (VEGFa) [13]. HIF1A has been shown to upregu-
late adenosine receptor 2B in activated macrophages to promote inflammation in
idiopathic pulmonary fibrosis (IPF) [14]. There is evidence to suggest that adenos-
ine receptor 2B signaling in COPD and IPF increases hyaluronan synthesis leading
to pulmonary vascular remodeling and PH [11, 15, 16]. CD4+ T cells, particularly
the TH 17 subset, have also been implicated in the development in PH due to hypoxia,
and IL-6 plays a major role for TH 17 differentiation [17, 18].
Transforming growth factor beta (TGF-β), a profibrotic cytokine, has been impli-
cated in pathogenesis of fibrotic lung diseases [19]. Bone morphogenetic protein
(BMP) and TGFβ signaling (↓BMP/↑TGFβ) impairment plays a role in pulmonary
vascular remodeling in animal models of PH [20]. In a detailed study involving
explanted lung tissue from patients with IPF and experimental animal model of
pulmonary fibrosis, there was a significant decrease inBMPR2A protein with evi-
dence of increased PSMAD 2/PSMAD 3 signaling suggestive of TGFβ activity in
human lung tissue with IPF and IPH + PH versus controls. IL-6 was significantly
increased in IPF + PH compared to IPF alone, activated STAT3 signaling leading to
several expression of miRNAs with the end result of depletion of BMPR2 pro-
tein [21].
itochondrial Structural and Metabolic Alterations

M
in the Pulmonary Artery
Mitochondrial metabolic remodeling could contribute to pulmonary vascular

remodeling and PH disease progression. Oxidative phosphorylation through fatty
acid oxidation and glucose oxidation in the mitochondria are sources of energy
production. Glucose oxidation in the mitochondria is a minor contributor of energy
production [22]. Hypoxia-inducible factor (HIF-1∝), transcription factor, activated
in response to hypoxia and inflammation drives the metabolic switch from oxidative
phosphorylation to glycolysis, which is a less efficient energy source. Animal mod-

els of PAH induced by monocrotaline or chronic hypoxia with Sugen 5416 demon-
strated increased FDG-positron emission tomography (PET) uptake in the lungs.
Further analysis revealed increased expression of GLUT1 (mediator of increased
glucose uptake) in pulmonary artery endothelial cells and pulmonary artery smooth
muscle cells (PASMC) but not in airway tissue samples. There is increased expres-
sion of HIF-1∝ in proliferating PAMSC supporting indirect evidence of increased
glucose uptake by cells [23]. HIF -1α signaling plays a major role in the glycolytic
shift by activating pyruvate dehydrogenase kinase, an enzyme known to inhibit
pyruvate dehydrogenase that is involved in glucose oxidation [24]. Glycolytic shift
enables cell survival and energy production under hypoxic conditions [25]. Under
chronic hypoxic conditions, HIF -1α signaling reduces reactive oxygen species pro-
duction in mitochondria resulting in inhibition of potassium channels (KV 1.5), par-
ticularly the α subunits altering the membrane potential of mitochondrial membrane
with consequent depolarized state. The mitochondrial membrane depolarization
allows Ca2+ entry through the voltage-gated Ca2+ channels causing pulmonary artery
vasoconstriction [26]. Elevated intracellular Ca2+ levels (cytoplasmic, sarcolemmal,
and nuclear) promote pulmonary artery smooth muscle proliferation by activating
transcription factors like c-fos, nuclear factor-ҡ, and c-jun and progression of cell
cycle [27, 28]. The increased Ca2+ entry also promoted activation of nuclear factor
of activated T cells (NFAT), a transcription factor involved in immune response,
with increased gene expression of bcl-2 and downregulated potassium channels pro-
moting unopposed cell proliferation [29]. Potassium channel inhibition prevents
activation of caspases and mitochondrial cytochrome c release preventing pulmo-
nary artery smooth muscle apoptosis [30]. In addition, increased activity of the gly-
colytic enzyme, hexokinase-II, results in decreased activity of mitochondrial
permeability transition pore (MPTP) preventing cell death [24].
The complex interplay of mitochondrial energetics and electrical remodeling
under HIF-1α signaling activated in response to local inflammation and hypoxia
creates a self-perpetuating cellular microenvironment promoting cell proliferation
and preventing programmed cell death leading to pulmonary vascular remodel-
ing and PH.
Neurohormonal Dysregulation in the Pulmonary Circulation
Adrenergic and cholinergic innervation of pulmonary vasculature mediate vascular

tone [31]. In animal models, alveolar hypoxia results in increased pulmonary vascu-
lar constriction as a result of sympathetic activation. Human studies demonstrating
strong mechanistic links between CLD, sympathetic activation, and progression of
pulmonary hypertension are lacking.
Renin-angiotensin aldosterone system (RAAS) activation has been associated
with progression of pulmonary artery hypertension. Angiotensin II (Ang II)
activates signaling pathways with activation of protein kinases and non-receptor

tyrosine kinases with end result of vascular smooth muscle proliferation and fibro-
sis. Ang II has been implicated in production of reactive oxygen species (ROS)
through NAPH oxidase activation resulting in increased vascular inflammation [32].
Pulmonary vascular endothelium is one of the major sites for angiotensin-converting
enzyme activity (ACE) [33].
In rats exposed to hypoxia, there was increased ACE mRNA and ACE immunos-
taining in the small neo-muscularized pulmonary arteries [34]. Administration of
captopril and losartan to hypoxic rats improved mean pulmonary artery pressures,
decreased right ventricular hypertrophy, and decreased medial thickening and mus-
cularization of small pulmonary arteries providing indirect evidence of the role of
Ang II production and activation via angiotensin 1 (AT1) receptor in progression of
pulmonary hypertension [34]. In rats exposed to chronic cigarette smoke, pulmo-
nary hypertension developed with increased ACE and Ang II expression in lung
tissue [35].
In normal human subjects, ACE immunostaining was highest in the alveolar cap-
illary endothelium, whereas in subjects with PAH, increased ACE immunostaining
was seen in large pre-acinar and small acinar arteries. In addition, there was
increased ACE immunostaining in arteries with fibrotic and plexiform lesions [36].
In a study of idiopathic PAH patients, there was increased renin activity, angiotensin
1, and Ang II, and increasing trends were associated with risk of death or lung trans-
plantation. Ang II increases pulmonary artery smooth muscle proliferation via AT1
receptor signaling [37].
Ang II via activation of AT1 receptor and increased production of growth factors
(TGF-β, PDGF) promotes human lung fibroblast proliferation in patients with idio-
pathic pulmonary fibrosis [38]. Renal denervation in animal models of PH decreased
AT1 receptor density and mineralocorticoid with decreased proliferation of pulmo-
nary arterial smooth muscle suggesting combined role of sympathetic nervous sys-
tem (SNS), RAAS, and aldosterone in PH disease progression [39].
The endothelin system has been implicated in pathogenesis of WHO group 1
pulmonary arterial hypertension (idiopathic), and one of the major therapeutic tar-
gets is endothelin receptor antagonism. Increased expression of endothelin-1 was
found in alveolar epithelial cells in lung specimens obtained from patients with
pulmonary fibrosis and in muscular pulmonary arteries from patients with concomi-
tant pulmonary fibrosis and pulmonary hypertension [18]. Arterial endothelin-1 lev-
els at rest were significantly elevated in patients with interstitial lung disease (ILD)
and emphysema with pulmonary hypertension compared to patients with lung dis-
ease without pulmonary hypertension. With exercise, arterial levels of endothelin-1
increased in patients with ILD and correlated significantly with alveolar-arterial
oxygen difference [40]. Endothelin-1 increases extra-adrenal synthesis of aldoste-
rone in human pulmonary vascular endothelial cells and animal rodent models of
PH by increased expression of aldosterone synthase. Aldosterone increases oxidant
stress by increasing NADPH oxidase type 4 (NOX4), and generated reactive oxygen
species (ROS) impair endothelin-B (ETB) receptor eNOS (nitric oxide synthase)
signaling with decreased nitric oxide synthesis and pulmonary vascular dysfunc-
tion. Aldosterone antagonists restored endothelin-1-ETB receptor signaling to
increase nitric oxide availability and potentially prevent adverse pulmonary vascu-
lar remodeling [41]. We can speculate from these studies that activation of endothe-
lin system contributes to pathogenesis of pulmonary hypertension in patients with
CLD with concomitant pulmonary hypertension.
Pulmonary Hypertension and the Right Ventricle
The classical view of cor pulmonale is that parenchymal lung disease causes
hypoxic vasoconstriction and remodeling of the pulmonary vascular bed, which
elevates pulmonary vascular resistance, which then leads to PH. The PH
increases right ventricular work and causes RV dilation and/or hypertrophy and
subsequently RV failure. In other words, PH is the central component in cor
pulmonale [42, 43].
In patients with COPD and IPF, the prevalence of PH correlates with the severity
of underlying lung disease. The majority of patients who develop PH, however,
have PA pressures in the mild range, i.e., mean PAP (mPAP) ≤ 35 mmHg. A small
minority have severe PH [44]. Some investigators have postulated that these may
represent distinct phenotypes, i.e., predominant respiratory limitation with mild PH
vs. predominant pulmonary vascular perturbation out of proportion to the degree of
lung disease, with important management implications [45, 46]. The development
of PH, even mild, is associated with more exercise limitations and worse prognosis
[47–51].
Recent evidence, however, challenges some assumptions of the classical view of
cor pulmonale. In an important study, Hilde and colleagues evaluated 94 patients
with Gold II–IV COPD and 34 controls. Patients were categorized as having PH if
mPAP was ≥25 mmHg on resting right heart catheterization. Those without PH
were further divided into mPAP ≤20 and mPAP 21–24 groups. Echocardiographic
RV parameters were impaired in both patients with PH and those without PH com-
pared to controls. RV strain, RV myocardial performance index, and RV isovolumic
relaxation were impaired compared to controls in patients with mPAP ≤20 mmHg,
and RV size and wall thickness had already increased in COPD patients with mPAP
≤20 mmHg [7]. Similar findings were found in a series of 52 patients with IPF,
where impaired RV systolic and diastolic function was observed in patients without
PH by echocardiography [52].
This dissociation between RV remodeling and PH suggests that other mecha-
nisms are involved in RV dysfunction and that RV dysfunction is a process that
begins long before resting PH. It is also important to note that 50% of the pulmo-
nary vascular bed has to be damaged before resting PA pressures increases, and
resting PA pressures may not reflect hemodynamics during exercise or intermittent
nocturnal hypoxemia that could lead to altered pulmonary vascular compliance well
before manifest pulmonary hypertension [53].
Pathophysiology of the Right Ventricle
Right Ventricular Response
Right ventricular function is a major determinant of prognosis in CLD and pulmo-

nary hypertension [22]. The molecular, metabolic, and adrenergic system altera-
tions in the right ventricle (RV) determine the adaptive versus maladaptive changes
in the right ventricle in response to hypoxia or PH. Adaptive changes are character-
ized by minimal RV dilation, increased concentric hypertrophy, and minimal fibro-
sis with preserved RV cardiac output. Maladaptive changes in RV result in increased
fibrosis, RV dilation, decreased RV systolic function with impaired functional
impairment, and decreased survival. As discussed earlier, studies in patients with
COPD have revealed that there is dissociation between RV remodeling process and
PH suggesting other mechanisms may contribute to RV systolic dysfunction [7]. In
a study involving two different animal models of PH, there was a variable degree of
RV dilation, fibrosis, and capillary density despite similar increase in RV afterload.
Animal model with PH induced by combination of hypoxia and VEGF receptor
blocker (SU5416) resulted in more RV fibrosis, decreased capillary density, and
decreased VEGF protein expression when compared to PH induced by pulmonary
artery banding (PAB) alone. Susceptibility to oxidative stress due to decreased anti-
oxidant transcription factor E2-related factor 2 (Nrf2) and HO-1 gene may contrib-
ute to differences in the degree of RV impairment [54]. Right ventricular ischemia
has been implicated in the development of RV dysfunction in patients with primary
pulmonary arterial hypertension [55]. Right ventricular ischemia could result from
decreased right coronary artery perfusion pressure from elevated RV end-diastolic
pressure, decreased capillary density from impaired angiogenesis, and hypoxemia
[22]. RV ischemia can further trigger a cascade of events leading to neurohormonal
activation and metabolic and mitochondrial alterations that promote maladaptive
remodeling.
Neurohormonal Activation
Sympathetic nervous activation in chronic left ventricular systolic heart failure

leads to maladaptive left ventricular remodeling with decreased long-term sur-
vival [56]. Patients with pulmonary arterial hypertension (WHO group 1) with
increased muscle sympathetic nerve activity (MSNA) had disease progression
with clinical deterioration [57]. Patients with chronic respiratory failure due to
COPD and pulmonary fibrosis demonstrated increased MSNA likely due to
peripheral arterial chemoreceptor activation providing evidence of increased sym-
pathetic activation in CLD [58]. Patients with COPD have elevated resting heart
rate, decreased heart rate variability, and decreased baroreceptor sensitivity indic-
ative of heightened sympathetic activation [59]. In a small study involving COPD
patients, increased MSNA activity was significantly higher in patients who died
or were hospitalized for COPD exacerbation [60]. The untoward consequences of
sympathetic activation seen in PAH (WHO group 1) and COPD may be pertinent
to patients with CLD with increased sympathetic activity. There is lack of data
regarding long-term consequences of sympathetic nervous system activation in
worsening respiratory function, pulmonary hypertension, and RV failure in
patients with CLD. The mechanisms of sympathetic activation in COPD are pos-
tulated due to peripheral arterial chemoreceptor stimulation from hypoxia, stimu-
lation of central chemoreceptors due to hypercapnia, breathing patterns, chronic
hyperinflation resulting in alteration of local pulmonary stretch receptors, dia-
phragmatic remodeling, use of beta sympathomimetics, and inflammatory state
[59, 61, 62]. Plasma norepinephrine levels were elevated twofold in end-stage
emphysematous patients and elevated threefold in patients with acute cor pulmo-
nale due to COPD [63, 64]. Data regarding prognostic significance of elevated
norepinephrine levels in CLD is lacking.
Remodeling of adrenergic receptor signaling in right ventricle resulted in
decreased inotropic reserve in PH in animal models of RVH caused by combination
of VEGFR inhibitor and hypoxia or monocrotaline. There was increase in G protein-
coupled receptor kinase-2 (GRK2) activity with end result of β1-AR downregula-
tion and decreased contractile reserve in response to inotropes [65].
Role of Renin-Angiotensin System
Activation of renin-angiotensin system in chronic left ventricular systolic heart fail-

ure leads to maladaptive remodeling and progression of disease [66]. In animal
models with chronic exposure to hypoxia, there is 3.4-fold increase in right ven-
tricular ACE expression and correlated with presence of right ventricular hypertro-
phy [67]. Activation of renin-angiotensin system and sympathetic nervous system
from increased right atrial pressures with exercise and hypoxia in patients with
COPD creates a vicious cycle of sodium and fluid retention and worsening RV sys-
tolic function [46].
Metabolic Alterations in the Right Ventricle
The right ventricle is a thin-walled structure with one-fifth the energy of the left
ventricle due to low pulmonary vascular resistance [68]. The energy source for a
normal adult heart is predominantly fatty acids (60–90%) with glucose accounting
for 10–40% [22]. With chronic pressure overload to the right ventricle and hypoxia
due to CLD, metabolism in the right ventricle shifts from predominantly fatty acid
oxidation to glycolysis. Evidence of increased glycolysis has been studied exten-

sively in animal rodent models and human subjects. In patients with iPAH, [18 F]flu-
orodeoxyglucose (FDG) PET imaging demonstrated increased accumulation in the
RV free wall and correlated with increased RV wall stress, and there was a decrease
in uptake in treatment responders to pulmonary vasodilators [69]. Patients with
PAH with increased FDG uptake in the RV free wall experienced clinical worsen-
ing, poor exercise tolerance, and higher all-cause mortality [70]. Impaired RV myo-
cardial fatty acid uptake in patients with RV hypertrophy due to PH (idiopathic and
chronic thromboembolic) using iodine-123-labeled 15-(p-iodophenyl)-3-(R,S)-
methyl pentadecanoic acid was associated with poor RV contractility and decreased
survival [71]. Metabolic shift to glycolysis was mediated by activation of pyruvate
dehydrogenase kinase (PDK) which inhibits pyruvate dehydrogenase phosphoryla-
tion in rodent models of MCT-induced RVH. There is inefficient energy production
with consequent decreased RV systolic function. The expression of PGC-1α protein
and mRNA levels, a key regulator of peroxisome proliferator-activated receptor
gamma coactivator 1-alpha that is responsible for fatty acid oxidation, is decreased
in animal rodent models of PH induced by combination of SU5416 and hypoxia
with significant RV dysfunction as opposed to rodents that have right ventricular
hypertrophy due to pulmonary artery banding. Human RV tissue samples from
patients with PAH undergoing transplantation exhibited a similar decrease of
PGC-1αmRNA in failing RVs compared to normal hearts. The findings of increased
gene expression (GLUT-1 and hexokinase) responsible for glycolysis and decreased
expression of genes responsible for encoding proteins for fatty acid transport into
cells and mitochondria, mitochondrial fatty acid oxidation, and glucose oxidation in
the failing RV are suggestive of maladaptive metabolic remodeling [72]. Evidence
from animal models of PH have shown that increased glutaminolysis by cMyc acti-
vation (similar to cancer cells) promotes cell growth causing RVH and supports the
increasing metabolic needs of the right ventricle [73]. The findings of decreased
high-energy phosphates in the RV myocardium, decreased mitochondrial oxygen
consumption, and dysfunction enzyme activity of mitochondrial electron transport
chain could reflect a transition from a compensated to a decompensated state of RV
dysfunction [74]. Mitochondrial DNA damage by reactive oxygen species, changes
to the mitochondrial structure, decreased mitochondrial content, and abnormal cel-
lular respiration are seen in RV dysfunction due to PH. Right ventricular hypertro-
phy due to pulmonary artery banding which is a more adaptive remodeling of RV
has less pronounced mitochondrial dysfunction [72]. Right ventricular myocardial
gene remodeling with decreased angiogenic factors VEGF, Ang 1, and apelin con-
tributes to decreased capillary density and consequent myocardial ischemia in fail-
ing right ventricle [75]. In addition, impaired hypoxia-inducible factor (HIF1 α)
signaling due to increased mitochondrial reactive oxygen species production impairs
angiogenesis leading to decompensated RV failure. Finally, into metabolic remodel-
ing, there is evidence of electrical remodeling with prolonged QTc interval due to
decreased expression of potassium channels [73].
Hypoxia and Right Ventricular Dysfunction
Acute hypoxia can cause pulmonary vasoconstriction, whereas chronic hypoxia is

associated with remodeling. The mechanisms of remodeling are complex and
include myofibroblast differentiation, release of growth factors, vasoconstrictors,
adhesion molecules, matrix proteins, altered calcium handling, and inflammatory
mediators. A detailed review is provided by Stenmark et al. [76]. Hypoxia is a
marker of the severity of lung disease, is associated with worse outcomes, and may
lead to pulmonary hypertension and secondary RV failure.
However, the role of hypoxia in primary RV dysfunction is unclear, and hypoxia
may not be a necessary prerequisite for RV dysfunction. In one study, right ventricu-
lar hypertrophy was observed in 25 patients, of whom the majority [19] had resting
normoxia (PaO2 > 80 mmHg) and the rest had mild hypoxia (PaO2 60–80).
Therefore, RV structural abnormalities occur well before resting hypoxemia. It
should be noted that dynamic changes in oxygenation during exercise or sleep were
not evaluated in this study [77].
Disease-Specific Pathophysiologic Responses
A large proportion of early human clinical research on RHD in CLD focused on cor
pulmonale from COPD, which accounts for 80–90% of cor pulmonale [42]. More
recently, investigation on other causes, including IPF, interstitial lung diseases
related to connective tissue diseases, cardiac sarcoidosis, and cystic fibrosis, has
increased. The RV pathology as well as response to hypoxemia, pressure, and vol-
ume overload may vary based on the underlying condition. For some processes,
there may also be direct involvement of the right ventricle in addition to the paren-
chymal lung disease. For example, pathologic analysis of the right ventricles of
patients who died of idiopathic PH vs. systemic sclerosis-related PH (SScPAH)
revealed that those with systemic sclerosis had significantly more inflammatory
cells than IPAH but a similar degree of fibrosis [78]. SScPAH patients also have
higher pro-BNP levels than IPAH patients despite less severe hemodynamic abnor-
malities, and pro-BNP is a stronger predictor of survival in SScPAH than IPAH,
suggesting differences in neurohormonal responses between the two conditions
[79]. Patients with systemic sclerosis also have increase in RA area, increase in RV
wall thickness, and impaired diastolic function compared to controls despite similar
resting pulmonary pressures and RV systolic function [80]. Other conditions, such
as sarcoidosis, also have demonstrated pathophysiologic heterogeneity [44]. It is
beyond the scope of this manuscript to discuss the details of all such pathophysio-
logic differences, but these types of disease-specific responses may lead to distinct
phenotypes that are currently poorly understood but may have implications regard-
ing need for close surveillance, aggressiveness of therapy, and in some cases treat-
ment and response to pulmonary vasodilators.
Diagnosis of Right Heart Dysfunction in Chronic Lung Disease
The diagnosis of right heart dysfunction in CLD is not always straightforward and
reflects the pathophysiologic complexity and heterogeneity of the condition.
Symptoms of dyspnea, exertional intolerance, and fatigue can be nonspecific and
potentially related to the underlying CLD rather than RHD. The development of
peripheral edema can be due to activation of the renin-angiotensin-aldosterone sys-
tem from hypoxia and/or hypercapnia and subsequent altered sodium and fluid
hemodynamics and does not necessarily indicate right heart dysfunction. Physical
exam findings of jugular venous distension, tricuspid regurgitation, right ventricular
heave, epigastric pulsation, and pulsatile liver are more specific, but by the time
these findings occur the RV dysfunction is advanced.
Echocardiography is the most important screening test for early as well as
advanced RV dysfunction or PH. Standard measurements include ventricular and
atrial size, RV wall thickness, systolic and diastolic measurements, and RA pressure
estimation using IVC diameter and collapsibility. Pulmonary artery systolic pres-
sure is estimated using tricuspid regurgitation velocity and RA pressure. Reference
values from the American Society of Echocardiography are listed in Tables 5.1 and
5.2 [81]. Early pathophysiologic changes may not be detected by standard
Table 5.1 Summary of reference limits for recommended measures of right heart structure and
function
Variable Unit Abnormal
Chamber dimensions
RV basal diameter cm >4.2
RV subcostal wall thickness cm >0.5
RVOT PSAX distal diameter cm >2.7
RVOT PLAX proximal diameter cm >3.3
RA major dimension cm >5.3
RA minor dimension cm >4.4
RA end-systolic area cm2 >18
Systolic function
TAPSE cm <1.6
Pulsed Doppler peak velocity at the annulus cm/s <10
Pulsed Doppler MPI – >0.40
Tissue Doppler MPI – >0.55
FAC (%) % <35
Diastolic function
E/A ratio – <0.8 or > 2.1
E/E′ ratio – >6
Deceleration time (ms) ms <120
Reproduced with permission from Ref [81]
FAC fractional area change, MPI myocardial performance index, PLAX parasternal long axis,
PSAX parasternal short axis, RA right atrium, RV right ventricle, RVD right ventricular diameter,
RVOT right ventricular outflow tract, TAPSE, tricuspid annular plane systolic excursion
Table 5.2 Estimation of RA pressure on the basis of IVC diameter and collapsibility
Normal (0–5 Intermediate (5–10
Variable [3] mm Hg) [8] mm Hg) High (15 mm Hg)
IVC diameter ≤2.1 cm ≤2.1 cm >2.1 cm >2.1 cm
Collapse with sniff >50% <50% >50% <50%
Secondary indices of Restrictive filling
elevated RA pressure
Tricuspid E/E′ > 6
Diastolic flow predominance in
hepatic veins (systolic filling
fraction <55%)
Reproduced with permission from Ref. [81]
Ranges are provided for low and intermediate categories, but for simplicity, midrange values of
3 mm Hg for normal and 8 mm Hg for intermediate are suggested. Intermediate (8 mm Hg) RA
pressures may be downgraded to normal (3 mm Hg) if no secondary indices of elevated RA pres-
sure are present, upgraded to high if minimal collapse with sniff (<35%) and secondary indices of
elevated RA pressure are present, or left at 8 mm Hg if uncertain
IVC inferior vena cava, RA right atrial
Fig. 5.3 Stages of pulmonary

hypertension. As pulmonary
hypertension progresses, CO
pulmonary vascular resistance
continues to rise. When the
right ventricle fails, the
systolic pulmonary pressure PAP
PVR = MPAP-PCWP
decreases, as does the cardiac
PVR CO
output. (Reproduced with
permission from Ref. [82])
Time
measures, and tissue deformation/strain rate imaging may detect more subtle ven-
tricular dysfunction and may be less load-dependent.
It is important to recognize that echocardiography may not accurately diagnose
PH if there are poor windows, if the probe angulation is not parallel to the tricuspid
jet, or if there is no tricuspid regurgitation jet. Also, we advise caution in using
echo-derived PA systolic pressure alone to longitudinally evaluate pulmonary pres-
sures, because a decrease in PA systolic pressure could reflect either improvement
in PH or worsening PH with RV failure and inability of the RV to generate high
pressure [82](Fig. 5.3).
Cardiac magnetic resonance imaging provides accurate, comprehensive assess-
ment of the heart but is not widely available, is time-consuming, and is not cost-
effective as an initial screening test for all patients with CLD. However, it can be
valuable to provide detailed ventricular size and volume measurements in order to
track subtle changes and assess responses to therapy or for research purposes. It can
also be a useful noninvasive exam when echocardiographic images are suboptimal
or there is still clinical uncertainty after echocardiogram.
Hemodynamic assessment with a right heart catheterization (RHC) is the most

direct physiologic assessment of the right heart, left heart, and the pulmonary circu-
lation. The degree of RV failure, the severity of pulmonary hypertension, the pulmo-
nary vascular resistance, the relationship between the pulmonary vasculature and
right heart dysfunction, and the left ventricular contribution to pulmonary pressures
by the pulmonary capillary wedge pressure can all be measured. Exercise RHC may
provide important information regarding changes in pulmonary pressure with exer-
tion and/or hypoxia and can sometimes unmask mild left ventricular diastolic dys-
function. Careful measurement of pressures at end expiration (but avoiding Valsalva
maneuver) is crucial, since there are often very wide respiratory variations in intra-
thoracic pressures in patients with COPD, OSA, and other lung diseases, and auto-
mated measurements or inadequate attention can make the measurements
uninterpretable.
Conclusion
Right heart dysfunction in chronic lung disease is a complex, multifaceted process,

both related to and independent of PH. Large-scale human studies are limited, and
pathway redundancies and relationships are not well understood. Further investiga-
tion into these processes may provide new models and innovative therapeutic tar-
gets for right heart dysfunction in chronic lung diseases.
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Chapter 6
Pulmonary Hypertension Associated
with Chronic Lung Diseases: Treatment
Considerations
Jason Weatherald, David Montani, and Olivier Sitbon
Key Pearls
• Pulmonary hypertension (PH) is associated with worse survival in patients
with chronic lung diseases, but treatment consists of optimizing the under-
lying lung disease, long-term oxygen, and consideration of lung
transplantation.
• Pulmonary arterial hypertension (PAH) therapies have been studied in a
small number of randomized controlled trials including patients with
COPD, interstitial lung disease, and sarcoidosis-associated PH with no
consistent therapeutic benefits on symptoms, exercise capacity, or clinical
outcomes. In one trial of patients with idiopathic pulmonary fibrosis,
ambrisentan was harmful.
• Patients with mild lung disease and severe PH without another explanation
should be evaluated in centers with expertise in the diagnosis and treat-
ment of PAH.
J. Weatherald (*)
University of Calgary, Department of Medicine, Division of Respiratory Medicine,
Calgary, AB, Canada
Libin Cardiovascular Institute of Alberta, Calgary, AB, Canada
e-mail: jcweathe@ucalgary.ca
D. Montani · O. Sitbon
Université Paris-Sud, Faculté de Médecine, Université Paris-Saclay,
Le Kremlin-Bicêtre, France
e-mail: david.montani@aphp.fr; olivier.sitbon@aphp.fr

80 J. Weatherald et al.
Introduction
Pulmonary hypertension (PH) is an important complication of chronic parenchymal

lung diseases. The current definition of PH requires an abnormal resting mean pulmo-
nary arterial pressure > 20 mmHg during right heart catheterization (RHC) [1, 2]. The
most common chronic lung conditions that cause PH are chronic obstructive pulmo-
nary disease (COPD) and idiopathic pulmonary fibrosis (IPF), but PH can occur in the
context of other parenchymal lung diseases including combined pulmonary fibrosis
and emphysema (CPFE), sarcoidosis, lymphangioleiomyomatosis (LAM), and pul-
monary Langerhans cell histiocytosis (PLCH). PH that occurs due to chronic lung
diseases or chronic hypoxia (high altitude or severe sleep-disordered breathing) com-
prises Group 3 PH, whereas conditions such as sarcoidosis, LAM, and PLCH have
multiple or multifactorial mechanisms and are classified into Group 5 PH [3].
When present, PH contributes to more severe symptoms and exercise intolerance
and can lead to right heart failure, which portends a worse prognosis in patients with
chronic lung disease. Most patients have mild elevations in mPAP, but a smaller
proportion develop severe PH, which is defined by a resting mPAP ≥35 mmHg or
mPAP ≥25 mmHg with a low cardiac index (CI) < 2.0–2.5 L.min.m−2 [2–4].
Usually, the severity of PH is proportional to the severity of lung disease; however,
in some cases, severe PH is present with only mild parenchymal lung disease or
mild to moderately impaired pulmonary function testing, making it difficult to
determine whether there are two conditions present (i.e., Group 1 pulmonary arte-
rial hypertension with comorbid mild lung disease).
In patients with Group 1 PAH, targeted medical therapies improve endothelial
cell dysfunction, have vasodilatory and anti-proliferative effects on the pulmonary
vasculature, reduce the right ventricular afterload, and improve symptoms, exercise
capacity, and clinical outcomes in randomized trials. Given the similar pre-capillary
hemodynamic profile (elevated mPAP ≥20 mmHg, pulmonary arterial wedge pres-
sure ≤ 15 mmHg, and pulmonary vascular resistance >3 Wood units) and common
histopathological changes in patients with PAH and some patients with PH due to
chronic lung disease, there has been interest in studying the effects of PAH therapies
in these patients. In general, treatment of PH in chronic lung disease should be
directed at the underlying condition and contributing etiologies such as left heart
disease, thromboembolic disease, and sleep-disordered breathing (Fig. 6.1). Because
of the negative impact of PH on survival in most chronic lung diseases, those who
develop PH should be considered for lung transplantation if they are appropriate
candidates [5]. In this chapter, we will focus on literature regarding therapies that
target the pulmonary vasculature in chronic lung diseases. However, it is important
to state from the outset that no PAH therapies are proven to be effective in chronic
lung diseases and there is clear evidence that worsening gas exchange can occur due
to the effects of these therapies on hypoxic vasoconstriction and worsening
ventilation-perfusion matching. Therefore, the use of PAH therapies in patients with
chronic lung disease-associated PH should be restricted to trial protocols, registries,
and centers with considerable expertise.
6 Pulmonary Hypertension Associated with Chronic Lung Diseases: Treatment… 81
Parenchymal disease Chronic Hypoxia

• Vascular destruction • Vasoconstriction
Optimize • Fibrosis • Neovascularization
treatment of • Inflammation and remodelling
Long-term
underlying lung
• Venous obstruction/occlusion oxygen therapy
• Effects of lung volume on
disease alveolar and extra-alveolar
vessels
Comorbidities
• Left heart disease
• Thromboembolic disease
• Sleep disordered breathing
Treat comorbidities and

contributing etiologies
Fig. 6.1 Management of pulmonary hypertension in chronic lung diseases
PH Associated with Chronic Obstructive Pulmonary Disease
Treatment of PH in COPD begins with optimization of medical therapy for COPD

according to guidelines [6]. Several factors can lead to the development of an
increased mPAP and pulmonary vascular resistance (PVR) in COPD, including air-
flow limitation, alveolar hypoxia and vasoconstriction, destruction of the pulmo-
nary vascular bed due to emphysema, polycythemia, and inflammation (Fig. 6.1)
[7]. Long-term oxygen treatment improves survival in hypoxemic COPD patients
but was unrelated to the degree of PH in the Nocturnal Oxygen Therapy Trial [8].
Continuously administered oxygen for at least 18 hours per day does not fully cor-
rect PH to normal but improves the pulmonary vascular resistance and cardiac func-
tion [9] and may prevent progressive mPAP elevation [10].
Other than long-term oxygen therapy, there has been significant interest in PAH
therapies for treating PH in COPD, particularly those with severe PH, which has
usually been defined by the presence of mPAP >35–40 mmHg or a low CI < 2.0–2.5 L.
min.m−2 [4, 7]. Severe PH is present in less than 5% of COPD patients, and many
have other explanations for a severely elevated mPAP such as concurrent left ven-
tricular dysfunction, pulmonary embolism, pulmonary fibrosis, or sleep-disordered
breathing [11]. However, a small proportion (approximately 1%) of COPD patients
have severe PH without an alternative explanation or have severe PH in the presence
of only mild lung disease. COPD patients with severe PH, relatively preserved pul-
monary function, and little-to-no emphysema often exhibit cardiovascular limita-
tion to exercise rather than ventilatory mechanical limitation to exercise, which may
be a “pulmonary vascular phenotype” of COPD [12]. Pulmonary vasodilator thera-

pies could potentially be beneficial in this group of patients; however, the evidence
to support this is limited [2, 12, 13].
An uncontrolled study by Girard et al. included 26 patients with moderate-to-
severe COPD (mean FEV1 57 ± 20% predicted) and severe PH (mean mPAP
48 ± 9 mmHg) who were treated with PAH-targeted medications and found that
PVR and mPAP decreased, CI increased, but there were no significant improve-
ments in exercise capacity or NT-pro-BNP [14]. Calcaianu et al. reported similar
findings in 28 patients with mild-to-moderate airflow limitation and severe pre-
capillary PH [15]. Targeted PAH therapy improved PVR and CI but had no effect on
exercise capacity or functional class. A study from the ASPIRE registry found no
difference in survival for patients with COPD (mean FEV1 65 ± 23% predicted) and
severe PH (mPAP ≥40 mmHg) who were treated with PAH treatments and those
who were not treated [16]. However, 8 of the 43 patients who were treated with PAH
therapies in this study demonstrated a clinical improvement, defined as decrease in
PVR of >20% or an improvement in WHO functional class, and these individuals
had better survival than those not demonstrating clinical improvement. Relatively
few prospective clinical studies of specific PAH therapies have been performed in
COPD patients despite the relative burden and prognostic importance of PH in this
population. Unfortunately, most of the available trials in COPD-associated PH have
been small and have shown no convincing benefit of PAH therapies.
Calcium Channel Blockers
Calcium channel blockers, such as nifedipine, cause pulmonary arterial vasodilation

and improve hemodynamics acutely in patients with COPD but have no demon-
strated long-term benefits [17, 18]. Furthermore, nifedipine may worsen arterial
oxygenation at rest and during exercise by inhibiting normal hypoxic vasoconstric-
tion in lungs of COPD patients, leading to worsened ventilation-perfusion matching
and worsening gas exchange [19].
Inhaled Vasodilators
Similar to calcium channel blockers, inhaled nitric oxide (NO) causes pulmonary
vasodilation, which may be advantageous in COPD-associated PH by theoretically
causing vasodilation only in ventilated lung units. However, studies have shown that
inhaled NO decreases PaO2 in COPD by impairing hypoxic regulation of ventilation-
perfusion matching [20]. However, when added to oxygen, inhaled nitric oxide
reduces PVR and mPAP and improves cardiac function in COPD patients with
pulmonary hypertension compared to oxygen alone, without causing arterial desat-

uration [21]. Despite these promising findings, no long-term studies of inhaled NO
in COPD-associated PH have been performed. Iloprost is an inhaled prostacyclin
analogue with potent acute vasodilatory effects, which should act preferentially in
well-ventilated lung regions. In ten moderate-to-severe COPD patients (FEV1
47.4 ± 8.2% predicted), 5.0 μg of inhaled iloprost improved ventilatory efficiency
(VE/VCO2) during exercise and 6-minute walk distance (6MWD) with a reduction
in the alveolar-arterial O2 gradient (PA-aO2) and no arterial desaturation [22].
However, in contrast, a randomized double-blind crossover study including 16
patients with COPD-associated PH found inhaled iloprost had no effect on 6MWD,
caused a reduction in peak VO2, and a 2.2% reduction in resting SpO2 with a 10 μg
dose of iloprost [23]. Although no long-term studies of inhaled prostacyclins have
been performed to date, the existing evidence suggests no benefit in COPD-
associated PH.
Phosphodiesterase-5 Inhibitors in COPD-Associated PH
The acute effects of sildenafil, a phosphodiesterase-5 inhibitor (PDE5i), were stud-

ied in 20 patients with severe or very severe COPD, 17 of whom had an mPAP
>20 mmHg at rest (mean mPAP 27 ± 10 mmHg) and all of whom had PH during
exercise [24]. Sildenafil given at 20 mg or 40 mg reduced mPAP and PVR acutely
and improved hemodynamics during exercise but caused mild worsening of gas
exchange at rest, which was related to increased pulmonary blood flow to poorly
ventilated lung units as measured with the multiple inert gas technique. Several
longer-term randomized controlled trials (RCTs) have evaluated PDE5i therapy in
COPD-associated PH with disappointing results (Table 6.1) [25–29]. Only one
study by Rao et al. [25], which only used echocardiography-derived estimates of
PH, found a significant improvement in exercise capacity, while all other studies
have found no improvement in exercise tolerance using peak VO2 or 6MWD. The
largest study by Goudie et al. compared a low dose of tadalafil (10 mg) to placebo
in 120 patients with COPD and evidence of PH on echocardiogram and found no
effect on 6MWD, quality of life, or B-natriuretic peptide levels [28]. It is unclear
whether the usual dose of 40 mg used in treating PAH would have more significant
clinical effects. Only one randomized study by Vitulo et al. reported long-term
hemodynamic effects of PDE5i compared to placebo in COPD patients with severe
PH, which were modest but significant (PVR – 1.38 Wood units and CI +0.4 L.min.
m−2) [29]. Interestingly, while 6MWD did not significantly improve in this study at
16 weeks, dyspnea scores improved, there was no worsening in PaO2, and quality of
life scores on the Short Form-36 improved by a clinically significant 9.85 units [29].
Therefore, sildenafil could be considered in patients with COPD and severe PH who
have refractory breathlessness despite optimal medical therapy.
Table 6.1 Randomized trials of PDE5i in COPD-associated PH

Author Ref N Drug Severity of PH Follow-up Endpoints
Rao [25] 33 Sildenafil 20 mg sPAP >40 mmHg on 12 weeks 6MWD: +190 m
(2011) TID echo vs. placebo
vs. placebo sPAP decreased
Lederer [26] 10 Sildenafil 25 mg No PH 4 weeks 6MWD: no effect
(2012) TID VO2: no effect
vs. placebo QoL: worsened
Blanco [27] 60 Sildenafil 20 mg mPAP 31 ± 5 mmHg 12 weeks Cycle endurance
(2013) TID time: no effect
vs. placebo added VO2: no effect
to pulmonary 6MWD: no effect
rehabilitation
Goudie [28] 120 Tadalafil 10 mg sPAP 12 weeks sPAP: decreased
(2014) daily 42 ± 10 mmHg −12.3 mmHg
vs. placebo (echo estimated) 6MWD: no effect
QoL: no effect
BNP: no effect
Vitulo [29] 28 Sildenafil 20 mg mPAP 25 mmHg in 16 weeks PVR: −1.38 WU
(2017) TID 68%, mPAP CI: +0.42 L.min.m−2
vs. placebo 39 ± 8 mmHg, PVR BODE: improved
7 ± 2.6 WU 6MWD: no effect
SF-36: +9.85 units
PH pulmonary hypertension, TID thrice daily, 6MWD 6- minute walk distance, sPAP systolic
pulmonary arterial pressure, VO2 maximum oxygen consumption measured during incremental
exercise, QoL quality of life, mPAP mean pulmonary arterial pressure, BNP brain natriuretic pep-
tide, PVR pulmonary vascular resistance, WU Wood unit, BODE body-mass-index, airflow
obstruction, dyspnea, exercise capacity
Endothelin Receptor Antagonists in COPD-Associated PH
Two randomized trials have evaluated bosentan, an endothelin receptor antagonist

(ERA), in patients with COPD. Stolz et al. randomized 20 patients with severe or
very severe COPD to bosentan 125 mg twice daily and 10 to placebo with a primary
endpoint of change in 6MWD at 12 weeks [30]. While most patients had echocar-
diographic evidence of PH, right heart catheterizations were not performed in this
study. Six patients in the bosentan arm dropped out due to adverse effects compared
to only one in the placebo group. There were no differences in 6MWD, echocardio-
graphic parameters, or Borg dyspnea index, while PaO2 decreased significantly and
quality of life deteriorated in the bosentan group. In another randomized non-
blinded trial of 32 patients, Valerio et al. found reductions in mPAP and PVR and an
improvement in 6MWD for bosentan-treated patients with no significant changes in
either variable in the standard care group at 18 months [31]. There have been no
reported trials with the other ERAs (macitentan, ambrisentan, sitaxsentan) in
COPD-associated PH. Based on the available data, ERAs are not recommended in
patients with COPD and PH.
Other PAH Therapies in COPD-Associated PH
Epoprostenol is an intravenously administered prostacyclin that revolutionized the

treatment of PAH, improving symptoms, hemodynamics, and survival [32]. There
are no long-term randomized trials of parenteral epoprostenol in COPD-associated
PH; however, one small, short-term randomized study used epoprostenol in COPD
patients with PH and acute respiratory requiring mechanical ventilation [33]. Small
uncontrolled studies suggested hemodynamic benefits, but worsening oxygenation
frequently occurs with epoprostenol in stable COPD patients or those with PH and
acute respiratory failure [33, 34]. Riociguat is a soluble guanylate cyclase stimulator
approved for use in PAH and chronic thromboembolic pulmonary hypertension
(Group IV). An open-label pilot study of 23 patients with COPD-associated PH
found acute decreases in mPAP and PVR and improvements in CI with riociguat,
but PaO2 decreased on average by 10–15 mmHg [35]. Although PAH therapies con-
sistently worsen oxygenation in COPD, total oxygen delivery may conceivably
increase if cardiac output improves to a greater extent; furthermore, administration
of supplemental oxygen may mitigate the hypoxemia. Thus, future studies should
consider the effects of these medications with or without supplemental oxygen on
important endpoints such as quality of life, exercise tolerance, and clinical events.
PH Associated with Interstitial Lung Diseases
PH can occur in association with most fibrotic interstitial lung diseases (ILD), of
which IPF is the most frequent. Importantly, PH can result due to several potential
mechanisms in ILD patients including as a direct result of parenchymal fibrosis and
vascular destruction, venous and venular involvement, and other comorbidities
including thromboembolism, sleep-disordered breathing, and left heart disease with
post-capillary PH [36–39]. Therefore, it is important to search for and treat other
contributing causes before even considering further treatment with PAH therapies.
In a registry-based study, patients with PH associated with chronic fibrosing
idiopathic interstitial pneumonias had worse survival than patients with PAH, and
while some short-term improvements in 6MWD were seen in patients treated with
PAH therapies, it is unclear whether treatment of PH improves outcomes [40].
Systemic sclerosis can cause PH through multiple mechanisms, including left ven-
tricular dysfunction (post-capillary, Group 2), pre-capillary PH secondary to ILD
(Group 3), pulmonary veno-occlusive disease, and Group 1 PAH [41]. Patients with
systemic sclerosis and ILD-associated PH have worse outcomes than those who
have PAH and no ILD [42, 43]. While PAH therapies are effective in systemic scle-
rosis patients with Group 1 PAH, observational studies have shown no clear benefit
of PAH therapies in systemic sclerosis ILD-associated PH in terms of functional
capacity, 6MWD, or hemodynamics, but arterial oxygenation significantly wors-
ened [44].
Several open-label, uncontrolled, and retrospective studies had suggested poten-

tially favorable effects of sildenafil, endothelin receptor antagonists, and prostacy-
clins in patients with ILD. Several RCTs have subsequently evaluated PAH therapies
in IPF, and one RCT has evaluated bosentan in the treatment of ILD secondary to
systemic sclerosis. However, the inclusion of patients with PH in these studies was
variable, and no studies have demonstrated clinical efficacy (Table 6.2). Pre-clinical
Table 6.2 Randomized controlled trials of PAH therapies in ILD with or without associated PH
Lung PH patients
Author Ref N disease Drug included? Duration Endpoints
Krowka [54] 51 IPF Iloprost vs. Yes 12 weeks Safety: similar rate
(2007) placebo of adverse events
6MWD: no
difference
NYHA: no
difference in
proportion who
improved
King [45] 158 IPF Bosentan Yes – mild 12 months 6MWD: no
(2008) 125 mg BID PH on echo difference
(starting dose (RVSP Disease
62.5 mg BID <50 mmHg) progression: trend
× 4 weeks) vs. included in favor of
placebo bosentan
Lung function: no
difference
Dyspnea and QoL:
trends in favor of
bosentan
Zisman [49] 180 IPF Sildenafil Yes 12 weeks 6MWD
(2010) 20 mg TID vs. improvement of
placebo >20%: no
significant
difference
Secondary
endpoints:
Improved dyspnea
scores, DLCO, and
PaO2
Jackson [55] 29 IPF Sildenafil Yes – mild 6 months 6MWD: no
(2010) 20 mg TID vs. PH on echo difference
placebo (RVSP Dyspnea scores: no
<50 mmHg) difference
included Lung function no
difference
RVSP: no
difference
Adverse effects
higher in sildenafil
group
Table 6.2 (continued)
Lung PH patients
Seibold [56] 163 Systemic Bosentan Excluded 12 months 6MWD: no
(2010) sclerosis 125 mg BID difference
ILD (starting dose Time to death or
62.5 mg BID worsening PFTs:
× 4 weeks) vs. no difference
placebo Change in FVC or
DLCO: no
difference
King [46] 616 IPF Bosentan Yes 20 months Time to IPF
(2011) 125 mg BID worsening or
(starting dose death: no
62.5 mg BID difference
× 4 weeks) vs. QoL: no difference
placebo Dyspnea: no
difference
Change in FVC: no
difference
Raghu [47] 494 IPF Ambrisentan Yes excluded 34 weeks Time to IPF
(2013a) 10 mg daily patients on progression:
vs. placebo other terminated early
long-term PH due to higher
therapies disease progression
in ambrisentan
group
Hospitalizations:
increased in
ambrisentan group
6MWD: no
difference
Lung function
decline: no
difference
Raghu [48] 178 IPF Macitentan Yes 12 months Change in FVC: no
(2013b) 10 mg vs. difference
placebo Time to IPF
worsening or
death: no
difference
Dyspnea: no
difference
Adverse events: no
difference
(continued)
Table 6.2 (continued)
Lung PH patients
Corte [51] 60 Fibrotic Bosentan Yes – Only 16 weeks Decrease in PVRi
(2014) IIP (IPF 125 mg BID included PH >20%: no
n = 46, (starting dose confirmed on difference
fibrotic 62.5 mg BID RHC 6MWD: no
NSIP × 4 weeks) vs. difference
n = 14) placebo Symptoms and
QoL: no difference
RV function on
echo: no difference
BNP: no difference
O2 requirements:
trend toward
increased O2 needs
in bosentan group
Disease
progression: no
difference
IPF idiopathic pulmonary fibrosis, 6MWD 6-minute walk distance, NYHA New York Heart
Association, PH pulmonary hypertension, TID thrice daily, BID twice daily, RVSP right ventricu-
lar systolic pressure, QoL quality of life, DLCO diffusing capacity of carbon monoxide, PaO2
partial pressure of oxygen in arterial blood, PFT pulmonary function test, FVC forced vital capac-
ity, NSIP non-specific interstitial pneumonitis, BNP brain natriuretic peptide, RHC right heart
catheterization, PVR pulmonary vascular resistance
studies showed that endothelin-1 is involved in the pathogenesis of IPF and that
endothelin-1 blockade may have anti-fibrotic effects, but all major trials of endothe-
lin receptor antagonists in IPF have been negative: bosentan (BUILD-1 and
BUILD-3) [45, 46], ambrisentan (ARTEMIS-IPF) [47], and macitentan (MUSIC)
[48]. Beyond the absent signal for efficacy, there are also potential safety concerns
with endothelin receptor antagonists in IPF. The ARTEMIS-IPF trial was actually
stopped prematurely, as there was a signal for harm in the ambrisentan group, with
1.74-fold increase in the risk of disease progression and 2.6-fold increase in the risk
of hospitalization [47]. The STEP-IPF trial evaluated sildenafil in IPF, which did
have some positive secondary outcomes including improvements in symptoms and
gas exchange, but the primary outcome (improvement in 6MWD) was negative
[49]. In a subgroup analysis of patients from the Sildenafil Trial of Exercise
Performance in Idiopathic Pulmonary Fibrosis (STEP-IPF) study who had echocar-
diography performed, those with baseline right ventricular dysfunction had
improved exercise capacity (+99 m) and better quality of life with sildenafil com-
pared to placebo, suggesting these IPF patients might still benefit from silde-
nafil [50].
Unfortunately, there have been very few RCTs specifically evaluating the effi-
cacy of PAH therapies in patients with ILD-associated PH. The only RCT to study
the effect of PAH therapies specifically in patients with ILD and PH was by Corte
et al. who compared bosentan to placebo in 60 patients with IPF (n = 46) or fibrotic
non-specific interstitial pneumonia (n = 14) [51]. Patients in this study had severe
ILD as evidenced by a forced vital capacity of 54.2 ± 21.2% predicted and severe
reduction in diffusion capacity for carbon monoxide <30% predicted and moderate-
to-severe PH (mean mPAP 36.0 ± 8.9 mmHg and PVRi 13.0 ± 6.7 Wood units/m2).
There was no benefit with bosentan over placebo with regard to hemodynamics,
exercise capacity, symptoms, lung function, or right ventricular function on
echocardiography.
Based on the available evidence, PAH therapies are not recommended in IPF
irrespective of whether PH is present and treatment should consist of treating the
underlying condition according to current guidelines, which consists of oxygen and
anti-fibrotic agents, such as pirfenidone or nintedanib, in appropriate patients [52].
It remains unclear whether patients with mild-to-moderate IPF and severe, dispro-
portionate PH may benefit from PAH therapies. This population is uncommon and
has not been specifically studied in an RCT. It may be that these patients have two
diseases, PAH and IPF, and they may be candidates for PAH therapy. However, a
post hoc analysis of patients from the ARTEMIS-IPF study who had <5% honey-
combing on high-resolution CT scan, mild-to-moderate restriction, and severe PH
on baseline right heart catheterization (mPAP ≥35 mmHg) found no differences in
progression-free survival between ambrisentan and placebo [53]. Patients with sys-
temic sclerosis and mild ILD associated with pre-capillary PH have similar out-
comes to systemic sclerosis PAH without ILD, whereas those with extensive ILD
have a much worse prognosis [43]. Therefore, patients with systemic sclerosis and
severe PH and only mild extent of ILD might be considered for treatment with tar-
geted therapies according to guidelines for PAH [3].
Other PAH Therapies in ILD-Associated PH
A randomized open-label trial by Ghofrani et al. compared the acute effects of silde-
nafil and epoprostenol infusion in 16 patients with fibrotic lung disease and PH [57].
While epoprostenol improved CI by 42% and reduced mPAP and PVR, there was a
significant effect on ventilation-perfusion inequality and pulmonary shunt flow,
with resultant hypoxemia. Similarly, sildenafil acutely reduced mPAP and PVR
with an increase in CI by 9.1% but with, in contrast to epoprostenol, a considerable
improvement in PaO2 [57]. There have been no further studies using epoprostenol in
fibrotic lung disease; however, a small, non-randomized, open-label study described
long-term hemodynamic benefits, echocardiographic improvements in right ven-
tricular function, some improvement in quality of life scores, and an increase in
6MWD with parenteral administration of treprostinil [58]. There was a trend to
worsening oxygenation in this study, but room air oxygen saturation and oxygen
delivery were not significantly different after 12 weeks of treatment. The effects of
riociguat have also been assessed in a small pilot study including 22 patients with
ILD-associated PH [59]. Riociguat was generally well tolerated (three patients dis-
continued therapy due to side effects), and there was a modest improvement in
6MWD by 25 m. Hemodynamics improved with an increase in CI by 0.7 L.min.

m−2, and there was not a major concerning effect on gas exchange at 12 weeks.
However, the RISE-IIP study found no improvements, more adverse effects, and
more deaths in the group treated with riociguat versus placebo (eight deaths with
riociguat versus three) [60]. Thus, PAH therapies should generally not be used in
patients with ILD unless future placebo-controlled trials demonstrate convincing
benefit.
PH Due to Other Parenchymal Lung Diseases (Group 5 PH)
Group 5 PH includes several chronic parenchymal lung diseases that cause PH

through multiple and/or poorly understood mechanisms [61].
Sarcoidosis-Associated PH
Pulmonary vascular disease is frequently observed in sarcoidosis, particularly in the

advanced stages of the disease. The mechanisms of PH in sarcoidosis are multiple
and often combined. In cases of post-capillary PH on right heart catheterization
(mPAP ≥20 mmHg and pulmonary artery wedge pressure > 15 mmHg), left heart
involvement and fibrosing mediastinitis with venous compression are potential
explanations. In the setting of pre-capillary PH (mPAP >20 mmHg, PVR ≥3 Wood
Units and PAWP ≤15 mmHg), three main mechanisms have been identified which
warrant different treatment strategies [62]. Severe pre-capillary PH may be second-
ary to granulomatous pulmonary vasculopathy, vascular bed destruction, and/or
vascular remodeling due to chronic hypoxia. Significant pulmonary venous involve-
ment may occur, mimicking pulmonary veno-occlusive disease, which carries a risk
of pulmonary edema when PAH therapies are given. The presence of PH is associ-
ated with impaired functional capacity and worse survival in patients with sarcoid-
osis [63, 64]. However, data supporting specific treatment strategies are few due to
its rarity and the heterogeneous mechanisms of PH in sarcoidosis. There has been
only one randomized controlled trial in sarcoidosis-associated PH, which reported
improvements in mPAP and PVR at 16 weeks in bosentan-treated patients com-
pared to placebo; however, there was no improvement in 6MWD [65]. Observational
studies have reported similar effects of oral PAH-targeted medications or parenteral
prostacyclin therapy on hemodynamics without improvements in exercise capacity
[64, 66, 67]. A study of 126 patients with sarcoidosis-associated PH from the French
PH Registry found that PAH therapies improved PVR significantly from 9.7 ± 4.4
to 6.9 ± 3.0 Wood units and NYHA functional class improved, but there was no
improvement in 6MWD [64]. Immunosuppressive therapies may be useful in spe-
cific cases of sarcoidosis-associated PH caused by compression of pulmonary
arteries from mediastinal lymphadenopathy and mediastinitis or in those with pul-

monary vascular granulomatous inflammation [62, 64, 68]. Pulmonary angioplasty
with stenting is also an option when PH is attributable to vascular stenoses [69].
Pulmonary Langerhans Cell Histiocytosis-Associated PH
A rare smoking-related parenchymal lung disease, pulmonary Langerhans cell his-

tiocytosis (PLCH), is characterized by airflow obstruction, granulomatous inflam-
mation, parenchymal nodules, and cysts. A diffuse vasculopathy and venous fibrotic
obliteration with capillary dilatation evocative of pulmonary veno-occlusive disease
can be present in regions unaffected by parenchymal lesions [70]. The primary man-
agement of PH in PLCH is to treat the underlying lung disease, which involves
smoking cessation and potentially cladribine [71, 72]. Although there have been no
prospective randomized studies of PAH-specific therapies in PLCH, long-term
improvements in hemodynamics and symptoms have been reported with oral thera-
pies. A retrospective observational study by Le Pavec et al. described 14 patients
with PLCH-associated PH who received PAH therapies [73]. Functional capacity
improved in 67% of patients, 6MWD increased ≥10% in 45% of patients, and there
was a 33% decrease in PVR, which was sustained over the long-term. Although PH
is common in advanced PLCH, because of the potential venous involvement, PAH
therapies must be used cautiously due to the risk of inducing pulmonary edema.
Lymphangioleiomyomatosis-Associated PH
Lymphangioleiomyomatosis (LAM) is a rare condition almost exclusively affecting

females that is characterized by diffuse cystic lung disease, chylous effusions and
ascites, renal angiomyolipomas, and lymphangioleiomyomas [74]. Arteriolar, bron-
chial, and venous infiltration with LAM cells can lead to PH through multiple
mechanisms, justifying its inclusion Group 5 of the PH classification [75]. PH
occurs in approximately 8% of patients with LAM although the proportion is higher
(45%) in LAM patients referred for lung transplantation [76]. In 44 women with
LAM undergoing lung transplantation, most patients had mild-to-moderate PH
(average mPAP 33 ± 8.3 mmHg), but mPAP was as high as 47 mmHg [76].
There have been no prospective studies or RCTs of PAH therapy in LAM-
associated PH. Cottin et al. described the management and outcomes of 20 patients
with LAM-associated PH, most of whom had severe airflow obstruction
(FEV1 < 50% predicted) and mild-moderate PH (mPAP 32 ± 6 mmHg and PVR
4.7 ± 2.3 Wood units) [75]. Two patients in this study, however, had severe PH
(mPAP >35 mmHg) with a normal FEV1. Six patients (30%) received PAH thera-
pies (bosentan or sildenafil) with hemodynamic improvements and no detrimental
effect on gas exchange or episodes of pulmonary edema, but no improvements in

dyspnea or 6MWD. Current guidelines recommend the use of sirolimus or everoli-
mus in LAM patients with abnormal or worsening lung function; however, the
effects of these therapies on hemodynamics or exercise capacity in LAM-associated
PH are unknown [74].
Conclusions
Pulmonary hypertension is a complication of chronic lung disease, which adversely

impacts survival and causes further disability. Management of PH in patients with
chronic lung disease should be directed toward optimization of the underlying lung
condition, the administration of supplemental oxygen in hypoxemic patients, and
consideration of lung transplantation where appropriate. Despite promising results
from observational studies, randomized controlled trials do not support the use of
PAH therapies in PH due to chronic lung diseases, and they indeed may be harmful
in some groups. Therefore, current guidelines recommend against the use of PAH
therapies in PH due to lung disease. Although PH occurs frequently in the context
of severe lung disease, it may also manifest with severe hemodynamic impairment
with only mild-moderate lung disease. Other contributing causes such as left heart
disease, thromboembolic disease, and sleep-disordered breathing should be system-
atically sought, and such patients should be evaluated in expert referral centers and/
or considered for clinical trials.
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Chapter 7
Imaging in Chronic Lung Disease: Cardiac
Considerations
Firdaus A. A. Mohamed Hoesein
Pearls
• Echocardiography is the first-line imaging technique used, but is often less
reliable in those with emphysema.
• Cardiac computed tomography (CT) is frequently used to assess coronary
atherosclerosis which is increased in many chronic lung diseases,
like COPD.
• Cardiac magnetic resonance imaging (MRI) provides detailed information
on left and right ventricular (dys)function and morphology, valvular
disease, and presence and extent of cardiac fibrosis.
Introduction to Imaging Techniques and State of the Art
Introduction
In this chapter, non-invasive imaging methods and their applications in cardiac

imaging will be discussed including echocardiography, computed tomography, and
magnetic resonance imaging. Further on, the role of cardiac imaging in chronic lung
disease will be reviewed by cardiac disease entity: coronary artery disease, pulmo-
nary hypertension, right ventricular dysfunction, left ventricular disease, and cere-
brovascular and peripheral arterial disease.
F. A. A. Mohamed Hoesein (*)
Department of Radiology, University Medical Center Utrecht, University Utrecht,
Utrecht, The Netherlands

98 F. A. A. Mohamed Hoesein
Echocardiography
Echocardiography is frequently used as a first-step imaging modality in many car-

diac diseases and for evaluation of cardiac function. One of the advantages of echo-
cardiography is its non-invasiveness and that it is harmless to patients. It can be used
for the diagnosis of cardiac diseases, but also for prognostication and for follow-up
in patients with chronic disease. There are many indications for the use of echocar-
diography, but quantification of ventricular function and measuring atrial and ven-
tricular dimensions probably is the most common indication. Echocardiography is
also frequently used for cardiac valve evaluation. Valvular regurgitation can be diag-
nosed and graded. Recent advances in echocardiography include three-dimensional
(3-D) echocardiography and deformation imaging which will extend the use of
echocardiography in the near future. 3-D echocardiography is more accurate in
determining left ventricular volumes and function compared to 2-D echocardiogra-
phy. Deformation imaging provides quantitative information on regional cardiac
(dys)function. One of its advantages is that it can provide quantitative information
on function. Traditional echocardiography is based on visual assessment, which is
more prone to operator subjectivity, but also is less sensitive for early changes and
(mal-)adaptation of the left ventricle. In patients with chronic lung diseases, defor-
mation imaging may be used to detect and follow up right and left ventricular func-
tion abnormalities. One of the drawbacks of echocardiography is the poor acoustic
window in individuals with COPD, especially in those with emphysema and/or
hyperinflation. This makes echocardiography a less reliable imaging tool in COPD
patients.
Computed Tomography
Computed tomography (CT) is commonly used in the evaluation of coronary artery

disease, cerebrovascular disease, and peripheral artery disease. In patients with
chronic lung disease, a chest CT is commonly performed for evaluation of pulmo-
nary disease. Improvements of CT techniques in the last decade have allowed radi-
ologists to also evaluate the heart.
Cardiac CT is mainly used for the detection and quantification of coronary artery
calcium (Fig. 7.1) and detection of coronary artery stenosis (Figs. 7.2 and 7.3). The
Agatston score, which is a marker of cardiovascular disease and an independent risk
marker of future cardiovascular events, is calculated from a non-contrast cardiac CT
(Fig. 7.1). The amount of coronary calcium is dependent on age, sex, and race [1].
The Agatston score is a risk factor independent of known cardiovascular risk factors
like age, sex, hypertension, cholesterol levels, family history, and smoking. Non-
contrast non-ECG-gated chest CT can be used to reliably determine coronary artery
calcification. This is important information because in most of the COPD patients
and patients with other pulmonary diseases, a non-contrast non-ECG-gated chest
7 Imaging in Chronic Lung Disease: Cardiac Considerations 99
Fig. 7.1 Agatston score. Coronary artery calcifications scored by the Agatston method.
Non-contrast CT scan and annotated scan. Table gives the score per coronary artery and in total
Fig. 7.2 Left anterior

descending (LAD) artery
with significant stenosis
due to non-calcified plaque
Fig. 7.3 Left anterior

descending artery with
multiple calcified plaques
with a significant stenosis
CT will be performed. The correlation between Agatston scores derived from non-
contrast non-ECG-gated and ECG-gated scans is excellent [2].
In the last decade, technical advances in CT scanning equipment and acquisi-
tion techniques have led to high spatial and temporal resolution and a significant
decrease of radiation dose for the imaging of the coronary arteries. Several fac-
tors are important to ensure adequate imaging quality including CT scanning
equipment (low versus high number of detector rows; dual-energy imaging),
patient characteristics (body mass index (BMI); heart rhythm; heart rate), and
post-processing techniques (reconstruction algorithms). One of the most impor-
tant patient-related factors for high-quality images is the heart rate. Ideally, heart
rate should be 60 beats per minute or less, although some CT scanners allow a
slight higher rate. Beta-blocker is used to ensure the desired heart rate; however,
in chronic lung disease patients with bronchospasm, this is contraindicated. If a
heart rate of 60 beats per minute cannot be achieved, so-called retrospective
scanning can be done. In retrospective scanning, the heart and the coronaries are
imaged during an entire heart cycle. This is in contrast to the standard scanning
method (prospective scanning) in which the heart is imaged at one time-point at
which the cardiac motion is least (end-diastole, 78% of the R-R interval). CT
uses x-rays to produce images, and thus radiation dose control is an important
factor. Recent advances have led to significant decreases in dose in such a way
that dose is no longer an issue if the indication to perform cardiac CT is appropri-
ate. However, retrospective scanning still has a relatively high radiation dose,
and thus prospective scanning is preferred when possible.
In most of the cases, chest CT in COPD is performed to evaluate the pulmo-
nary manifestations of COPD. However, information on cardiovascular manifes-
tations of COPD can also be captured on chest CT. Body composition can be
quantified on chest CT by measuring subcutaneous, mediastinal, and epicardial
fat. The latter is associated with coronary artery disease [3]. COPD patients have
more epicardial fat compared to controls, and it is associated with future cardio-
vascular events [4].
MRI
Cardiac magnetic resonance imaging (MRI) is widely used for evaluation of cardiac
disease. It provides detailed high-quality information on left and right ventricular
(dys)function and morphology, valvular disease, and presence and extent of cardiac
fibrosis. Respiratory gating and ECG-triggering allow for high temporal and spatial
resolution images (Fig. 7.4). Use of the intravenous contrast agent gadolinium gives
information on the presence and extent of cardiac fibrosis (Fig. 7.5). Late gadolin-
ium enhancement is good in the detection of focal areas of fibrosis, however is not
suited to detect diffuse fibrosis of the left ventricle. Diffuse fibrosis is missed by late
gadolinium enhancement because there is no normal non-diseased myocardial tis-
sue to compare with. New mapping techniques and imaging sequences do provide
information on diffuse fibrosis by measuring the extracellular volume and T1 values
of the left ventricular myocardium (Fig. 7.6) [5]. In case of diffuse fibrosis, the
interstitium and extracellular matrix are enlarged resulting in an increase in extra-
cellular volume.
Fig. 7.4 MRI cine images of the heart. Left: 2-chamber view showing the left ventricle and the
right ventricle. Right: 4-chamber view showing the ventricles and atria
Fig. 7.5 Delayed
enhancement MR image
showing mid-wall septal
delayed enhancement
Fig. 7.6 T1 mapping at MRI of a patient with systemic sclerosis and a slightly lowered ejection
fraction. T1 values were slightly increased, which could be a sign of diffuse cardiac fibrosis in a
patient with systemic sclerosis. There were no abnormalities on delayed enhancement images
Role of Imaging
Coronary Artery Disease
Calcifications of the coronary artery and thoracic aorta are correlated with the sever-
ity of COPD and the presence of emphysema. COPD patients have more coronary
artery calcium compared to non-COPD controls. These correlations remain even
after extensive correction for known confounding risk factors for cardiovascular
disease. Higher coronary artery calcium scores are associated with lower FEV1%
predicted values [6, 7]. In addition, in COPD patients coronary artery calcifications
are associated with an increased morbidity and mortality compared to non-COPD
controls [8]. Because COPD patients have a higher risk of cardiovascular disease,
screening in this high-risk group by CT could be beneficial [9].
Pulmonary Hypertension
The gold standard for diagnosing pulmonary hypertension is right heart catheteriza-
tion to directly measure the pulmonary artery pressure. However, in most patients
suspected of pulmonary hypertension, non-invasive imaging techniques are performed
first to assess the likelihood of the diagnosis. Pulmonary hypertension causes are clas-
sically classified into five groups, of which lung diseases and hypoxia (group 3) are an
important group of causes of pulmonary hypertension [10]. Lung diseases known to
cause pulmonary hypertension include COPD, sarcoid, interstitial lung disease, and
sleep apnea. In fact, COPD is the second most common cause of pulmonary hyperten-
sion in the general population [11]. Prevalence of pulmonary hypertension varies from
up to 60% in COPD patients to up to 84% in interstitial lung disease [12].
Echocardiography is frequently used as a first imaging step in pulmonary hyperten-
sion. Pulmonary artery pressure can be estimated by Doppler. However, in lung dis-
ease, echocardiography is suboptimal because parenchymal diseases and COPD limit
the acoustic windows [13]. Echocardiography is mainly used to exclude significantly
elevated pulmonary artery pressures. However, an estimated elevated pulmonary
artery pressure by Doppler warrants additional diagnostic tests to confirm the
diagnosis.
In patients with pulmonary hypertension but without a clear cause, a CT pulmo-
nary angiogram is recommended in order to try to classify the cause into one of the
five groups of pulmonary hypertension. Dual-energy CT can be used to create a
perfusion map providing information beyond morphologic imaging (Fig. 7.7). In
clinical practice, ventilation-perfusion scintigraphy still is the gold standard.
Pulmonary artery diameter can be used as a marker of pulmonary hypertension
[14]. COPD subjects with pulmonary hypertension have a significantly larger pul-
monary artery diameter compared to COPD subjects without pulmonary hyperten-
sion (Fig. 7.8) [15–18]. Pulmonary artery diameter can also be used as a prognostic
marker in COPD patients. COPD patients with a pulmonary artery-to-aorta ratio of
more than 1 have a significantly higher number of exacerbations [19]. In interstitial
lung diseases, the ratio of the main pulmonary artery diameter to the ascending
aorta diameter on chest CT is more reliable for the presence pulmonary hyperten-
sion than the diameter of the main pulmonary artery [14]. Combining echocardiog-
raphy with the ratio of the main pulmonary artery diameter to the ascending aorta
diameter on chest further improves the diagnostic value.
MRI can be used to assess pulmonary arterial stiffness non-invasively by mea-
suring pulmonary arterial pulse wave velocity and pulsatility. It has been shown that
pulmonary arterial stiffness is associated with COPD and emphysema [20].
Fig. 7.7 Right: Normal CT pulmonary angiogram showing a pulmonary embolus in a right lower
lobe artery. Left: Results from dual-energy CT showing a segmental subpleural iodine defect
Fig. 7.8 Contrast-
enhanced CT scan. The
pulmonary artery diameter
is increased which is a sign
of pulmonary hypertension
Pulmonary arterial stiffness is an early indicator for pulmonary vascular remodeling

and is associated with measures of right ventricular dysfunction [21, 22].
Right Ventricular Dysfunction
COPD and its severity are associated with right ventricular function impairment.
Cor pulmonale has traditionally been described as hypertrophy of the right ventricle
resulting from diseases affecting the function and/or structure of the lungs including
pulmonary hypertension. Right ventricular ejection fraction is significantly lower in
COPD subjects compared to controls, and subjects with more severe COPD have
significantly lower right ventricular ejection fractions compared to those with mild
COPD [23]. Right ventricular ejection fraction was measured on a retrospectively
CT scan and on cardiac MRI. The measured ejection fraction on both techniques
were highly correlated showing that both CT and MRI are capable of measuring
ejection fraction in COPD subjects. MRI is preferred as CT uses a relatively high
dose of radiation. In patients with both COPD and obstructive sleep apnea, signs of
right ventricular dysfunction are more common compared to patients with COPD
alone [24].
Left Ventricular Disease
COPD
COPD and heart failure are each important causes of death. In addition, concur-
rent COPD and heart failure are not uncommon [25]. In patients with heart failure
and COPD, left ventricular ejection fraction measured by echocardiography is
lower compared to patients with heart failure alone [26, 27]. Also left ventricular
diastolic function is abnormal in COPD patients which can be evaluated with
echocardiography [27]. In COPD patients, the quality of echocardiography may
be hampered because of emphysema impeding acoustic windows. Estimations of
unsatisfactory echocardiography in COPD patients range from 10% up to even
50% depending on disease severity. In case of poor-quality echocardiography,
cardiac MIR can be performed to evaluate left ventricular function. A diagnosis
of heart failure with preserved ejection fraction is even harder to establish in
COPD patients as natriuretic peptides can be elevated in both heart failure and
COPD [28].
Many patients with COPD and individuals at-risk of COPD undergo chest CT
scanning. The chest CT includes information not only on the lungs but also on extra-
pulmonary structures like the heart and the great vessels. COPD is associated with
left ventricular dysfunction and with heart failure with preserved ejection fraction.
Because in most patients with COPD non-contrast non-ECG-gated chest CTs will
be performed, no reliable information on cardiac volumes and function can be
attained [29].
Changes in the pulmonary vasculature are related to COPD. Pruning of distal
pulmonary vessels is already present in smokers [30]. The area of small pulmonary
vessels in COPD patients is associated with pulmonary hypertension [31]. Automatic
segmentation and separation of pulmonary arteries and veins is possible, but more
studies are needed to explore the clinical relevance. Pulmonary vein dimensions can
be assessed by MRI and contrast-enhanced CT, and it has been shown that COPD
and emphysema are associated with lower pulmonary vein dimensions [32].
Quantifying hyperinflation in COPD patients can be done by measuring total lung
capacity at CT. Hyperinflation in COPD is a known cause of cardiovascular disease
[32, 33], and decreasing of the extent of hyperinflation is associated with an

improvement of right ventricular filling indices on cardiac MRI [34]. Reducing
hyperinflation is also associated with improvement in left ventricular filling [35].
Hyperinflation on CT in COPD patients is also associated with an increase in pul-
monary artery diameter suggesting an association with pulmonary hyperten-
sion [36].
On cardiac MRI structural changes of the myocardium may be visualized, for
instance, due to chronic hypoxia. Myocardial extracellular volume (ECV) and T1
mapping were increased in a small study comparing COPD patients with controls.
ECV was associated with left ventricular remodeling and reduced left atrial func-
tion [37]. Although only a small number of subjects were included, the study showed
that patients with COPD have evidence of diffuse myocardial fibrosis. Future
research should show whether ECV can be used as an early marker for myocardial
fibrosis in COPD and/or if it could be used to stratify COPD patients with a high and
low risk for cardiac abnormalities.
Sarcoid
Cardiac involvement of sarcoid is not rare and can result in conduction abnormali-
ties, heart failure, and even sudden cardiac death. Cardiac sarcoid may even occur
in patients without pulmonary involvement [38]. In post-mortem studies up to
20–25% of sarcoid patients have cardiac involvement [39]. Morbidity and mortal-
ity of cardiac sarcoid are related to the site and extent of cardiac involvement.
Mortality in most cases is related to conduction defects resulting in ventricular
fibrillation. In patients with an unexplained AV block, cardiac sarcoid is the cause
in almost a third of cases [40]. Morbidity is related to cardiomyopathy caused by
infiltration of the myocardium by granulomas resulting in (progressive) heart fail-
ure and to conductional defects like atrioventricular blocks. Cardiac involvement
can be imaged by echocardiography, MRI, and 18F-fluorodeoxyglucose positron
emitting tomography (18F-FDG-PET) (Fig. 7.9). Echocardiography is mainly used
to evaluate ventricular function, dimensions, and hypertrophy, but is not suitable to
diagnose cardiac sarcoid. A lowered left ventricular ejection fraction is associated
with poorer prognosis [41]. Cardiac MRI with gadolinium can detect myocardial
sarcoid involvement. Enhancement is seen both in fibrosis and in active cardiac
disease in which delayed enhancement associates with inflammation. In case of
cardiac involvement, focal patchy delayed enhancement of the epicardium and/or
mid-myocardium can be seen, although cardiac sarcoid can also be associated with
non-specific enhancement patterns. This is in contrast to ischemic enhancement
which is sub-endocardial and mostly in a coronary territory [42]. The presence and
extent of delayed enhancement in cardiac sarcoid may serve as a prognostic tool.
Patients without delayed enhancement have a better prognosis, and the number of
segments involved is associated with left ventricular dysfunction [43]. It is not pos-
sible to differentiate fibrosis from active disease with delayed enhancement
Fig. 7.9 18F-FDG-PET CT showing increased uptake in mediastinal and hilar lymph nodes in a
patient with sarcoid. Cross-sectional sections through the heart show increased uptake in the sep-
tum indicating active cardiac sarcoid
MRI. 18F-FDG-PET is frequently used for diagnosing and staging of sarcoid.

18F-FDG-PET can detect active cardiac sarcoid, which is in contrast to delayed
enhancement MRI. Key to a reliable evaluation of the myocardium on PET scan is
adequate suppression of normal FDG uptake. To ensure this, a low-carbohydrate
diet and prolonged fasting protocol are prescribed to switch to free fatty acid
metabolism. In many centers, low doses of intravenous unfractionated heparin are
administered before scanning. Heparin induces lipolysis resulting in higher serum
free fatty acid levels which suppresses physiologic FDG uptake [44]. In most
patients suspected of cardiac sarcoid, both cardiac MRI and 18F-FDG-PET are
performed. Cardiac MRI is more sensitive for cardiac fibrosis and 18F-FDG-PET
for inflammation without cardiac fibrosis. Combining the results of both studies
increases the diagnostic value for cardiac sarcoid [42]. Follow-up PET scans can
be used to evaluate response to therapy as increased FDG uptake is related to active
disease [45]. Cardiac MRI is not suited for monitoring of disease severity as both
fibrosis and inflammation cause similar delayed enhancement [46]. Currently,
there are no guidelines regarding dosage and duration of corticosteroid therapy and
the use of additional immunotherapies such as like infliximab. Deciding on the
duration of treatment in patients without significant symptoms or complaints,
but with cardiac abnormalities on initial 18F-FDG- PET, is challenging.
With 18F-FDG-PET, corticosteroid and new immunological therapies can be

monitored and doses can be titrated.
Connective Tissue Disease
Lung involvement of connective tissue diseases (CTD), including rheumatoid

arthritis, scleroderma, Sjogren’s syndrome, systemic lupus erythematosus (SLE),
and vasculitides, is not rare. Lung involvement in CTD most commonly includes
interstitial lung disease. Cardiac involvement is also common in these conditions
[47]. Peri-myocarditis and diastolic dysfunction are most commonly reported, but
coronary artery disease is also common. Patients with rheumatoid arthritis and SLE
have a high prevalence of coronary artery disease [48–49]. Cardiac MRI can detect
cardiac involvement in early and acute stages. Late gadolinium enhancement may
be used to diagnose (peri-)myocarditis which occurs in up to 15% of SLE patients
[50]. New cardiac MRI techniques like T1 and T2 mapping may play a role in
assessing myocardial involvement in CTD. A study in SLE patients suspected of
cardiac involvement showed that T1 and T2 mapping values were higher compared
to control patients [51]. After treatment, mapping values in SLE patients decreased.
Cardiac involvement in ANCA-associated small vessel vasculitides (eosinophilic
granulomatosis with polyangiitis [EGPA] and granulomatosis with polyangiitis
[GPA]) is not common, but if present has a poor prognostic outcome. Cardiac
involvement is more common in EGPA than in GPA. Cardiomyopathy, myocarditis,
pericarditis, and endomyocardial fibrosis are the most common patterns of involve-
ment. Cardiac MR with late gadolinium is used for the evaluation of cardiac involve-
ment. The cardiomyopathy is caused by microvascular ischemia. In endomyocardial
fibrosis, there is sub-endocardial delayed enhancement with intraventricular throm-
bus. Signs of pericarditis on cardiac MRI are pericardial fluid in combination with
pericardial thickening and pericardial late gadolinium enhancement. Also in ANCA-
associated vasculitis, T1 and T2 mapping values are increased indicating that new
mapping methods may play a role in detecting cardiac involvement [52].
Cardiac involvement of systemic sclerosis is not rare and if present has a poor
prognosis [53–54]. Cardiac systemic sclerosis includes myocarditis, valvular regur-
gitation, cardiac fibrosis, and microvascular disease. Myocarditis and cardiac fibro-
sis can be detected by late gadolinium enhancement on MRI. In a study of 58
systemic sclerosis patients, almost half had late gadolinium enhancement on MRI
[55]. Abnormalities in the coronary microcirculation are common in systemic scle-
rosis and are thought to be the main cause of cardiac fibrosis in systemic sclerosis.
Microvascular disease can be detected by stress perfusion MRI and cardiac PET CT
[53, 56]. A “cardiac” Raynaud’s phenomenon has also been described in systemic
sclerosis as patients with Raynaud’s phenomenon more frequently have cardiac
fibrosis. Epicardial coronary disease is not more common in systemic sclerosis.
T1 mapping at cardiac MRI, a marker of diffuse cardiac fibrosis, was found to be
significantly higher in systemic sclerosis compared to control patients [57].
Cerebrovascular Disease and Peripheral Arterial Disease
COPD patients have an increased prevalence of carotid atherosclerotic disease and

an increased risk of stroke [58]. In COPD patients the prevalence of stroke is
6.9–9.9% [59]. There is a lot of knowledge on the use of carotid ultrasound to
assess subclinical atherosclerosis. Carotid ultrasound can measure the intima-
media thickness which is a marker for cardiovascular disease [60]. COPD is asso-
ciated with greater intima-media thickness at carotid ultrasound [61], and in COPD
patients, there is a correlation between intima-media thickness and lung function
[62–63]. In elderly subjects with carotid artery wall thickening, COPD is an inde-
pendent predictor for the evaluation of vulnerable plaques [64]. Carotid ultrasound
thus may be a surrogate marker for (subclinical) atherosclerosis and cardiovascular
risk assessment in COPD. However, future studies are needed how to incorporate
carotid ultrasound in the optimal management strategy of COPD patients.
CT angiography (CTA) and MR angiography (MRA) are excellent in depicting
cranial and extra-cranial vessels and can reliably detect stenosis and occlusions.
CTA requires the use of intravenous contrast agents. MRA can be performed with-
out and with administration of intravenous gadolinium. To my knowledge, there are
no studies examining CTA and/or MRA of the carotids or peripheral arteries
in COPD.
Next to carotid atherosclerotic disease, it is known that peripheral arterial disease
(PAD) is also more prevalent in COPD patients (8.5% versus 1.8%) [65]. COPD
patients with PAD have a significantly lower 6-minute walk distance after extensive
correction for confounding factors.
Conclusion
Imaging plays a central role in the evaluation of cardiac involvement of chronic lung
diseases. Echocardiography, cardiac CT, and cardiac MRI all have their own indica-
tions and pros and cons.
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pulmonary disease in the COPD and systemic consequences-comorbidities network study. Am
J Respir Crit Care Med. 2017;195(2):189–97.
Chapter 8
Lung Disease: The Role
of Cardiopulmonary Exercise Testing
J. Alberto Neder, Alcides Rocha, Flavio F. Arbex, Mayron Oliveira,

Maria Clara N. Alencar, and Denis E. O’Donnell
Clinical Pearls
• Cardiopulmonary exercise testing (CPET) provides unique insights into
the sensory and physiological determinants of exercise intolerance in
patients with chronic lung disease (e.g., COPD and ILD) and associated
cardiovascular disease.
• Poor muscle O2 delivery, impaired stroke volume, and increased ventila-
tory demands (i.e., “out of proportion” to emphysema burden in COPD
and hypoxemia in ILD) suggest a relevant role for impaired cardiocircula-
tory responses to decrease exercise tolerance.
• In overlapping COPD-heart failure, CPET can determine if symptomatic
patients are primarily limited by critical mechanical-ventilatory constraints
(suggesting a greater role for COPD) or, alternatively, exercise is inter-
rupted due to poor muscle O2 delivery but preserved mechanical reserves
(suggesting a dominant contribution of heart failure).
• In COPD or ILD patients with suspected or proven pulmonary hyperten-
sion at rest, severe ventilatory inefficiency, impaired intra-pulmonary gas
exchange efficiency, and preserved mechanical reserves at peak exercise
provide evidence that pulmonary vascular disease contributes to exercise
intolerance.
J. A. Neder (*) · D. E. O’Donnell

Laboratory of Clinical Exercise Physiology (LACEP), Queen’s University & Kingston
General Hospital, Kingston, ON, Canada
Respiratory Investigation UniT (RIU), Queen’s University & Kingston General Hospital,
Kingston, ON, Canada
e-mail: alberto.neder@queensu.ca
A. Rocha · F. F. Arbex · M. Oliveira · M. C. N. Alencar
Pulmonary Function and Clinical Exercise Physiology Unit (SEFICE), Division of
Respirology, Federal University of Sao Paulo, Sao Paulo, Brazil

116 J. A. Neder et al.
Symbols and Abbreviations
Ca Arterial content
Cv Venous content
CO Cardiac output
COPD Chronic obstructive pulmonary disease
CPET Cardiopulmonary exercise test
EELV End-expiratory lung volume
EILV End-inspiratory lung volume
f or RR Respiratory frequency or respiratory rate
FEV1 Forced expiratory volume in one second
HR Heart rate
IC Inspiratory capacity
ILD Interstitial lung disease
IRV Inspiratory reserve volume
LT Lactate threshold
LVEF Left ventricular ejection fraction
mPAP Mean pulmonary artery pressure
MVV Maximal voluntary ventilation
Pa Arterial partial pressure
PA Alveolar partial pressure
PA Mean alveolar pressure
PH Pulmonary a hypertension
Pc Capillary (arterialized) pressure
PE Expiratory partial pressure
PET End-tidal partial pressure
PFT Pulmonary function test
RER Respiratory exchange ratio
RV Residual volume
Sa Arterial saturation
Sp Saturation by pulse oximetry
SV Stroke volume
TLC Total lung capacity
TLCO Transfer factor for carbon monoxide
⩒E Minute ventilation
VC Vital capacity
Ú CO2 Carbon dioxide output
VD Dead space
Ú O2 Oxygen uptake
VT Tidal volume
WR Work rate
8 Cardiovascular Comorbidity in Chronic Lung Disease: The Role… 117
…it does not seem that all movement is exercise, but only when
it is vigorous…The criterion of vigorousness is change of
respiration; those movements which do not alter the respiration
are not called exercise. But if anyone is compelled by any
movement to breathe more or less faster, that movement
becomes exercise for him.
In: Galen. A translation of Galen’s hygiene (De Sanitate
Tuenda) by Green RM. Charles C Thomas, Springfield, IL; 1951
Introduction
Exercise intolerance is a hallmark of chronic lung and heart disease. Effort-related

symptoms, particularly dyspnea, are key clinical outcomes leading to impaired
quality of life and poor survival in these patients [1]. Cardiopulmonary exercise
testing (CPET) integrates a range of mechanical-ventilatory, cardiovascular, meta-
bolic, and perceptual measurements to unravel the causes and consequences of
exercise intolerance in cardiorespiratory diseases [2–5]. In symptomatic patients
with chronic respiratory diseases, particularly chronic obstructive pulmonary dis-
ease (COPD) and interstitial lung disease (ILD), CPET is frequently useful to elu-
cidate the underlying mechanisms and to quantify functional impairment [6]. The
usual pattern of CPET responses in these diseases, however, can be substantially
modified by comorbid cardiac and pulmonary vascular conditions. Thus, abnor-
malities in cardiac performance, central hemodynamics, and blood flow distribu-
tion compound with mechanical-ventilatory and gas exchange disturbances to
worsen symptom burden and severely impair exercise tolerance in lung-heart dis-
ease [7].
This chapter succinctly presents how CPET interpretation in chronic lung dis-
eases is impacted by coexistent cardiocirculatory disease. Special attention is given
to translate pathophysiological concepts into clinical outcomes; thus, we critically
discuss the key clinical scenarios wherein CPET might (or not) provide relevant
information in these patients. We start by summarizing the normal cardiorespira-
tory responses to exercise. We then focus on overlapping COPD-heart failure to
illustrate the devastating clinical consequences of abnormal lung mechanics and
gas exchange associated with a failing heart. After briefly presenting what should
be expected in a CPET performed in “isolated” COPD or heart failure, we highlight
emerging concepts from recent CPET-based investigations which shed new light on
the complex cardiopulmonary interactions in COPD-heart failure. We then explore
the consequences of pulmonary hypertension on ventilatory control and pulmonary
gas exchange efficiency during exercise in COPD and ILD. We finalize outlining
some extant clinical gaps which might benefit from future CPET-based
investigations.
Cardiopulmonary Adjustments to Incremental

Exercise: The Basics
A rapidly incremental CPET (i.e., continuous increase in work rate (ramp) or dis-
crete increase every 1 or 2 min) performed in cycle ergometer is the more common
test format in clinical laboratories [2–5]. Thus, we will restrain our discussion to the
findings observed in this testing modality, usually accompanied by serial measure-
ments of inspiratory capacity and symptoms (Borg category-ratio scale) [8].
Respiratory Responses
The respiratory system adapts to the increased muscle metabolism by closely fol-
lowing its key by-product, i.e., CO2. Thus, ventilation ( Ú E ) required to wash out a
given rate of CO2 production ( Ú CO2 ) is higher the lower the arterial CO2 (PaCO2) (as
more Ú E is needed to keep PaCO2 at a low compared to a high value) and the larger
the ventilation “wasted” in the dead space (VD), i.e., [2]
Ú E / Ú CO2 ∼ 1 / PaCO 2 ´ (1 - VD / VT ) (8.1)

where Ú E / Ú CO2 ratio is the ventilatory equivalent for CO2 and VD/VT is the phys-
iological (anatomic plus alveolar) dead space fraction of tidal volume. Efficiency of
gas exchange (i.e., lower VD/VT) is optimized by higher VT, enhanced ventilation/
perfusion matching, and higher lung perfusion pressures due to higher cardiac out-
put (CO) and lower pulmonary vascular resistance [9]. As discussed in Section
“Cardiovascular Responses,” the development of anaerobioses further stimulates
Ú E at higher exercise intensities [2].
Increases in Ú E during exercise depend on changes in VT and respiratory fre-
quency (f). Although both VT and f change almost simultaneously with activity
onset, VT expansion predominates over f up to the mid-stages of incremental exer-
cise. VT expands to about 50–60% of the vital capacity (VC) [10] by encroaching on
both the inspiratory and expiratory reserve volumes [11]. Assuming that total lung
capacity (TLC) does not change appreciably [12], higher inspiratory capacity (IC)
on exercise means that end-expiratory lung volume (EELV) decreases due to expira-
tory muscle recruitment [13]. The decrease in EELV is crucial to avoid breathing
too close to TLC where compliance is low and the work of breathing is high [14].
At the point of exhaustion in a normal subject, VT/IC < 0.7, end-inspiratory lung
volume (EILV)/TLC < 0.9, large flow reserves at a given lung volume and dyspnea
scores lower than muscle effort scores indicate that the ventilatory pump is not the
proximate source of exercise limitation [15]. Arterial blood typically remains well-
saturated with O2 throughout exercise in healthy subjects. Thus, exertional hypox-
emia and hypercapnia are not normal features in non-trained to moderately trained
younger humans.
Cardiovascular Responses
Muscle O2 utilization during exercise increases through higher O2 delivery (DO2)

and O2 extraction, i.e., a wider difference between arterial and venous capacity for
O2 (CaO2–CvO2). The main determinant of DO2 in non-hypoxemic subjects is car-
diac output, i.e., stroke volume (SV) and heart rate (HR). Thus,
Ú O2 = ( HR ´ SV ) ´ ( CaO 2 - CvO 2 ) (8.2)

where Ú O2 is the O2 uptake. CO increases by early SV augmentation and a con-
tinuous acceleration of HR throughout exercise. Despite four- to fivefold increase in
cardiac output at peak exercise, pulmonary intra-vascular pressures increase only
modestly due to lower vascular resistance secondary to capillary recruitment and
dilatation [3]. A large fraction of the cardiac output is redirected to the contracting
peripheral muscles and, to a lesser extent, to the respiratory muscles. Extraction is
maximized by decreases in hemoglobin affinity for O2 due to lower pH and higher
temperature within the exercising muscle. It follows that if the work rate increases
continuously during exercise, Ú O2 also increases linearly (Fig. 8.1).
Rearranging (Eq. 8.2) gives how much O2 is consumed per beat:
Ú O2 / HR = SV ´ ( CaO 2 - CvO 2 ) (8.3)

Work rate
VO 2 Active
Sedentary
Mild disease
Moderate disease
Obese Advanced disease
Unload
Time (% test duration)
Fig. 8.1 Expected changes in oxygen uptake ( Ú O2 ) in response to a rapid and continuous increase
in work rate (“ramp”) in normal subjects and in patients with cardiocirculatory disease. Note the
continuum of longer Ú O2 delay and shallower Ú O2 responses as disease progresses from mild to
advanced stages. Although obesity is associated with increased O costs, the incremental cost of
work (Δ Ú O2 /Δwork rate) remains unaltered. (Reproduced with permission of the publisher, from
Neder et al. [80])
Thus, a low Ú O2 /HR ratio (O2 pulse) might be secondary to central hemody-
namic abnormality (low SV) and/or poor muscle ability to extract O2 (low CaO2–
CvO2) [4]. As exercise progresses, the rate of O2 offered due to either low O2 content
or low blood flow might be insufficient to muscle O2 needs. At this point, there is a
shift toward anaerobic metabolism leading to lactate accumulating in arterial blood.
This is called the “lactate (anaerobic) threshold,” a physiological phenomenon
which decreases the tolerance to further exercise [16].
CPET in Combvined COPD-Heart Failure
Key CPET Findings in COPD
In a patient with COPD, the most noticeable CPET abnormalities reflect reduced
ventilatory reserves, increased ventilatory demands, critical mechanical con-
straints, and disturbed pulmonary gas exchange in variable combinations (Fig. 8.2)
[8, 15]. These derangements may coexist with secondary evidence of impaired skel-
etal muscle strength and function (e.g., an early “anaerobic threshold”) [17].
Reduced ventilatory reserve has been traditionally indicated by a low breathing
reserve, usually expressed as an increased peak Ú E /maximal voluntary ventilation
(MVV) ratio (>0.8) [18]. However, the proximate limitation of exercise tolerance in
chronic lung disease is very often intolerable symptoms, particularly dyspnea [13];
thus, low peak Ú E and apparently preserved breathing reserve may merely reflect
early symptom limitation before the physiological limits of the respiratory system
are reached. It follows that peak Ú E /MVV may underestimate the role of ventila-
tion in limiting patients’ exercise tolerance (Fig. 8.2, panel 4).
Increased ventilatory demand is expressed by a high submaximal Ú E / Ú CO2 ratio
usually due to a high physiological dead space (wasted ventilation) (Eq. 8.1). It
should be emphasized, however, that increased dead space is readily translated into
high Ú E / Ú CO2 in patients with only mild to moderate ventilatory constraints. As the
disease progresses, inspiratory constraints and higher PaCO2 preclude large
increases in Ú E / Ú CO2 (Fig. 8.2, panel 4); in fact, “normal” or even low Ú E / Ú CO2
might be seen in end-stage COPD (Fig. 8.2, panel 5 and Fig. 8.3) [19].
Critical mechanical constraints (Fig. 8.2, third row) stem from expiratory flow
limitation and the curtailing of expiratory time when f increases; thus, expiratory
time becomes too short to allow full exhalation if airflow is slowed by airway dis-
ease and/or loss of lung elastic recoil [20]. The resulting gas trapping leads to a
temporary increase in EELV above the resting value, i.e., dynamic hyperinflation
[21]. As a consequence, IC decreases (Fig. 8.2, panel 7), and VT happens at higher
volumes, where compliance is decreased and the inspiratory muscles are function-
ally weakened. Thus, EILV encroaches on TLC leading to a critically reduced IRV
and dynamic mechanical constraints (Fig. 8.2, panel 8) [22]. The high physiological
and perceptual (dyspnea) “price” to further decrease IRV explains why VT cannot
further increase (note VT plateau in Fig. 8.2, third row). Increased respiratory motor
PRED LT
1.9 1.6 1.3 150 PRED 14
1 1.8 2 1.2
3 13
140 PRED
1.7 1.4 12
1.1
1.6 LLN 130 11
1.2 1.0
1.5 10
120
O2 pulse (mL/min/beat)
0.9
1.4
9
VCO2 (mL/min)
1.0
HR (beats/min)
1.3 0.8 110
VO2 (L/min)
8
1.2 0.7
RER
0.8 100 7
1.1 0.6
S=11.5 S = 25 6
1.0 0.5 90
0.6 5
0.9
0.4 80 4
0.8 0.4 0.3 3
0.7 70
0.6 0.2 2
0.2
60
0.5 0.1 1
PRED
0.0 0.0 50 0
0 10 20 30 40 50 60 70 80 90 100110120130 0.0 0.2 0.4 0.6 0.8 1.0 1.2 1.4 1.6 0.0 0.2 0.4 0.6 0.8 1.0 1.2 1.4 1.6
Work rate (W) VO2 (L/min) VO2 (L/min)
PETO2 PcCO2
SpO2
70 100 LT
50 50 105 48
4 5 6
90
60
80
ULN 45 45 44
50 100
Ventilatory reserve (%)
70
PETCO2 (mmHg)
60
VE (L/min)
40 40 40 40
mmHg or %
VE / VCO2
VE / VO2
50
95 LLN
30
40
S= 25 35 35 36
20 30
LLN 90
20
30 30 32
10
10 NADIR
I = 6.3
0 0
0.0 0.2 0.4 0.6 0.8 1.0 1.2 1.4 1.6 25 85 28
0.0 0.2 0.4 0.6 0.8 1.0 1.2 1.4 1.6 0.0 0.2 0.4 0.6 0.8 1.0 1.2 1.4 1.6
VCO2 (L/min)
VO2 (L/min) VO2 (L/min)
2.5 1.0 1.00 2.00 1.6 50 RR
7 8 9
0.9 0.95 VT plateau 1.75 ULN 45

2.4
1.4 VT plateau
VT plateau 1.50
40
0.8 0.90 ULN
2.3 35
ULN 1.25
1.2
0.85
EILV/TLC
0.7 30
IRV (L)
VT / IC
VT (L)
IC (L)
2.2 1.00
0.6 0.80 25
1.0
0.75
2.1 PRED 20
0.5 0.75 LLN
0.50
15
0.8
2.0
0.4 0.70 0.25 10
1.9 0.3 0.00 5

5 10 15 20 25 30 35 40 45 50 5 10 15 20 25 30 35 40 45 50 5 10 15 20 25 30 35 40 45 50
VE (L/min) VE (L/min) VE (L/min)
10 Maximum 10 Maximum
A C
9 9
Leg Discomfort (Borg score)
8 8
Dyspnoea (Borg score)
7 Very intense 7 Very intense
6 6
Dyspnea threshold
5 Intense 5 Intense
4 4
3 Moderate 3 Moderate
2 Mild 2 Mild
1 1
0 0
0 5 10 15 20 25 30 35 40 45 50 55 60 65 70 0 5 10 15 20 25 30 35 40 45 50 55 60 65 70
Work rate (W) Work rate (W)
B D
9 9
8 8
6 6
5 Intense 5 Intense
4 4
Dyspnea threshold
2 Mild 2 Mild
1 1
0 0
5 10 15 20 25 30 35 40 45 50 0.0 0.2 0.4 0.6 0.8 1.0 1.2 1.4 1.6
VE (L/min) VO2 (L/min)
Fig. 8.2 Metabolic/cardiovascular (first row), ventilatory/gas exchange (second row), mechanical/
breathing pattern (third row), and perceptual (bottom graphs) responses to incremental exercise in
a 68-year-old male with COPD (FEV1 = 56% predicted). See text for detailed discussion. Definition
of abbreviations and symbols: pred predicted, LLN lower limit of normal, ULN upper limit of
normal, S slope, I intercept, Ú O2 oxygen uptake, WR work rate, Ú CO2 carbon dioxide output, RER
respiratory exchange ratio, LT estimated lactate threshold, HR heart rate, ⩒E minute ventilation, Pc
capillary (arterialized) pressure, PET end-tidal pressure, SpO2 oxyhemoglobin saturation by pulse
oximetry, IC inspiratory capacity, VT tidal volume, IRV inspiratory reserve volume, EILV end-
inspiratory lung volume, TLC total lung capacity, RR respiratory rate
a b
12 p<0.05 45
*
10 40
*
Intercept L·min-1
8 35
Slope
6 30 *
4 25
2 20
0 15
Controls 1 2 3 4 Controls 1 2 3 4
c
GOLD stage d GOLD stage
45 24 p<0.05
40 20
*
35 16
Nadir–slope
Nadir
30 12
25 8
20 4
15 0
Controls 1 2 3 4 Controls 1 2 3 4
GOLD stage GOLD stage
Fig. 8.3 Effects of COPD severity on markers of ventilatory efficiency during incremental exer-
cise, i.e., ventilation ( Ú E )-carbon dioxide output ( Ú CO2 ) relationship. Note that the intercept of
the linear Ú E − Ú CO2 relationship (i.e., its starting point in the Ú E axis) increases as COPD
progresses (a); in contrast, the slope decreases from GOLD 1 to GOLD 4 (b) (i.e., the difference
between both parameters increases, (d)). Considering that both slope and intercept influence the
Ú E / Ú CO2 ratio at its lowest point, the latter tends to diminish from GOLD 1 to GOLD 4. See text
for the practical implications of these findings. (Reproduced with permission of the publisher, from
Neder et al. [19])
drive and inspiratory muscle effort which are not rewarded with chest-lung expan-
sion explain why dyspnea increases as a function of WR and Ú E at the so-called
dyspnea threshold (Fig. 8.2, bottom panels) [23].
Disturbed pulmonary gas exchange might be demonstrated by variable degrees
of (usually mild to moderate) hypoxemia and, in more severe patients, hypercapnia
[8]. An estimate of mean alveolar PCO2 (end-tidal PCO2, PETCO2) can increase
(Fig. 8.2, panel 6) as a result of alveolar hypoventilation or late emptying of poorly
ventilated units with higher PCO2 (Fig. 8.4, panels b, e). Conversely, some patients
a b Advanced c
Normal COPD PAH/CHF
mmHg 50 50 PACO2 50
PACO2 ∆=+5
40 ∆=+2 40 40 PACO2
∆=+5
30 30 30
Rest
PECO2
PECO2 PECO2
20 20 20
10 10 10
0 0 0
d e f
50 50 PACO2 ∆=+5
50
40 PACO2 ∆=-7 40 40
Exercise
PACO2
30 30 30
PECO2 PECO2
∆=+12
20 20 20
PECO2
10 10 10
0 0 0
Expiratory time Expiratory time Expiratory time
Fig. 8.4 Schematic representation of expiratory partial pressure for CO2 (PECO2) over a single
breath at rest and exercise. “Δ” is the difference between mean alveolar ( A ) and end-tidal (ET)(°)
partial pressures. At very early expiration, PECO2 remains near zero as the first exhaled air comes
from the anatomical dead space (with very low CO2 concentration). Subsequently, PECO2 increases
faster: (a) the better CO2 is washed out from mixed venous blood to the alveoli (better ventilation/
perfusion matching) and (b) the more homogeneous the lungs empty. The last part of the exhaled
tidal volume is less “contaminated” with the air from dead space; thus, it is biased to reflect alveo-
lar gas which has the highest CO2 concentration (PETCO2). Resting PETCO2, however, is slightly
lower than PaCO2 (and P A CO2) with their difference correlating well with wasted ventilation in
both health and disease (panels, (a, b, c)). During exercise, PETCO2 becomes greater than PaCO2
in health (i.e., the PaCO2-PETCO2 difference becomes negative) due to the effects of (a) pulsatile
increases in pulmonary perfusion with CO2-enriched mixed venous blood, (b) faster and more
homogenous lung emptying, and, importantly, (c) a larger VT leading to greater sampling of alveo-
lar gas (panel (d)). Less ventilated units (with high PECO2) are the last to empty in COPD: this
further increases PETCO2 in more advanced disease (panels b, e). In the presence of impaired
pulmonary blood flow (i.e., high ventilation/perfusion due to low perfusion), PECO2 increases
slowly, thereby leading to a lower PETCO2; thus, PaCO2-PETCO2 difference fails to turn negative
during exercise (PAH/CHF) (panel (f)). As expected, this abnormal response is worsened if a
patient develops a shallow and faster breathing pattern as a relatively lesser amount of alveolar gas
is sampled and expiratory time becomes too short. Additional decrements in PETCO2 may occur if
a patient with PAH or CHF presents with alveolar hyperventilation (panel (f))
may show normal-low PETCO2 because impaired pulmonary perfusion relative to

ventilation (e.g., emphysema) decreases the amount of CO2 washed out in each
breath (Fig. 8.4, panels c, f ). Low VT due to mechanical constraints, leading to less
alveolar air sampling, may also contribute to decrease PETCO2 in some patients [24].
Key CPET Findings in Heart Failure
In a non-treated patient with overt heart failure with reduced left ventricular ejection
fraction, the most noticeable CPET abnormalities reflect poor O2 delivery, impaired
SV, and increased ventilatory demands (Fig. 8.5) [7].
Poor O2 delivery secondary to low CO might lead to a downward inflection on
Ú O2 at an abnormally low work rate (Fig. 8.1 and Fig. 8.5, panel a). Thus, the
slower rate of increase in Ú O2 for a given change in work rate (shallow Δ Ú O2 /
ΔWR) and a low peak WR contribute to a low peak Ú O2 [25]. An early shift to a
predominantly anaerobic metabolism is reflected by an early lactate threshold. Ú O2
may also struggle to increase at exercise onset due to poor muscle oxidative capac-
ity and a long circulatory delay. Similarly, Ú O2 may take long to decrease on recov-
ery (Fig. 8.5, panel (g)) [26].
Impaired SV means that HR should increase faster to increase O2 delivery, lead-
ing to a steep ΔHR/Δ Ú O2 (note that this applies only to patients whose HR is not
under pharmacological or external control, e.g., β-blocker (Fig. 8.5, panels b, c) and
pacemaker, respectively). If C(a-v)O2 is unable to fully compensate the low SV, low
submaximal and maximal O2 pulse can be expected. A plateau in O2 pulse, in par-
ticular, has been associated with severe impairment in SV [27]. Some patients, how-
ever, do develop chronotropic insufficiency which indicate that CPET variables
based on HR should be viewed with caution in these patients [28].
Increased ventilatory demands are not uncommon in patients with heart failure
[29]. For instance, steep Ú E − Ú CO2 slope (Fig. 8.5, panel e) has been related to
reflex mechanisms (central and peripheral chemoreflexes, muscle metaboreflex,
Bainbridge reflex) associated with sympathetic activation leading to a downward
shift of the CO2 set point. Higher VD/VT with a shallow breathing pattern may reflect
the combined effects of impaired pulmonary perfusion, increased areas of ventila-
tion/perfusion, and the restrictive effects of heart failure [30]. These abnormalities
may jointly explain why PETCO2 decreases as the disease evolves (Figure 8.4, pan-
els c, f). A minority of patients with heart failure present with decrements in IC
during exercise which might represent true dynamic hyperinflation or exercise-
induced respiratory muscle weakness [31]. Another important CPET finding with
ominous prognostic implications is exercise oscillatory ventilation (Fig. 8.5, panels
d, h, i), a pattern of cyclic variations in Ú E , due to elevated left heart filling pres-
sures, increased CO2 chemosensitivity, and prolonged circulatory time [32].
a 2.2 d 110 g 1.8 1.8

MVV
100 PRED
2.0 1.6 1.6
1.8 PRED 90
1.4 1.4
80 Ventilatory
1.6 Reserve
1.2 1.2
70
VCO2 (L/min)
VO2 (L/min)
VO2 (L/min)
VE (L/min)
1.4
60 1.0 1.0
1.2
50 0.8 0.8
1.0
40
0.6 0.6
0.8 30
0.6 0.4 0.4
20
0.4 10 0.2 0.2
0
0 10 20 30 40 50 2 4 6 8 10 12 2 4 6 8 10 12
Work rate (W) Time (min) Time (min)
b 160 PRED
e 70
h120 90
150 110 85
60
140 80
100
130 S = 59
50 75
90
HR (beats/min)
120
VE (L/min)
70
VE / VCO2
VE / VO2
110 40 80
65
100 70
30
S2 = -12 60
90
60
80 20 55
50 50
70
10
60 S1 = 39 40 45
I = 0.4
0 30 40
0.0 0.2 0.4 0.6 0.8 1.0 0.0 0.2 0.4 0.6 0.8 1.0 1.2 1.4 1.6 2 4 6 8 10 12
Time (min)
c f i
VO2 (L/min) VCO2 (L/min)
175 12 PETO2 SpO2

3.2 50
125 35
165
PRED 2.8 45
155 10 120
PRED
30
O2 pulse (mL/min/beat)
145 2.4 40
8 115
HR (beats/min)
PETCO2 (mmHg)
135 2.0 35
RR (bpm)
mmHg or %
125 25
VT (L)
110
6 1.6 30
115
1.2 25 105
105 20
4
95 0.8 20 100
85 2 15
0.4 15 95
75
65 0 0.0 10
2 4 6 8 10 12 10 20 30 40 50 60 90 10
2 4 6 8 10 12
Time (min) VE (L/min)
Time (min)
j 10 Maximum
9
8 leg discomfort
7 Very Intense
Borg scale
6
5 Intense
4
3 Moderate dyspnea
2 Mild
1
2 4 6 8 10 12
Time (min)
Fig. 8.5 Metabolic/cardiovascular (panels (a–c, g)), ventilatory/gas exchange (panels (d, e, h, i)),
breathing pattern (panel (f)), and perceptual (bottom graph) responses to incremental exercise in a
68-year-old male with heart failure with reduced left ventricular ejection fraction (LVEF = 26%
predicted). Note the presence of exertional oscillatory ventilation (EOV) (panel (d)) leading to
cyclic fluctuations in expired gas tensions (panel (i)). Inspiratory capacity was not measured dur-
ing exercise precluding assessment of non-invasive mechanics. See text for detailed discussion.
Definition of abbreviations and symbols: pred predicted, S slope, I intercept, Ú O2 oxygen uptake,
WR work rate, Ú CO2 carbon dioxide output, HR heart rate, ⩒E minute ventilation, PET end-tidal
pressure, SpO2 oxyhemoglobin saturation by pulse oximetry, VT tidal volume, RR respiratory rate
Conflating Cardiopulmonary Abnormalities

in COPD-Heart Failure
Among the cardiovascular comorbidities of COPD, there is growing interest in heart

failure with reduced left ventricular ejection fraction (LVEF). The prevalence of
overlapping COPD-heart failure varies from 9% to 33% [33–37] depending on the
availability of pulmonary function tests, local practices regarding heart failure
screening by trans-thoracic echocardiography in advanced COPD, definition crite-
ria for each disease, and, in particular, whether the patients have been primarily seen
by pulmonologists or cardiologists. Regardless of the actual prevalence, it is out of
debate that incident heart failure carries a dismal prognosis in patients with COPD
[33, 35]. The opposite, i.e., the impact of a “new” diagnosis of COPD in a patient
with established heart failure, remains controversial – particularly in patients with
less severe heart failure [38].
Nevertheless, it is now well-established that COPD-heart failure patients present
with higher symptom burden, lower exercise tolerance, and poorer quality of life
than their counterparts with COPD or heart failure with similar resting functional
impairment [33–39]. In this context, there is a strong appeal for CPET in overlap-
ping COPD-heart failure as, by definition, it carries the highest risk for negative
cardiopulmonary interactions under the stress of exercise. Unfortunately, however,
we are only starting to understand those complex interactions and their systemic
consequences. It follows that much needs to be discovered, an enterprise that might
greatly benefit from clinical physiology investigations (see 6 “Unanswered
Questions”).
Ventilatory Control and Gas Exchange
There is mounting evidence that the coexistence of heart failure in patients with
COPD is associated with Ú E − Ú CO2 values that are significantly higher than
expected by the severity of resting ventilatory abnormalities (Fig. 8.6 for a represen-
tative patient and Fig. 8.7) [40–42]. Notably, however, there is a large variability in
the Ú E − Ú CO2 relationship regardless of the chosen metrics (i.e., Ú E − Ú CO2 slope
or Ú E / Ú CO2 nadir) (Fig. 8.8) [40, 41]. In order to uncover the underlying mecha-
nisms, we measured PCO2 in arterialized (capillary, c) blood allowing VD/VT calcu-
lation. Our results demonstrated that the key abnormality leading to higher
Ú E − Ú CO2 values in a subset of patients (Fig. 8.9, panel b) was not a particularly
high VD/VT (Fig. 8.9, panel c) but a low PcCO2 set point (Fig. 8.9, panel e) [43]. This
suggests a chronically increased drive to breathe which led to a ventilatory response
beyond that required to wash out metabolically produced CO2 and overcome an
enlarged physiological dead space. Strictly from the gas exchange perspective, this
strategy was beneficial as patients maintained better arterial oxygenation (Fig. 8.9,
panel e) than their counterparts despite similar (in)efficiency in intra-pulmonary
oxygenation. Thus, it is conceivable that the heightened ventilatory drive which led
1.4 PRED LT 150 12

1 2 0.9 1.3 3 PRED
1.3 1.2 140 11
0.8
1.2 1.1 PRED 10
LLN 130
0.7
O2 pulse (mL/minbeat)
1.1 1.0 9
0.9 120
8
HR (beats/min)
1.0 0.6
VCO2 (mL/min)
0.8 110
VO2 (L/min)
0.9 7
0.5 0.7
RER
0.8 100 6
0.4 0.6
0.7 90 5
S= 6.8 0.5
0.3 4
0.6 0.4 80
3
0.5 0.2 0.3 70 S2= 73 2
0.4 0.2
0.1 60 1
0.1 S1= 23
PRED
0.0 0.0 50 0
0 10 20 30 40 50 60 70 80 90 100 0.0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 0.0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9
Work rate (W) VO2 (L/min)
VO2 (L/min) PETO2
SpO2
70 100 LT
42
4 5 65 65 6 110
90
60
ULN 80 60 60 105
Ventilatory reserve (%)
50 70 38
PETCO2 (mmHg)
55 55 100
60
VE (L/min)
mmHg or %
40
VE / VCO2
VE / VO2
50
50 50 95 LLN 34
30
40
S= 36
20 30 45 45 90
20 30
LLN
10 40 ULN 40 85
10 NADIR
I = 3.5
0
0.0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 35 35 80 26
0.0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 0.0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9
VCO2 (L/min)
VO2 (L/min) VO2 (L/min)
3.0 1.0 1.00 2.00 1.5 55 RR
7 8 9
0.9 1.75 ULN
50
0.95
0.8
1.50 45
ULN
0.7 0.90 ULN
2.5 1.0
1.25 40
0.6
EILV/TLC
0.85
IRV (L)
VT / IC
VT (L)
IC (L)
0.5 1.00 35
0.80
0.4 0.75 30
2.0 0.5
0.3 0.75 LLN
0.50 25
0.2 RR/VT
0.70 0.25 20
0.1
1.5 0.0 0.00 15
5 10 15 20 25 30 35 5 10 15 20 25 30 35 5 10 15 20 25 30 35
VE (L/min) VE (L/min) VE (L/min)
A C
9 9
8 8
6 6
5 Intense 5 Intense
4 4
2 Mild 2 Mild
1 1
0 0
0 5 10 15 20 25 30 35 40 45 50 0 5 10 15 20 25 30 35 40 45 50
B D
9 9
8 8
6 6
5 Intense 5 Intense
4 4
2 Mild 2 Mild
1 1
0 0
15 20 25 30 35 0.0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9
VE (L/min) VO2 (L/min)
Fig. 8.6 Metabolic/cardiovascular (first row), ventilatory/gas exchange (second row), mechanical/
breathing pattern (third row), and perceptual (bottom graphs) responses to incremental exercise in
a 74-year-old male with COPD (FEV1 = 58% predicted)-heart failure (LVEF = 34%). See text for
detailed discussion. Definition of abbreviations and symbols: pred predicted, LLN lower limit of
normal, ULN upper limit of normal, S slope, I intercept, Ú O2 oxygen uptake, WR work rate, Ú CO2
carbon dioxide output, RER respiratory exchange ratio, LT estimated lactate threshold, HR heart
rate, ⩒E minute ventilation, Pc capillary (arterialized) pressure, PET end-tidal pressure, SpO2 oxy-
hemoglobin saturation by pulse oximetry, IC inspiratory capacity, VT tidal volume, IRV inspiratory
reserve volume, EILV end-inspiratory lung volume, TLC total lung capacity, RR respiratory rate
100
> 36
80
≤3.5
>33
Sensitivity 60
≤31
40
AUC (95% CI)
VE-VCO2 intercept† 0.788 (0.693-0.865)*
20
VE-VCO2 slope† 0.782 (0.686-0.860)*
Peak VE/VCO2 0.763 (0.666-0.844)*
Peak PETCO2 0.717 (0.616-0.804)*
0
0 20 40 60 80 100
100-Specificity
Fig. 8.7 Receiver operating characteristic (ROC) curve analysis showing the best CPET variables
able to discriminate patients with combined COPD-heart failure from those with COPD alone.
Circles depict the optimal thresholds according to individual variables. Note that these variables
reflect poor ventilatory and gas exchange efficiency. * P < 0.05. † P < 0.05 vs. peak PETCO2.
Abbreviations: AUC area under the curve, CI confidence interval, Ú E ventilation, Ú CO2 carbon
dioxide output, PET end-tidal partial pressure. (Reproduced with permission of the publisher, from
Arbex et al. [41])
to alveolar hyperventilation and better arterial oxygenation is part of a concerted

systemic response to improve tissue O2 delivery in the face of a failing heart [44].
PETCO2 frequently does not increase with exercise progression in COPD-heart fail-
ure (compare PETCO2 trajectory in panel 6, Fig. 8.6 (COPD-heart failure) versus
panel 6, Fig. 8.2 (COPD)) due to the combining effects of low PaCO2 set point and
worse pulmonary perfusion (Fig. 8.4, panels c, f).
Heart failure-related sympathetic overstimulation, lactic acidosis, and increased
stimulation or enhanced sensitivity of central chemoreceptors and peripheral mus-
cle ergoreceptors might be involved in the exacerbated ventilatory response shown
by the hypocapnic group in Fig. 8.9 [45]. Higher resting tricuspid annular plane
systolic excursion/pulmonary artery systolic pressure ratio suggests worse right
ventricle-pulmonary circulation uncoupling [46] due to higher afferent stimulation
from cardiopulmonary receptors in patients with higher exertional pulmonary arte-
rial pressures [47]. Greater emphysema burden may have also contributed to higher
pulmonary vascular resistance [48] and overstimulation of stretch receptors in the
right heart chambers (Bainbridge reflex) leading to hyperventilation. Low transfer
factor for carbon monoxide in patients with higher Ú E − Ú CO2 and hypocapnia are
consistent with those hypotheses [49]. The former, in particular, may decline with
even moderate lung congestion (Fig. 8.10), being associated with poorer prognosis
in heart failure [50]. It remains to be explored whether the association of COPD and
heart failure decreases transfer factor beyond the expected values for underlying
emphysema burden. If so, this might enhance its prognostic role in this specific sub-
population of patients with COPD [33].
All Patients FEV1-matched patients

55 55
COPD (N = 57) COPD (N = 35)
50 50
Overlap (N = 41) Overlap (N = 28)
45 45
40 40
VE-VCO2 slope
35 35
30 30
25 25
20 20
15 15
-4 -3 -2 -1 0 1 2 3 4 5 6 7 8 9 10 11 12 -4 -3 -2 -1 0 1 2 3 4 5 6 7 8 9 10 11 12
VE-VCO2 intercept (L/min) VE-VCO2 intercept (L/min)
60 60
55 COPD (N = 57) 55 COPD (N = 35)

Overlap (N = 41) Overlap (N = 28)
50 50
Peak PETCO2 (mmHg)
45 45
40 40
35 35
30 30
25 25
20 20
20 25 30 35 40 45 50 55 60 65 20 25 30 35 40 45 50 55 60 65
Peak VE/VCO2 Peak VE/VCO2
Fig. 8.8 Ventilation ( Ú E )-CO2 output ( Ú CO2 ) slope versus intercept (upper panels) and end-tidal
partial pressure for CO2 (PETCO2) versus peak Ú E / Ú CO2 ratio in COPD and combined COPD-
heart failure (“overlap”). Dotted lines indicate the optimal thresholds for “overlap” discrimination
as established by the ROC curve analysis (Fig. 8.7). (Reproduced with permission of the publisher,
from Arbex et al. [41])
Lung Mechanics
The effects of heart failure on resting pulmonary function have been extensively
investigated and recently reviewed in ref. [51]. Although patients with decompen-
sated heart failure commonly present with airflow limitation, the disease tends to
reduce the “static” lung volumes in COPD, particularly TLC and functional residual
capacity (FRC) [52]. In a stable patient, those decrements are roughly similar which
tends to somewhat “preserve” IC (Fig. 8.11) [53]. Of note, residual volume (RV)
remains elevated in COPD-heart failure [54]; in fact, RV > 120% predicted has been
found the most consistent finding in patients with COPD-heart failure [55]
(Fig. 8.12). It follows that expiratory reserve volume is severely reduced. In prac-
tice, however, it is not uncommon to find patients with low RV (and TLC) due to
associated morbid obesity [56]. Particularly low TLC values are seen in the pres-
ence of severe cardiomegaly and long-term lung congestion, leading to pronounced
decrements in VC and IC (Fig. 8.10) [57]. Low (F)VC and increased lung elastic
recoil may result in reduction in both FEV1 and FVC leading to a pseudo-normal
a b c
45 60 0.55
40 *
55
* 0.50
Physiological VD/VT
35
* 50
*
VE (L/min)
VE / VCO2
0.45
30 *
* *
45
* * *
25
0.40
40
20
0.35
35
15
10 30
Rest 0 10 20 30 40 50 60 Rest 0 10 20 30 40 50 60 Rest 0 10 20 30 40 50 60

Work rate (W) Work rate (W) Work rate (W)
d e f
30 47 90
45
* * * *
25 * 43
85
* *
* 41
80
PCO2 (mmHg)
PcO2 (mmHg)
VA (L/min)
20 39
* Pc
37 75
* PET
15 35
70
33
* *
10 31
* * *
* 65
29
* *
* *
5 27 * *
60
Rest 0 10 20 30 40 50 60 Rest 0 10 20 30 40 50 60 Rest 0 10 20 30 40 50 60

Fig. 8.9 Ventilatory (panels (a–d)) and pulmonary gas exchange (panels (e, f)) responses to incre-
mental cardiopulmonary exercise testing in COPD-heart failure patients separated by presence
(N = 10) or not (N = 12) of exercise hypocapnia (closed symbols and open symbols, respectively).
* P < 0.05 for between-group comparisons at rest, standardized work rates, and the highest work
rate attained by all subjects in a given group. Values are means ± SEM. Abbreviations: VD/VT dead
space/tidal volume ratio, Ú A alveolar ventilation, Pc capillary (arterialized) partial pressure, PET
end-tidal partial pressure. (Reproduced with permission of the publisher, from Rocha et al. [43])
FEV1/FVC ratio, i.e., the non-specific pattern of ventilatory dysfunction [58]. Thus,
FEV1 alone may overestimate the functional severity of COPD in some patients
with combined COPD-heart failure [55].
Evaluation of operating lung volumes by serial exercise IC maneuvers is fraught
with complexities in COPD-heart failure. It remains unclear, for instance, whether
TLC actually remains stable during exercise in these patients [12]. For instance,
TLC might decrease in some patients who develop exercise-induced pulmonary
congestion. Patients with COPD-heart failure might present with greater inspiratory
muscle weakness than their counterparts with either disease on isolation [59]. This
casts doubt on whether they are able to fully activate their inspiratory muscles as
exercise progresses. Despite those concerns, limited evidence demonstrates that IC
either remains unaltered or decreases (Fig. 8.6, panel 7, and Fig. 8.13, panel d),
thereby reducing the limits for VT expansion [43]. Earlier attainment of critical
mechanical constraints (higher VT/IC ratio and low IRV) was found in patients with
higher Ú E / Ú CO2 (Fig. 8.13) [43] and exertional oscillatory ventilation (Fig. 8.14)
[94]. Under this unfavorable combination of circumstances (high neural drive and
FEV1/FVC Body
weight
FVC
DLCO
PAPm
PCWP
Lung congestion
Dry Pulmonary
lung oedema
Fig. 8.10 Schematic representation of potential trajectories of lung function, hemodynamics, and
body weight with lung congestion in heart failure. DLCO diffusing capacity for carbon monoxide,
FEV1 forced expiratory volume in the first second, FVC forced vital capacity, PAPm mean pulmo-
nary artery pressure, PCWP pulmonary capillary wedge pressure. (Reproduced with permission of
the publisher, from Magnussen et al. [51])
TLC
IRV
EILV IC
VT IRV
EELV IC
ERV VT
ERV
RV
RV
COPD COPD + CHF
Fig. 8.11 Lung volumes and capacities expressed as absolute values (a) and corrected for differ-
ences in total lung capacity (b) in patients with COPD only and in those with combined COPD and
chronic heart failure (CHF). TLC total lung capacity, RV residual volume, ERV expiratory reserve
volume, VT tidal volume, IRV inspiratory reserve volume, FRC functional residual capacity, EILV
end-inspiratory lung volume, IC inspiratory capacity. (Modified with permission of the publisher,
from de Souza et al. [53])
neuromechanical dissociation) [1], it is not surprising that these patients reported

higher dyspnea for a given work rate and Ú E (Fig. 8.6, bottom panels). It follows
that therapeutic attempts to increase the “ceiling” for VT expansion (e.g., increasing
TLC by improving lung congestion and inspiratory muscle weakness) and/or to
Fig. 8.12 Residual volume HF Only HF+COPD COPD Only

was significantly higher in (n = 557) (n = 108) (n = 194)
patients with COPD (alone 200
or in association with
Residual volume (% pred)

chronic heart failure 180
(CHF)) compared to CHF
alone. (Based on data 160
from [55])
140
120 *
100
80
CHF CHF-COPD COPD
a b c
1300 35 2.8
2.6
1200 *
2.4
30
1100 *
* 2.2
f (breaths/min)
VT (mL)
1000 2.0
TE (s)
25 *
900 1.8
1.6
800
20
1.4
700 *
1.2
* *
*
600 15 1.0
*
Rest 0 10 20 30 40 50 60 Rest 0 10 20 30 40 50 60 Rest 0 10 20 30 40 50 60
d e f
2.4 100 0.0
Rest 0 10 20 30 40 50 60
95 Work rate (W)

2.3
EILV/TLC and EELV/TLC (%)
* * *
90 * 0.5 *
2.2
*
85
2.1
IRV (L)
IC (L)
* 80 1.0
2.0
75
*
1.9 *
70 1.5
1.8 65
1.7 60 2.0
Rest 0 10 20 30 40 50 60 Rest 0 10 20 30 40 50 60
Fig. 8.13 Pattern and timing of breathing (panels (a–c)) and operating lung volume (panels (d–f))
during incremental exercise in cardiopulmonary exercise testing in COPD-heart failure patients
separated by presence (N = 10) or not (N = 12) of exercise hypocapnia (closed symbols and open
symbols, respectively). Shadowed areas in panels (e) and (f) represent the volumes typically asso-
ciated with critical inspiratory constraints in COPD [30, 45]. * P < 0.05 for between-group com-
parisons at rest, standardized work rates, and the highest work rate attained by all subjects in a
given group. Values are means ± SEM. Abbreviations: VT tidal volume, f respiratory rate, IC inspi-
ratory capacity, EILV end-inspiratory lung volume, EELV end-expiratory lung volume, TLC total
lung capacity, IRV inspiratory reserve volume. (Reproduced with permission of the publisher,
from Rocha et al. [43])
a b
35 1.0 10
30 MVV
0.8 8
Dyspnea score (Borg)

25
Tidal volume (L)

Ventilation (L)
Inflection point
EOV cessation 0.6 6
20
15
0.4 4
10
0.2 2
5
0 0.0 0
c d
TLC
45 45 0.0
Inflection point IRV

End-tidal PCO2 (mmHg)
Capillary PCO2 (mmHg)
40 40 IC
0.5
Lung volume (L)
VT
35 35
1.0
30 30
1.5
25 EOV cessation 25
REST UNL INC REC REST UNL INC REC

20 20 2.0
0 100 200 300 400 500 600 700 0 100 200 300 400 500 600 700
Time (s) Time (s)
Fig. 8.14 Physiological and perceptual responses to incremental exercise in a representative

patient with heart failure-COPD (female, age = 63 yrs, height = 146 cm) presenting with exercise
oscillatory ventilation (EOV). Abbreviations: MVV maximal voluntary ventilation, TLC total lung
capacity, IRV inspiratory reserve volume, VT tidal volume, IC inspiratory capacity. (Reproduced
with permission of the publisher, from Rocha et al. [94])
decrease its “floor” (i.e., decreasing EELV by reducing expiratory flow limitation
and f) in association with less afferent ventilatory stimuli (e.g., heart failure treat-
ment optimization) might positively impact on patient’s activity–related dyspnea.
Central and Peripheral Hemodynamics
Non-invasive CPET (i.e., without concomitant cardiac catheterization) is ill-suited to

expose the potential hemodynamic consequences of negative cardiopulmonary inter-
actions in COPD-heart failure (Fig. 8.15) [60]. For instance, crude estimates of SV
behavior (i.e., O2 pulse) are likely invalid if HR is under pharmacological modulation
(β-blockers) (Figure 8.5, panels b and c) and/or suffering the consequences of loss or
desensitization of cardiac β1 receptors (heart failure-related chronotropic incompe-
tence [28]). In fact, SV alone may not provide the complete picture of underlying
PPL
ITP PPL
Palv
Decreased
PO2 and pH
PTM
ITP SVR
Fig. 8.15 Schematic representation of potential negative cardiopulmonary interactions in moder-

ate to severe COPD which could be further worsened by the coexisted with heart failure with
reduced left ventricular ejection fraction. Increases in mean intra-thoracic pressure (ITP) and large
swings in pleural pressure (PPL) may reduce venous return and right ventricular (RV) preload. High
PPL swings, compression of juxta-alveolar capillaries, and hypoxic vasoconstriction increase RV
afterload and intra-cavitary pressures. The latter occurrence, in association with extrinsic compres-
sion of the right heart by the overdistended lungs, can impair RV relaxation and displace the inter-
ventricular septum to the left. Reduced left heart filling pressures and dimensions may contribute
to further impairments in stroke volume (SV). Large PPL swings can also increase left ventricular
(LV) afterload secondary to high transmural pressures (PTM). Moreover, decreased aortic imped-
ance and augmented systemic vascular resistance (SVR) further increase LV afterload, thus com-
promising cardiac output. Of note, the relative contribution of each of the above factors is likely to
vary according to different phases of respiratory and cardiac cycles. (Reproduced with permission
of the publisher, from Oliveira et al. [77])
abnormalities. For instance, patient’s dyspnea might still be influenced by heart failure
if a “normal” SV is maintained at expenses of high left ventricular filling pressures [61].
Under the light of those important limitations, a non-invasive CPET study which
measured SV by signal-morphology cardio-impedance found lower ΔCO/Δ Ú O2
relationship in COPD-heart failure compared with isolated heart failure despite
similar resting LVEF (Fig. 8.16, panels a, b) [62]. These data suggest that some of
negative cardiopulmonary interactions outlined in Fig. 8.15 contributed to further
impair cardiac output in the former group. Of note, low leg muscle oxygenation [63,
64] and excessive lactate production (Fig. 8.17, panels c, d, e,f) worsened in tandem
with dynamic abnormalities in cardiac output and peripheral blood flow (Fig. 8.16.
panels c, d, e, f) leading to higher ratings of leg effort on exercise in COPD-heart
failure compared to COPD alone [62]. Considering the lack of hypoxemia [62],
these data lend support to the notion that central hemodynamic abnormalities in
COPD-heart failure are instrumental to further decrease muscle blood flow under
the stress of exercise [63, 64]. Interestingly, inspiratory muscles overloading also
decreased leg muscle perfusion in these patients [65], likely a consequence of
heightened sympathetic over-excitation [59] (Fig. 8.18). Peripheral arterial disease
a b
* 8
Control * vs. all groups
∆ Cardiac Output / ∆ Oxygen uptake (L/L)

14
COPD † vs. COPD and controls
7
CHF
12 Overlap
Cardiac output (L/min)
6
†
10 5
4
8 †
*
3
*
6 2
* vs.patients 1
4
† among patient groups
0
0.4 0.6 0.8 1.0 1.2 1.4 1.6
Oxygen uptake (L/min)
c d
10 * ∆ Muscle blood flow index / ∆ Oxygen uptake 8
Muscle blood flow index (fold-increase)
7
8
6
(fold-increase/L/min)
5 †
6
4
* †
4 3
*
2
2
1
0 0
0.4 0.6 0.8 1.0 1.2 1.4 1.6
e f
∆ Muscle blood flow index / ∆ Cardiac output
10 2.0
Muscle blood flow index (fold-increase)
8
1.5
(fold-increase/L/min)
6
1.0
4
0.5
2
0 0.0
4 6 8 10 12 14 Control COPD CHF Overlap
Cardic output (L/min)
Fig. 8.16 Central (panels (a) and (b)) and peripheral (panels (c) and (d)) hemodynamic responses
as a function of exercise intensity and their relationship (panels (e) and (f)) in healthy controls and
patients with chronic obstructive pulmonary disease (COPD), chronic heart failure (CHF), and
COPD-CHF (overlap). “Δ“is the difference between 20% and 80% peak work rate. (Reproduced
with permission of the publisher, from Oliveira et al. [62])
a b
12 *
∆ Lactate / ∆ Oxygen uptake (mEq/L/min)

12
Control
COPD †
10 CHF 10
Overlap *
Lactate (mEq/L)
8 8
†
6 6
4 4
2 2 * vs. all groups

* vs. all groups
† vs. Control and COPD † vs. controls and COPD
0 0
0.4 0.6 0.8 1.0 1.2 1.4 1.6
c d
100 * 100
∆ HHb / ∆ Oxygen uptake (%/L/min) *
80 † 80 †
HHb (%max)
60 60
40 40
20 20
0.4 0.6 0.8 1.0 1.2 1.4 1.6
e f
10 0.18
0.16
∆ Lactate / ∆ HHb (mEq/L/%)
0.14
Lactate (mEq/L)
6
0.12
4
0.10
2
0.08
0 0.06
20 40 60 80 100 Control COPD CHF Overlap
HHb (% max)
Fig. 8.17 Blood lactate concentration (panels (a), (b), (e) and (f)), and muscle deoxygenation
(HHb) (panels (c) and (d)) as a function of exercise intensity in healthy controls and patients with
chronic obstructive pulmonary disease (COPD), chronic heart failure (CHF), and COPD-CHF
(overlap). “Δ“is the difference between 20% and 80% peak work rate. (Reproduced with permis-
sion of the publisher, from Oliveira et al. [62])
a b
2% MIP 60% MIP
160
*,#,¶
COPD
140 COPD+CHF
*,¶
Control ¶
*
MAP mmHg
120
100
80
60
0
c d
6
Calf blood flow mL·min-1 per 100 mL
3 *,¶
2
*
* *
1 *,# *,#
* *,#,¶ *,#,¶
0
e f
140
*,#,¶
120
Calf Vascular resistance units
100
80 *,#,¶ *,#,¶ *,¶

*
* *
60 * *
*
40 *
20
0
Rest 1 2 3 Rest 1 2 End
Time min Time min
Fig. 8.18 Central (panels (a) and (b) and peripheral (panels (c), (d), (e) and (f)) hemodynamic
responses to inspiratory resistive loading set at 2% (sham) and 60% maximal inspiratory pressure
(MIP) in patients with chronic obstructive pulmonary disease (COPD) or COPD plus chronic heart
failure (CHF) and healthy controls. The 2% MIP trials lasted 3 min in all participants. Compared
with controls, however, the 60% trials were significantly shorter in the COPD plus CHF group
compared with COPD alone and controls, respectively (see main text for actual values). Data are
presented as mean ± sd. MAP: mean arterial blood pressure. ∗: p < 0.05, COPD plus CHF or
COPD versus controls; #: p < 0.05, COPD plus CHF versus COPD; ¶: p < 0.05, within-group dif-
ference from rest. (Reproduced with permission from the publisher, from: Chiappa et al. [65])
(including diabetes related) [66], which is more common in COPD-heart failure

than COPD or heart failure alone [67], might worsen those abnormalities. It follows
that rehabilitation strategies aimed at improving peripheral muscle capillarization
and bioenergetics might be particularly valuable to improve exercise tolerance in
these patients [44].
Cerebral Blood Flow
Cerebral muscle perfusion and oxygenation are paramount to normal muscle activa-
tion during exercise [68]. Despite the presence of powerful autoregulation mecha-
nisms, brain blood flow (particularly through the small arterioles) is frequently
impaired in heart failure [69]. In COPD-heart failure, Oliveira et al. [70] found that
despite better preserved arterial oxygenation compared with COPD alone (Fig. 8.19,
panel b)), the former group had poorer pre-frontal cortical oxygenation (Fig. 8.19,
panel a)). As expected, this was associated with impaired central hemodynamics (low
CO and low mean arterial pressure) (Fig. 8.19, panels c, d)); surprisingly, however,
the closest correlate of poorer microvascular cerebral blood flow [71] (Fig. 8.20, pan-
els c, d) was a low PaCO2 (CO2 is a potent cerebral vasodilator) (Fig. 8.20, panel b).
a b
2.0 98
COPD+HFrEF #
1.6 COPD 96
∆COx fold change
#
1.2 94
#
SpO2 %
0.8 # 92
#
#
0.4 # 90
*,#
*,# *,#
0.0 * * * 88 *,#
* *
-0.4 86
c d
12 # 130
#
11
# # 120 # #
#
10 # #
#
MAP mmHg
#
QT L·min-1
9 110
#
8
# *,# 100
#
7
*
90 *
6
5 80
Unload 10 20 30 40 50 60 Peak Unload 10 20 30 40 50 60 Peak
Work rate W Work rate W
Fig. 8.19 Changes in (a) pre-frontal cerebral oxygenation (ΔCOx), (b) arterial oxygen saturation
measured by pulse oximetry (SpO2), (c) cardiac output (QT), and (d) mean arterial pressure (MAP)
as a function of exercise intensity in chronic obstructive pulmonary disease (COPD) patients with
or without heart failure with reduced ejection fraction (HFrEF) as comorbidity. Data are presented
as mean ± se. ∗: p < 0.05 for between-group comparisons; #: p < 0.05 for intragroup comparisons
against unloaded cycling. (Reproduced with permission from the publisher, from: Oliveira
et al. [70])
a b
100 44
98
*
Arterial oxy-hemoglobin saturation (%)
* 42
96 *
Arterialized PCO2 (mmHg)

40
94
92 38
90 36
88
34
86 *
32
84
82 30
c d
50 25
20
∆ Cerebral oxy-hemoglobin (µmol/L)
Cerebral blood flow index (ηmol/s)
40
15
30 10
5
20
10
-5
* *
* * *
0
-10 *
REST 20 40 60 80 REST 20 40 60 80
Work rate (% peak) Work rate (% peak)
Fig. 8.20 Arterial oxygen saturation (a), arterialized partial pressure of carbon dioxide (b), and
cerebral blood flow (c) and oxygenation (d) as a function of exercise intensity in COPD (open
symbols) and COPD-heart failure (closed symbols). ∗Between-group differences at a given time
point; † intragroup differences versus rest. (Reproduced with permission from the publisher, from:
Oliveira et al. [71])
In this context, chronic hypocapnia has been found to impair cerebrovascular

reactivity to CO2 which is crucial to main pH relatively constant near the central
chemoreceptors [72]. It follows that a blunted cerebrovascular reactivity to CO2
might add to the stimulation of the central chemoreflex by avoiding adequate CO2
washout [68]. This might constitute a self-perpetuating mechanism that contributes
to the chronic hyperventilation effects of a low CO2 set point [73]. The results of
Oliveira et al. [71] indicating impaired cerebral perfusion and hypocapnia (Fig. 8.20)
in conjunction with the findings of Rocha et al. [43] showing a strong association
between low PcCO2 and high Ú E / Ú CO2 (Fig. 8.9) raise the prospect of a putative
link between hypocapnia, impaired cerebrovascular reactivity to CO2 [74], and
excess exercise ventilation in COPD-heart failure [41]. Of note, poor cerebral oxy-
genation has been associated with low exercise tolerance in heart failure [69] and
pulmonary arterial hypertension [75]. The potential contribution of reduced motor
activation due to cerebral hypoxia (“central fatigue”) [76] remains open to investi-
gation in COPD-heart failure. A comprehensive discussion of the topic is provided
in Ref. [77].
PET in Pulmonary Hypertension Secondary to Chronic

C
Respiratory Diseases
High pulmonary arterial pressures might develop on exercise in patients with COPD
and ILD due to the combined effects of alveolar hypoxia (worse in ILD), microvas-
cular destruction (or compression in COPD), and lower VT [78]. Pulmonary hyper-
tension secondary to hypoxemia is more likely to be seen in patients who present
with exertional SaO2 below 88% [78]. Due to the sigmoid shape of the O2 dissocia-
tion curve, however, appreciable decrements in PaO2 (a closer correlate of pulmo-
nary arterial pressures than SaO2) [78] may be occasionally missed by the isolated
measurement of SaO2 or SpO2.
Patients with combined pulmonary fibrosis and emphysema (CPFE) are particu-
larly prone to develop pulmonary hypertension (PH) [79]. Impaired pulmonary per-
fusion and larger areas of high alveolar ventilation ( Ú A )/lung capillary perfusion
(Qc) are expected to increase the amount of ventilation wasted in the physiological
VD leading to high Ú E / Ú CO2 and low PETCO2 (Fig. 8.4, panels e, f) [80]. Increased
neural drive due to heightened afferent stimulation from pulmonary artery or car-
diopulmonary receptors may also contribute as well as higher sympathetic drive and
increased ergoreceptor stimulation [81]. In line with these considerations, there is
growing evidence that a subset of patients with COPD who present with higher Ú E
/ Ú CO2 and lower PETCO2 develop higher pulmonary arterial pressures on exercise
[81, 82]. If pulmonary hypertension (PH) is not yet apparent at rest, these patients
are at greater risk of developing those abnormalities even without the stress of exer-
cise. There is a trend of COPD patients with severe PH (resting mean mPAP ≥ 40 mm
Hg) to stop exercise with more preserved ventilatory reserves (at least when esti-
mated by the Ú E /MVV ratio) and “exhausted” cardiocirculatory reserves [78].
linical Application of CPET in Combined

C
Lung-Heart Disease
Currently, the most obvious application of CPET in chronic lung disease at risk of
cardiovascular complications relates to the search for physiological abnormalities
suggestive of poor muscle O2 delivery, impaired SV, and increased ventilatory
demands which are deemed “out of proportion” to the severity of underlying respi-
ratory disease, e.g., emphysema burden in COPD and hypoxemia in ILD. It should
be recognized, however, the lack of unequivocal cutoffs to define what can be con-
sidered “out of proportion” in individual patients.
In COPD-heart failure, CPET is valuable to determine if symptomatic patients
are primarily limited by critical mechanical-ventilatory constraints and hypoxemia
(suggesting a greater role for COPD) or, alternatively, exercise is interrupted due to
complaints of severe leg discomfort and preserved mechanical reserves (suggesting
a dominant contribution of heart failure). This might impact on clinical
decision-making vis-à-vis optimization and step-up of COPD or heart failure treat-

ment. CPET results indicating excess exercise ventilation (high Ú E / Ú CO2 , low
PETCO2) when accompanied by hypocapnia and low transfer factor are associated
with severe exertional dyspnea leading to poorer exercise tolerance [43].
Accordingly, it seems advisable that these patients are prioritized to closer follow-
up and early rehabilitation. In fact, high Ú E / Ú CO2 and low PETCO2 emerged as
useful predictors (in association with resting echocardiographic evidences of right
ventricular strain) of poor prognosis in these patients (Fig. 8.21) [42]. In COPD or
ILD patients with suspected or established PH at rest, severe ventilatory ineffi-
ciency, low PETCO2 with positive P(a-ET)CO2, low SpO2, and preserved mechani-
cal reserves at peak exercise provide objective evidence that pulmonary vascular
disease is contributing to patient’s exercise intolerance.
a b
1.0 1.0
100%
0.9 0.9 RVFAC > 45% and
VE/VCO2 NADIR d36 mmHg
0.8 0.8
82%
0.7 0.7
Event-free survival (%)
0.6 RVFAC > 45% 0.6
0.5 0.5
0.4 0.4
0.3
31% RVFAC d 45% 0.3
RVFAC d 45% and
0.2 0.2 25% VE/VCO2 NADIR >36 mmHg
0.1 p = 0.01 (Log-rank) 0.1 p < 0.01 (Log-rank)
p = 0.04 (Breslow) p = 0.02 (Breslow)
0.0 0.0
c d
1.0 1.0
100%
0.9 0.9 RVFAC > 45% and
PETCO2 PEAK >33 mmHg
0.8 84% 0.8
RVFAC > 45% and
0.7 'PETCO2 PEAK-REST d-2 mmHg 0.7
Event-free survival (%)
0.6 0.6
0.5 0.5
0.4 0.4
0.3 0.3
20% RVFAC d 45% and
0.2 0.2
0% PETCO2 PEAK d33 mmHg
0.1 p < 0.01 (Log-rank) RVFAC d 45% and 0.1 p < 0.01 (Log-rank)
p = 0.01 (Breslow) 'PETCO2 PEAK-REST >-2 mmHg p = 0.02 (Breslow)
0.0 0.0
0 100 200 300 400 500 600 700 800 900 0 100 200 300 400 500 600 700 800 900 1000
Time (days) Time (days)
Fig. 8.21 Kaplan-Meier survival curves for (a) resting right ventricular fractional area change
(RVFAC) by echocardiography, (b) RVFAC plus exercise ventilation ( Ú E / Ú CO2 ) ratio at its lowest
point during incremental CPET (nadir), (c) RV FAC plus peak exercise rest differences (Δ) in end-
tidal partial pressure for CO2 (PETCO2), and (d) RVFAC plus PETCO2 at peak exercise. Optimal
thresholds were established by receiver-operating characteristics (ROC) curve analyses.
(Reproduced with permission from the publisher, from: Alencar [42])
Unanswered Questions
We are only beginning to appreciate the potential clinical usefulness of CPET in

combined lung-heart disease. Thus, the unanswered questions largely outnumber
what has been learned in the past decade. Obviously, the individual contribution of
COPD or heart failure to their combination varies markedly between subjects and so
their impact on the mechanisms of exercise intolerance. For instance, we do not know
if dyspnea and exercise intolerance parallel the progression of each disease in the
same fashion. Based on available data from each disease in isolation, this seems
unlikely. In this context, CPET might provide important clues regarding to those at
greater risk of progressing to disabling dyspnea. Despite almost a century of interest
in cardiopulmonary interactions, very little is known of how heart failure modulates
the potential central hemodynamic consequences of COPD (Fig. 8.15). For instance,
are the negative consequences of COPD on RV afterload particularly critical in com-
bined COPD-heart failure? In fact, the combination of a left-shifted septum, disturbed
ventricular interdependence, and low RV stroke volume might dynamically change
the LV pre-load on exercise – with marked deleterious effects on the cardiac output.
It is important to develop milder, submaximal (constant load) tests in uncovering
abnormalities in such severely disabled patients [83–85]. At least in those with
COPD alone, poor ventilatory efficiency and low PETCO2 are also seen during
minimal, unloaded exercise and, occasionally, at rest [86]. Thus, if these variables
also prove useful in these tests, we might not need to expose such frail patients to
the discomfort and risks of progressive exercise. They might also prove helpful to
indicate increased ventilatory drive secondary to high pulmonary venous pressures
in COPD patients with (moderate to severe) diastolic dysfunction, left atrial enlarge-
ment, or atrial fibrillation.
Alone atrial fibrillation, in particular, has been associated with sympathetic over-
excitation leading to high afferent ventilatory stimuli and dyspnea, likely from an
hyper-activated ergoreflex [87]; interestingly, this remained true even when HR is
“controlled” [87]. Does it mean that decreasing HR with atrial fibrillation might not
be sufficient to substantially improve exertional dyspnea in COPD patients, i.e.,
should cardioversion or ablation be used more liberally in these patients? Assuming
that persistent atrial fibrillation may also lead to lung congestion on exertion [88], it
is conceivable that the retrograde transmission of increased left atrial filling pres-
sures is higher in patients with more extensive destruction of the lung (micro)vascu-
lature [89]. This might also apply to heart failure with preserved LVEF where
marked elevations in LV filling pressures on exercise [90] coexist with high Ú E
/ Ú CO2 [91]. If so, COPD patients presenting with the emphysema phenotype might
be particularly sensitive to relatively modest increases in pulmonary venous pres-
sures [89]. It is conceivable that most of these questions could only be satisfactorily
answered by combining CPET with minimally invasive (e.g., arterialized capillary
blood) [92] or non-invasive (exercise echocardiography) [93] techniques in large,
multi-centric studies, i.e., an epi-physiologic approach to interrogate those highly
variable biological phenomena.
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Chapter 9
Physiology of Heart-Lung Interactions
Alicia K. Gerke and Gregory A. Schmidt
Chapter Pearls
1. The effects of heart and lung interactions differ by spontaneous and

mechanical ventilation and depend upon intrathoracic pressure and vol-
ume changes.
2. Hemodynamic changes related to the heart-lung interaction are most often
dominated by right ventricular preload changes. Occasionally, effects on
ventricular afterload, pulmonary vascular resistance, or gas exchange
become important.
3. The interaction between the lungs and the heart is complex and unpredict-
able; the ultimate outcome is affected by volume status, metabolic demand,
mode of ventilation, and underlying chronic heart or lung disease.
The Importance of Heart-Lung Interaction
The goal of the cardiopulmonary system is to supply oxygen and other nutrients to
body tissues while eliminating carbon dioxide, and the heart and lung work closely
together to achieve these ends. Because the heart and lung share volume and pres-
sures within the thorax, each system tends to alter the other, especially when there
is preexisting heart or lung disease, or when challenged by rising demand.
Cardiopulmonary interactions are mediated by changes in pleural pressure (Ppl),
lung volume, and gas exchange, all explored in the sections to follow. The complex-
ity of their interactions is further magnified by comorbidities, such as heart failure,
COPD, interstitial lung disease, and acute respiratory distress syndrome (ARDS),
and by intravascular volume state. Finally, drug therapy, mechanical ventilation, and
A. K. Gerke · G. A. Schmidt (*)

University of Iowa, Department of Internal Medicine, Division of Pulmonary Diseases,
Critical Care, and Occupational Medicine, Iowa City, IA, USA
e-mail: alicia-gerke@uiowa.edu; gregory-a-schmidt@uiowa.edu

150 A. K. Gerke and G. A. Schmidt
Table 9.1 Considerations in Considerations in heart-lung interactions

heart-lung interactions
Intravascular volume
Cardiac function
Lung compliance
Pulmonary vascular resistance
Gas exchange abnormalities (hypoxia, hypercarbia,
acidemia)
Overall oxygen demand
extracorporeal circulatory devices may dramatically impact how the heart and lungs
interact. For the clinician managing patients with heart or lung failure, understand-
ing cardiopulmonary physiology is essential for guiding therapy and avoiding unin-
tended harms. In this chapter, we first focus on the heart-lung interaction in both the
normal physiologic state and with mechanical ventilation and then discuss the com-
plexities of predicting heart-lung interactions in different clinical scenarios
(Table 9.1).
Impact of Respiration on the Circulation
Respiration has cyclical effects on the circulation, as witnessed by respiratory varia-

tion in stroke volume, pulse pressure, and heart rate. These overt circulatory changes
are the consequence of varying right and left ventricular preload and afterload, auto-
nomic output, and ventricular interdependence. In health, most of this variation is
due to the impact of Ppl on right ventricular (RV) preload. In the presence of disease,
however, other factors may predominate.
Cardiovascular effects of changing pleural pressure As described by Guyton,
blood returns to the heart under the influence of the pressure difference between
upstream venous reservoirs (at the mean systemic pressure, not varying significantly
with respiration) and the right atrium [1, 2]. Because the right atrial pressure (Pra) is
directly altered by respiration, instantaneous venous return varies cyclically and this
preload effect represents the largest contributor to normal heart-lung interaction. At
the same time, breathing also affects RV afterload and the left ventricle (both pre-
load and afterload), as well as abdominal pressure; in certain circumstances, these
effects become magnified (Fig. 9.1).
(i) Spontaneous breathing During spontaneous inspiration, the Ppl drops by

roughly 5 cmH2O. Although there are complex regional differences in pleural pres-
sure, especially in the presence of lung disease, a reasonable approximation is that
inspiration causes the juxtacardiac pressure (Pjuxtacardiac) to fall by a similar value. As
a consequence, right atrial transmural pressure (Pra minus Pjuxtacardiac) rises, tending
to transiently augment venous return (Fig. 9.2). Right heart volume increases so
that, through ventricular interdependence, left heart filling is impeded. At the same
time, left ventricular (LV) systolic transmural pressure (systolic LV pressure minus
9 Physiology of Heart-Lung Interactions 151
Ventilation
a b
Pleural pressure: –5 cm H2O Pleural pressure: +5 cm H2O

Spontaneous Inspiration Positive pressure inspiration
• Increase in RV preload • Decrease in RV preload
• Increase in LV afterload • Decrease in LV afterload
• Increase in instantaneous cardiac output • Decrease in instantaneous cardiac output
Fig. 9.1 Hemodynamic effects of inspiration in normal lungs with (a) spontaneous inspiration and
(b) mechanical ventilation (RV = right ventricular, LV = left ventricular)
Fig. 9.2 Increase in right

ventricular inflow at the
tricuspid valve with deep
inspiration in a normal
healthy patient (sweep
speed 25 mm/s)
left ventricular Pjuxtacardiac) rises, increasing LV afterload and tending to transiently

depress LV stroke volume. Overall, the effect of inspiration is to briefly increase
preload to the right heart, raising its stroke volume, while depressing LV ejection.
Expiration reverses these effects, producing the classic respiratory variation in
blood pressure and pulse pressure (a surrogate for LV stroke volume).
(ii) Spontaneous breathing in pathological states Respirophasic variation in

stroke volume is amplified by conditions that cause pleural pressure to abnormally
vary. Even breathing at high tidal volumes intensifies these cardiovascular changes
[3], but they are particularly notable in the presence of lung disease. A common
example is status asthmaticus, in which dramatic swings in pleural pressure produce
pulsus paradoxus, a finding which is not truly paradoxical but, instead, an exagger-
ated manifestation of the normal heart-lung interaction. Similar findings, albeit less
striking, accompany the raised Ppl swings in chronic obstructive pulmonary disease
(COPD) and interstitial lung disease (ILD).
Spontaneous inspiration raises intra-abdominal pressure as the diaphragm
descends, reducing the unstressed volume of the abdominal vasculature, pushing
blood flow towards the thoracic cavity. This acts synergistically with the fall in Pra
to further boost venous return, but is generally very modest in magnitude. Its role is
revealed in pathological states that demonstrate Kussmaul respiration (an inspira-
tory rise in Pra), such as severe RV dysfunction, restrictive cardiomyopathy, con-
strictive pericarditis, or tricuspid stenosis. Abdominal venous congestion and an
inability of the right heart to accommodate increased flow from the abdomen com-
bine so that inspiration causes Pra to rise, despite the fall in Pjuxtacardiac [4, 5].
Inspiration also raises LV afterload as transmural pressure rises [6]. This effect is
normally modest, since the left ventricle is not usually afterload-sensitive, but can
be very detrimental in patients with LV systolic dysfunction. The onset of cardio-
genic pulmonary edema is poorly tolerated as the elevated work of breathing, and
attendant supranormal swings in Ppl combine with reduced lung compliance to seri-
ously compromise cardiac output. The LV afterload effect of spontaneous inspira-
tion may be an important mechanism of weaning failure [7, 8]. Moreover, this could
explain the efficacy of noninvasive ventilation to reduce reintubation risk in patients
extubated following acute respiratory decompensation due to cardiac failure [9].
(iii) Passive ventilation During mechanical ventilation of the passive patient, Ppl rises
in proportion to tidal volume and chest wall compliance, causing Pra also to rise. This
reduces the pressure gradient for venous return; as a result, intrathoracic blood vol-
ume, transmural Pra, and cardiac output fall [6]. Positive end-expiratory pressure
(PEEP) has similar consequences. For these reasons, significant hypotension can
occur upon initiation of mechanical ventilation, especially in the hypovolemic patient,
which can be mitigated by volume loading. Compensatory autonomic reflexes raise
mean systemic pressure, tending to reestablish the pressure gradient, defending car-
diac output [10]. Similarly, the increase in lung volume and lowering of the diaphragm
can augment the venous return to minimize the effect of increased right atrial pressure.
The rise in Ppl due to PEEP and passive ventilation also reduces LV afterload, an
effect that is usually small, but in the setting of LV systolic dysfunction can become
meaningful. Because these patients often operate on the flat portion of the cardiac
function curve (i.e., cardiac output is not sensitive to changes in preload), PEEP may
even increase cardiac output [11]. In addition, increases in PEEP and mean airway
pressures can compress the congested pulmonary venous bed and increase LV end-
diastolic volume so that stroke volume increases on both a preload and afterload basis.
Cardiovascular effects of changing lung volume The pulmonary vasculature bed

normally is characterized by low resistance (and low transpulmonary pressure
gradient) which allows increased blood flow with minimal pressure changes.

Pulmonary vascular resistance (PVR) can be viewed as a U-shape relationship with
lung volumes, with higher resistance at very low or very high lung volumes and
lowest resistance around functional residual capacity (FRC). At markedly low vol-
umes below FRC (as can be seen with forced expiration or in ARDS), the larger
extra-alveolar vessels collapse which increases PVR. With large tidal volumes, the
hyperinflation seen in obstructive lung disease, or tidal overdistention of the “baby
lung” of ARDS, pulmonary vascular resistance rises due to increased alveolar pres-
sure and compression of the intra-alveolar vasculature [12–14]. Due to the effect of
gravity, this compression varies between dependent and nondependent lung zones
and is affected by intravascular volume status [15]. Large tidal volumes (with zero
PEEP), causing large variations in Ppl and alveolar pressure, have been shown to
produce acute cor pulmonale in healthy animals [16]. Perhaps not coincidentally,
the era of low tidal volume ventilation for patients with ARDS has led to a substan-
tial reduction in the incidence of clinical cor pulmonale [17].
In contrast to the LV, the RV is more sensitive to changing afterload. Acutely, the
RV responds to increased afterload through homeometric adaptation in which con-
tractility is augmented to match afterload (the Anrep effect). When the limits of this
mechanism are exceeded, the RV dilates to preserve flow (heterometric adaptation
or Starling mechanism), but at the cost of venous congestion. The lung volume
effect on PVR takes on special significance when the RV is in a compensated, but
precarious, state. In these settings, the added impact of excessive (or even normal
tidal) lung expansion can precipitate RV decompensation [18, 19].
Recent data on the effect of PEEP in patients with RV dysfunction due to ARDS
show the relevance of this effect. Increasing PEEP (while limiting tidal volume and
plateau airway pressure) caused cardiac output to fall, a finding that was not surpris-
ing [20, 21]. However, this was not the result of reduced preload since end-diastolic
volume rose instead of falling (Table 9.2). Rather, the fall in cardiac output was
attributed to increased RV afterload, as revealed by a rise in end-systolic RV vol-
ume. An additional complexity is that volume state can also determine which effect
(preload vs. afterload) will predominate, and increasing PEEP to a preload-depleted
Table 9.2 Comparative effects of increased positive end-expiratory pressure (PEEP) in

mechanically ventilated patients with acute respiratory distress syndrome (ARDS) versus
mechanical ventilation in normal lungs showing that afterload effects predominate in ARDS
compared to preload effects in the normal lung
Hemodynamic parameter ARDS + PEEP Normal lung + PEEP
Pulmonary vascular resistance Increases Increases
RV end-diastolic area Increases Decreases
Transmural right atrial pressure Increases Decreases
End-diastolic RV/LV area ratio Increases Unchanged
Adapted from Fougeres et al. [20]
heart may further diminish cardiac output [22]. These results have been documented
in patients with ARDS, but likely pertain also to those ventilated with acute-on-
chronic pulmonary hypertension [23].
Gas exchange and heart-lung interaction Blood gas tensions have important cir-
culatory consequences. In addition, overall body gas exchange, such as the total
body oxygen consumption, can challenge hemodynamic homeostasis, especially in
the presence of disease.
(i) Blood gas tensions Blood values of partial pressure of oxygen (PO2), carbon
dioxide (PCO2) and pH modulate vascular tone, myocardial function, and the auto-
nomic nervous system. Acute and chronic lung disease can induce hypoxemia,
hypercarbia, and acidemia, altering PVR and contributing to pulmonary heart dys-
function [24]. Hypoxia impairs contractility of the heart and induces hypoxic
pulmonary vasoconstriction (HPV), especially at partial pressures less than

60 mmHg [25]. Hypoxic vasoconstriction improves ventilation/perfusion (VQ)
matching by reducing blood flow to poorly ventilated regions, but also raises overall
PVR. However, the response to hypoxia and HPV is not uniform across individuals,
thereby patient responses to hypoxia are difficult to predict [26, 27]. Similarly,
hypercarbia and acidemia cause increased PVR and can induce increased RV after-
load, RV dilation, and subsequent cor pulmonale [21].
These gas exchange effects can produce a spiral of decompensation. For exam-
ple, worsening pulmonary dead space can raise PCO2, provoking RV deterioration
which, in turn, compromises cardiac output, lowering venous PO2, amplifying
HPV, causing more RV dysfunction, and culminating in circulatory failure. For
mechanically ventilated patients, gas exchange and mechanical effects can be inter-
twined in complex ways, making it hard to predict the consequences of changing
ventilator settings. For example, if a patient ventilated for severe ILD becomes
hypoxemic, the impact of raising PEEP is complex. If the dominant effect of PEEP
is to recruit lung and raise PO2, the circulatory impact may be salutary. On the other
hand, if PEEP raises dead space fraction, impedes RV filling, or presents an over-
whelming afterload challenge to the RV, the patient may become unstable. Even the
amount of PEEP transmitted to the pleural space is highly variable, ranging from
more than 50% to less than 25% [28], and may be distributed quite heterogeneously
[29]. These effects may not be apparent immediately, but may play out over many
minutes, making it very difficult for the clinician to disentangle the many potential
threads of decompensation.
(ii) Overall oxygen consumption and carbon dioxide production The total body
demand for gas exchange will rise with exercise, fever, seizure, and many other
causes, testing the limits of both respiration and circulation. Three clinical scenarios
are particularly germane. The first is seen in patients with severe airflow obstruc-
tion, in whom increasing minute ventilation causes dynamic hyperinflation, raising
the juxtacardiac and alveolar pressures. At times, this can produce shock (largely
due to impaired right heart filling), especially in the setting of mechanical or bag-
mask ventilation. A second example is that of cardiogenic pulmonary edema, in

which heart failure leads to reduced lung compliance, increased airway resistance,
and failing gas exchange, precipitating respiratory failure on top of circulatory
failure. A third illustration is of weaning failure in patients with circulatory compro-
mise: the work of spontaneous breathing for many patients with lung disease is
severalfold that of normal individuals [30], overloading the circulation and precipi-
tating weaning failure [31].
xample Clinical Scenarios: Why Are Heart-Lung

E
Interactions Relevant?
1. Pulmonary function alterations in heart disease Just as lung disease can

cause alterations in the vasculature and cardiac performance due to hyperinflation
and dynamic air trapping, disease of the vasculature and heart has been shown to
conversely affect lung function. Hypertrophy and dilation of the muscular and elas-
tic arteries such as those seen in idiopathic pulmonary hypertension have been asso-
ciated with peripheral airway obstruction and increased residual volume, in addition
to the expected decrease in diffusing capacity [32, 33]. These obstructive changes
are presumably due to the close proximity of the vasculature to the airway, but other
causes related to the effects of vasoconstrictors on bronchial epithelium have been
postulated. More remote studies have shown mild restrictive ventilatory defects in
patients with precapillary pulmonary hypertension with decrease total lung capacity
and vital capacity [34, 35]. Similarly, patients with left heart failure and an elevated
wedge pressure have restrictive defects on pulmonary function testing with reduced
vital capacity and total lung capacity [36]. Obstructive defects are less common, but
can occur with bronchial wall congestion in patients with decompensated heart fail-
ure. Pulmonary function abnormalities in patients with chronic heart failure have
been associated with poorer survival [37, 38].
2. Nocturnal noninvasive ventilation: heart-lung consequences In patients with

obstructive sleep apnea, high levels of negative inspiratory force against a closed
glottis lead to high amounts of venous return. A shift in the interventricular septum
in response to this volume leads to a reduction in LV compliance and stroke volume
with increased LV afterload. Nighttime hypoventilation and chronic hypoxemia
lead to HPV with elevated sympathetic activation related to frequent arousals and
gas exchange abnormalities. These factors contribute to high pulmonary pressures,
increased RV afterload, and eventual cor pulmonale in a proportion of patients,
particularly those with concurrent COPD or obesity. Positive pressure decreases the
work of the heart and oxygen consumption by opening the airways and alleviating
severe negative swings of inspiratory effort. Further, positive pressure can decrease
pulmonary vascular resistance by raising FRC as described earlier, improving
hemodynamics in these patients.
In chronic heart failure patients, obstructive sleep apnea is common and associ-
ated with poor outcomes [39]. Use of noninvasive ventilation in heart failure patients
diminishes intrathoracic swings in pressure, lowers LV afterload, and improves car-
diovascular performance. Positive pressure maintains alveolar patency, improving
oxygenation, and shifts fluid from the lung interstitium into the pulmonary vascula-
ture [40]. There may also be humoral effects of CPAP on the heart, as positive pres-
sure ventilation induces pressure on the heart and diminishes atrial stretch with
consequent improved blood flow. Likely because of these mechanisms, use of CPAP
has been associated with decreased atrial peptides, decreased sympathetic catechol-
amines, improved LV contractility, improved symptoms, and increased survival in
patients with congestive heart failure [41–46]. However, these benefits of NIV may
not translate to patients with low ejection fraction with prominent central sleep
apnea, as treatment with adaptive servo-ventilation did not improve outcome in
these patients; rather this group of patients appears to have higher all-cause and
cardiovascular mortality and no improvement in quality of life when treated with
adaptive servo-ventilation [47]. It is unclear whether varying effects of nocturnal
ventilation are due to disruption of the compensatory mechanisms for heart failure
or a reflection of the ventilator settings or pressures trialed.
3. Hypotension on initiating mechanical ventilation There are many issues to
consider upon initiating mechanical ventilation in the critically ill patient, including
the patient’s volume status, induction medications, and underlying cardiac function.
Upon intubation itself, hypotension can be marked if a patient is hypovolemic, in
combination with medications that diminish mean systemic pressure and sympa-
thetic drive, synergistically reducing venous return. Since most patients are thera-
peutically paralyzed at the time of intubation, ventilation raises Pjuxtacardiac, impeding
RV filling. This effect can be even greater when PEEP or recruitment maneuvers are
added [48]. In patients with COPD or asthma, close attention to minute volume and
best PEEP are important to limit dynamic hyperinflation and unnecessary cardiac
compression, which could produce shock. At the same time, mechanical ventilation
can lessen the work of breathing and sympathetic tone, as well as ameliorating
hypoxemia or respiratory acidosis. These beneficial effects could outweigh any
negative impact on cardiac preload or afterload.
4. Predicting fluid responsiveness The interaction of the lungs and heart allows
prediction of fluid responsiveness in critically ill patients by examining the impact
of positive pressure ventilation on the circulation. For example, respiratory varia-
tions in pulse pressure, stroke volume, superior and inferior vena cava diameters,
LV outflow tract velocity time integral, and other cardiovascular parameters predict
accurately the ability of a fluid bolus to raise cardiac output [49–51]. Significant
respiratory change in these parameters indicates a preload-responsive state that
might hemodynamically benefit from volume resuscitation. These predictors rely
on the RV preload effect and can be confounded in the presence of significant RV
systolic dysfunction (in which case respiratory variation may be due to RV afterload
changes, rather than preload reserve) or abdominal hypertension [52, 53]. Especially
important is the input signal: if tidal volume is insufficient (<8 mL/kg ideal body
weight), so too will be the cardiovascular impact, potentially causing a false-
negative assessment [7, 54]. Finally, patients must be passively ventilated – active
effort makes these predictors unreliable [55, 56]. These functional assessments are
attractive, as traditional static measures of volume status such as central venous
pressure, pulmonary artery occlusion pressure, or ventricular end-diastolic volumes
do not correlate well with fluid responsiveness [57, 58]. The accuracy of functional
hemodynamic monitoring may be limited to specific patient subgroups in the clini-
cal setting [59, 60].
Conclusions
Heart-lung interactions are complex, however, and multiple conflicting interactions

can occur simultaneously, making it more difficult to predict actual outcome of the
combined forces in any one individual patient. Many of these above-described
effects differ based on volume status, the underlying disease process, medications,
and baseline cardiac function. In ill patients with high work of breathing necessitat-
ing increased oxygen delivery and cardiac output, the intervention of mechanical
ventilation can improve some of these parameters by decreasing demand and energy
consumption, which may predominate over the potential negative effects on the
cardiopulmonary circulation. Although this concept is clearly exemplified by the
critically ill patient, this may also contribute to the mechanism by which noninva-
sive ventilatory interventions improve cardiopulmonary performance in patients
with obstructive sleep apnea or other sleep-disordered breathing on an outpatient
basis. It is important for the clinician to understand the normal cardiopulmonary
interaction, as both diagnostic and therapeutic strategies depend on how the homeo-
stasis is altered in the disease state.
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Chapter 10
Medication Safety in Chronic Lung Disease
with Cardiac Comorbidity
Roy Pleasants
Clinical Pearls
1. Although not often considered by clinicians, significant alterations in the
pharmacokinetics of inhaled agents because of renal or hepatic disease or
interacting drugs may lead to higher systemic exposure and should be con-
sidered in patients, particularly those at high risk of adverse effects.
2. At recommended doses, the CV risks of inhaled long-acting β2-agonists
and antimuscarinics as well as chronic azithromycin in COPD appear
to be low.
3. Corticosteroids, particularly systemic therapies, can directly affect heart
disease through worsening heart failure and also augmentation of cardiac
effects of β2-agonists leading to increased adverse effects such as
tachyarrhythmias.
4. Cardioselective β-blockers provide significant clinical and mortality ben-
efits in COPD and are unlikely to worsen lung function.
Introduction
In 2015, CVD and COPD together accounted for nearly 780,000 deaths in the
United States [1] and 12 million worldwide [2]; likely many of these patients had
both types of diseases. COPD-related mortality is common, and in one US state
COPD was listed as the primary or secondary cause of death among 1 in 6 adults
[3]. Because drug therapies play such a vital role in managing chronic obstructive
R. Pleasants (*)
Division of Pulmonary Diseases and Critical Care Medicine,
University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
Pulmonary Department, Durham VA Medical Center, Durham, NC, USA
e-mail: roy.pleasants@unchealth.unc.edu

162 R. Pleasants
pulmonary and cardiac diseases, ensuring optimal medication efficacy and safety
has significant implications at many levels. Drug regimens are often complex in the
typical elderly patient with pulmonary and cardiac diseases because of polyphar-
macy, other diseases, reliance upon inhalational therapies, and alterations in drug
disposition. As the diseases progress, drug regimens change and often become more
challenging, further increasing the risk of adverse drug effects. The elderly patient
with lung and heart disease is at particularly high risk of adverse effects.
The Institute of Medicine report “To Err is Human” highlights the tremendous bur-
den of adverse drug effects, which are responsible for many deaths each year [4].
Adverse drug effects can be directly from the individual agent, as the result of an inter-
action between medications, and/or as a consequence of the underlying pathophysiol-
ogy. Further, some would define nonadherence as a side effect of medications when
efficacy is not achieved. Whereas oral therapies are the first-line maintenance treat-
ments for CVD, inhalational therapies constitute the bulk of medications for
COPD. Both CV side effects of drugs used for COPD treatment and respiratory-related
side effects of cardiac drugs are important factors that can influence patient outcomes.
To best minimize risks associated with drug therapies, an understanding of the pharma-
cokinetics and pharmacodynamics is necessary. The purpose of this chapter is to dis-
cuss clinical pharmacology, drug interactions, and adverse effects of medications used
in COPD and heart disease that can affect the pulmonary and/or cardiovascular systems.
Drug Disposition in the COPD Patient with Heart Disease
For patients with concurrent COPD and CV diseases, the key factors influencing drug
disposition are 1) the unique pharmacokinetics of drugs administered by the aerosol
route 2) the effect of impaired cardiac function on drug pharmacokinetics, and 3) age-
related changes in drug disposition. Whereas there is substantial evidence of altered
pharmacokinetics with heart failure [5, 6], there is little such evidence that COPD can
directly alter drug disposition. Although inhaled medications are targeted delivery, the
drug primarily reaches the systemic circulation through the pulmonary vasculature
and to a lesser extent gastrointestinal (GI) absorption of swallowed drug; thus, clini-
cally relevant extrapulmonary effects may occur [7]. Polypharmacy and aging also
affect drug disposition, but are not unique to patients with COPD and/or CVD.
Disposition of Drugs Administered by the Systemic Route
After a drug is ingested orally, it is typically absorbed in the upper intestine and then
enters the enterohepatic circulation where liver metabolism can occur; it then enters
the systemic circulation to reach target tissues and receptors. Although dissolution
of solid dosage forms occurs in the stomach, the vast majority of drugs are primarily
absorbed in the jejunum [8]. If a significant portion of the drug is removed when
initially delivered to the liver, it is considered to have a high first-pass effect and
10 Medication Safety in Chronic Lung Disease with Cardiac Comorbidity 163
lower systemic bioavailability. Sublingual, parenteral, inhalational, and to some

extent rectal administration of drugs bypass the initial hepatic first-pass metabolism.
In various organs including the liver, lungs, and intestine, cytochrome (CYP) P450
metabolizes drugs, largely to increase the water solubility of lipophilic compounds by
oxidative metabolism (Phase I metabolism) to facilitate renal or GI elimination [9].
Some parent drugs and metabolites undergo Phase I and Phase II conjugative metabo-
lism (e.g., UDP-glucuronosyltransferases and sulfotransferases). The nomenclature of
CYP enzymes is based on their amino acid sequence where the number represents the
family based on amino acid identity (CYP2), a letter represents the subfamily (CYP2D),
and the last number represents the specific isoenzyme [10, 11]. In humans, among ~30
CYP isoforms, less than ten are responsible for the metabolism of the majority of
drugs – CYP1, 2, and 3 families [12]. Overall, CYP3A4 and CYP2D6 are the most
important drug-metabolizing enzymes, whereas a smaller number of drugs metabo-
lized are by CYP2C9, CYP2C19, CYP1A2, and CYP2E1 [10–12].
Pharmacogenomics (or pharmacogenetics) is the study of the effects of genetic
differences on a human’s response to a drug or on disposition [11, 14]. Genetic
makeup determines inherent pharmacokinetics and may affect interperson differ-
ences in drug absorption, distribution, metabolism, and excretion as well as drug
responses. Pharmacogenomics is relevant to drug metabolism and response in the
COPD patient with comorbid CVD, mostly from the perspective of cardiac-related
agents, but also to some extent for pulmonary medications. Some of these differ-
ences can be explained by genetic variations in the presence and/or function of
Phase I or Phase II drug-metabolizing enzymes and/or membrane transport proteins
(e.g., P-glycoprotein [P-gp]) and drug targets (e.g., adrenergic receptors).
Drug metabolism via CYP450 enzymes exhibits significant genetic polymorphism
for isoenzymes such as CYP2D6, whereas CYP3A4 polymorphisms either are rare or
lack phenotypic effect and are thus unable to explain a sizeable fraction of heritable
variation [14]. The polymorphic enzymes CYP2C9, CYP2C19, and CYP2D6 mediate
40% of CYP-mediated drug metabolism, which can make drug dosing problematic
because of genetic differences for these isoenzymes. In general, there are four pheno-
types of metabolism with these isoenzymes: (1) poor metabolizers that lack the func-
tional enzyme; (2) intermediary metabolizers who are heterozygous for one deficient
allele or carry two alleles that have reduced activity; (3) extensive metabolizers, who
have two normal alleles; and (4) ultrarapid metabolizers, who have multiple gene copies
[13]. Genetic polymorphisms relevant to pulmonary and cardiac diseases can greatly
affect the activity of some of the CYP450 enzymes, e.g., CYP2C19 and CYP2D6, such
as occurs with the metabolism of formoterol, isoniazid, warfarin, and clopidogrel.
Also important in drug disposition are efflux membrane transporters, such as P-gp
and organic anion transporting polypeptide (OATP) [15]. Found in the liver, small and
large intestine, and kidney among other tissues, P-gp serves a protective role by influ-
encing the transmembrane diffusion of drugs thus limiting tissue distribution (e.g.,
central nervous system), reducing absorption (intestine), or increasing excretion (kid-
ney). P-gp present on the luminal surface of enterocytes can regulate the intestinal
absorption of some drugs and can therefore promote their excretion through the GI
tract. It is also present on the tubular side of the renal epithelium and the biliary side
of hepatocytes. Drugs which induce P-gp, such as rifampin, can reduce the
164 R. Pleasants
bioavailability of drugs by increasing the transport into the intestinal lumen, where it
is excreted. Inhibitors of P-gp, such as verapamil or clarithromycin, increase the bio-
availability of susceptible drugs by increasing transport into the systemic circulation.
Enterocytes in the stomach and intestine, like hepatocytes, also express the major
drug-metabolizing enzyme CYP3A4 [9]. The symbiosis between drug efflux by
P-gp and metabolism by CYP3A4 via repeated cycles of absorption and efflux can
have a significant effect on drug disposition [15]. As with alterations in metabolism
by CYP isoenzymes, drug effects on P-gp might have a greater impact on agents
with a narrow therapeutic index.
Beyond drug metabolism, other factors that can affect drug disposition include
absorption, distribution, and renal excretion. For inhaled medications, body size
may influence systemic exposure, assuming each patient inhales the same amount
of drug, a patient with a low body mass index (BMI) can have higher lung and sys-
temic exposure than a larger patient. The typical emphysema patient tends to have a
low body mass index. For example, inhaled fluticasone furoate was associated with
a higher area under the serum concentration curve (AUC) in Asians compared with
White/Caucasians, in part due to differences in body size [16, 17].
Disposition of Drugs Administered by the Inhalational Route
Nearly every COPD patient will be receiving one or more inhaled medications due to
the effectiveness and relative safety of therapies administered by this route. Figure 10.1
shows the initial fate of an aerosolized medication after inhalation, where some por-
tion reaches the airways and the remainder is deposited into the oropharynx where it
is swallowed [18]. Where the drug is delivered is highly dependent on the inhalational
device, drug formulation, and patient factors such as inhalational technique and degree
of airflow obstruction. Large aerosol particles tend to deposit by impaction in the
oropharynx (>5 um), whereas smaller particles (1–5 um) are deposited by either
impaction or gravitational sedimentation in the conducting airways (bronchi, bronchi-
oles) and alveolar regions (terminal bronchioles, alveoli) [7, 19]. Smaller aerosol par-
ticles tend to deposit more distally in the lungs and thus can reach the alveoli. The
smallest particles (<0.5–1 um) tend to remain suspended via Brownian movement and
either rapidly diffuse after impacting onto the epithelium or are exhaled. Drug clear-
ance from the lung occurs through a combination of mucociliary functions, exhalation
of aerosol particles, and diffusion into the systemic circulation [7, 19]. Although lipo-
philicity promotes binding to tissues, it also makes the drug more likely to be removed
by mucociliary clearance [19]. Once the drug deposits on the airway surfaces, mole-
cules can diffuse across cell membranes to reach receptor sites. Target receptors of
drugs include those in the epithelium, vasculature, airway smooth muscle, inflamma-
tory cells, and mucus-producing glands. Depending on the lipophilicity and other
physiochemical characteristics of the drug, molecules reach the receptors and exert
pharmacological effects [7, 19].
Typically, inhaled drugs for obstructive lung diseases are lipophilic as to promote
activity in the lungs including exerting a prolonged effect, while this characteristic
slows the transition of a drug into the systemic circulation [7]. For most inhaled
Deposition in lung
(10-60%)
Absorption
Swallowing ry
ocilia
(40-90%) Muc lator
esca Macrophage
clearance
Absorbition
from gut
CV/Renal
Infections Hypertension
Muscle Eyes
Bone CNS Cataracts
Myopathies Adrenal
Skin Metabolic Glaucoma
Osteoporosis
aseptic necrosis HPA Insufficiency
Hyperglycemia Neuropsychiatric
of femur Skin weight gain disorders
First-pass Systemic thinning Fluid retention

Cushingoid appearance
inactivation side effects
Fig. 10.1 Disposition of inhaled drug therapies Matera et al. [18])
medications, it is the parent drug that exerts the pharmacological effects, whereas
for some ICS, the parent drug is inactive and the metabolite exerts the principal
pharmacological effects.
The β2- and corticosteroid receptors are distributed throughout the small, medium,
and large airways, whereas, although not exclusively, muscarinic receptors are in the
medium and large airways [19, 21]. Endogenous substances that interact with these
receptors include norepinephrine, epinephrine, acetylcholine, and cortisol among oth-
ers. Drug therapies for COPD mimic or antagonize the processes affected by these
endogenous substances. Not all receptors have to be occupied to exert clinically rele-
vant pharmacological effects nor does a receptor have to remain occupied by the drug
for its function to continue to be altered – analogously, there is the pharmacokinetic
half-life and there is the pharmacodynamic half-life; the latter is often longer.
Drug metabolism and membrane transporters affect the activity and disposition of
drugs in the airways [7, 20]. Excluding what portion is expectorated, drug deposited
into the lung may undergo enzyme metabolism in the mucus or lung tissue by CYP450
isoenzymes and be eliminated by active transport or passive diffusion across mem-
branes to reach the pulmonary vascular bed [7, 20]. In the lungs, including in Type I
cells, several CYP450 isoforms are expressed as well as other biotransformation
enzymes such as esterases, sulfotransferases, and glutathione S-transferases [22].
CYP3A5 and CYP1A1 (the latter inducible by tobacco smoking) appear to be the most
common CYP450 enzymes in the lungs. The most abundant liver CYP450 enzyme,
CYP3A4, is expressed to a lower degree in pulmonary tissue. CYP3A5 is responsible
166 R. Pleasants
for most CYP3A-related metabolism in the lungs [7]. There are differences between
CYP3A4 and CYP3A5, for example, the latter does not appear to metabolize erythro-
mycin, quinidine, or 17 α-ethinyl estradiol at significant rates [23]. As occurs in other
tissues such as the liver, intestines, and kidney, efflux transporters such as P-gp may
also affect drug disposition in the lungs. The drug-metabolizing capacity of the lungs is
substantially lower than that of the liver. For most inhaled medications in COPD, the
lung is usually not the major contributor to systemic drug clearance, except indirectly
through diffusion of drug into the blood circulation.
As shown in Fig. 10.2, beclomethasone dipropionate, the first marketed inhaled
corticosteroid (ICS) in the United States, is extensively metabolized in the airways
[24]. Beclomethasone dipropionate is a prodrug that is converted to the active
metabolite, beclomethasone monopropionate, by esterases in the respiratory tract
and is further metabolized by CYP3A5 to less active metabolites in the lungs and
ultimately the liver. Although esterases are also present in the bloodstream, they
contribute little to the overall metabolism of BDP [24]. With the exception of the
ICS including ciclesonide, other current inhaled medications do not undergo sub-
stantial metabolism in the respiratory tract [25].
For inhaled medications, the principal route where the drug reaches the systemic
circulation is from the lungs, rather than absorption from the GI tract [7, 20]. Inhaled
drug that reaches the systemic circulation does not undergo initial hepatic first-pass
metabolism, but eventually will reach the liver and may undergo metabolism,
although some inhaled drugs, like tiotropium [26] and glycopyrrolate [27], rely
more on renal clearance. Diffusion of drug from the lungs into the systemic circula-
tion can occur quite rapidly, for many inhaled drugs in a matter of minutes, although
for some it takes longer to achieve peak blood levels.
Similar to oral therapies, inhaled drug that is swallowed is exposed to metabo-
lism and transport in enterocytes and subsequently reaches the enterohepatic circu-
lation for further metabolism by the liver microsomes [20]. In some drugs, like
albuterol, that have discernible oral absorption, there can be two peak blood levels,
Beclomethasone dipropionate
(PRO-DRUG)
Esterases in respiratory CYP3a5 (and to a lesser

tract extent 3A4) in respiratory tract
6β-OH-BDP
Beclomethasone 17- Delta superscript6 –OH-BDP I (inactive
monopropionate metabolite)
(ACTIVE METABOLITE)
and
Beclomethasone21-
monopropionate 6β-OH-BDP
(INACTIVE METABOLITE) Delta superscript6 –OH-BDP
(Inactive metabolite)
Fig. 10.2 Metabolic pathways of beclomethasone dipropionate (BDP) in the respiratory tract
(Roberts [24])
one shortly after inhalation and the second delayed reflecting oral absorption [28].
The extent of absorption of inhaled bronchodilators such as albuterol and salmeterol
that reach the GI tract is usually less than 50%, whereas for ICS, systemic bioavail-
ability from the GI tract is quite low because of the significant first-pass effect.
Effect of COPD and Heart Disease on Drug Disposition
In contrast to CHF, there is little evidence that COPD directly alters drug disposition.
One study found lower plasma concentrations of fluticasone and budesonide in COPD
than in healthy volunteers [29], whereas vilanterol showed essentially no difference
[30]. Lower blood levels of nebulized revefenacin were found in COPD than healthy
volunteers [31]. Whether this is a function of greater systemic clearance or because of
changes in the lungs related to COPD is unknown. Studies have also shown that smok-
ing inhibits tight junctions in the lung resulting in faster drug absorption through the
airway epithelia into the systemic circulation; therefore, it is possible that current
smokers may have increased systemic exposure to drugs than nonsmokers; however,
this has not been well-studied [32], and this was not seen with vilanterol [30]. Smoking
can also induce metabolism by CYP1A1 [33], although it is a relatively uncommon
source for drug metabolism. There is also some evidence that hypoxia related to pul-
monary and/or heart disease may affect drug disposition [34].
It is well documented that CHF can alter the pharmacokinetics of various sys-
temic medications, largely due to decreased blood flow to major organs, thus poten-
tially affecting drug absorption, metabolism, distribution, and excretion [5, 6]. The
best example of altered oral absorption related to CHF is that of the loop diuretic,
furosemide, where due to poor blood flow to the GI tract and subsequent engorge-
ment, the already poor GI absorption is further impaired [5, 6]. This can be addressed
by increasing the oral dose of furosemide, administering intravenously, or switching
to a loop diuretic that is less affected such as torsemide.
CHF can affect drug metabolism in the liver by alterations in blood flow [5, 6].
Metabolized drugs can be classified by whether their hepatic clearance is enzyme-
limited (extraction ratio <0.3) or blood flow-limited (extraction ratio >0.7). High
extraction ratio drugs are dependent on blood flow to the liver, whereas low extrac-
tion ratio drugs are primarily dependent on the intrinsic metabolic capability of the
liver (affected by cirrhosis or hepatitis) [35]. If the drug is metabolized mainly in the
liver, a decrease in metabolic activity as a result of hepatic impairment leads to an
increase in the AUC of an orally administered drug. Therefore, CHF is more likely
to alter metabolism of a high extraction ratio drug. All ICS including beclometha-
sone, budesonide, and fluticasone propionate and furoate are high extraction ratio
drugs [25], where systemic exposure from oral absorption could be increased in
patients with heart failure; however, this has not been studied. Theophylline’s metab-
olism can be substantially affected by heart failure as well as liver impairment [36].
The pharmacokinetics of medications are not always predictable or stable in
CHF, particularly as it waxes and wanes; but the net effect of alterations in drug
168 R. Pleasants
distribution and clearance is that plasma concentrations are usually greater than in
healthy persons [5]. If metabolism of a drug is impaired, prolongation of the elimi-
nation half-life of that agent leads to higher blood concentrations and delay in
reaching steady state; therefore, dosing adjustments and subsequent monitoring of
adverse effects should consider this. When possible, pharmacodynamic measures
such as blood chemistries used for some anticoagulants or serum drug concentration
measurements can be helpful. Theophylline is such an example, but probably should
be avoided in heart failure patients.
Pharmacokinetics of Drug Therapies Used to Treat COPD
Corticosteroids
Systemic corticosteroids Systemic corticosteroids are typically reserved for acute

worsening of COPD using 5–14-day courses [37], whereas a small portion of
patients will be prednisone-dependent. In recent years, doses of prednisone 40 mg
for 5 days are being used increasingly for exacerbations in noncritically ill patients
[38]; notably doses of methylprednisolone 60 mg IV every 6 hours have been used
in the not too distant past. The oral corticosteroids, prednisone, prednisolone, dexa-
methasone, and methylprednisolone, are well absorbed from the GI tract [39]. Food,
nor does the P-gp and CYP3A4 inhibitor grapefruit juice, appear to significantly
affect absorption. The serum and biological half-lives of corticosteroids can differ
significantly as the on-going effects continue after the drug is no longer present. The
typical onset of action of systemic steroids in the lungs occurs in a matter of a few
hours, initially upregulating β2-receptors as well as beginning to exert anti-
inflammatory effects [39]. The half-life of dexamethasone is significantly greater
than others; all are extensively distributed throughout the body and rely upon hepatic
clearance for removal. Prednisone is a prodrug where metabolism to the active moi-
ety, prednisolone, is necessary to be pharmacologically active [39]. Even in the
presence of hepatic impairment, the conversion of prednisone to prednisolone is
still largely complete; however, higher serum levels of prednisolone may occur [40].
Intravenous methylprednisolone sodium succinate and dexamethasone sodium
phosphate are also prodrugs that are rapidly converted by hydrolysis to
methylprednisolone and dexamethasone in the bloodstream and tissues.

Corticosteroids are extensively metabolized by CYP3A4 in the liver microsomes,
making them subject to a number of pharmacokinetic drug interactions [39].
ICS ICS are used as a maintenance therapy for COPD in combination with long-
acting β2-agonist (LABA). High doses of nebulized budesonide alone can be used
in the treatment of exacerbations [37], and although not studied specifically in
patients with concurrent COPD and CHF, inhaled budesonide is likely to cause less
systemic effects than oral or parenteral corticosteroids [41]. The oral bioavailability
of ICS are generally low, ranging from <1% for fluticasone propionate to ~25% for
beclomethasone due to a significant hepatic first-pass effect [25]. P-gp may play a
greater role in the gut for ICS than systemic corticosteroids [42]. The elimination
half-life after inhalation can differ for ICS than when administered systemically. For
example, the half-life for fluticasone propionate is ~8 hours after intravenous admin-
istration, but increases to ~14 hours after inhalation [25]. The intracellular esterifica-
tion of budesonide and the ciclesonide active metabolite (and to some extent
beclomethasone dipropionate) increases the retention time of these drugs in the air-
ways and thereby prolongs their durations of action [25]. The free parent compound
becomes available when these esterified forms are slowly hydrolyzed back to their
active form and this mechanism contributes to the prolonged effect duration.
All ICS are substrates to metabolizing enzymes present in the lungs, liver, and
intestine [25]. High first-pass metabolism by CYP3A4 occurs in the liver and conse-
quently negligible oral bioavailability occurs with fluticasone furoate, fluticasone
propionate, mometasone furoate, and ciclesonide, whereas modestly greater oral bio-
availability is found for budesonide (10%) and beclomethasone dipropionate (~25%)
[25]. In contrast, inhaled drug that reaches the systemic circulation from the lungs
does not undergo first-pass metabolism before it reaches other sites in the body. For
BDP, 97% is converted in the lung to the more potent beclomethasone monopropio-
nate (BMP). CYP3A4 and CYP3A5 (predominant in the lungs) metabolize BMP at
similar overall rates, although the former is less evident in the lung [24]. For cicle-
sonide, the conversion rate to its active metabolite in the lung is less complete [25,
43]. Inhaled budesonide is also metabolized by CYP3A5 isoenzymes in the lungs
and liver. Figure 10.1 shows multiple potential systemic adverse effects of ICS.
Bronchodilators
Inhaled β2-Agonists In the United States, β2-agonists are primarily given via
inhalation, although oral agents are occasionally used, whereas in some other coun-
tries [44], the oral route is used more often. The onset and duration of action varies
among the inhaled β2-agonists largely due to differences in tissue penetration and
interactions with receptors and exo-receptors [21]. Current β2-agonists undergo
varying degrees of metabolism in the liver, although dosage adjustments are not
normally recommended in the presence of hepatic impairment as the doses are rela-
tively small when administered via the inhalational route [21].
Albuterol, one of the most frequently used inhaled medications used for the treat-
ment of COPD, is a racemic mixture of R- and S-enantiomers. As is the case with
epinephrine, the pharmacological effects are due to the R-isomer whose affinity for
the β-adrenergic receptor is a hundredfold greater than the S-isomer [45]. In con-
trast, olodaterol and vilanterol are single enantiomer products that exert full agonist
activity [30, 46]. For these enantiomers, the molecule appears as chiral mirror
images that are nonsuperimposable (similar to right- and left-hand gloves). These
170 R. Pleasants
configurations, levo (R) and dextra (S) enantiomers, rotate light in different direc-
tions and can be handled differently in the body.
Pharmacokinetic disposition differs between albuterol and levalbuterol [47].
Inhaled albuterol that is swallowed is metabolized through hepatic enzymes and
through sulfotransferase enzymes (SULTIA3) present in the GI tract to albuterol
4′-O-sulfate. Metabolic products and unchanged drug are excreted through urine.
Stereoselective metabolism of both the R- and S-enantiomers occurs where sulfo-
transferases work more effectively on the former. The bioavailability of the S-isomer
is significantly greater than the R-enantiomer, particularly at high doses, resulting in
higher S- than R-salbutamol plasma concentrations. The S-enantiomer is less phar-
macologically active, although it has been suggested it is more likely to contribute
to adverse effects. However, comparative study has found no difference in CV
effects between albuterol and levalbuterol in COPD [48].
Formoterol is moderately lipophilic and hydrophilic, exerting a faster onset of
action than the more lipophilic salmeterol – the latter diffuses more slowly to
reach β2-receptors [21, 49]. Formoterol is metabolized primarily by direct gluc-
uronide conjugation and O-demethylation (CYP2D6 and CYP2C19) in the liver
to metabolites with reduced activity [48]. Some patients may be deficient in
CYP2D6 or 2C19 or both; however, the clinical implications are not known [49].
A patient exhibiting intolerance to formoterol (e.g., excessive tachycardia) may
be deficient in CYP2D6; thus, changing to a β2-agonist not dependent on metabo-
lism by this CYP450 enzyme such as vilanterol and indacaterol may be helpful.
Pharmacokinetic studies of formoterol in hepatic or renal failure have not been
conducted [49]. As the main route of clearance is hepatic, patients with significant
liver impairment or receiving concomitant drugs altering CYP2D6 metabolism
should be monitored more closely.
Salmeterol is extensively metabolized by hydroxylation by CYP3A4 to
α-hydroxysalmeterol, and the less active metabolite is eliminated predominantly in
the feces [50]. The package insert indicates that because salmeterol is predomi-
nantly cleared by hepatic metabolism and that liver dysfunction may lead to accu-
mulation of salmeterol in plasma, such patients should be closely monitored [50].
Because of the reliance upon CYP3A4, a number of potential drug interactions can
occur with salmeterol (see section “Drug-Drug Interactions in the COPD Patient
with Comorbid Cardiac Disease”) [50].
Indacaterol, the first commercially available ultralong-acting LABA, has a rapid
onset of action, and depending on the dose, up to a 24-hour duration [51]. Indacaterol
undergoes metabolism by CYP3A4 to a hydroxylated metabolite, as well as other
minor pathways [52, 53]. Unmetabolized drug accounts for about one-third of total
systemic drug exposure [52, 53]. In vitro studies showed that indacaterol is a low-
affinity substrate for P-gp. The pharmacokinetics of indacaterol was studied in
patients with mild and moderate hepatic impairment, where no relevant changes in
peak blood level or AUC of indacaterol occurred [52]. Studies in subjects with
severe hepatic impairment were not performed. Due to the very low contribution of
the urinary pathway to total body elimination, renal dysfunction is not expected to
alter drug clearance.
Vilanterol, which has a relatively quick onset of action and extended duration
[54], is also principally metabolized by CYP3A4 (O-dealkylation) to less active
metabolites. The package insert recommends caution when considering the coad-
ministration of vilanterol with strong CYP3A4 inhibitors [30] (e.g., itraconazole).
Vilanterol is also a substrate of P-gp, where the effect of inhibitors (e.g., verapamil)
or inducers of this membrane transporter can affect gastric absorption of a swal-
lowed drug and therefore systemic bioavailability. Closer monitoring is recom-
mended when used in patients with moderate to severe hepatic impairment.
Olodaterol has a fast onset and 24-hour duration of action [46]. It is metabolized
by direct glucuronidation and by O-demethylation with the only metabolite, an
unconjugated demethylation product, also having activity by binding to β2-receptors.
However, according to the package insert, this metabolite was not detectable in
plasma after chronic inhalation at the recommended dose [46]. CYP2C9 and
CYP2C8 are the principal enzymes responsible for metabolizing in the liver, with
minimal contribution of CYP3A4; therefore, poor metabolizers for these isoen-
zymes may alter the systemic response to olodaterol; however, this has not been
studied. The package insert reports that olodaterol blood levels were increased by
approximately 40% in subjects with severe renal impairment. Data in patients with
less severe renal impairment were not reported [46]. In contrast, patients with mild
to moderate liver impairment showed minimal changes in systemic drug expo-
sure [55].
Inhaled Antimuscarinics The onset of effect of ipratropium is evident within
20–30 minutes with a duration of action approaching 6–8 hours [56]. It is a quater-
nary compound, poorly absorbed in the GI tract with most of the swallowed drug
excreted in the feces. Ipratropium is partially metabolized to multiple, largely inac-
tive, metabolites primarily by ester hydrolysis and conjugation [57]. The pharmaco-
kinetics of ipratropium has not been studied in patients with renal or liver impairment,
perhaps because of drug regulatory requirements for inhaled medications at the time
the drug was marketed in the 1980s. Following intravenous administration, nearly
50% is excreted unchanged in the urine. Although not included in the package
insert, a conservative approach would be to monitor adverse effects more closely in
patients with severe renal dysfunction.
Tiotropium was developed as a structural analog of glycopyrrolate and was the
first long-acting antimuscarinic approved for COPD [58]. It exerts its bronchodila-
tory effects within 30 minutes and has a duration of action of at least 24 hours [54].
Biotransformation of tiotropium appears to be minimal as nearly three-fourths of
the drug is renally excreted unchanged and metabolites do not bind to muscarinic
receptors [58]. Although, ex vivo experiments with hepatocytes show CYP2D6 and
CYP3A4 are involved in tiotropium metabolism, the relatively small portion of
metabolized drug would indicate enzyme inhibitors or inducers or pharmacogenetic
differences are unlikely to cause significant changes in drug disposition. A very
small fraction (<5%) of the swallowed portion of inhaled tiotropium is absorbed
through the GI tract [26]. According to the package insert, patients with moderate to
severe renal impairment (ClCr <60 mL/min) receiving tiotropium should be
172 R. Pleasants
monitored closely for anticholinergic side effects [26]. The effects of hepatic impair-
ment on the pharmacokinetics of tiotropium have not been studied, but would likely
be insignificant except perhaps in the most severe cases.
Aclidinium exerts bronchodilatory effects within 30 minutes and has a duration
of action of ~12 hours [54]. Clinical pharmacokinetic studies of aclidinium indicate
that the major route of metabolism is chemical and enzymatic hydrolysis by ester-
ases in the respiratory tract [59]. Metabolites do not bind to muscarinic receptors
and thus are pharmacologically inactive. Blood levels quickly decline after inhala-
tion due to the rapid hydrolysis by esterases [60]. No significant differences in phar-
macokinetics of aclidinium were found in patients with varying degrees of renal
impairment. The reliance on esterases on metabolism would indicate that hepatic
impairment would have minimal effects on aclidinium disposition. This may be the
preferred LAMA in patients with severe renal or liver impairment, particularly if the
patient is predisposed or is experiencing anticholinergic side effects.
Glycopyrrolate was originally used in the 1980s where the parenteral formulation
was nebulized. It is now commercially available in the United States as a twice-daily
LAMA for COPD in MDI, DPI, and nebulized formulations [61]. It exerts broncho-
dilatory effects within 30 minutes and has a duration of action of ~12 hours [54]. The
majority of glycopyrrolate that reaches the systemic circulation goes through the
lungs as oral absorption is incomplete [54]. Renal elimination of the parent drug
accounts for about two-thirds of total clearance of systemically available glycopyr-
rolate, whereas nonrenal clearance processes including metabolism also occur.
According to the package insert, the AUC and elimination half-life of intravenous
glycopyrrolate were significantly altered (up to 2.2-fold) in patients with mild to
severe renal impairment [27]. In vitro investigations showed that multiple CYP iso-
enzymes contribute to the oxidative biotransformation, whereas glucuronide and/or
sulfate conjugates of glycopyrrolate in the urine account for about 3% of the dose [27].
Umeclidinium exerts its bronchodilatory effects within 1 hour and has a duration
of action of at least 24 hours [62]. It is primarily metabolized to metabolites with
decreased activity by CYP2D6 followed by conjugation, with little contribution by
CYP3A4. As the blood levels of this drug decline very quickly after inhalation, it is
uncertain whether esterases may play a role in its metabolism. No clinically signifi-
cant difference in systemic exposure to umeclidinium was observed following
repeat inhaled dosing in CYP2D6 normal, ultrarapid, extensive, and intermediate
metabolizers and poor metabolizer subjects [63]. Patients with mild to moderate
hepatic impairment showed no decrement in clearance, and severe disease was not
studied [64]. There was no evidence of significantly altered pharmacokinetics in
severe renal impairment [65]. Although it is a substrate for P-gp, oral bioavailability
is poor, where systemic exposure of umeclidinium is mostly through the lung after
inhalation [66].
Revefenacin, a nebulized LAMA, exerts bronchodilatory effects in less than an
hour, peaks at 1–2 hours, and has a duration of 24 hours [31, 67]. The absolute oral
bioavailability of revefenacin is low (<3%). It is primarily metabolized via
hydrolysis to an active metabolite, the latter at much higher concentrations than the
former. The active metabolite is formed by hepatic metabolism and possesses activ-
ity at target muscarinic receptors lower (approximately one-third to one-tenth) than
revefenacin, but could potentially contribute to systemic antimuscarinic effects at
therapeutic doses. The manufacturer recommends avoiding this drug in hepatic
impairment. There are modest changes in excretion of revefenacin in patients with
renal impairment [66]. Although revefenacin is a substrate for efflux transporters
such as P-gp and uptake transporters such as OATP1B1, its low blood levels and less
active metabolite lead to a low probability of significant pharmacokinetic drug
interactions. Like aclidinium, revefenacin may be preferred in patients with signifi-
cant renal disease to decrease the risk of systemic adverse effects.
Theophylline Theophylline, a nonselective phosphodiesterase inhibitor, has

been used for over 60 years in obstructive lung diseases and as an oral sustained-
release product since the 1980s. Theophylline, including oral sustained-release
products, is rapidly and completely absorbed when administered orally under
fasting conditions [36]. Aminophylline, 80% theophylline, is also well absorbed
when administered orally. It is primarily eliminated by hepatic biotransformation,
predominantly CYP1A2 but also CYP3A4 and to a lesser extent by urinary excre-
tion (10–15%) [36]. At higher doses, theophylline can exhibit nonlinear pharma-
cokinetics, causing blood levels to rise disproportionately with dose increases.
Although blood concentrations are determined mainly by hepatic metabolism,
they may also be increased in congestive heart failure, where the half-life mark-
edly increases [36]. Targeting lower blood levels (<10 mcg/ml by using “low”
doses) is currently recommended to decrease the risk of serum concentration-
related adverse effects and these blood levels have been shown to exert anti-
inflammatory effects [68].
Roflumilast Roflumilast, a selective phosphodiesterase inhibitor indicated for the

COPD phenotype with severe disease and frequent exacerbations, is currently avail-
able as an oral formulation [69]. The oral bioavailability of roflumilast is ~80%, and
although food delays absorption, it does not decrease the extent of absorption [70,
71]. Therefore, if given with food, it may improve GI tolerability. Roflumilast is
eliminated through hepatic metabolism by CYP1A2 and CYP3A4, primarily to the
active metabolite roflumilast N-oxide [72]. The metabolite roflumilast N-oxide is
substantially more active than the parent compound and is responsible for much of
its effects. In contrast to theophylline, tobacco smoking has little effect on the clear-
ance of roflumilast or its active metabolite [72]. With regards to liver disease,
roflumilast was studied in subjects with mild to moderate hepatic impairment
(Child-Pugh A and B) where the serum AUC for roflumilast and roflumilast N-oxide
were increased by 51–92% and 24–41%, respectively. Renal clearance is minimal
for roflumilast; thus, dosing adjustments are not necessary, although use in end-
stage renal disease may warrant closer monitoring for adverse effects.
174 R. Pleasants
rug-Drug Interactions in the COPD Patient with Comorbid

D
Cardiac Disease
Drug-drug interactions (DDIs) are a common cause of medication adverse effects,

particularly in the elderly due to susceptibility, polypharmacy, and multi-morbidities
[9, 73]. In the era of electronic records and order entry, the prescriber is confronted
with drug therapy alerts in nearly every patient and sorting through this myriad of
drug information can be difficult, particularly in these complex patients with mul-
tiple drug interactions or alerts. DDIs can be classified into two main types: (1)
pharmacokinetic alterations in absorption, distribution, metabolism, and excretion
of one drug by another and (2) pharmacodynamic that can be divided into three
subtypes, (a) interference with a physiological or biological control process, (b)
direct effect on receptor function, and (c) additive or opposed pharmacological
effect(s). Little has been published regarding drug interactions specifically in the
COPD patient with CVD. One study reported the type and frequency of drug inter-
actions that occur in hospitalized patients with COPD and CHF [74]. The median
number of drugs patients were receiving upon admission was six and there was a
median of six drug interactions in each patient encountered. The use of concomitant
β-blockers and β2-agonist, a pharmacodynamic drug interaction, was found in two-
thirds of patients, although, as will be discussed later in this chapter, this is gener-
ally not a clinically relevant interaction when using a cardioselective β1-blocker.
Other interactions included angiotensin-converting enzyme inhibitors with medica-
tions that can increase serum potassium.
The principal source of pharmacokinetic DDIs of medications used for COPD is
through alterations of drug metabolism. ICS, systemic corticosteroids, roflumilast,
theophylline, and most β2-agonists are primarily dependent on drug metabolism to
facilitate removal from the body, whereas most inhaled antimuscarinics rely more
on excretion through the kidney and/or biliary tract. For azithromycin, little metabo-
lism occurs, and most of the drug is excreted through the biliary and GI tract [75].
For drugs used in the treatment of CVD, agents subject to DDIs include amiodarone
and dronedarone (strong metabolizing enzyme inhibitors), verapamil (moderate
potency P-gp inhibitor), warfarin (substrate), statins (substrate), and digoxin (sub-
strate) [9]. Pharmacodynamic drug interactions with CVD medications are numer-
ous including ACEI, loop diuretics, β-blockers, and potassium-sparing diuretics
among others. It should be noted that not every patient will exhibit a clinically sig-
nificant drug interaction when two interacting medications are combined, or there
may be no significant interaction at all.
There are other comorbid pulmonary conditions in the COPD patient where drug
interactions are relatively common including lung transplantation and pulmonary
hypertension [76, 77]. In lung transplantation, numerous agents are subject to drug
interactions including immunosuppressives (e.g., cyclosporine, mycophenolate,
azathioprine, corticosteroids, sirolimus) and antibiotics (e.g., quinolones, azoles,
and caspofungin) [76]. Drug interactions that may be seen in the patient with
pulmonary hypertension include the concurrent use of bosentan and warfarin [78]
or the use of rifampin and treprostinil [79]. The focus of this section will be on the
interactions of drugs typically used in the management of the COPD patient with
comorbid CVD and will not cover DDIs in the lung transplant or pulmonary hyper-
tension patient populations.
Systemic and Inhaled Corticosteroids
The potential for DDIs is significant with corticosteroids, largely because of the
dependence on metabolism by CYP3A4 and the implications of systemic effects
[39]. All currently available systemic and inhaled corticosteroids are subject to CYP
enzyme inhibition or induction, principally through altering the function of CYP3A4
and CYP3A5 [80]. Examples of clinical scenarios of such drug interactions include
the development of an adrenal crisis when a prednisone-dependent patient receives
rifampin (strong enzyme inducer) [81] or the development of Cushingoid side
effects when itraconazole is coadministered in the long term with inhaled flutica-
sone propionate [82]. Whereas drug interactions with systemic steroids may be evi-
dent soon after the interacting drugs are coadministered, systemic effects that can
occur as a consequence of interactions with ICS would likely take much longer to
manifest.
Table 10.1 shows the pharmacokinetic interactions that may occur with corti-
costeroids. Drug classes prone to impair the metabolism of corticosteroids include
macrolides, azoles, and HIV medications [80]. Cobicistat and ritonavir are some
of the HIV medications documented to interact with corticosteroids. Grapefruit
juice can increase methylprednisolone systemic exposure by altering P-gp and
CYP3A4 activity [83]. It should be noted that not all triazoles or macrolides will
impair CYP3A metabolism [84] where fluconazole and voriconazole have less
effect on CYP3A4; in contrast, itraconazole and posaconazole are strong inhibi-
tors of CYP3A4 [85]. Notably, voriconazole is less likely to interact with cortico-
steroids than itraconazole [85] or posaconazole [86–88]. For macrolides,
erythromycin and clarithromycin are much more likely to impair CYP3A4 than
azithromycin [89].
For systemic steroids, metabolizing enzyme inducers include rifampin, pheno-
barbital, phenytoin, and carbamazepine [90]. Phenobarbital increased the total body
clearance of methylprednisolone twofold, phenytoin fivefold, and carbamazepine
threefold. Rifampin is a very strong inducer of drug metabolism; even a few days of
treatment can alter metabolism. Erythromycin for 1 week decreased the clearance
of methylprednisolone by nearly one-half [91]. In addition, ketoconazole increased
the methylprednisolone and prednisone AUC by more than twofold [92].
There are also a number of pharmacodynamic interactions of drugs with sys-
temic corticosteroids as shown in Table 10.2 [39]. Corticosteroids, like prednisone,
commonly increase blood sugar by decreasing insulin receptor sensitivity and
176 R. Pleasants
Table 10.1 Pharmacokinetic drug interactions with corticosteroids

Substrate drug Principal pathways of metabolism Inhibitors Inducers
Beclomethasone Esterases in respiratory tract Azoles Rifampin,
dipropionate convert prodrug beclomethasone (ketoconazole, St. John’s
dipropionate to active metabolite itraconazole, wort,
beclomethasone posaconazole) phenytoin
17-monopropionate, further Macrolides
metabolized by CYP3A4 and (clarithromycin,
CYP3A5 erythromycin)
Antiretrovirals
(cobicistat and
ritonavir)
Ciclesonide Esterases in respiratory tract Azoles Rifampin,
convert prodrug ciclesonide to (ketoconazole, St. John’s
active metabolite des-ciclesonide, itraconazole, wort,
which is further metabolized by posaconazole) phenytoin
CYP3A4 and CYP3A5 Macrolides
(clarithromycin,
erythromycin)
Antiretrovirals
(cobicistat and
ritonavir)
Budesonide, fluticasone Metabolized by CYP3A4 Azoles Rifampin,
propionate, fluticasone (ketoconazole, St. John’s
furoate, mometasone itraconazole, wort,
posaconazole) phenytoin
Macrolides
(clarithromycin,
erythromycin)
Antiretrovirals
(cobicistat and
ritonavir)
Prednisone, Prodrug prednisone converted by Azoles Rifampin,
prednisolone, liver CYP3A4 to prednisolone (ketoconazole, St. John’s
methylprednisolone, itraconazole, wort,
dexamethasone posaconazole, phenytoin
voriconazole)
Macrolides
(clarithromycin,
erythromycin)
Antiretrovirals
(cobicistat and
ritonavir)
increasing gluconeogenesis [93]. This typically occurs within 1–2 days after initia-
tion in susceptible patients and is dose-dependent. Systemic corticosteroids may
also increase blood pressure by sodium retention and thus decrease the effectiveness
of antihypertensives [94]. Systemic corticosteroids can also increase potassium
excretion through the kidneys and promote hypokalemia.
Table 10.2 Pharmacodynamic drug interactions with systemic corticosteroid therapy

Antidiabetic agents Antagonism of blood glucose lowering; hyperglycemia; effects of
corticosteroids on blood glucose are dose-dependent and occur quickly
NSAIDs and Increased risk for gastrointestinal bleeding (consider using concurrent
salicylates acid blockers)
Antihypertensives Antagonism of hypotensive effects
Inhaled β2-agonist Increased risk of hypokalemia, tachycardia, and tremors
Warfarin Increased or decreased effect of warfarin, increased risk of GI bleeding
Vaccines Reduced effectiveness of vaccines
Inhaled β2-Agonists
Pharmacokinetic and pharmacodynamic drug interactions are reported with inhaled

β2-agonists and may have particular implications in the CVD patient. Potential car-
diac effects include tachycardia, hypokalemia, and ECG changes; noncardiac effects
include tremors and nausea [95]. Each of the LABAs undergo extensive metabo-
lism; therefore, pharmacokinetic drug interactions can occur. As the net effect of
these drug interactions is increased systemic exposure of the LABA, the patient
with underlying heart disease may be more susceptible to these side effects.
Table 10.3 shows DDIs for the LABAs. For indacaterol, reported drug interac-
tion studies include verapamil (P-gp inhibitor), erythromycin (CYP3A4 and P-gp
inhibitor), ketoconazole, and ritonavir – leading to increases in systemic exposure
(AUC) ranging from 1.4- to 2-fold [52]. Compared to doses approved in the United
States, these interactions may be more relevant with the higher doses approved in
Europe. As inhibition of metabolism by drugs may be slow, multiple days of con-
comitant therapy may be necessary to assess the potential for increased β-agonist
side effects such as tachycardia. For olodaterol, studies in healthy subjects showed
no interaction with fluconazole, whereas ketoconazole (potent CYP3A4 and P-gp
inhibitor) increased olodaterol AUC by 68% [46]. The drug interaction between
salmeterol and ketoconazole was quite profound where the AUC increased 16-fold –
considered due to increased systemic bioavailability [50]. Although not studied, one
would expect a similar interaction with itraconazole and salmeterol. Erythromycin
was reported to increase the salmeterol peak blood level by 40% [50]. For for-
moterol and arformoterol, metabolism is primarily through CYP2D6 and CYP2C19
[96, 97]. Although DDIs are not documented, inhibitors of CYP2D6 such as amio-
darone, bupropion, fluoxetine, and propafenone could theoretically increase sys-
temic exposure to these drugs.
Pharmacodynamic interactions with β2-agonists include diuretics, corticosteroids,
β-blockers, and drugs that prolong the QT interval [21]. In a dose-dependent manner,
β2-agonists can augment hypokalemia and associated ECG changes via the shift of
potassium from the extracellular fluid to intracellular fluid compartment, thus augment-
ing the effects of diuretics [21]. Systemic corticosteroids can also contribute to hypoka-
lemia through their mineralocorticoid and glucocorticoid effects causing increased
excretion of potassium [39]. The COPD patient with concomitant CHF would be at
178 R. Pleasants
Table 10.3 Pharmacokinetic drug interactions with long-acting β2-agonists

LABA Mechanism of DDI Inhibitors Inducers
Arformoterol, CYP2D6, CYP2C19 NR Rifampin
formoterol St. John’s
wort
Indacaterol CYP3A4, P-gp Erythromycin NR
ketoconazole
ritonavir, verapamil
Olodaterol CYP2C8,CYP2C9, CYP3A4, Ketoconazole NR
P-gp
Salmeterol CYP3A4, P-gp Erythromycin NR
ketoconazole
Vilanterol CYP3A4, P-gp Ketoconazole NR
verapamil
particular risk of hypokalemia when aggressive diuretic dosing is combined with

inhaled β2-agonists. Additional cardiac effects of corticosteroids when combined with
β2-agonists include tachycardia that may occur due to augmenting the effect of adren-
ergic bronchodilators on the myocardium [98]. Inhaled β2-agonist can prolong QT
interval modestly, usually <5 milliseconds (ms) at normal doses; however, it may be
additive to other agents that increase the QT [21] including some tricyclic antidepres-
sants, fluoroquinolones, macrolides, amiodarone, and antiarrhythmics among others.
A pharmacodynamic drug interaction occurs between β-blockers and β2-agonists
where the effects of each may be opposed on the β2-adrenoreceptor [99]. However,
if using cardioselective β1-blockers, there is a small probability of worsening respi-
ratory status in the COPD as the predominant β-adrenoreceptors in the lungs are β2
[99, 100]. The effects of β-blockers on pulmonary function and clinical outcomes
will be further discussed under Pulmonary Effects of Drug Therapies for CVD.
Inhaled Antimuscarinics
As most inhaled antimuscarinics primarily depend on renal excretion, drug interac-

tions are most often pharmacodynamic in nature, potentially leading to anticholin-
ergic effects such as urinary retention, blurred vision, constipation, and dry
mouth – albeit much less frequently than seen with systemic agents [101, 102].
These effects are largely due to inhaled drug reaching the systemic circulation,
whereas dry mouth may occur as a local as well as a systemic side effect. Infrequently,
tachycardia attributable to these agents may be encountered in susceptible patients
receiving higher doses.
Additive effects due to concurrent inhaled and systemic anticholinergics are
most likely to occur in the elderly patient with polypharmacy. Examples include
concomitant amitriptyline or nortriptyline used as a hypnotic or a medication used
for urinary retention such as oxybutynin. Whereas combining short-acting and
long-acting β2-agonists is considered acceptable, it is not recommended to
combine ipratropium with a LAMA. Little additional bronchodilation and added

side effects occur when ipratropium is added to tiotropium – likely the same holds
true for other LAMAs [101]; thus, the risk/benefit does not favor combining these
two therapies. There may be differences in propensities for anticholinergic topical
adverse effects among the different inhalers – e.g., tiotropium Respimat® [26] has
a lower reported frequency of dry mouth than the tiotropium Handihaler® [102],
possibly related to differences in aerosol particle size and oropharyngeal deposition.
Pharmacokinetic interactions can occur with umeclidinium and glycopyrrolate
as alterations in membrane transporter function have been reported one study found
coadministration of verapamil, a moderate P-gp inhibitor, with umeclidinium led to
~1.4-fold increase in AUC in healthy volunteers [103]. In another study involving
healthy subjects, cimetidine, an inhibitor of organic cation transport (contributes to
the renal excretion of glycopyrrolate) increased the systemic exposure (AUC) of
glycopyrrolate by 22% and decreased overall renal clearance by 23% [104]. In these
studies of umeclidinium and glycopyrrolate in healthy volunteers, the minimal
adverse effects observed from increased drug exposure are not necessarily indica-
tive of what may occur in an elderly patient with impaired drug clearance because
of organ dysfunction and/or greater susceptibility because of underlying
CVD. Therefore, monitoring is warranted for anticholinergic adverse effects, espe-
cially when initiating these therapies in the presence of interacting drugs.
Theophylline
Theophylline is subject to both pharmacokinetic and pharmacodynamic drug inter-

actions [68] (Table 10.4). Because of its narrow therapeutic index, drug interactions
should always be considered [105]. However, lower target blood levels used today
significantly decrease the likelihood of clinically significant drug interactions. By
the nature of one of its pharmacological mechanisms, theophylline can antagonize
adenosine [106]; thus, when a patient is receiving parenteral adenosine in the treat-
ment of atrial arrhythmias, an inadequate clinical response may result in the pres-
ence of theophylline.
There are numerous pharmacokinetic drug interactions with theophylline,
largely due to alterations in hepatic metabolism, primarily with CYP1A1 and
CYP1A2 and less so with CYP3A4 [105] (Table 10.4). Interacting drugs prescribed
in the COPD patient include the inhibitors cimetidine, ciprofloxacin, erythromy-
cin, and clarithromycin as well as the inducers phenytoin and rifampin.
Ciprofloxacin is well-known to increase blood levels of theophylline by inhibiting
CYP1A2 isoenzyme, typically within a few days after coadministration. Inhalation
of hydrocarbons such as tobacco smoking can induce metabolism of theophylline
by CYP1A1 quite substantially [36, 105, 107]. If a patient is receiving theophylline
and quits smoking, it should be expected that blood levels will increase, typically
within a week. Inhalation or ingestion of nicotine alone would not be expected to
alter theophylline metabolism.
180 R. Pleasants
Table 10.4 Pharmacokinetic drug interactions with theophylline and roflumilast

Theophylline Metabolized by Ciprofloxacin, cimetidine, Rifampin,
CYP1A2 and CYP itraconazole, posaconazole, St. John’s wort,
3A4 clarithromycin, erythromycin phenytoin
Roflumilast Metabolized by Itraconazole, posaconazole, Rifampin,
CYP1A2 and clarithromycin, erythromycin St. John’s wort
CYP3A4
Roflumilast
Due to the dependence of roflumilast on metabolism by CYP3A4, it is subject to

drug interactions [72]. Gastrointestinal side effects of roflumilast tend to be dose-
dependent, and like theophylline, GI side effects are usually worse when initiating
therapy and lessen with continuation. It was found that initiating roflumilast at 250-
mcg doses for 4 weeks led to better tolerance than initiating at 500 mcg daily [108].
Among the different drug interaction studies in healthy volunteers of roflumilast,
erythromycin and ketoconazole, both CYP 3A4 inhibitors, were shown to increase
the AUC of roflumilast by 70% and 99%, respectively [72] (Table 10.4). It is recom-
mended that the following drugs be given cautiously in persons receiving roflumi-
last (cimetidine, erythromycin [109], ketoconazole [110], fluvoaxamine [111],
enoxacin, and gestodene and ethinylestradiol [72]. There is no data evaluating the
potential interaction between roflumilast and grapefruit juice (flavonoids) or itra-
conazole; however, these could be a clinically relevant interaction through CYP3A4
inhibition. It is also recommend that the strong enzyme inducer, rifampin, not be
given with roflumilast [112]. Although not recommended by the manufacturer,
because of the 99% binding of roflumilast to albumin, it is reasonable to monitor
warfarin effects more closely for a short time period after starting roflumilast.
Antibiotics
Some macrolides, fluoroquinolones, and triazoles are well documented to cause

drug interactions by impairing metabolism of other drugs [9, 84, 85, 87]. In general,
β-lactams do not effect CYP metabolism to a significant extent; however, nafcillin
can impair CYP3A4 activity [89]. Long courses of antimicrobials, such as an itra-
conazole for Aspergillus infection in a COPD patient, may increase the risks associ-
ated with these drug interactions. In addition to drug interactions involving drug
metabolism, anti-infectives can be associated with prolongation of the QT interval
and will be further discussed in the section “Cardiac Effects of Medications Used in
the Treatment of COPD”.
Antimicrobials differ in their ability to bind and inhibit metabolizing isoenzymes

such as CYP3A4 [9, 11]; thus, generalizations of pharmacokinetic drug interactions
are not valid on the basis of drug class, as often occurs in drug information data-
bases. In contrast to erythromycin and clarithromycin, azithromycin has been shown
to interfere poorly with the cytochrome P450 system in vitro, where numerous drug
interaction studies have shown a very low risk of altered drug clearance associated
with azithromycin [84]. For the macrolides like erythromycin and clarithromycin, it
typically takes at least several days to a week of administration before the pharma-
cokinetic interaction is maximal.
All azoles inhibit the metabolism of CYP3A4, therefore having the potential to
interact with drugs used in the treatment of COPD, although some have been
determined to be nonsignificant interactions [85]. Among the commonly used tri-
azoles, itraconazole is the azole most likely to be an inhibitor of membrane trans-
porters including P-gp [85]. Voriconazole can be a strong inhibitor of several
other CYP isoenzymes including CYP2C19 and CYP2C9. Posaconazole has little
effect on CYP2C9 and CYP2D6. The newest triazole, isavuconazonium sulfate
(prodrug for isavuconazole), appears to affect CYP metabolism coenzymes simi-
lar to voriconazole, with some differences [113]. The voriconazole package insert
has a number of drugs that are either contraindicated or strong warnings about
monitoring with coadministration of sirolimus, warfarin, and benzodiazepines,
among others [86].
Among the azoles, itraconazole is most likely to decrease metabolism of sys-
temic and inhaled corticosteroids [85]. Both voriconazole and isavuconazole have
been shown to have a minimal effect on the metabolism of methylprednisolone in
healthy volunteers [85, 114]. Ketoconazole is typically used for superficial fungal
infections and thus is used infrequently in the COPD patient; however, it is used for
drug interaction studies during Phase 2 development as it is a prototype CYP3A4
enzyme and P-gp inhibitor. Based on pharmacokinetic studies for indacaterol, olo-
daterol, vilanterol, and salmeterol demonstrating an interaction with ketoconazole,
it is anticipated that itraconazole would interact with these drugs to increase sys-
temic exposure and potential adverse effects.
Among the fluoroquinolones, ciprofloxacin has the greatest potential to impair
hepatic metabolism of substrate drugs, although levofloxacin and moxifloxacin can
also alter drug metabolism [89]. In contrast to macrolides, the effects of fluoroqui-
nolones on metabolism of the substrate drug occurs more rapidly, such as seen with
ciprofloxacin and theophylline. Fluoroquinolones have less effect on CYP3A4 than
azoles and macrolides and greater effects on isoenzymes such as CYP1A2, particu-
larly ciprofloxacin. In the COPD patient, an important drug interaction with fluoro-
quinolones is reduced oral bioavailability by caused by coadministration of cations
[89] such as calcium for osteoporosis prevention or enteral feeds for cachexia in the
COPD patient. In serious respiratory tract infections, parenteral quinolones may be
preferred.
182 R. Pleasants
ardiac Effects of Medications Used

C
in the Treatment of COPD
ffect of Heart Disease on Myocardial Adrenergic

E
and Muscarinic Receptors
Changes in β-receptors and muscarinic receptors can occur in heart disease. CHF is
characterized by adaptive responses that lead to abnormal neurohormonal activation
to compensate for left ventricular function decline [115], and increased activity of
the sympathetic nervous system is well-known [116]. As a result of excessive and
persistent sympathetic overstimulation, the β1-receptors downregulate substantially
and β2-receptors become more prominent [116, 117]. A study in heart failure
patients showed that β1 receptors are less evident, whereas β2-receptors increase
such that the β2:β1 ratio is ~1:2, which essentially reverses to ~2:1 in the failing
myocardium [118]. This may partially explain why the patient with heart failure
may be more susceptible to inhaled β2-agonists. Also, changes in the muscarinic
system occur in heart failure where the interaction between muscarinic and adreno-
ceptors changes such that the sympathetic ganglia convert more to a cholinergic
phenotype [115]. However, differences in the number and function of muscarinic
receptors in the failing human heart are not substantially changed [119].
Corticosteroids
Systemic corticosteroids are used widely in COPD largely because of effective-

ness, low costs, and wide availability, although side effects are quite common
even with low-dose, short courses [38]. Corticosteroid effects are mediated by
the intracellular glucocorticoid receptors and the mineralocorticoid receptors;
both are expressed in the myocardium and blood vessels. Both glucocorticoid
and mineralocorticoid effects of corticosteroids could lead to CV effects via
upregulated β-receptor sensitivity as well as other effects on the myocardium and
sodium/fluid retention [39]. In the REDUCE trial evaluating systemic corticoste-
roids for COPD exacerbations, prednisone 40 mg daily for 5 days caused wors-
ening heart failure in some patients [38]. However, it has also been reported that
low doses of prednisone (10 mg/day) may promote the activity of diuretics in
patients with CHF [94]. As shown in Table 10.5, differences exist among the
synthetic glucocorticoids with regards to anti-inflammatory and sodium-retain-
ing potencies [39].
Methylprednisolone has modestly lesser mineralocorticoid effects than prednis-
olone; however, when given IV and higher doses are used, this would likely negate
that advantage. Dexamethasone has little mineralocorticoid effect compared to
other corticosteroids, a potential advantage in the CHF patient, although it is
Table 10.5 Relative anti-inflammatory and mineralocorticoid potencies of systemic

glucocorticoids
Relative anti- Relative
Equivalent inflammatory sodium-retaining Biological
Compound potency (mg) potency potency half-life
Cortisone 20 1 1 8–12
Hydrocortisone 20 1 0.8 8–12
Prednisone 5 4 0.8 18–36
Prednisolone 5 5 0.8 18–36
Methylprednisolone 4 5 0.5 18–36
Dexamethasone 0.75 25 0 or slight 36–54
Modified from Becker [39]
generally not used in COPD because of its long half-life and potential for adrenal
suppression. However, if using dexamethasone instead of prednisone for the treat-
ment of a COPD exacerbation in a prednisone-dependent patient, the lack of miner-
alocorticoid effects may lead to a decrease in blood pressure.
Both short-term and long-term administration of corticosteroids have been
reported to be associated with an increased risk of ischemic heart disease, hyperten-
sion, atrial arrhythmias, and CHF. In a population-based study (non-COPD), the
risk for CHF, myocardial infarction, stroke, and transient ischemic attacks com-
bined was 3.7, 3.3, 1.7, and 7.4 (risk ratio), respectively [120]. However, another
study in patients exposed and unexposed to glucocorticoids found no difference in
CV events [121]. Risk of atrial fibrillation and flutter have been reported to be
increased in those on high doses of glucocorticoids [122, 123]. However, low dose
was reported to decrease the risk of arrhythmias in patients who had undergone
coronary artery bypass surgery [124].
Glucocorticoids are associated with weight gain, likely related to increased appe-
tite and fluid retention [125]. Some studies suggest that moderate or higher doses of
prednisone promote fluid retention [120], whereas other studies have not supported
this association [126]. In some patients, systemic corticosteroids have been shown
to worsen heart failure, largely through mineralocorticoid effects leading to fluid
retention [127].
ICS have thus far not been associated with worse CV outcomes and may even
have positive cardiac effects. In the TORCH study, the fluticasone propionate arm
did not show worsened CV outcomes compared to placebo or in combination with
salmeterol [128]. The SUMMIT trial (Study to Understand Mortality and MorbidITy)
trial was an international, multicenter trial of patients with COPD and either a his-
tory of CVD or heightened risk for CVD in 16,485 patients [129, 130]. When com-
paring ICS/LABA, ICS, LABA, and placebo over 1 year in COPD patients at high
risk of CVD, there was a nonsignificant trend towards improved CV survival (adju-
dicated) with ICS compared to placebo (hazard ratio = 0.90, p = 0.12) [130].
Additional research is warranted with ICS in COPD patients with heart disease,
particularly over extended time periods.
184 R. Pleasants
β2-Agonists and Antimuscarinics
The principal mechanisms that inhaled bronchodilators cause CV side effects

are through alterations to the sympathetic and parasympathetic nerve pathways
in the heart and vasculature [131] (Figs. 10.3 and 10.4). For the muscarinic sys-
tem, M2 is the predominant muscarinic isoform present in the heart, while in the
coronary circulation subtype, M3 is present [132]. Muscarinic receptors are
coupled to the Gi-protein, where vagal activation decreases cAMP. Gi-protein
activation also leads to the activation of KACh channels that increase potassium
efflux and hyperpolarizes the cells to regulate the heart rate by altering the elec-
trical activity of the sinoatrial node. By inhibiting the regulatory actions of ace-
tylcholine, muscarinic receptor antagonists block the effects of vagal innervation
on the heart, principally to the SA and AV node, thus increasing heart rate and
conduction velocity. In ventricular preparations, anticholinergics decrease the
force of contraction previously activated by cAMP-elevating agents such iso-
proterenol [117].
Activation of the β1- and β2-adrenoceptors in the human heart leads in coupling
G-proteins to activate adenylyl cyclase, increasing the intracellular level of cAMP,
promoting calcium influx and thus enhancing myocardial function [117]. The den-
sity of β2-adrenoreceptors on the heart and skeletal muscle is much lower than
Parasympathetic autonomic nervous system
Brainstem
Vagus nerve
Lungs Heart
Anticholinergics
Acetylcholine
Bronchial smooth
muscle
Submucosal Acetylcholine
Muscarinic Muscarinic
gland
receptor receptor SA node
Airway
epithelium ↑ Heart rate
↓ Bronchoconstriction ↓ Mucus secretion
Fig. 10.3 Parasympathetic innervation to the lungs and heart. (Reprinted with Permission
from 131)
Sympathetic autonomic
nervous system Spinal cord
Thoracic region
Paravertebral ganglion
Lungs Heart
β2 agonists
+
Norepinephrine
Norepinephrine +
+
β2-adrenergic receptor β1>β2 adrenergic
receptors
SA node
Bronchial smooth
muscle
Cardiac muscle
↑ Bronchodilation ↑ Stroke volume ↑ Heart rate
Fig. 10.4 Sympathetic innervation to the lungs and heart. (Reprinted with Permission from 131)
airway smooth muscle cells. β2-agonists bind principally to the β2-adrenoreceptors

located in the nodal tissue, conducting system, and contracting myocytes.
β2-agonists can be arrhythmogenic because of chronotropic and inotropic effects,
depolarization, repolarization, and cellular potassium shifts [21]. These
β2-cardioselecetive inhaled agents exhibit minimal agonist effects on the β1-receptor,
and β2-agonist-induced tachycardia results from the direct stimulation of cardiac
β2-adrenoceptors in the SA node as well as indirect activation of peripheral recep-
tors leading to vasodilatation and reflex vagal withdrawal. If tachycardia is signifi-
cant enough, this may increase myocardial oxygen consumption and electrical
instability – possibly detrimental in the failing heart.
β2-agonists induce cardiac-related side effects in a dose-dependent manner and
include an increase in myocardial oxygen consumption, changes in blood pressure,
tachycardia, arrhythmias, and hypokalemia [21]. β2-agonist-related ECG changes
include flattening of the T wave, prolongation of the QT interval, and ST segment
depression. One study showed that COPD patients with preexisting cardiac arrhythmias
and hypoxemia exhibited dose-dependent effects of formoterol on the myocardium [133].
Other relevant effects of β2-agonists on the CV system are shifting of potassium
intracellularly into skeletal muscle, liver-induced glycogenolysis thus increasing
blood glucose, and increased renin from the kidney [21]. Both tremors and hypoka-
lemia are due to direct stimulation of β2-receptors in skeletal muscle and occur in a
186 R. Pleasants
dose-dependent manner. Long-term use of β2-agonists can lead to receptor desensi-

tization through dampening of the signaling or downregulation of β2-receptor num-
bers (e.g., tachyphylaxis), which may lessen reported side effects such as tachycardia
and tremor over time [21]. Ventilation/perfusion mismatches can occur when first
administering inhaled β2-agonists; however, this may not be clinically significant in
the COPD patient [21].
In general, the effects of inhaled β2-agonists on the QT interval are modest –
however, such effects may be additive and therefore relevant – whereas inhaled
antimuscarinics have minimal, if any, effects on QT. A double-blind, placebo, and
active-control (moxifloxacin) study in healthy volunteers showed dose-dependent
changes with indacaterol in QTc of 2.7, 3.0, and 3.3 ms following doses of 150, 300,
and 600 mcg, respectively [134]. Olodaterol was also shown to have minor effects
on QTc where supratherapeutic doses led to an increase in QTc of ~6 ms, and near-
normal doses only increased the QTc by ~2 ms [135]. At 8 times the recommended
dose for 10 days, umeclidinium did not prolong the QTc to any clinically relevant
extent in more than 80 subjects [66]. In a study of aclidinium 200 mcg and 800 mcg
administered to healthy volunteers for 3 days, no effects on prolongation of the QT
interval were observed [58].
It has also been reported that inhaled β2-agonists may improve cardiac perfor-
mance by enhancing cardiac and stroke volume and reducing peripheral vascular
resistance, although the clinical significance is unknown [136, 18]. In addition,
recent studies have evaluated the effects of LABA, LAMA, and ICS on arterial stiff-
ness in COPD [137–139]. In a non-placebo-controlled study, arterial stiffness, mea-
sured by aortic pulse wave velocity, was lower with both ICS/LABA and LAMA in
COPD [139]. Another study comparing ICS/LABA and placebo did not show a
significant effect of arterial stiffness; however, a post hoc analysis did show a sub-
group who benefited from ICS/LABA treatment [137]. In a more recent placebo-
controlled study by Bhatt et al., LABA or ICS/LABA over 24 weeks did not alter
arterial stiffness [138].
Theophylline
It is well documented that at “toxic” blood concentrations of theophylline, cardiac

side effects like supraventricular and ventricular arrhythmias can occur and at
very high levels, e.g., >40 mcg/ml can cause cardiac-related death [68, 140–142].
At blood concentrations more than 20 mcg/ml, sinus tachycardia, supraventricular
ectopic beats, and ventricular premature beats are common. More evidence has
substantiated this finding but has also added to the evidence that this effect can
also happen during so-called nontoxic therapeutic doses. One study found that
patients with toxic levels associated with the chronic use of theophylline were
more likely to experience arrhythmias and death than acute overdoses [141].
Theophylline can induce alterations in ECGs including significant reductions in

the atrioventricular and His-Purkinje conduction intervals and SA node conduc-
tion time [142].
Antimicrobials
Antibiotics are used commonly in COPD, fluoroquinolones for exacerbations and

macrolides for the treatment as well as prevention of exacerbations. Azoles used for
the short-term and long-term treatment of fungal infections in the COPD patient are
reported to cause adverse CV effects, albeit infrequently. A number of warnings
regarding antibiotics have come from the US FDA over the last 2 decades regarding
cardiac toxicities. In 2001, a warning was issued regarding the increased risk of
worsened CHF with itraconazole; the mechanism is unknown [143].
The potential adverse cardiac effects of azithromycin came under scrutiny in
2012 by the FDA and then in 2013 when the warning in the package insert was
updated [143]. The change in the package insert was largely in response to a retro-
spective study in one US state’s Medicaid population [144] and by FDA review
indicating there is a risk of cardiac events associated with azithromycin.
In 2016, a warning concerning the multiple and potentially serious side effects of
fluoroquinolones was issued by the FDA. The FDA discourages the use of this drug
class unless other antibiotics are not a good option [145]. In 2018, the US FDA
issued a warning about the cardiotoxicity of clarithromycin [146] in patients with
stable coronary artery disease based on a 10-year follow-up study [147]. Notably
the risk was evident beginning about 1 year after receiving 2-week courses of clar-
ithromycin. The hazard ratio was 1.1 (95% CI 1.0–1.21), which was significant over
the 10-year period, and a greater risk was evident in the first 4 years after therapy
and was most evident in persons not taking statins [8]. It is unclear how a 2-week
course of clarithromycin would affect CV outcomes over a multiyear period.
Effects of these anti-infectives may be due to direct actions on the myocardium
leading to arrhythmias or heart failure as well as indirectly through drug interactions
by increasing systemic exposure of other medications that can affect the heart. One
of the leading proposed mechanisms that these agents adversely affect cardiac func-
tion is through prolongation of the QT interval increasing the risk of developing the
ventricular arrhythmia torsades de pointes (TdP). Drugs have been associated with
this arrhythmia for many years but regulatory awareness was heightened when terf-
enadine, an oral antihistamine, was reported to cause cardiac deaths in the early
2000s. It was determined that slowed CYP3A4 metabolism of the parent drug was
associated with the arrhythmia [148]. Since then, an emphasis has been placed on
the proarrhythmic risk of drug therapies, principally based on the likelihood of pro-
longing the QT interval. Although QT interval prolongation is considered the major
proarrhythmic mechanism, it is perhaps better considered a surrogate for TdP [148,
188 R. Pleasants
149]. Drugs that prolong the QT interval range from having potent torsadogenic
activity to no proarrhythmic action and even antiarrhythmic effects [148]. Blockade
of hERG channels is the primary cause of TdP, but blockade/activation of other
channels can also be torsadogenic. While it appears that the standard assays (hERG
channel activity, action potential duration, and QT/QTc interval) are very good at
predicting the risk of QT interval prolongation, they are less useful in determining
the proarrhythmic effects of agents [148]. Thus, drug-induced QT prolongation is
considered by some to be a suboptimal surrogate for TdP and other ventricular
arrhythmias.
TdP from antimicrobials is a low-frequency event, but can be life-threatening,
particularly in susceptible persons [148, 150, 151]. Risk factors for developing TdP
include older age, electrolyte disturbances, baseline prolonged QTc, increases in
QT interval >60 ms, and administration of multiple drugs that prolong the QT inter-
val [148, 150] (Table 10.6). Typically, for a patient to develop TdP, multiple risk
factors must be present. The obtainment of an EKG with interpretation is recom-
mended in some instances. CredibleMeds, a program of the Arizona Center for
Education and Research on Therapeutics, maintains an evidence-based list of poten-
tial QT-prolonging medications stratified by their risk of TdP (risk, possible, condi-
tional, and avoided) [152].
The US FDA provides guidance on determining risks of TdP [153] including a
recommendation to have a positive control group – moxifloxacin can be used (as
noted in the indacaterol study previously described [134]). After initial studies look-
ing at the potential for drugs to affect the mechanisms associated with QTc prolon-
gation, such as Ikr channels, it is required to conduct such studies using therapeutic
doses of the investigational drugs with metabolic inhibitors. These investigations
tend to be done late in drug development.
Table 10.6 Risk factors Prolonged QTc >500 ms or increase in QTc >60 ms from
for drug-induced torsades offending agent
de pointes
Concomitant use of other QTc-prolonging agents
Excessive doses of an agent that can induce TdP
Elderly
Female gender
Underlying CV disease including history of MI and CHF
Electrolyte abnormalities (hypokalemia,
hypomagnesemia, hypocalcemia)
Clinical Studies Evaluating CV Safety of COPD Medications
Inhaled Bronchodilators
Studies evaluating the cardiac safety of inhaled antimuscarinics and β2-agonists in

COPD have reported mixed findings. Since the mid-1990s, there have been more
than 25 observational studies and 60 clinical trials reporting on CV effects of inhaled
β2-agonists and antimuscarinics, with or without ICS [131]. There have also been a
number of pooled and meta-analysis. The vast majority of the prospective clinical
trials excluded patients with significant CV disease and thus may not be indicative
of the efficacy and safety of these agents in a COPD patient with comorbid CVD,
although heart disease is present in some patients without being properly diagnosed.
Only recently have prospective studies of inhaled therapies been conducted in
patients with significant CV risks where the primary outcome was cardiac events
[130, 154, 155]. Regulatory agencies such as the FDA-mandated post-marketing
safety studies and EMA post-authorization safety studies (PASS) will continue to
assess CV safety of these agents.
Among retrospective observational studies reported in the review by Lahousse,
approximately one-half showed significantly higher CV risks in COPD patients
who received inhaled bronchodilator therapy [131]. In retrospective, observational
studies, numerous variables come into play; perhaps the most important is that these
patients are very complex and proper diagnosis and assignment of outcomes to any
particular factor is very difficult retrospectively. Further, there are inaccuracies in
documentation in medical records and lack of control on medication compliance –
thus should be considered hypothesis-generating awaiting prospective trials. A
study in more than 200 hospitalized COPD patients showed ~20% of the patients
never used their ICS/LABA inhaler after discharge, and in those that did, the major-
ity used it incorrectly [156]. In a post hoc analysis, medication nonadherence in
COPD was found to be a risk factor for mortality among subjects in the TORCH
study [157]. Nonadherence to COPD and other medications may pose a greater risk
of CV events and is unaccounted for in retrospective database studies.
COPD patients appear to be most susceptible to CVD events during or shortly
after hospitalization for a COPD exacerbation. Using an administrative database in
the UK, a study evaluating COPD exacerbations and CVD relationships, among
COPD patients, prescriptions for oral antibiotics and corticosteroids were associ-
ated with a higher risk for myocardial infarction and stroke [158]. Similarly, in the
recent SUMMIT study, where overall, there were no increased CV risks with fluti-
casone furoate or vilanterol, there was an increased risk of CVD events in the post-
hospitalization period [159]. A retrospective analysis of patients in Taiwan health
190 R. Pleasants
system by Wang attributed worse CV outcomes in the 30-day period posthospital-

ization with the use of long-acting bronchodilators [44].
β2-Agonists Both short-acting and long-acting β2-agonists can be associated with
adverse cardiac effects. Regarding the short-term use of short-acting β2-agonists
like albuterol, a Cochrane analysis reported no serious adverse effects [160]. In the
extensive review by Lahousse of cardiac toxicity of pulmonary medications in
COPD [131], among 39 prospective studies of LABA alone or in combination with
other inhaled therapies such as ICS, only one study reported statistically significant
worse CV outcomes – specifically in a placebo-controlled study of arformoterol by
nebulization [161]. In the largest of these prospective studies, the Towards a
Revolution in COPD Health (TORCH) over 3 years, COPD patients were random-
ized to placebo, fluticasone propionate alone, salmeterol alone, or their combination
in greater than 6000 COPD patients [162]. All-cause mortality was the primary
outcome and deaths were adjudicated during the study. Patients at high risk of dying
within 3 years were excluded. ICS/LABA combination product had the lowest pro-
portion of patients who withdrew from the study (34% vs 44% in the placebo group)
and had a nonsignificant decrease in all-cause mortality compared with placebo
(p = 0.052). A post hoc analysis of the TORCH trial addressed CV-related second-
ary outcomes where it was found that one in five subjects reported a CV event dur-
ing the 3-year study and there were no increased risks for either salmeterol
monotherapy or the fixed-combination treatment [128]. There appeared to be some
cardioprotective effects of the ICS/LABA combination in this post hoc analysis.
Based on this finding in TORCH as well as other evidence, a large prospective
study (SUMMIT) of a newer ICS/LABA combination of vilanterol and fluticasone
furoate was conducted [130]. The study was conducted for at least 1 year in more
than 16,000 moderate COPD patients with or at high risk of CV disease. The pri-
mary endpoint (all-cause mortality) was not significantly affected by combination
therapy (HR 0.88, p = 0.14). It is possible that longer-term studies of ICS/LABA
may show benefits as these drugs are administered for years, especially in light of
the trend for better CV outcomes in the SUMMIT study. However, as shown in
other studies, all treatments did reduce the rate of moderate and severe exacerba-
tions. In a secondary analysis of CV events, individual or combination inhaled
therapies were not associated with CV outcomes different than that of placebo
[163]. In a post hoc analysis of SUMMIT, using the sensitive troponin I as a marker
of cardiac risk, neither inhaled B2 or combination ICS/LABA resulted in higher
blood levels [164].
Some clinical trials have employed Holter monitoring in a subset or all study
subjects receiving LABA therapy. In a study in COPD patients, using Holter moni-
tors, dose-dependent effects of formoterol on supraventricular tachycardia and
plasma potassium were observed [133]. Among more than 700 patients with Holter
monitoring comparing nebulized arformoterol, salmeterol, and placebo, it was
found that in nearly 42%, atrial arrhythmias were evident at baseline and this
increased by 2–5% over placebo after randomization to inhaled bronchodilator
[165]. Rates of serious arrhythmias did not increase over the 12-week study period.
One important consideration of the safety of inhaled bronchodilators is that

nearly all studies have evaluated therapies administered by multi-dose inhalers
and not by nebulization where doses are typically much higher (ipratropium, for-
moterol, and arformoterol). It has been shown that the type of device and particle
size affect systemic drug concentrations [19]. It was found in a 1-year study that
measuring serial electrocardiograms while receiving arformoterol by nebulization
resulted in an approximately 3.0-ms higher QTc compared to salmeterol
inhaler [96].
Antimuscarinics One of the first prospective clinical studies to suggest CV safety
issues existed with an inhaled antimuscarinic was the Lung Health Study [166].
This randomized controlled trial assessed the effects of different interventions on
long-term outcomes including the cardiovascular risk of inhaled ipratropium. This
study observed a relationship between ipratropium and a higher risk of death and
hospitalization secondary to CV disease. Notably, there was a failure to adjust
p-values for multiple statistical comparisons, and a reanalysis of the data showed
that the increased risk of CV morbidity and mortality was largely among patients
who were randomized to the ipratropium group but who did not take ipratropium
and thus would be defined as nonadherent [167].
Among the 20 prospective clinical studies of inhaled antimuscarinics reported in
the review by Lahousse, none showed significantly worse CV outcomes [131]. As
with studies of inhaled LABAs, a weakness of these studies is the exclusion of
patients with substantial cardiac risks. In the largest prospective study evaluating
the efficacy and safety of tiotropium (UPLIFT) [168], the relative risks of CHF,
angina, myocardial infarction (MI), and cardiac failure were significantly lower
with tiotropium than placebo [169]. Around that time, a meta-analysis by Singh
indicated a higher risk of CV events with tiotropium, but did not include the UPLIFT
study in that meta-analysis [170]. In 2010, the Food and Drug Administration (FDA)
concluded that because of the limitations of that meta-analysis and the strengths of
the UPLIFT trial, there was no increased risk of MI or death was associated with
tiotropium DPI [171]. In a combined analysis of multiple clinical trials in 727
patients using Holter monitoring, tiotropium DPI or SMI was not associated with
changes in heart rate, supraventricular premature beats, or ventricular premature
beats and pauses compared with placebo or the pretreatment baseline period [172].
In 2013, a pooled safety analysis by Halpin showed either no difference or lower
rates of serious adverse events or fatal CV events to tiotropium SMI or Handihaler®
compared to placebo [173]. A meta-analysis in 2013 by Dong also showed an asso-
ciation with tiotropium SMI and ICS/LABA with CV deaths in severe COPD, but
not tiotropium DPI [174].
Because of the concerns of potentially greater CV events with the tiotropium
SMI, the manufacturer undertook a large prospective study comparing two
doses of tiotropium SMI with tiotropium dry powder inhaler (DPI) in patients
with CV risks – TIOSPIR [155]. Patients with COPD and concomitant cardiac
disease were included unless they had unstable CVD (MI in the last 6 months,
admission to hospital admission for New York Heart Association Functional
192 R. Pleasants
class III or IV, or unstable or life-threatening arrhythmia in the previous

12 months), as well as moderate to severe renal impairment. Among nearly
17,000 patients, tiotropium SMI was found to be noninferior to tiotropium DPI
with respect to the risk of death (hazard ratio 0.96). The incidence of major
cardiovascular adverse events (MACE) was also similar between the two tiotro-
pium groups, although a trend towards an increased incidence of myocardial
infarction was reported in the SMI group as compared with the DPI group (haz-
ard ratio 1.4, p = 0.06).
The most recent prospective studies to evaluate the CV safety of a LAMA were
the 3-year ASCENT study for aclidinium in subjects with CV disease or risk factors
[154] and a report on the effect of revefenacin on MACE in Phase III studies [175].
The primary objectives of the long-term Aclidinium Bromide on Long-Term
Cardiovascular Safety and COPD Exacerbations in PatieNTs with Moderate to Very
Severe COPD were to evaluate the long-term effects of twice-daily aclidinium on
MACE, overall safety, and COPD exacerbations in patients with moderate to very
severe disease with a history or significant risk factors for CV comorbidities and
renal insufficiency (ClCr <60 ml/min) [154]. Aclidinium met its primary safety end-
point, demonstrating a favorable CV safety profile, with the time to patients experi-
encing a first MACE similar to placebo.
LAMA/LABA Dual Bronchodilators Several new LAMA/LABA combination
products are available including umeclidinium/vilanterol, glycopyrronium/for-
moterol, and tiotropium/olodaterol. A LAMA with a LABA dual bronchodilator
product provides greater bronchodilation than that achieved with an ICS/LABA
combination and may have similar or greater effects on COPD exacerbations [176].
Among 3 clinical trials for indacaterol and glycopyrronium in more than 3000
subjects, there were no safety signals for CV events. A pooled safety analysis in
11,404 patients also reported that there were no greater risks on death, MACE, and
atrial arrhythmias of the combination vs placebo or tiotropium [177]. MACE tended
to occur in patients with a body mass index >30 kg/m2 given glycopyrronium vs
placebo.
The clinical studies of tiotropium/olodaterol, aclidinium/formoterol, and
umeclidinium/vilanterol did not show a safety signal regarding CV events; however,
as other key clinical trials for individual long-acting bronchodilators, subjects with
significant CV were excluded [131]. A 52-week study of glycopyrrolate/formoterol
MDI in 3274 moderate to very severe COPD patients also did not show an increased
risk of CV events including in comparison to tiotropium [178].
It appears that in certain COPD patients, bronchodilation can produce favorable
effects on the myocardium [179, 180]. A 2015 study in COPD patients with hyper-
inflation and heart disease showed cardiac benefits of indacaterol [179]. A crossover
study of indacaterol/glycopyrronium for 14 days vs placebo was undertaken to
assess effects on cardiac function. Treatment with indacaterol and glycopyrronium
increased left ventricular end-diastolic volume by ~6 ml/m2 as well as improve-
ments in right ventricular end-diastolic volume and cardiac output [180].
Anti-infectives
Fluoroquinolones Fluoroquinolones are widely used for COPD exacerbations due

to their spectrum of activity, availability of oral and IV formulations, modest cost,
and clinical trials supporting efficacy in COPD exacerbations. Fluoroquinolones are
associated with rare CV adverse effects, most often reported to be related to QTc
prolongation [181, 182]. Fluoroquinolones exhibit the potential, as do most other
agents that can cause QT prolongation, to block the cardiac voltage-gated potassium
channels, particularly the rapid component (IKr) of the delayed rectifier potassium
current (IK) [148, 181, 182]. Prolongation of the QT interval does not solely have
adverse cardiac effects, but, by causing early after depolarizations, may induce
TdP. Fluoroquinolones downregulate a gene involved in cardiac repolarization,
which can cause prolongation of the QT interval [148]. Grepafloxacin was with-
drawn from the market because of cardiac toxicity, whereas the cardiac risks of
those currently in clinical use are less clear. Data concerning CV risks of fluoroqui-
nolones are based on animal studies, drug development clinical studies, case reports,
and retrospective studies using large healthcare databases. Early clinical trials are
apt to not show this side effect as it tends to be rare and typically high-risk patients
are excluded from the Phase 2 and 3 studies.
In one study, 2 European healthcare databases were used to estimate the risk of
arrhythmias among adults treated with fluoroquinolones in Denmark (1997–2001)
and Sweden (2006–2013). Sixty-six cases of arrhythmia were identified among
more than 900,000 fluoroquinolone courses [183]. The low rate was nearly identical
to the rate of arrhythmia in an equally large control group that received penicillin
V. The most commonly prescribed fluoroquinolones were ciprofloxacin (83%) and
norfloxacin (12%); both of these fluoroquinolones have a relatively low arrhythmic
potential. A 2017 meta-analysis by Liu found that levofloxacin and moxifloxacin
were associated with an increased risk of TdP, whereas ciprofloxacin was not [184];
this is consistent with the potential for QTc prolongation of these fluoroquinolones.
It has been shown that the higher the fluoroquinolone dose and serum AUCs, the
higher the QT prolongation risk and subsequently the risk of TdP [181].
Macrolides Of the three principal macrolides on the US market, azithromycin is

the most commonly used for COPD exacerbations and as a maintenance therapy to
decrease exacerbation risks [185]. Like fluoroquinolones, the mechanism that
macrolides can cause a prolongation of the QT interval is blockade of the rapid
delayed rectifier potassium current (IKr) conducted by the human ether-a-go-go-
related gene (hERG)-encoded potassium channel [186]. In a study reported in the
package insert, azithromycin doses of 500 mg, 1000 mg, and 1500 mg were admin-
istered to 113 heathy subjects [75]. There was a dose-dependent effect of azithro-
mycin on the QTc interval of 5 ms, 7, ms, and 9 ms, respectively. A 2012 FDA
guidance on drugs that can be proarrhythmic reports that an increase in the QTc of
5 milliseconds (ms) should lead to additional studies evaluating potential cardiac
194 R. Pleasants
effects [153]. Thus, the effect of a azithromycin 500 mg dose based on a 5-ms
increase in QT would indicate that there is a low risk of CV adverse effects.
Oral azithromycin has low oral bioavailability of ~30% [75]; thus, intravenous
azithromycin would yield much higher concentrations and may have a greater risk of
cardiac events in the hospitalized setting where this route of administration might be
employed. The difference in potential cardiac effects of azithromycin between oral
and intravenous has not been elucidated. Intravenous erythromycin has been shown
to have a higher risk of QT interval prolongation than oral administration [187].
Published data concerning the potential cardiac effects associated with azithro-
mycin include animal studies, published case reports, prospective clinical trials
of macrolides for acute infections and anti-atherogenesis effects in coronary
artery disease, retrospective studies using healthcare databases, FDA spontane-
ous adverse event reporting system [188], and studies of chronic azithromycin for
COPD. Animal studies indicate azithromycin has a lower potential for prolong-
ing the QT interval than erythromycin and clarithromycin. At much higher con-
centrations than achieved clinically in humans, animal studies showed that
azithromycin exhibited either a very low [189–191] or no [192] potential for QT
interval prolongation. One study indicated even though azithromycin prolonged
QT interval at very high concentrations, ventricular arrhythmias did not occur
because of the manner of the drug affecting cardiac conduction [190]. Bradycardia
was reported with very elevated concentrations of azithromycin [190]. Macrolides,
like clarithromycin and erythromycin, are considered to have an increased risk of
causing TdP because of “metabolic liability,” that is, some macrolides are strong
inhibitors of CYP3A4. Azithromycin therefore has low metabolic potential [182].
Case reports have been sporadic [193] – this is notable considering the more than
40 million prescriptions for azithromycin during 1 year [145]. Data from FDA Adverse
Event Reporting System showed that between 2004 and 2011, there were a total of 203
reports of azithromycin-associated QT prolongation, torsades de pointes, ventricular
arrhythmia, and/or sudden cardiac death resulting in a total of 65 fatalities [194].
Clarithromycin was associated with a similar number of reports. The time frame that
included the US and European databases likely reflects several hundred million
patients who received azithromycin, manyfold greater than for clarithromycin.
Several retrospective studies using healthcare databases have been published
regarding potential azithromycin-associated cardiac effects [144, 195–198]. Studies
in the Tennessee Medicaid population [144] and the Veterans Administration health
system [196] reported an increased risk of cardiac events with azithromycin com-
pared to amoxicillin; the latter study also showed that levofloxacin was associated
CV greater risks. In the Medicaid study [144], although the authors attempted to
adjust for cardiac risk factors, among 20+ measures that may have affected outcomes
in these patients, 21 were worse in those persons receiving azithromycin. In both of
these studies, the increased cardiac events were more likely to occur in the first
5 days. One might expect that if it was a function of tissue concentrations in cardiac
tissues, the effects would be more likely to occur a week or longer into therapy as the
drug accumulated due to its 70-hour half-life [75]. Notably, in a retrospective study
in patients hospitalized for community-acquired pneumonia, the overall 90-day
mortality was lower in those who received azithromycin [198]. In that study, there
was either no difference in overall cardiac events and a slight increase of myocardial
infarction with azithromycin. Two large European retrospective studies – one in
Denmark and another using various databases throughout Europe – found no differ-
ence in cardiac events between azithromycin and amoxicillin [195, 197]. Both stud-
ies also found the risk was greater for azithromycin and amoxicillin than no antibiotic
therapy. Although these studies tried to account for other cardiac risk factors, the
reality is that quinolones and macrolides are more likely to be used in sicker patients
than amoxicillin as well as in patients not receiving antibiotics.
A meta-analysis was published that included 12 prospective placebo-controlled
clinical trials (n = 15,558). Four of the studies were of azithromycin for acute infec-
tions and five studies assess potential benefits of macrolides against Chlamydiae-
related atherogenesis in patients with coronary heart disease [199]. The latter
represents a population at high risk for CV events. No increased risks for total mor-
tality or CV events were found with azithromycin compared with placebo. These
prospective studies may represent the strongest evidence for the lack of significant
cardiac risks associated with azithromycin among the general adult population.
Several prospective studies have been conducted of chronic azithromycin to pre-
vent COPD exacerbations, where each of these studies excluded patients with
known prolonged QT intervals and significant cardiac risk factors [200, 201].
Neither study found an increased risk of cardiac events, although they excluded
high-risk patients. In all likelihood, the intense scrutiny of CV events and related
costs related to the use of azithromycin in COPD is disproportionate to the actual
risk associated with the drug.
Azoles Some azoles have rarely been associated with the development of TdP
and worsening of heart failure [182, 202]. Effects on the QT interval are slight
and the principal mechanism for these drugs is through inhibition of metabolism
of other agents. Itraconazole appears to be unique among the azoles as it has
been reported to worsen heart failure. The FDA recommends avoiding itracon-
azole in patients with ventricular dysfunction or a history of heart failure for
onychomycosis and only to consider itraconazole in case of life-threatening fun-
gal infections [203]. In the COPD patient population, with the typical long
courses of itraconazole for aspergillus lung infections in COPD patients, the
development or worsening of cardiotoxicity should be monitored. The mecha-
nisms of this adverse effect are unknown; however, potential etiologies include
inhibition of metabolism of endogenous hormones and negative inotropic effects.
dverse Effects of Cardiovascular Medications

A
on the Respiratory Tract
A number of cardiovascular drug therapies can cause adverse effects to the respira-
tory system. Adverse effects include bronchoconstriction, upper airway angio-
edema, cough, interstitial pneumonitis, organizing pneumonia, and eosinophilic
196 R. Pleasants
pneumonia. However, these adverse effects are uncommon, although they can be
associated with significant morbidity in some patients, rarely leading to death.
Considering the number of patients affected, perhaps the most important among
these is the concern that β-blockers can cause bronchoconstriction and thus worsen-
ing respiratory status in the COPD patient, leading to underutilization of a drug
class that is well established to decrease CV-related mortality.
Angiotensin-Converting Enzyme Inhibitors
All of the angiotensin-converting enzyme (ACE) inhibitors can induce a dry, persis-
tent, and sometimes nocturnal cough (in 5–20% of patients); yet these agents are
unlikely to worsen COPD or asthma [204]. It is more common in women, nonsmok-
ers, and African Americans [205]. The mechanism of the cough is due to mast cell
degranulation. The cough may develop within hours of the first dose to months later,
but usually occur within 1–2 weeks after initiation. The cough typically resolves
1–4 weeks after discontinuation of the ACE inhibitor, but in a subgroup, resolution
may take longer. An increased incidence of cough does not appear to occur with the
angiotensin II receptor antagonists and switching from an ACEI to one of these
agents usually leads to resolution of the cough. ACEI can also be associated with
angioedema and in its most severe form can cause airway obstruction [206].
Antiarrhythmics
Amiodarone and dronedarone (an analogue of amiodarone), used for atrial as well
as ventricular arrhythmias, are the principal antiarrhythmics reported to cause acute
interstitial pneumonitis [207, 208], typically reversible if identified early and effec-
tively managed effectively including discontinuing the drug. Initially, it was thought
that dronedarone did not cause pulmonary toxicity; however, in 2012 the FDA
issued a warning after reports of toxicity occurred [209]. Amiodarone and droneda-
rone pneumonitis have been reported to occur in as many as 5% of patients [210]. It
can present in an insidious or rapidly progressive manner, as soon as within days
after initiation of the drug or as long as years later [210].
Amiodarone and its metabolites as well as dronedarone produce lung damage
directly by a cytotoxic effect and indirectly by an immunological reaction [211,
212]. It appears to occur in a dose-dependent manner, and when amiodarone was
first marketed, doses of 400 mg daily were widely used, but today lower doses are
typically used and are less likely to cause pneumonitis. It has also been reported that
total cumulative dose may also be predictive of the risk of pneumonitis [211].
Although toxicity can occur at any time after treatment is initiated, those considered
at greatest risk are individuals who have received a daily dose of 400 mg or more for
more than 2 months, or lower doses, commonly 200 mg daily, for more than 2 years
[213]. It occurs more frequently in men and increases with age [214]. Individuals
with preexisting lung disease and males appear to be more susceptible [213, 214].
Systemic corticosteroids may provide benefit and drug discontinuation is necessary
in many patients, depending on the type of lung damage [210].
β-Blockers
β-Blockers decrease mortality and improve cardiac-related symptoms in patients

with CHF and ischemic heart disease; however, they are underutilized in patients
with concurrent COPD [215]. Reasons for underuse include the concern for wors-
ening respiratory status in obstructive lung disease in part due to the exclusion of
COPD patients from key clinical trials of β-blockers in heart failure and ischemic
heart disease. In a retrospective international study of patients admitted for acute
heart failure, it was found that COPD patients were underprescribed β-blockers
both upon admission and at discharge compared to those without COPD [216].
Another study found that non-cardioselective β-blockers were used in 3% of the
patients with atrial fibrillation and 26% of those with CHF – principally
carvedilol [217].
The mechanisms that β-blockers can improve outcomes in COPD patients
include benefits associated with the treatment of concurrent CHF and ischemic
heart disease, improved bronchodilator responsiveness by upregulation of
β-receptors within the lung, and decreased deleterious effects of β2-agonists on the
myocardium. β2-Agonists are unlikely to antagonize the effects of cardioselective
β1-blockers on adrenergic receptors in the heart; however, β2-agonist do stimulate
β2-receptors in the heart, which are known to be increased in the presence of CHF
[218]. Studies evaluating the effects of cardioselective β-blockers have found no
consistently deleterious effects on exacerbation risks [219–223], on pulmonary
function [219–222], or on exercise capacity [220] as well as showing mortality ben-
efits [222, 223].
Although decreases in FEV1 can be significant in some patients with nonselec-
tive β-blockers like propranolol and carvedilol, cardioselective β1-blockers (ateno-
lol, metoprolol, and bisoprolol) do not reduce FEV1 either acutely or with long-term
use. In a study of 12 COPD patients, it was found that metoprolol did not impede
the bronchodilator effects of isoprenaline, whereas propranolol did – two subjects
needed treatment of acute dyspnea when given propranolol during the investigation
[224]. In a study by Agostini in patients with CHF, changes in pre- and post-
bronchodilator (albuterol) FEV1 were greater with bisoprolol than carvedilol and
DLCO changes also favored the cardioselective β-blocker [225]. In another study
comparing bisoprolol and carvedilol in patients with COPD and CHF, FEV1
increased to a greater extent with the cardioselective agent [226]. One study did find
at high doses that cardioselective β-blockers may adversely affect the bronchodila-
tor response to albuterol, which was not observed with lower doses [227]. A
Cochrane review of 20 randomized trials of cardioselective β1-blockers in COPD
found no significant effect on FEV1 or bronchodilator response after a single dose
or up to 12 weeks of treatment [100].
198 R. Pleasants
Mortality benefits of β-blockers appear to be maintained in COPD patients in the

acute care and long-term settings. Two studies were performed in acute settings
[219, 223]. A single-center analysis found that β-blocker use in COPD was an inde-
pendent predictor of survival to hospital discharge, with no evidence that these
agents reduce the beneficial effects of short-acting β2-agonist use [228]. In a cohort
of patients with cardiovascular disease admitted due to acute COPD exacerbation to
404 acute care hospitals, there was no association between β-blocker therapy and
in-hospital mortality, 30-day readmission, or late mechanical ventilation [219]. Of
note, receipt of nonselective β-blockers was associated with an increased risk of
30-day readmission compared with β1-selective blockers. In a meta-analysis of 15
retrospective studies of 21,596 patients with COPD, the pooled estimate for reduc-
tion in overall mortality attributed to the use of β-blockers was 28% and for exacer-
bations was 38%. The reduction in mortality was 26% (95% CI, 7–42%) in the
subgroup with known HF [222]. A 2019 study, (BLOCKCOPD), [229] investigated
the role of cardioselective metoprolol to decrease exacerbations in COPD patients in
whom β-blockers were not otherwise clinically indicated such as in CHD. This pla-
cebo-controlled study was terminated early because of increased severe COPD
exacerbations and a trend towards mortality in the treatment arm, although the time
to first exacerbation was shorter with metoprolol. This suggests that primary benefits
of cardioselective β-blockers in COPD occur at least in part due to cardiac effects.
dverse Effects of Drugs Used for the Treatment of Pulmonary

A
Hypertension in the COPD Patient
Pulmonary arterial hypertension (PAH) occurs in a minority of COPD patients,

typically occurring late in the disease in those with chronic hypoxemia or those with
combined pulmonary fibrosis and emphysema. As COPD progresses, hypoxia may
activate vasoconstriction meant to increase the amount of oxygen transferred to the
blood, where chronic hypoxic vasoconstriction leads to PAH. PAH in the COPD
patient is classified as World Health Organization Group III [230]. Numerous drugs
are now available for the treatment of PAH including phosphodiesterase inhibitors
such as sildenafil and tadalafil, endothelin receptor blockers such as bosentan and
macitentan, and prostacyclins such as IV epoprostenol and oral, IV, and inhaled
trepostinil [231, 232]. Newer agents include selexipag and riociguat that work
through somewhat different mechanisms, affecting the same pathways on vascular
smooth muscle. Selexipag is a highly selective, high-affinity agonist of the prosta-
cyclin receptor. Riociguat acts on the nitric oxide pathway by promoting the pro-
duction of cyclic guanosine monophosphate through sensitizing to endogenous
nitric oxide and directly stimulating soluble guanylate cyclase independent of its
effects on nitric oxide. These medications can exhibit both vasodilatory and antip-
roliferative effects that help to decrease the load on the right ventricle.
Side effects of these medications are widely varied depending on the mechanisms
and individual agent within classes including hypotension, liver dysfunction,
headaches, blood disorders, GI intolerance, and dermatological disorders, among oth-

ers [231, 232]. The primary pulmonary-related concern is worsened respiratory status.
Deterioration of oxygenation due to ventilation/perfusion mismatching is the primary
reason for deterioration of respiratory status. However, these agents can improve respi-
ratory status including exercise capacity among other benefits in COPD patients.
Use of drug therapies for PAH in patients with COPD remains poorly defined,
largely owing to sparse evidence. A survey of US pulmonary hypertension treat-
ment centers reported various approaches to treating the COPD/pulmonary hyper-
tension patient including using FEV1 and right heart catheterization data. The
minority indicated they do not use drug therapies to treat these patients [233].
Studies are conflicting regarding risk of worsened hypoxia when initiating these
agents in COPD patients. In a placebo-controlled pilot study in severe PAH in 28
GOLD stage II and III COPD patients, with modest oxygen requirements and not in
decompensated heart failure, it was found that sildenafil had a favorable hemody-
namic effect, with no significant effect on gas exchange and a good safety profile
[234]. They also observed a statistically significant increase in the DLCO% in the
treated group (32.8–35.0%). Another study evaluated 20 COPD patients with PAH
before and after a randomized single dose of sildenafil (20 or 40 mg), where both
doses improved pulmonary hemodynamics at rest and during exercise, but wors-
ened arterial oxygenation at rest [235]. A 2017 meta-analysis of five randomized
clinical trials of sildenafil and tadalafil among 257 COPD patients showed that
symptoms were not reduced, nor reduced pulmonary artery pressure and pulmonary
vascular resistance; however, hypoxia was not worsened [236].
In a randomized study of bosentan in 30 patients with severe COPD, 20% with
pulmonary hypertension at rest showed no significant functional benefit, and it was
found that arterial oxygenation and quality of life declined in patients taking bosentan
compared with placebo [237]. A placebo-controlled trial of 16 COPD patients in
severe acute respiratory failure and mild PH showed that intravenous epoprostenol
treatment was associated with a transient improvement in pulmonary pressures, but
also with a significant decrease in oxygenation, rendering intravenous prostacyclins as
nonselective vasodilators [238]. Inhaled prostacyclins may work preferentially in ven-
tilated regions of the lung due to deposition to unobstructed areas of the lung, avoiding
nonselective vasodilation and worsening ventilation/perfusion mismatch. Inhaled
treprostinil in nine COPD patients with PAH showed that most patients tolerated the
drug, although the minority had moderate to severe adverse reactions including wors-
ening shortness of breath and exacerbation. FEV1, FVC, and DLCO declined, whereas
measures like 6MWT and ABG overall did not change [239]. In an acute vasodilator
study in ten COPD patients with PAH (based on echocardiography), inhaled iloprost
was associated with improvement in ventilation/perfusion matching [240]. Another
study in COPD/PAH patients showed that inhaled prostanoids can acutely reduce
mean pulmonary artery pressures while largely maintaining gas exchange [241].
Based on current evidence, treatment of PAH due to chronic respiratory condi-
tions centers on the optimization of the management of the underlying lung disease.
One group of authors suggested that drug therapy for pulmonary hypertension
should be considered (1) when pulmonary hypertension persists despite the normal
200 R. Pleasants
care being optimal such as using nonpharmacological interventions like supplemen-

tal oxygen and COPD medications and (2) when pulmonary hypertension is consid-
ered to be disproportionate to the degree of airflow limitation. Data is sparse, and
based on the list from clintrials.gov in early 2018, the newer agents do not have any
ongoing studies for COPD patients with PAH.
Conclusion
In the spirit of the first rule of Hippocrates – first do no harm – minimizing adverse
effects of drug therapies used for COPD patients with cardiac disease is important
when prescribing and monitoring medications. This is challenging if the mechanism
that the drug benefits one condition can also worsen the other. Compared to oral or
parenteral medications, inhaled therapies are relatively safe; however, it can cause
extrapulmonary side effects as most of each inhaled dose is eventually absorbed into
the bloodstream.
By the inherent mechanisms of action of the principal COPD drugs – β2-agonists,
antimuscarinics, and corticosteroids – all have the potential to adversely affect the
CV system. In the case of inhaled bronchodilators, reported side effects include
tachycardia, arrhythmias, hypertension, myocardial infarction, and stroke. Some
retrospective studies and meta-analysis have indicated that inhaled bronchodilators
are associated with increased cardiac events. These studies are limited by the ability
to control for the numerous factors that can influence outcomes – yet may provide
some indication that LABA and LAMA may affect CV outcomes in the “real
world.” However, there are now several large prospective studies in COPD patients
with heart disease that show these inhaled bronchodilators exhibit an acceptable
risk/benefit – and may even have positive effects in heart disease under certain
circumstances.
Whereas inhaled steroids are not associated with adverse cardiac effects, sys-
temic steroids can worsen heart failure and contribute to tachycardia. In contrast,
there is some evidence that inhaled steroids either do not affect or possibly could
benefit heart disease. Systemic steroids have also been associated with a decreased
risk of arrhythmias.
Medications to treat heart disease can have significant adverse effects on the
respiratory system including β-blockers, some antiarrhythmics, and ACEI. As long
as β2-cardioselective β-blockers are utilized in the COPD patient, there is minimal
negative effects on respiratory function and may improve cardiac and pulmonary
outcomes including exacerbations and mortality. Likewise, drugs for the treatment
of pulmonary hypertension can provide cardiopulmonary benefits, yet they may
also worsen respiratory status in the COPD patient.
Anti-infectives, used in the short term for exacerbations or in the long term for
prevention, may also be associated with adverse cardiac effects by directly affecting
the heart or indirectly through drug interactions. Differences in the potential for
drug interactions and cardiac effects among the anti-infectives should be considered
when using these agents. Assigning a potential drug interaction to a class of anti-
infectives is incorrect as there can be substantive differences among the similar
agents within that class.
There is a significant amount of pharmacokinetic and pharmacodynamic data of
inhaled and oral therapies, although not always specifically studied, considering
disease-related disposition and relevant drug interactions could lessen adverse
effects. Thus, the information presented in the chapter could be used to guide
selection and monitoring of drug therapies. Notably, considering many of the
inhaled drugs are heavily dependent on liver metabolism, the effect of CHF on
hepatic drug clearance is largely unstudied. It is not possible to avoid these inhaled
or systemic drugs in the COPD patient with heart disease; otherwise, the conse-
quences would be quite profound considering limitations from debilitating short-
ness of breath and health impairment. Therefore, we must continue to strive to best
understand how to optimize these therapies at the population level and in individ-
ual patients.
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Chapter 11
Cardiovascular Co-Morbidity in Chronic
Lung Disease: Exercise Training
Rachael A. Evans
Clinical Pearls
• Unstable cardiac disease must be optimally managed prior to participation
in an exercise program, but patients with co-morbid cardiac disease should
not be routinely excluded from participation.
• Recommended components of an exercise training program such as com-
bined aerobic and resistance training are strikingly similar for both cardiac
and pulmonary conditions.
• The pulmonary rehabilitation team should receive adequate training on dif-
ferent cardiac conditions and symptoms of decompensation akin to under-
standing chronic lung diseases and exacerbations.
Introduction
Although the services of cardiac rehabilitation (CR) and pulmonary rehabilitation

(PR) are organised according to specialty, this is a slight misnomer as the main
benefits of both services occur via the systemic features of the conditions. Many
patients do not fit neatly into one disease or specialty category. The prevalence of
cardiovascular disease in patients with COPD referred for PR is estimated to be
between 20% and 50% [1, 2]. In a CR population, only 6% had underlying respira-
tory conditions but this is likely to be an underestimate either due to under-diagnosis
R. A. Evans (*)
National Institute of Health Research Biomedical Research Centre, Respiratory Sciences,
University of Leicester, Leicester, UK
Department of Respiratory Medicine, Thoracic Surgery and Allergy, Glenfield Hospital,
University Hospitals of Leicester NHS Trust, Leicester, UK
e-mail: re66@leicester.ac.uk

214 R. A. Evans
or referral bias [3]. The prevalence of COPD when systematically assessed in

patients undergoing percutaneous coronary intervention was nearly 25%. There is
therefore a need to consider how services are organised for patients to maximise
benefit both in terms of access and in receiving a tailored program which best serves
their individual needs.
This chapter provides an overview of the existing CR and PR models, but will
focus on how all elements of the PR model can be best tailored for the patient with
chronic lung disease and a cardiovascular co-morbidity.
reathlessness and the Role of Pulmonary Rehabilitation

B
for Chronic Lung Disease
Despite differing underlying pathology among chronic lung diseases, the conse-
quent symptomatology is extremely similar. Exertional breathlessness is one of
the most commonly experienced symptoms and results in a variety of clinical
problems. Early on, sufferers reduce either the distance walked or the walking
speed to reduce breathlessness. Although almost undetectable initially, partly due
to assumptions that ‘slowing down’ is a natural part of aging, over time activity
reduces to the point where it is unacceptable to the person and typically triggers a
visit to a healthcare professional for assessment. Physical inactivity and decon-
ditioning are associated with the well-described skeletal muscle impairment in
chronic lung disease which increases the load on an already burdened ventilatory
system, thus worsening breathlessness. Further negative consequences impair
almost all aspects of life including work, social activities, hobbies, and family
life. The feeling of breathlessness is very frightening and evokes anxiousness, and
coupled with the social impacts above, depressive symptoms become very common.
PR targets all the described extra-pulmonary manifestations of chronic lung
diseases such as skeletal muscle impairment, mood disturbances, and bone and
cardiovascular diseases causing improvements in dyspnea, walking distance, and
health-related quality of life [4]. There are no improvements in lung function and
hence this is not the mechanism of benefit. The recommended components of PR
are individually prescribed exercise training, multidisciplinary education, self-
management, and psychosocial support. It developed through the 1970s with the
first randomised controlled trial of PR versus usual care published in the 1980s.
Subsequently, a body of work evolved and a recent meta-analysis confirmed PR as
one of the, if not the most, effective treatments for patients with chronic lung dis-
ease [5]. PR results in reduction in dyspnea, improvements in health-related qual-
ity of life, and increased walking distance. Although much of the original research
involved predominantly patients with COPD, PR is beneficial for many patients
with chronic lung disease such as interstitial lung diseases and bronchiectasis, and
inclusion in PR programs is recommended [4]. Patients with severe disease should
11 Cardiovascular Co-Morbidity in Chronic Lung Disease: Exercise Training 215
not be excluded including those with respiratory failure and cor pulmonale [4].
Benefits of PR extend to a reduction in hospital bed-days in the year post-PR with
improvements in known prognostic factors such as exercise capacity. To date,
there are no trials with an adequate sample size to definitively report the effects
upon survival and it may be unethical to conduct such trials contemporarily.
econdary Prevention in Cardiovascular Disease and the Role

S
of Cardiac Rehabilitation
The traditional population for CR includes patients who are post-myocardial infarc-
tion, coronary artery bypass grafting, percutaneous coronary intervention, and non-
coronary heart surgery. The process of CR has three phases and is initiated at the
point of the ‘event’:
• Phase 1 – Initiated while the patient is still in the hospital
• Phase 2 – A supervised ambulatory outpatient program typically lasting
8 to 12 weeks
• Phase 3 – A lifetime maintenance phase in which physical fitness and additional
risk factor reduction are emphasised
The typical components of phase 2 include the management of nutrition, weight,
blood pressure, lipids, diabetes, tobacco cessation, psychosocial issues, physical
activity counselling, and exercise training. A recent meta-analysis of exercise-based
CR versus usual care showed the intervention to be associated with an improvement
in health-related quality of life and a reduction in admissions. However, despite a
reduction in cardiovascular mortality, but not overall mortality, the risk of myocardial
infarction is unchanged [6].
Data from the UK National Audit of Cardiac Rehabilitation (NACR) showed that
only 27% patients received a measure of exercise performance perhaps inferring
that aerobic training prescription is not routinely individually prescribed in practice
[7]. The American Heart Association guidelines recommend 30 minutes of at least
moderate-intensity physical activity a minimum of five times a week [8]. However,
importantly a physical activity history is provided as an alternative to an exercise
test to guide prescription. This is particularly relevant to patients with heart failure
as individually prescribed moderate- to high-intensity aerobic exercise training was
an essential part of the Heart Failure: A Controlled Trial Investigating Outcomes of
Exercise Training (HF-ACTION) trial [9]. The positive results of the latter trial
contributed a large part to Medicare supporting reimbursement for CR in patients
with heart failure in 2014. A question therefore remains as to which model of
rehabilitation (cardiac or pulmonary) is most relevant to the breathless patient with
heart failure [10].
216 R. A. Evans
ardiovascular Risk in Chronic Lung Disease

C
and Breathlessness in Heart Failure
As described in Chap. 5, cardiovascular disease is a common co-morbidity of many

chronic lung diseases by shared risk factors of smoking and physical inactivity and
potentially underlying systemic inflammatory pathways. In a cohort of patients with
COPD attending PR, arterial stiffness was increased in comparison to healthy
controls [11] and similar data has recently been reported in bronchiectasis [12]. The
PR population typically has multiple co-morbidities including cardiovascular
disease and they do as well from PR [13]. Other data suggests a prognostic role of
cardiovascular disease as patients with mild to moderate COPD more commonly die
from cardiovascular disease than respiratory failure. Although improving exercise
capacity may improve cardiovascular risk, currently cardiovascular risk reduction is
not part of the assessment, process, or outcome of PR.
Abdominal aortic aneurysms (AAA) are common in patients with COPD due to
shared risk factors and there is often concern about the safety of exercise, particularly
of high-intensity exercise. Expert opinion suggests participation in PR for AAA
<5.5 cm; for aneurysms >5.5 cm, surgery is indicated depending on fitness. In cases
where surgery is contraindicated, mild to moderate exercise, with the avoidance of
exercise that precipitates transient increases in blood pressure such a high load
resistance training, is recommended [14].
Exercise training is recommended for patients with heart failure and a meta-
analysis of exercise rehabilitation versus usual care reported improvements in the
intervention group in health status with a reduction in healthcare utilisation but no
difference at 1 year in mortality [15]. Exercise training may also improve left
ventricular function through remodelling. Patients with heart failure (particularly
those with reduced ejection fraction where the literature is greatest) are currently
referred to CR but their symptoms and disability have more in common with patients
with chronic lung disease than the traditional CR population. Currently, only a small
proportion of patients with heart failure who might benefit receive CR in the UK
which is likely to be mirrored in other countries. In the USA, less than 30% of the
traditional patients post-MI and CABG are referred for CR [16]; it is therefore
reasonable to assume an even lower proportion for patients with heart failure since
reimbursement via Medicare only became available within the last 5 years.
Patients with pulmonary hypertension are another potential outlier to the current
exercise rehabilitation service structure. Exercise training improves exercise perfor-
mance and health-related quality of life and appears to be safe for patients with pul-
monary hypertension but which service should they be referred to? They are similarly
breathless on exertion to patients with chronic lung disease and therefore would ben-
efit from the symptom-based approach of PR, but their demographics and potential
need for cardiac monitoring would be more similar to a patient with cardiac disease.
There is a growing rationale to combine the approaches of CR and PR. However,
as the focus of this book is to understand cardiovascular disease in chronic lung
disease, the following section will focus on any adaptations necessary to the process
of PR for a patient with conditions across both cardiac and pulmonary specialities.
he Process of Pulmonary Rehabilitation and Modifications

T
Needed for Cardiovascular Disease
Assessment
The assessment is the time to further inform patients about the aims and the pro-
cess of pulmonary rehabilitation. There should be a systematic assessment of the
inclusion and exclusion criteria. The main inclusion criterion is breathlessness
limiting exertion commonly assessed by the Medical Research Council (MRC)
dyspnea scale of ≥2. Guidelines recommend MRC grades 3–5 but patients with
milder breathlessness (MRC 2) also benefit and are often included [17]. Exclusion
criteria include major neurological or musculoskeletal deficit preventing ability to
exercise or safety concerns such as unstable cardiac disease, for example, a myo-
cardial infarction within 4 weeks, unstable arrhythmias, unstable angina, and
unstable heart failure or severe aortic stenosis. Patients with pulmonary hyperten-
sion, right heart failure, heart failure with reduced or preserved ejection fraction,
angina, atrial arrhythmias, or other cardiovascular disease should not be routinely
excluded from participation in a PR program, but should be optimally managed
by an appropriately skilled healthcare professional prior to referral. As described
in Chap. 8, patients with chronic lung disease and co-existent cardiac disease have
more symptoms, worse exercise performance and health-related quality of life,
and so it is important that they are not excluded from a therapy with known
benefit.
An assessment of dyspnea, exercise performance, and health status before and
after the program is standard and can inform both individual progress and program
quality. An exercise assessment is performed to inform the exercise prescription,
requirements for safety, and as a baseline for the exercise outcome. It is increasingly
performed using simple, inexpensive field tests rather than expensive laboratory-
based exercise equipment. Blood pressure (BP) monitoring should be performed
before and after exercise. Symptoms of chest tightness causing exercise cessation,
symptomatic reduction of 10 mmHg in systolic BP, and either pre-syncope or
syncope on the exercise test should all precipitate a medical review prior to
participation. The need for electrocardiography throughout an exercise test for
cardiovascular disease is debated (but mostly employed), whereas this is rarely
performed for a PR assessment.
Patients with resting hypoxia should exercise with supplemental oxygen. The
criterion for ambulatory oxygen varies among jurisdictions. Those who desaturate
markedly on exercise to oxygen saturation <85% are often offered supplementary
oxygen during training but to date there is no evidence of superior efficacy. There
is often concern around patients who desaturate but this is frequently an everyday
occurrence for the individual. The American College of Sports Medicine advises
to only terminate exercise tests if the desaturation is accompanied by a complica-
tion such as arrhythmia, pre-syncope, or chest pain.
218 R. A. Evans
Outcome Measures
Cardiopulmonary exercise test is described in detail in Chap. 10.

The following field tests have been validated in both pulmonary and cardiac
conditions and would therefore be appropriate for patients with both chronic lung
and cardiovascular disease.
Six-Minute Walk Test
The most commonly used field test is the six-minute walk test (6MWT) which is
completed over a 30-meter flat course. It is self-paced, and standardised instructions
are given as the distance walked can be influenced by encouragement. Patients are
asked to walk as far as they can for 6 minutes and the result is usually presented as the
distance walked, although the speed can be calculated. The test is reproducible after
two practice tests and is responsive in both chronic lung and cardiovascular diseases.
Normal reference values for many different populations are available. It is often
referred to as a measure of functional capacity but in more severe disease it can reflect
maximal exercise capacity. The 6MWT distance is highly correlated with other out-
comes such as mortality for both chronic lung and cardiovascular diseases and is
featured in a multidimensional severity index, the BODE index, for COPD. It is used
to set exercise prescription for PR (usually as a percentage of the overall speed), but
the intensity will vary between individuals, will often reflect only mild to moderate
intensity training, and therefore may not be the best test available for this purpose.
Incremental Shuttle Walk Test
The incremental shuttle walk test (ISWT) is a symptom-limited, externally paced

test, conducted along a 10-meter course, and reflects maximal exercise capacity.
The walking speed increases every minute until the patient is too breathless or
fatigued to continue or can no longer maintain the required speed. The result is
presented as the total distance achieved. It is reproducible after a single practice test.
In contrast to the 6MWT, the ISWT has a graded physiological response. However,
normal reference values are not currently available. The test is also reliable, valid,
and interpretable, making it an excellent evaluative test.
Endurance Shuttle Walk Test
The endurance shuttle walk test (ESWT) was developed as a test of submaximal
exercise capacity. It is similarly symptom-limited and externally paced and uses the
same 10-meter course as the ISWT. After a two-minute warm-up, the patients walk
at the set speed until they can no longer maintain the required speed or are too
breathless or fatigued to continue. The result is presented as the time walked after
the warm-up and is reproducible after a familiarisation test. The advantage of the
ISWT and ESWT is the ability to develop individualised exercise prescriptions for
pulmonary rehabilitation. The speed of the walk can be set at a high intensity (85%
of the predicted peak oxygen consumption) derived from the ISWT distance. The
duration of the walk can then be progressed throughout the program. Both the ISWT
and ESWT are responsive outcome measures.
Peripheral Muscle Strength
Increasingly, measures of strength are included in a PR assessment most commonly

either finger grip strength or quadriceps strength. Isometric strength can be measured
using a handheld dynamometer or a strain gauge. A one-repetition maximum
(1-RM), the maximum weight a person can lift in one manoeuver, can be used with
knee extensor gym equipment. Isokinetic dynamometry is less frequently used for
clinical purposes.
Health-Related Quality of Life
Health-related quality of life is commonly assessed by questionnaires for clinical

and research purposes. Generic questionnaires such as the short-form 36 (SF-36)
and the EuroQol (EQ-5D) have been validated in both cardiac and respiratory
populations and tend to be discriminative but less responsive. The EQ-5D has the
added value of enabling cost-effectiveness to be calculated. They are also helpful in
assessing the multi-morbid patient. However, disease-specific questionnaires have
been developed in order to be more specific and are often more responsive to inter-
ventions. The Chronic Heart Questionnaire (CHQ) and the Chronic Respiratory
Questionnaire (CRQ) are almost identical except for one question despite being
developed in different populations by the same research team. They are valid and
responsive, and pragmatically either would be a good option to use for patients with
combined chronic respiratory and cardiovascular disease.
Anxiety and Depression
The Hospital Anxiety and Depression scale has been extensively used in a variety of
chronic cardiac and pulmonary diseases separately (and in many other long-term
conditions) and therefore pragmatically would be reasonable to use this for the
patient with combined cardiopulmonary disease.
Dyspnea
The Medical Research Council dyspnea scale assesses the degree of activity limita-
tion caused by breathlessness and is valid and reproducible. It is most commonly
used as an inclusion criterion for referral to PR rather than as an outcome measure.
220 R. A. Evans
The Borg breathless scale is commonly used to assess the degree of breathlessness
experienced at the end of an exercise test and is not disease-specific. However, it is
important to understand the impact of breathlessness on quality of life for which
there is the dyspnea domain of either the CHQ or the CRQ. However, scientifically
it is not recommended to report sections of questionnaires that have been validated
as a whole. Two questionnaires have been validated in both cardiac and pulmonary
conditions: the Multidimensional Dyspnea Profile questionnaire (MDP) [18] and
the Dyspnea-12 Questionnaire in patients with COPD, interstitial lung disease, and
chronic heart failure [19], and therefore either would be suitable for use for the
patient with both a pulmonary and cardiac condition.
Frailty Measures
Fried and colleagues defined frailty as a clinical syndrome in which three or more of
the following criteria are present: unintentional weight loss (10 lbs in the past year),
self-reported exhaustion, weakness (grip strength), slow walking speed, and low physi-
cal activity. Measures associated with frailty such as the Short Physical Performance
Battery (SPPB) and Timed Up and Go (TUG) have recently been extensively evaluated
in patients with chronic lung disease, and PR can modify frailty [20]. The results may
indicate a need for a targeted intervention such as balance training or strength training.
Exercise Prescription
The Effects of Physiological Aerobic Training
In health, the physiological effects of aerobic training occur predominantly within

the cardiovascular system and the skeletal muscle of the lower limbs. The
cardiovascular effects are both central and peripheral. The central effects result in a
lower resting heart rate by improving the efficiency of each heartbeat, i.e. increase
in stroke volume. With regular training, the oxidative capacity of the skeletal muscle
is increased by increasing peripheral vasculature particularly capillarisation and
thereby increasing blood flow, increasing the proportion of type 1 (slow-twitch non-
fatigable muscle fibre type), increasing the oxidative enzymes, and increasing
mitochondrial number. All these effects result in more efficient energy production
and utilisation, and therefore increase performance. There are also psychological
effects of training such as increasing tolerance of physical discomfort.
In chronic lung diseases, the effects of high-intensity aerobic training are largely
secondary to skeletal muscle adaptations. Central cardiovascular effects are rarely
achieved probably due to the low absolute training intensities achieved. The results
after training for the individual are either performing the same task with less dys-
pnea or improving physical performance for the same degree of dyspnea. There may
also be improved tolerance of dyspnea. Overall exercise training as part of PR pro-
grams results in increased health-related quality of life. The same benefits are not
seen if the training component is removed.
Patients with heart failure can also improve their exercise performance with
high-intensity aerobic training. The lower limb skeletal muscle improvements are
similar to that seen in patients with COPD. However, left ventricular remodelling
may also occur for patients with heart failure, whereas underlying pulmonary func-
tion is not altered by exercise training for patients with chronic lung diseases. The
mechanisms of benefit of aerobic training in patients with coronary heart disease are
predominantly similar to those in health.
Fundamental Principles Behind the Aerobic Exercise Prescription:
• The ‘currency’ for exercise is energy and in mammals ‘dollars’ are molecules
called ‘adenine trinucleotide phosphates’ or ATP.
• Different foods have a different energy equivalent per gram, for example, fat
approximately equates to 8 kcal and carbohydrate to 4 kcal and are utilised
differently by different organs.
• Skeletal muscle uses fatty acids (fats), glucose (carbohydrate), and amino acids
(protein) to generate energy.
• This energy needs replenishing in order to sustain exercise and different sub-
strates are used depending on the duration and intensity of exercise.
• In its simplest definition, anaerobic metabolism describes a pathway to make
energy without using oxygen and produces lactate as a by-product.
• Aerobic metabolism uses oxygen for glycolysis and energy is made in the mito-
chondria via the Krebs cycle producing two ATP molecules and the electron
transport chain producing 36–38 ATP molecules.
• The anaerobic threshold can be identified by the inflection point when the vol-
ume of oxygen utilised (VO2) is plotted versus volume of carbon dioxide elimi-
nated (VCO2) or by measuring serial blood lactate levels (see Chap. 10).
• The heart rate and/or oxygen uptake at the anaerobic threshold can be estimated
via a maximal incremental exercise test typically on a cycle ergometer.
• Critical power (or speed for walking) is the power below which exercise theo-
retically can be sustained indefinitely. Critical power would typically fall below
the anaerobic threshold. The relationship between power (or speed) and dura-
tion is not linear (which is particularly relevant if an endurance test is being
used as an outcome measure for an intervention such as pulmonary
rehabilitation).
• Usually a maximal exercise test, designed to reach the maximal oxygen uptake
(VO2 max) of the individual, would be used to ‘set’ the exercise prescription for
an endurance exercise session.
• High-intensity training prescribed between 60% and 80% of VO2 max or heart
rate is more effective in improving exercise capacity than low-intensity training
for chronic lung and heart diseases.
• For a high-intensity exercise session, the prescription would be set above the
anaerobic threshold, but ideally would be sustained for 20–30 minutes before
symptom limitation. Even in healthy adults, this is difficult to estimate accurately
and some adjustment is often needed.
222 R. A. Evans
• During high-intensity training, ideally a plateau of heart rate and peak oxygen
consumption will occur at the estimated peak heart rate or peak VO2 prescribed,
but commonly they will continue to increase and exercise will terminate due to
symptom limitation before the ideal 20–30 minutes.
xercise Prescription for Individuals with Chronic Lung Disease or

E
Cardiovascular Disease
To achieve beneficial exercise training, it needs to be prescribed akin to any medica-

tion. ‘FITT’ is a useful acronym which describes the components of the prescription
(Table 11.1).
Frequency
A minimum recommendation of three sessions (at least two supervised sessions)

per week is recommended for both chronic lung and cardiac conditions.
Intensity
High-intensity lower limb training is recommended for both chronic lung disease
and heart failure [4]. The recommendations for desired intensity for patients with
coronary artery disease varies across countries; North American, and European
guidelines suggest moderate to high-intensity training, whereas UK, Australia, and
New Zealand recommend lower-intensity training.
A maximal exercise test is often used to prescribe exercise: a laboratory cardio-
pulmonary exercise test on either a cycle ergometer or treadmill, or a field test such
as the incremental shuttle walk test (ISWT). Individuals with chronic lung disease
are commonly not able to achieve the necessary plateau to represent VO2 max on an
exercise test and therefore the term VO2 peak is used. A 60–80% peak VO2, peak
power, or peak heart rate is typically used for the exercise prescription.
The formula below is used to estimate the peak VO2 for the ISWT distance
achieved.
Predicted VO 2 peak [ ml / min/ kg ] = 4.19 + ( 0.025 ´ ISWT distance [ m ])

Table 11.1 The ‘FITT’ method of exercise prescription

Frequency Number of exercise sessions per week
Intensity Intensity of training typically prescribed from a maximal
exercise test
Time Duration of training session and length of exercise program
Type Mode of exercise
Fig. 11.1 Setting the 20

walking speed from an
incremental shuttle
walk test
Predicted VO2 peak (ml/min/kg)

15
10
0
0 1 2 3 4 5 6 7 8
Walking speed (km/h)
A training intensity of 85% VO2 peak is frequently used for chronic lung disease
when using the ISWT. The walking speed necessary to achieve this VO2 can be
estimated from Fig. 11.1 below and the endurance shuttle walk test (EWST) can be
used to externally pace the speed of the walk.
The ESWT can be used both for the exercise prescription and as an outcome of
pulmonary rehabilitation. There are 16 levels at different speeds. The same 10-m
course for the ISWT is used. The end point of the test is how long the patient walks
at the constant endurance speed. The test is stopped by the operator if 20 minutes
are achieved.
For example, if the ISWT distance was 400 m, the approximate peak VO2 is
14.19 ml/min/kg; 85% of peak VO2 is 12.09, and the walking speed is 4.6 km/h.
There are 16 walking speeds for the ESWT so the nearest walking speed should be
selected. For this example, the walking speed would be level 11, 4.65 km/h.
Time
The duration of the endurance exercise should be between 20 and 30 minutes.
Type
Walking and cycling are the common training modalities used but other modalities
have been used in both chronic lung and cardiac conditions such as water-based
training and resistance training.
224 R. A. Evans
xercise Training Prescription Variation Due to a Central

E
Limitation to Exercise
In practice, individuals with COPD rarely achieve 20–30 minutes of continuous

high-intensity training at 80% peak VO2. This is largely due to a ventilatory limita-
tion to exercise caused by a combination of airflow limitation, air trapping and
dynamic hyperinflation, and hypoxemia. To respond to the increasing demands dur-
ing exercise, ventilation (L/min) needs to increase. In people with normal lungs,
this is usually achieved without difficulty and the achievement of maximal heart
rate typically terminates exercise. In individuals with fixed airflow obstruction,
there is a point when ventilation is unable to be increased further as maximum
voluntary ventilation (MVV = FEV1 × 37.5) has been achieved. The only way of
matching the demands is to increase the respiratory rate which quickly becomes
intolerable.
Alternative exercise strategies have been designed to either increase peak
ventilation such as the use of non-invasive ventilation during exercise, long-
acting bronchodilators, supplemental oxygen, and breathing helium-hyperoxia.
Other strategies have focused on delivering increased stimulus to the skeletal
muscle without increasing ventilation demands such as neuromuscular stimula-
tion or reducing the exercising muscle mass by exercising one leg at a time
(either cycling one leg at a time or knee extensor training). The latter tech-
niques have also yielded positive results in heart failure. Interval training has
also been used by alternating high-intensity training for short periods with
either rest or low-intensity training. Overall, the results of interval training are
similar to continuous training for chronic lung disease [21] but may be superior
in heart failure [22].
Strength Training
Strength training has received much attention over the last two decades and is rec-
ommended by international guidelines for both patients with chronic lung disease
and cardiovascular disease. Although muscle strength is improved with resistance
training compared to endurance training alone, this has not translated to additional
improvements in exercise tolerance or health status in either chronic heart or lung
conditions. It has been shown to be safe in both conditions. Ideally, resistance
training should be individually prescribed, for example, at 40–60% of the one rep-
etition maximum, and progressed through the program. The studies advocating
strength training were performed on gym equipment but lower limb exercise in
practice often consists of sit to stand, step ups, and leg raises, progressing through-
out the program, but these exercises have not been thoroughly evaluated. Ankle
weights can also be employed to add resistance.
Other Training Components
There are other components of training such as inspiratory muscle training which
may reduce dyspnea in patients with chronic lung disease or heart failure, but simi-
lar to strength training, these effects do not translate to additional improvements in
walking performance or health status when added to aerobic training.
The Rehabilitation Team
An educated confident multidisciplinary team is key to the success of a PR program.

However, identifying the key education needs for a PR team and any additional
training to manage cardiovascular disease has not received the same research rigor
as the other aspects of a program. Training in cardiovascular diseases similar to
recommendations for chronic lung disease would seem necessary. Understanding
hypoxemia, arrhythmias, decompensation of heart failure, or cor pulmonale should
be included.
Setting
Until the last decade, the most common setting for PR was hospital outpatients
mostly due to safety with a hospital acute response or arrest team on standby and
medical opinions equally readily available. However, due to the unacceptability of
travel to the hospital or group-based therapy, home-based rehabilitation has been
evaluated. A recent study comparing home-based PR versus centre-based PR was
reported with the former being non-inferior [23] but the results from the centre-
based supervised program were lower than typically seen. Recent trials have not
reported severe adverse events without routine exclusion of cardiovascular disease.
Specific studies are probably warranted before this is widely implemented.
Currently, there is no accepted/validated risk stratification for choice of setting
which is largely payer or commissioner defined and then patient preference by
availability.
Conclusion
Unstable cardiac disease must be optimally managed prior to participation in an

exercise program, but patients with co-morbid cardiac disease should not be
routinely excluded from participation. The recommended components of an exercise
training program such as combined aerobic and resistance training are strikingly
similar for both cardiac and pulmonary conditions. The PR team should receive
226 R. A. Evans
adequate training on different cardiac conditions and symptoms of decompensation

akin to understanding chronic lung diseases and exacerbations. In the future,
combining the approach of cardiac and pulmonary rehabilitation may be clinically
cost-effective.
References
1. Vanfleteren LE, Franssen FM, Uszko-Lencer NH, Spruit MA, Celis M, Gorgels AP, et al.
Frequency and relevance of ischemic electrocardiographic findings in patients with chronic
obstructive pulmonary disease. Am J Cardiol. 2011;108(11):1669–74.
2. Crisafulli E, Gorgone P, Vagaggini B, Pagani M, Rossi G, Costa F, et al. Efficacy of standard
rehabilitation in COPD outpatients with comorbidities. Eur Respir J. 2010;36(5):1042–8.
3. Nonoyama ML, Kin SM, Brooks D, Oh P. Comparison of cardiac rehabilitation outcomes in
individuals with respiratory, cardiac or no comorbidities: a retrospective review. Can J Respir
Ther. 2016;52(2):43–9.
4. Spruit MA, Singh SJ, Garvey C, Zuwallack R, Nici L, Rochester C, et al. An official American
Thoracic Society/European Respiratory Society statement: key concepts and advances in pul-
monary rehabilitation. Am J Respir Crit Care Med. 2013;188(8):e13–64.
5. McCarthy B, Casey D, Devane D, Murphy K, Murphy E, Lacasse Y. Pulmonary rehabilitation
for chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2015;(2):CD003793.
6. Anderson L, Oldridge N, Thompson DR, Zwisler AD, Rees K, Martin N, et al. Exercise-
based cardiac rehabilitation for coronary heart disease: cochrane systematic review and meta-
analysis. J Am Coll Cardiol. 2016;67(1):1–12.
7. National Audit of Cardiac Rehabilitation. British Heart Foundation 2016 [cited
2017 Dec 20]. Available from: www.bhf.org.uk/publications/statistics/national-
audit-of-cardiac-rehabilitation-annual-statistical-report-2016.
8. Smith SC Jr, Benjamin EJ, Bonow RO, Braun LT, Creager MA, Franklin BA, et al. AHA/ACCF
secondary prevention and risk reduction therapy for patients with coronary and other athero-
sclerotic vascular disease: 2011 update: a guideline from the American Heart Association and
American College of Cardiology Foundation endorsed by the World Heart Federation and the
Preventive Cardiovascular Nurses Association. J Am Coll Cardiol. 2011;58(23):2432–46.
9. O’Connor CM, Whellan DJ, Lee KL, Keteyian SJ, Cooper LS, Ellis SJ, et al. Efficacy and
safety of exercise training in patients with chronic heart failure: HF-ACTION randomized
controlled trial. JAMA. 2009;301(14):1439–50.
10. Evans RA, Singh SJ, Collier R, Loke I, Steiner MC, Morgan MD. Generic, symptom based,
exercise rehabilitation; integrating patients with COPD and heart failure. Respir Med.
2010;104(10):1473–81.
11. Vanfleteren LE, Spruit MA, Groenen MT, Bruijnzeel PL, Taib Z, Rutten EP, et al. Arterial stiff-
ness in patients with COPD: the role of systemic inflammation and the effects of pulmonary
rehabilitation. Eur Respir J. 2014;43(5):1306–15.
12. Saleh AD, Kwok B, Brown JS, Hurst JR. Correlates and assessment of excess cardiovascular
risk in bronchiectasis. Eur Respir J. 2017;50(5):1701127.
13. Mesquita R, Vanfleteren LE, Franssen FM, Sarv J, Taib Z, Groenen MT, et al. Objectively
identified comorbidities in COPD: impact on pulmonary rehabilitation outcomes. Eur Respir
J. 2015;46(2):545–8.
14. Bolton CE, Bevan-Smith EF, Blakey JD, Crowe P, Elkin SL, Garrod R, et al. British Thoracic
Society guideline on pulmonary rehabilitation in adults. Thorax. 2013;68(Suppl 2):ii1–30.
15. Sagar VA, Davies EJ, Briscoe S, Coats AJ, Dalal HM, Lough F, et al. Exercise-based rehabili-
tation for heart failure: systematic review and meta-analysis. Open Heart. 2015;2(1):e000163.
16. Lavie CJ, Milani RV. Cardiac rehabilitation and exercise training in secondary coronary heart
disease prevention. Prog Cardiovasc Dis. 2011;53(6):397–403.
17. Evans RA, Singh SJ, Collier R, Williams JE, Morgan MD. Pulmonary rehabilitation is suc-
cessful for COPD irrespective of MRC dyspnoea grade. Respir Med. 2009;103(7):1070–5.
18. Meek PM, Banzett R, Parsall MB, Gracely RH, Schwartzstein RM, Lansing R. Reliability and
validity of the multidimensional dyspnea profile. Chest. 2012;141(6):1546–53.
19. York J, Jones P. Quantification of dyspnoea using descriptors: development and initial testing
of the Dyspnoea-12. Thorax. 2010;65(1):21–6.
20. Maddocks M, Kon SS, Canavan JL, Jones SE, Nolan CM, Labey A, et al. Physical frailty and
pulmonary rehabilitation in COPD: a prospective cohort study. Thorax. 2016;71(11):988–95.
21. Beauchamp MK, Nonoyama M, Goldstein RS, Hill K, Dolmage TE, Mathur S, et al. Interval
versus continuous training in individuals with chronic obstructive pulmonary disease–a sys-
tematic review. Thorax. 2010;65(2):157–64.
22. Wisloff U, Stoylen A, Loennechen JP, Bruvold M, Rognmo O, Haram PM, et al. Superior
cardiovascular effect of aerobic interval training versus moderate continuous training in heart
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23. Holland AE, Mahal A, Hill CJ, Lee AL, Burge AT, Cox NS, et al. Home-based rehabilita-
tion for COPD using minimal resources: a randomised, controlled equivalence trial. Thorax.
2017;72(1):57–65.
Chapter 12
Acute Exacerbations of Chronic Lung
Disease: Cardiac Considerations
Kate Milne and Don D. Sin
Pearls
• Cardiovascular disease and COPD commonly occur in the same patient
and share both risk factors and common pathophysiologic mechanisms.
• Diagnosis of cardiovascular comorbidities in patients with COPD can be
challenging and requires a low threshold for investigation in accordance
with disease-specific guidelines.
• Patients with COPD and cardiovascular disease are at risk of being under-
treated due to concerns regarding the safety of disease-specific therapies in
comorbid patients; however, most therapies are safe.
• Increased systemic inflammation during an exacerbation of COPD is asso-
ciated with cardiac dysfunction, morbidity, and mortality.
• Influenza vaccination reduces cardiovascular risk in COPD patients
• Long-acting bronchodilators are safe in patients with COPD and comorbid
cardiovascular conditions. They may even reduce the risk of cardiovascu-
lar events in select patients.
Introduction
The importance of appropriately recognizing and managing patients with cardiovas-

cular and pulmonary comorbidities is underscored by the poor outcomes described
in complex comorbid patients. Patients with chronic obstructive pulmonary disease
(COPD) have an increased risk, up to one-third greater than the general population,
K. Milne · D. D. Sin (*)

University of British Columbia (UBC) Division of Respiratory Medicine (Department of
Medicine) and Centre for Heart Lung Innovation, St. Paul’s Hospital, Vancouver, BC, Canada
e-mail: katemilne@alumni.ubc.ca; Don.Sin@hli.ubc.ca

230 K. Milne and D. D. Sin
of cardiovascular comorbidities including hypertension and diabetes [1]. Patients

with COPD have higher rates of ischemic heart disease, heart failure, and arrhyth-
mias with risks that are 2–5 times higher than those in age-matched control subjects
[1, 2]. This presence of cardiovascular disease in patients with COPD leads to lower
quality of life, increased rates of hospitalization, and death [3]. Patients with COPD
are at a particularly high risk of cardiovascular events during acute exacerbations of
COPD (AECOPD) [4]. Indeed, AECOPDs increase the risk of acute coronary
events and stroke by 3–5-fold, a risk that can be mitigated by preventing exacerba-
tions related to respiratory tract infections. Thus, understanding the common mech-
anisms and risk factors for COPD and cardiovascular disease, diagnostic and
management challenges, and the interplay between comorbidities during episodes
of an acute exacerbation of COPD is central for the clinical care of these complex
patients.
COPD Exacerbations
AECOPDs are defined by an increase in patient symptoms beyond the day-to-day

variation, which leads to increase in pharmacologic therapy [5]. Currently,
AECOPDs are diagnosed largely based on clinical acumen, irrespective of the etiol-
ogy. As there are no reliable ways of phenotyping exacerbations (e.g., infectious
versus noninfectious), all AECOPDs are empirically treated with systemic cortico-
steroids and/or broad-spectrum antibiotics, which likely leads to their overuse in the
community [5]. The treatment and outcomes for AECOPD are far from optimal.
Once patients are sick enough to come to emergency departments for AECOPD, 9
out of 10 patients will be admitted for treatment for an average length of hospital
stay of 10 days [6]. One in 12 of these patients will die either in hospital or within
6 months of hospital discharge; 1 in 8 patients will require noninvasive or invasive
mechanical ventilation, and 1 in 3 patients will suffer another exacerbation over
3–6 months of follow-up [6]. The treatment side effects are also substantial. During
therapy, more than 50% patients will experience new or worsening hyperglycemia,
12–18% will develop new or worsening of hypertension, and 12% will experience
other steroid-related adverse effects including adrenal insufficiency [6]. Incredibly,
treatment for AECOPD has not changed over the past 30 years. Health care provid-
ers treat everyone with AECOPD with antibiotics despite good data suggesting that
fewer than 50% of the episodes are associated with bacterial infections and with
prednisone even though approximately 30% of the episodes are not associated with
lung or systemic inflammation!
It is widely postulated, though not completely proven, that respiratory tract
infections by microbial agents are the leading cause of AECOPD [5]. By using
polymerase chain reaction on spontaneous sputum samples, Bafadhel et al. found
that the prevalence of “virus”-associated exacerbation was 29% (with rhinovirus
being the most common) and that of “bacteria”-associated exacerbation was more
than 40% [7]. However, it should be noted that many patients with COPD
12 Acute Exacerbations of Chronic Lung Disease: Cardiac Considerations 231
demonstrate evidence of bacterial colonization even during clinical stability,

whereas presence of viruses is distinctly rare except during exacerbations [7]. Thus,
the clinical relevance of identifying bacterial species in spontaneous sputum of
patients with COPD during exacerbations is uncertain.
Exacerbations and Cardiovascular Events
The multiple potentially reciprocal mechanisms through which either an exacerba-

tion of COPD may potentiate cardiovascular decompensation or through which car-
diac dysfunction can trigger an acute exacerbation of COPD are complex (Fig. 12.1)
[8]. Multiple mechanisms are triggered during an AECOPD that lead to cardiovas-
cular dysfunction and morbidity. Platelet activation, fibrinogen production, and
interleukin-6, interleukin-8, and tumor necrosis factor α levels are elevated during
an acute exacerbation of COPD, and these are pro-atherothrombotic. This cascade
can lead to atherosclerotic plaque rupture and acute coronary syndrome as demon-
strated in Fig. 12.2. The most important pathway appears to be related to inflamma-
tion. COPD patients have chronic lung inflammation which worsens during acute
exacerbations [7]. Acute coronary syndromes can be associated with an AECOPD
[4]. This increased risk seems most closely associated with respiratory infection and
inflammation as an exacerbation trigger [9].
CAUSES OF AECOPD
Bacterial Pulmonary Embolism
Viral
Poor Compliance
Heart Failure Pneumonia
Myocardial Idiopathic
Infarction
Fig. 12.1 Causes of acute exacerbations of COPD. There are multiple causes of acute exacerba-
tions of COPD (AECOPD). Although almost all clinically significant AECOPDs are treated with
oral antibiotics and/or systemic corticosteroids, at least 30% of the AECOPDs are caused by non-
inflammatory, noninfectious causes. A significant number of cases are caused by cardiovascular
events. In one study, approximately 20% of hospitalized AECOPDs were characterized by pulmo-
nary edema on chest radiograph [82]
Acute Lung Injury
•↑CRP and fibrinogen

•↑Cytokines (TNFα, IL-1β, IL-6)
• Monocyte & platelets recruitment
Systemic Oxidative Stress & Inflammation
from the bone marrow
•↑ROS & oxLDL
Destabilize Plaques Endothelial activation

monocyte & dysfunction
fibrinogen
•↑Endothelial permeability
VCAM-1
ICAM-1
•↑ET-1, ↓NO
Foam cells oxLDL
•↑Vasodilatation
Endothelial cells
smooth muscle cells

atherosclerotic plaque
↑ adhesion molecule expression
↑ Monocyte recruitment
↑ ROS & uptake of oxLDL
↑ foam cells and plaque lipid content
↑ Smoth muscle cell proliferation
↑ Proteinase activity (MMP’s) ↑Vascular Events
↓ Fibrose cap of plaques Heart Attacks & Strokes
Fig. 12.2 A proposed schema of how acute exacerbations of COPD may lead to acute cardiovas-
cular events. We propose that respiratory tract infection leads to acute lung injury, resulting in lung
inflammation and oxidant stress. This causes endothelial dysfunction and acute disruption of stable
atherosclerotic plaques, resulting in the conversion of stable plaques into unstable (or vulnerable)
ones. Vulnerable plaques are much more likely to rupture, causing acute myocardial infarction or
stroke than stable plaques [83]. Neutrophilic inflammation appears to play a central role in this
process [26]
Regardless of the etiology of the AECOPD, during AECOPD events, many

patients experience myocardial injury and stress. Patel et al., for instance, found
that approximately 16% of patients during AECOPD experienced a marked eleva-
tion in serum troponin, a biomarker of myocardial injury, and a similar number
experienced a rise in N-terminal pro b-type natriuretic peptide (NT-proBNP), a
biomarker of myocardial stretch and failure. In their study, the levels of these blood
cardiac biomarkers peaked at day 7 of the AECOPD event and then gradually
returned to normal levels after 30–90 days post-event [10]. Increased troponins and
electrocardiographic (ECG) changes have been reported in patients with COPD, in
the absence of an acute coronary syndrome, which complicates making the correct
diagnosis [11]. As a result, diagnosis of ST-elevation myocardial infarction
(STEMI) is frequently delayed in patients with COPD [12]. Increased troponin in
patients with acute exacerbation of COPD is an independent risk factor for mortal-
ity, even in the absence of acute coronary syndrome, and can be due to multiple
factors [13]. The pathophysiology of increased troponin observed during an acute
exacerbation of COPD may be related to the development of supply-demand mis-
match to the myocardium due to tachycardia or coexisting left ventricular
hypertrophy [8]. The hypoxemia and hypercapnia resulting from an acute exacer-
bation of COPD can also be pro-arrhythmogenic, leading to arrhythmias during an
acute exacerbation of COPD which can in turn trigger heart failure decompensation
[14]. Troponin may also be increased as a result of increased pulmonary pressures
and right heart dysfunction during an exacerbation [8]. Natriuretic peptides are a
useful tool in diagnosing acute heart failure in the setting of comorbid COPD as
heart failure is unlikely with normal values (BNP < 100 pg/ml or
NT-proBNP < 300 pg/ml) [15]. However, the appropriate cutoff value in patients
with pulmonary disease is debated as associations between elevated plasma
N-terminal proBNP (NT-proBNP) and decreased FEV1 have been described in
patients without heart failure. Elevations of BNP or NT-proBNP in patients with an
acute exacerbation of COPD predict worse cardiovascular outcomes and death [8].
BNP is released from ventricular myocytes due to either volume or pressure over-
load and resulting myocyte stretch. Changes in intrathoracic pressure during an
acute exacerbation of COPD impact venous return, cardiac function, and pulmo-
nary pressures leading to elevation of BNP [8].
During AECOPD, patients also demonstrate endothelial dysfunction systemi-
cally as evidenced by a significant increase in pulse wave velocity of the affected
blood vessels. Most importantly, the risk of myocardial infarction (MI) and stroke
increases substantially during the first few days of AECOPD. One study showed
that the risk of MI increased by 2.27 times the baseline rate within 1–5 days of
AECOPD, whereas the risk of stroke increased by 26% [4].
The relationship between acute respiratory tract infection and cardiovascular
events is particularly notable and interesting. In the largest study of its kind, Kwong
et al. evaluated 364 hospitalizations for MI between May 1, 2009, and May 31,
2014, in Ontario, Canada. They obtained nasal swab data using reverse-transcriptase
polymerase chain reaction (rtPCR; monoplex or multiplex assays), viral culture,
direct fluorescent antibody staining, and enzyme immunoassays on influenza A and
B as well as other respiratory viruses including respiratory syncytial virus, adenovi-
rus, coronavirus, enterovirus (such as rhinovirus), parainfluenza virus, and human
metapneumovirus [16]. They found that during the first 7 days of the respiratory
tract infection, the risk of MI was 6-fold higher than during “control” periods (i.e.,
weeks when they were infection-free). The highest risk period was within 1–3 days
of the respiratory tract infection (relative risk, RR, of 6.30) with the risk sharply
decaying by day 8 of the infection. In this study, most (82%) of the respiratory tract
infections were caused by influenza A and only 31% of the cohort had received
influenza vaccination prior to the study year.
These data are consistent with other studies including that by Warren-Gash et al.
who showed by using the General Practice Research Database (GPRD) in the
United Kingdom (UK) that the risk of MI was 4 times higher during the first 3 days
of the infection compared with controlled periods with the risk gradually decaying
over time and returning to baseline levels by 30–90 days postinfection [17]. Most
importantly, in a secondary prevention trial of 439 patients who had been hospital-
ized with an acute coronary syndrome, Phrommintikul et al. showed that influenza
vaccination therapy (versus no vaccination in the control group) resulted in 30%
lower rate of combined major cardiovascular end points including death, rehospital-
ization for acute coronary syndrome or from heart failure, or stroke and a strong
trend towards lower rate of cardiovascular mortality (hazard ratio, HR, 0.39;
p = 0.088) [18]. It should also be noted that influenza vaccination or pneumococcal
vaccination per se is not associated with any increase or decrease in cardiovascular
events [9]. Thus, vaccination is safe.
The relationship between infection and cardiovascular events is not restricted to
respiratory tract infections. Infection elsewhere in the body is also associated with
increased risk of cardiovascular events. Minassian et al. showed using a Medicare
beneficiary database that individuals who developed herpes zoster infection (i.e.,
shingles) experienced a 2.4-fold increase in the risk of ischemic stroke and 1.7-fold
increase in the risk of MI within the first week of infection [19]. It should be noted,
however, that while infection in other organ systems is associated with increased
risk of cardiovascular events, the relationship between respiratory tract infections
and cardiovascular events is particularly strong. For instance, Smeeth and col-
leagues showed using the UK GPRD database that the risk of MI in the first 3 days
of a respiratory tract infection was 5.0-fold higher than that during controlled peri-
ods, whereas the relative risk for MI for urinary tract infections was only 1.7 [9].
Together these data suggest that respiratory tract infections are one of the most
important triggers of MI and stroke and mitigation strategies to reduce these infec-
tions will not only decrease the risk of AECOPD but also prevent cardiovascu-
lar events.
ommon Mechanisms and Risk Factors for Cardiovascular

C
Disease and COPD
The mechanism by which AECOPD leads to cardiovascular events remains largely

a mystery. COPD and cardiovascular disease such as heart failure, atrial fibrillation,
and ischemic heart disease share common risk factors such as cigarette smoking and
age [15]. However, independent of the risk imposed by smoking, reduced lung func-
tion, assessed by using decrease in FEV1, has been associated with mortality due to
ischemic heart disease [20]. However, whether there exists a common mechanism
or link beyond shared risk factors is an ongoing subject of debate.
Systemic inflammation has been observed in patients with COPD, ischemic heart
disease, and atrial fibrillation and has been proposed as a potential mechanism lead-
ing to poor clinical outcomes [21, 22]. Smoking and alterations in the lung microbi-
ome and elastin fiber have been implicated as potential sources of ongoing
inflammation [23, 24]. Other environmental exposures including air pollution, viral
and bacterial respiratory infection, and oral disease are thought to increase inflam-
mation and contribute to inflammation associated with poor cardiovascular out-
comes [25]. Although the precise pathways are unknown, animal studies suggest
that inhalation of small particulate matter leads to chronic lung inflammation and
systemic inflammation. This chronic inflammatory state is thought to contribute to

the development of atherosclerotic disease, independent of dyslipidemia [25]. A
proposed model for how this may occur is presented in Fig. 12.2.
Another important consideration is the effect of lung inflammation related to
respiratory tract infection on the cardiovascular system. Jaw et al. modeled the
effects of respiratory tract infection on the cardiovascular system using lipopolysac-
charide (LPS) stimulation directly to the airways of mice, which were prone to
atherosclerosis [26]. LPS is a bioactive component of gram-negative bacterial wall
and induces local inflammation by stimulating toll-like receptor 4. In this model,
instillation of LPS into the airways resulted in conversion of 68% of the atheroscle-
rotic plaques from “stable” to “vulnerable” ones. In contrast, instillation of just
saline into the airways led to 12% of the plaques becoming vulnerable (p = 0.0004).
Repeating this experiment following temporary depletion of neutrophils using
Ly6G antibodies prevented conversion of stable to vulnerable plaques related to
LPS exposure. Interestingly, injection of LPS intraperitoneally to mimic infection
outside of the thoracic cavity did not lead to any significant destabilization of ath-
erosclerotic plaques. Together, these data suggest that acute respiratory tract infec-
tions induce neutrophilic inflammation locally and systemically that lead to
disruption of stable plaques and cause acute myocardial and cerebrovascular events.
These adverse effects may be prevented by reducing neutrophilic inflammation.
oes Prevention of AECOPD Reduce the Risk

D
of Cardiovascular Events?
As noted above, influenza vaccination is effective in reducing the risk of significant

cardiovascular events in patients with and without COPD. The effects of other drugs
commonly used in the treatment of COPD patients on the risk of cardiovascular
events are much more uncertain and controversial. The first line of therapy for
COPD patients with persistent symptoms is long-acting muscarinic antagonist
(LAMA) [5]. In the Understanding Potential Long-Term Impacts on Function with
Tiotropium (UPLIFT) trial, the rate of serious cardiac adverse events was 16%
lower in the group that was assigned to tiotropium (n = 2986) over 4 years compared
with the group that was assigned to placebo (n = 3006; p < 0.05). This relative
reduction was largely driven by lower rates of congestive heart failure (RR, 0.59)
and myocardial infarction (RR, 0.71) [27]. However, these data should be inter-
preted cautiously as the primary end point, the rate of decline in lung function, was
no different between tiotropium and placebo and the cardiac events were not fully
adjudicated; thus, misclassification of events could have occurred. In a population-
based study in Ontario, Canada, Gershon et al. demonstrated that elderly patients
(66 years of age and older) who were newly prescribed a LAMA or a long-acting
beta-2 agonist (LABA), another class of long-acting bronchodilator, had a 31%
increase in the risk of cardiovascular events [28]. Another population-based study in
the UK showed similar results with use of LAMA being associated with a small
increase in the risk of stroke and MI and a significant reduction in total mortality
[29]. LAMA in inhalation spray format, which leads to increased drug deposition in
the small airways, has been associated with increased risk of cardiovascular events
compared with LAMA in a dry powder formulation, which leads to increased drug
deposition in the upper and larger airways [30]. However, in the largest clinical trial
of its kind involving 17,135 patients with COPD, the use of tiotropium in inhalation
spray format was not associated with any significant increase in the risk of major
cardiovascular adverse effects compared with tiotropium in a dry powder formula-
tion, though in the higher tiotropium spray dose (5 μg daily), there was a trend
towards increased MI (RR, 1.41; p = 0.06) [31]. Collectively, these data suggest that
long-acting bronchodilators are safe in patients with COPD and may in select
patients reduce the risk of cardiovascular events, possibly by reducing the rate of
exacerbations.
Inhaled corticosteroids (ICS) in combination with a LABA are also frequently
used to prevent exacerbations in COPD. In one population-based study in
Saskatchewan, Canada, the use of ICS was associated with a 32% reduction in the
relative risk of MI [32]. However, a systematic review of randomized controlled
trials did not demonstrate any significant association between ICS use and the risk
of MI or other cardiovascular end points [33]. In the largest clinical trial of its kind
(n = 16,485), the use of ICS or ICS/LABA was not associated with cardiovascular
mortality or any other serious cardiovascular adverse events compared with placebo
[34]. In aggregate, these data suggest that neither ICS alone nor ICS in combination
with LABA has any salutary effects on cardiovascular events in patients with COPD.
Challenges in Cardiovascular Disease and COPD
Ischemic Heart Disease
COPD patients have an increased risk of ischemic heart disease (odds ratio [OR]
2.28, 95% confidence interval [CI] 1.76–2.96, p < 0.0001) compared to the general
population [1]. Patients with ischemic heart disease similarly have high rates of
COPD; however, it is often undiagnosed [35, 36]. Patients with coexisting airflow
limitation and ischemic heart disease, as opposed to ischemic heart disease alone,
have both a higher burden of COPD symptoms and cardiovascular risk [37].
Recognizing COPD in ischemic heart disease is important as it has been associated
with worse short- and long-term outcomes compared to patients with ischemic heart
disease alone [38, 39]. Cardiovascular death accounts for a large proportion of
deaths in patients with COPD, with estimates of up to 20–30% [3, 40].
Patients with COPD or ischemic heart disease may present with a variety of
symptoms including dyspnea, cough, sputum production, exertional chest pain, or
decreased exercise tolerance. Symptoms such as shortness of breath and decreased
exercise tolerance could be present in either COPD or ischemic heart disease and
require appropriate investigation in order to confirm a diagnosis [1]. In the presence

of ischemic heart disease, the diagnostic criteria of COPD are not altered and spi-
rometry is required [5]. In patients with COPD, ischemic heart disease symptoms
should be investigated in accordance with established guidelines [41].
Although some therapies for ischemic heart disease and COPD have previously
been scrutinized for potential harm in patients with both diseases, standard medica-
tions are thought to be safe in comorbid patients [15]. Antiplatelet therapy for isch-
emic heart disease should be prescribed in accordance with established guidelines
in patients with COPD [41]. Beta-blockers should not be withdrawn from patients
with COPD, are generally safe, and decrease mortality [42]. Although the proposed
common mechanism of systemic inflammation present in both ischemic heart dis-
ease and COPD raised the question of whether statin therapy may offer a benefit in
COPD alone, statin therapy does not impact acute exacerbation risk, but is indicated
in ischemic heart disease [39, 43]. Following invasive therapeutic interventions for
ischemic heart disease, COPD patients experience more morbidity [44]. COPD
patients undergoing percutaneous coronary intervention have increased rates of
revascularization and death [44]. Strategies to reduce perioperative as well as
longer-term morbidity following invasive therapies for ischemic heart disease in
patients with coexisting COPD will require ongoing research.
Inhaled therapies for COPD including LABA, LAMA, and ICS are safe and
effective in patients with coexisting ischemic heart disease [15]. In comparing
LABA-LAMA or ICS-LABA combination therapies for COPD, rates of MI, unsta-
ble angina, and revascularization did not differ between treatment groups [45]. In
another study that included patients with COPD and known ischemic heart disease
or risk factors for ischemic heart disease, rates of MI and unstable angina were simi-
lar between groups treated with LABA-ICS, LABA, ICS, and placebo [34]. This
evidence supports the safety of inhaled COPD therapies in patients with ischemic
heart disease.
Heart Failure
Similar to ischemic heart disease, heart failure is more common in patients with
COPD than the general population (OR 2.57, 95% CI 1.90–3.47, p < 0.0001) [1].
Patients with heart failure and concomitant COPD have higher mortality rates than
patients with heart failure alone (HR 1.24–1.7) [46]. Given this increased mortality
risk, making the appropriate diagnosis is especially important. Heart failure and
COPD share risk factors, frequently occur in the same patient, and share similar
presenting symptoms such as dyspnea and functional limitation. This makes distin-
guishing the presence of these diseases a clinical challenge. The diagnosis of COPD
requires spirometry and should be performed with a low threshold in patients with
established heart failure [5]. Heart failure with reduced ejection fraction (HFrEF)
can result in an up to 20% reduction in both FEV1 and FVC; however, it does not
affect the FEV1/FVC ratio, and spirometry therefore retains its diagnostic utility
[47]. Establishing a diagnosis of heart failure also requires a low threshold for inves-
tigation with echocardiogram in COPD patients [48].
Despite accepted guidelines and mortality benefit of beta-blockers in HFrEF,
clinicians underprescribe these medications in patients with COPD [49]. A large
retrospective study demonstrated no difference in outcomes between heart failure
patients with and without COPD taking cardioselective and nonselective beta block-
ers [50]. Retrospective analysis of patients from the STATCOPE and MACRO stud-
ies demonstrated no decrease in lung function overtime or increase in exacerbation
rate attributable to beta-blocker use in patients with COPD [51]. The benefits of
beta-blockers in heart failure outweigh potential risks, even in the context of severe
COPD, and should be prescribed as indicated [15, 52]. Other heart failure medica-
tions including angiotensin-converting enzyme inhibitors, mineralocorticoid recep-
tor antagonists, and ivabradine are recommended, as appropriate, in patients with
COPD [53, 54].
Although the use of ICS and roflumilast to treat COPD has not been associated
with an increased risk of cardiovascular events, the safety of inhaled bronchodila-
tors in patients with COPD and heart failure has been controversial [55, 56].
Observational studies previously identified an increased risk of hospitalization or
death with short-acting beta agonists in patients with HFrEF [57, 58]. However,
other studies have not identified an independent risk of mortality with long-acting
beta agonists in patients with heart failure [59]. Short-acting muscarinic agents have
also been associated with an increased risk of heart failure [60]. Longer-acting
agents such as tiotropium, glycopyrronium, aclidinium, and umeclidinium have not
been associated with an increased risk of heart failure [61–63]. The cardiovascular
safety of a combination long-acting bronchodilators, including LABA-LAMA com-
binations, are similar to the component medications and are generally safe [45, 64].
LABA and tiotropium use in patients with heart failure and COPD has been associ-
ated with an increased risk of emergency department visit and hospitalization for
heart failure [28]. It may be reasonable, taking the evidence currently available into
consideration, to preferentially choose LAMA agents over LABA bronchodilators;
however, there is no specific evidence that COPD must be treated differently in the
setting of heart failure [65]. It is recommended that patients with heart failure being
started on bronchodilators be closely followed up in the two to three weeks follow-
ing bronchodilator initiation for signs and symptoms of worsening heart failure [15].
Atrial Fibrillation
Atrial fibrillation is the most common arrhythmia in the general population and in
patients with COPD [2]. The risk of cardiac dysrhythmia in patients with COPD is
almost double that of the general population (OR 1.94, 95% CI 1.55–2.43,
p < 0.0001) [15]. Prevalence of atrial fibrillation in COPD varies from 4.7% to 15%
and up to 30% in severe COPD [66]. The severity of airflow obstruction is related to
an increased prevalence of atrial fibrillation [67]. Outcomes of patients with COPD
and coexisting atrial fibrillation are worse with increased risk of hospitalization,
lower quality of life, and all-cause mortality [66].
Patients with COPD and atrial fibrillation may present with dyspnea due to either
disease; however, co-occurring symptoms such as palpitations or cough may help to
increase suspicion for atrial fibrillation or COPD, respectively [15]. The diagnosis
of COPD in patients with atrial fibrillation can be made using spirometry, similar to
the setting of coexisting ischemic heart disease or heart failure [5]. Atrial fibrillation
can be diagnosed with an ECG, but may require 24-hour or longer recording devices
to diagnose paroxysmal atrial fibrillation. The detection of atrial fibrillation in
patients with COPD is important given the risk for worse outcomes in comorbid
patients as well as stroke risk reduction and highlights a potential role for screening.
However, screening for asymptomatic atrial fibrillation and mechanisms by which
this would most effectively be achieved in patients with COPD has not been defined.
The presence of COPD in atrial fibrillation creates a challenge for atrial fibrilla-
tion management. COPD is associated with progression from paroxysmal to perma-
nent atrial fibrillation, unsuccessful cardioversion, and recurrence following
interventional catheter ablation [68]. General recommendations regarding atrial
fibrillation treatment, including rate and rhythm control strategies and anticoagula-
tion to reduce risk of thromboembolic disease, include patients with COPD [69].
Rate control strategies using non-dihydropyridine calcium channel blockers for
patients with atrial fibrillation and COPD is recommended in major guidelines [69].
Cardioselective beta-blockers are also recommended for rate control and have been
associated with lower mortality [70]. Use of nonselective beta-blockers for atrial
fibrillation should be avoided in patients with severe airflow obstruction and COPD,
although evidence for this recommendation is limited [71]. Recommendations for
anticoagulation and stroke prevention can be applied to patients with COPD and
atrial fibrillation in accordance with guidelines [69].
Concerns exist regarding the pro-arrhythmogenic properties of short-acting beta-
agonist bronchodilators [72]. LAMA agents have demonstrated mixed results in
increasing rates of atrial fibrillation. Tiotropium does not increase cardiac arrhyth-
mias, but glycopyrronium has been associated with increased rates of atrial fibrilla-
tion compared to placebo [63, 73]. Despite evidence of these possible increased
risks, LABA, LAMA, and ICS preparations can be safely used to treat COPD in
patients with atrial fibrillation [31, 74].
Non-Pharmacologic Therapies
Given the shared risk factors and suspected common pathophysiological mecha-
nisms, a holistic approach to non-pharmacologic management and interventions is
important. Smoking cessation is key in the non-pharmacologic management of both
COPD and ischemic heart disease [75]. Dietary modification can play a role in
improving both cardiovascular and lung health [76]. Rehabilitation programs
involving supervised exercise training, education, and support are important and
help to improve outcomes in COPD [77]. These programs are also important in
patients with ischemic heart disease and heart failure [78, 79]. Despite the benefits
of rehabilitation programs in both COPD and cardiovascular disease, the existence
of comorbidities is associated with a lower referral rate to rehabilitation programs
[80, 81]. There is no evidence that the presence of comorbidities negatively affects
patient outcomes and complex comorbid patients should still be referred for cardio-
pulmonary rehabilitation [81].
Conclusions
Systemic inflammation is common to both COPD and cardiovascular disease.

Mechanisms contributing to chronic inflammation and cardiopulmonary disease
development as well as the cascade of changes during acute exacerbations of COPD
that can lead to decompensation of cardiovascular disease and increased morbidity
and mortality are increasingly understood. Elucidating the complex mechanisms
through which COPD and cardiovascular disease influence and modify each other
will be important in developing therapies and strategies to reduce the burden of
morbidity and mortality in these patients.
Cardiologists, respirologists/pulmonologists, internists, and primary care physi-
cians must be attuned to the presence of coexisting cardiac and respiratory disease.
Patients with cardiovascular disease and COPD should be investigated for COPD
and cardiovascular disease, respectively. A low threshold for investigation is
important in order to thoroughly assess presenting symptoms which these comor-
bidities share in common and reach the correct diagnosis. Therapeutic challenges
in treating patients with COPD and cardiovascular disease including ischemic
heart disease, heart failure, and atrial fibrillation have been hindered by concerns
regarding the safety of disease-specific therapies in patients with complex comor-
bidities. However, patients with COPD and cardiovascular disease can safely be
treated in accordance with major disease-specific guidelines. Given the complexity
of diagnosis and management of patients with cardiovascular disease and COPD,
models of care that can address the complex multimorbid patient must be developed.
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Chapter 13
Lung Transplantation for Chronic Lung
Disease: Cardiac Considerations
Keith M. Wille, Tyler R. Reynolds, and Victoria Rusanov
Clinical Pearls
1. Major adverse cardiovascular and cerebrovascular events (MACCE) are
more common in transplant recipients than in non-transplant, noncardiac
surgery patients, and lung transplant recipients have a higher MACCE risk.
2. Disorders such as significant coronary artery disease, arrhythmias, pulmo-
nary arterial hypertension, and valvular heart disease should be identified
and managed to improve the likelihood of a successful perioperative course.
3. Careful candidate selection, including a thorough assessment of cardiac
function, is essential for optimizing the likelihood of survival while await-
ing transplantation and minimizing the risk of cardiovascular and cerebro-
vascular events posttransplant.
Introduction
Lung transplantation (LT) has emerged as a viable treatment option for patients with
end-stage lung disease. The development and refinement of the surgical technique,
patient selection, and immunosuppression practices have resulted in both improved
quality of life and overall 1-year survival rates ≥85% for patients who otherwise
would have limited treatment alternatives [1]. However, longer-term survival fol-
lowing LT is limited largely by chronic lung allograft dysfunction (CLAD), with
K. M. Wille (*) · V. Rusanov

Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
e-mail: kwille@uabmc.edu; vrusanov@uabmc.edu
T. R. Reynolds
Louisiana State University, Baton Rouge, LA, USA

248 K. M. Wille et al.
5-year survival rates remaining at approximately 50% [2]. Improvements in organ

availability and donor and patient management have led to a greater demand for
LT. As success with LT has improved with time, criteria for the selection of appro-
priate LT candidates have also changed (Tables 13.1 and 13.2) [3–5]. Absolute con-
traindications such as severe cardiovascular disease (CVD) were established at the
start of LT with the development and dissemination of consensus guidelines; how-
ever, with greater experience and advances in the treatment of CVD, centers have
been more willing to consider higher-risk candidates, provided that any underlying
diseases could be effectively managed and both peri- and postoperative risk remain
acceptable. Since implementation of the Lung Allocation Score (LAS) in 2005, time
Table 13.1 Adult lung transplants performed by diagnostic indication (Jan 2005–Jun 2018)
Diagnosis N (%)
IIP 13,914 (29.24)
COPD 13,201 (27.74)
CF 6996 (14.70)
ILD not IIP 3144 (6.61)
Other 3015 (6.34)
Retransplant 2045 (4.30)
A1AT 1615 (3.39)
IPAH 1268 (2.66)
Non-CF bronchiectasis 1220 (2.56)
Sarcoidosis 1173 (2.46)
Total 47,591 (100)
Adapted from 2019 International Society for Heart and Lung Transplantation Registry Data (avail-
able at http://www.ishlt.org)
A1AT alpha-1-antitrypsin, CF cystic fibrosis, COPD chronic obstructive pulmonary disease, IIP
idiopathic interstitial pneumonia, ILD interstitial lung disease, IPAH idiopathic pulmonary arterial
hypertension. Transplants performed with unknown diagnoses are excluded from this tabulation
Table 13.2 Adult heart-lung transplants performed by diagnostic indication (Jan 2005–Jun 2018)
Diagnosis N (%)
PH not IPAH 267 (36.83)
IPAH 238 (32.83)
Other 90 (12.41)
CF 53 (7.31)
IIP 45 (6.21)
COPD 17 (2.34)
Non-CF bronchiectasis 10 (1.38)
A1AT 4 (0.55)
Retransplant 1 (0.14)
Total 725 (100)
Adapted from 2019 International Society for Heart and Lung Transplantation Registry Data (avail-
able at http://www.ishlt.org)
A1AT Alpha-1-antitrypsin, CF cystic fibrosis, COPD chronic obstructive pulmonary disease, IIP
idiopathic interstitial pneumonia, ILD interstitial lung disease, IPAH idiopathic pulmonary arterial
hypertension, PH pulmonary hypertension
13 Lung Transplantation for Chronic Lung Disease: Cardiac Considerations 249
to transplantation has decreased, wait-list mortality has decreased, and transplant

volume has increased without significantly changing outcomes. The LAS was more
recently modified to address disparities in wait-list urgency for patients with pulmo-
nary arterial hypertension (PAH) [6–8]. However, access to the LT waiting list (i.e.,
the time from a transplant-eligible diagnosis to wait-list registration) has remained
variable and can differ by underlying diagnosis [9]. Costs associated with transplan-
tation vary considerably by diagnosis, and complications such as those requiring
prolonged ventilatory support or additional interventions may drive costs associated
with LT significantly higher [10].
The most recent consensus from the International Society of Heart and Lung
Transplantation (ISHLT) for the selection of LT candidates, published in 2015,
recognizes untreatable significant dysfunction of another major organ system

(e.g., heart, liver, kidney, or brain) as an absolute contraindication to LT, unless
combined organ transplantation can be performed (e.g., heart-lung, lung-liver, or
lung-kidney) (Table 13.3) [5]. LT should be considered for patients with chronic,
end-stage lung disease with the following characteristics: (a) high (>50%) risk of
Table 13.3 Contraindications to lung transplantation

Absolute
Recent history of malignancy
Untreatable significant dysfunction of another major organ system (unless combined organ
transplantation is considered)
Uncorrected atherosclerotic and/or coronary artery disease not amenable to revascularization
Acute medical instability
Uncorrectable bleeding diathesis
Chronic infection with highly virulent and/or resistant microbes that are poorly controlled
before transplant (including active Mycobacterium tuberculosis infection)
Significant chest wall or spinal deformity
Significant (class II or III) obesity (BMI ≥ 35 kg/m2)
Limited functional status with poor rehabilitation potential
Nonadherence to medical therapy
Absence of adequate social support
Substance abuse or dependence
Relative
Age > 65 years associated with low physiologic reserve and/or other relative contraindications
Class I obesity (BMI 30–34.9 kg/m2)
Severe malnutrition
Severe osteoporosis
Extensive prior chest surgery with lung resection
Mechanical ventilation and/or extracorporeal life support
Atherosclerotic disease burden that may result in end-organ damage post-transplant
Colonization or infection with highly resistant or highly virulent organisms
HIV, Hepatitis B or C (transplant may be considered at select centers where infection is
well-controlled and end-organ disease is absent)
Uncontrolled medical conditions (such as diabetes, systemic hypertension, and
gastroesophageal reflux disease)
Adapted from Weill D et al. [5]
BMI body mass index
death from lung disease within 2 years if LT is not performed, (b) high (>80%)
likelihood of surviving at least 90 days after LT, (c) high (>80%) likelihood of
5-year posttransplant survival, and (d) no other available treatment options [5, 11].
Lung retransplantation has also been performed in select instances, typically for
recipients who develop CLAD, with variable outcomes [2, 12–18].
A recent study examined the rates of perioperative major adverse cardiovascular
and cerebrovascular events (MACCE) after noncardiac transplant surgery [19].
Using the Healthcare Cost and Utilization Project’s National Inpatient Sample,
Smilowitz et al. identified 49,978 hospitalizations for transplant surgery. The most
common surgeries performed were renal (67.3%), liver (21.6%), and lung (6.7%),
and in total, perioperative MACCE occurred in 1539 (3.1%) transplant surgeries.
Transplant recipients were more likely to have perioperative MACCE as compared
to patients undergoing non-transplant, noncardiac surgery (3.1% vs. 2.0%, adjusted
odds ratio [OR] 1.29, 95% confidence interval [CI] 1.22–1.36; p < 0.001). Moreover,
among hospitalizations for renal, liver, and lung transplantation, MACCE occurred
in 1.7%, 5.6%, and 7.5% of recipients, respectively. As cardiovascular complica-
tions are common in LT recipients, this review will focus on cardiac considerations
in the LT candidate and implications for the pre- and postoperative period.
Coronary Artery Disease
The severity of underlying coronary artery disease (CAD) may affect candidate
selection for LT. Obstructive CAD (typically defined as a luminal diameter stenosis
≥70%) [20] that is not correctable by percutaneous or surgical intervention has been
considered a relative contraindication to LT at most centers. At present, there are no
consensus guidelines regarding the optimal preoperative CAD evaluation for LT
candidates; society-endorsed practice guidelines were previously published for liver
and kidney transplant candidates [21]. While methods used for CAD detection in LT
candidates may vary among centers, coronary angiography remains a commonly
utilized study. The prevalence of CAD in patients with end-stage lung disease
referred for transplantation has ranged from 6% to 23%; however, when only the
studies that defined obstructive CAD were included, the prevalence was 11% [22–
27]. The rate of CAD in this population is thought to vary significantly in the litera-
ture for several reasons, including differences in the frequency of CAD risk factors
among candidate diagnostic groups (CF, COPD, ILD, etc.), differences in how stud-
ies define the presence of CAD, and potentially differences in referral practices as
well as racial and gender biases. Angiographic CAD has typically been defined as a
luminal stenosis ≥50%; however, lesions ≥70% are more often flow-limiting and
thus potentially amenable to intervention [20]. However, for LT candidates, it is
unclear whether detection of CAD on preoperative angiography is predictive of
postoperative complications. Further, in a large prospective trial, preoperative coro-
nary revascularization was not associated with improved postoperative or long-term
outcomes when compared with medical therapy in high-risk patients undergoing
major vascular surgery [28]. As there are no prospective trials for LT candidates,
whether this patient population derives any benefit from preoperative coronary
angiography and subsequent revascularization remains unknown.
Patients with advanced lung disease may develop CAD as a result of recognized
cardiac risk factors (including advancing age, diabetes, hyperlipidemia, hyperten-
sion, and tobacco use) and/or chronic inflammatory changes affecting the heart and
lungs. For example, studies have demonstrated that COPD patients have a greater
risk of cardiovascular morbidity and mortality as compared to the general popula-
tion. In a study of more than 5000 patients from the Saskatchewan Health database,
Huiart et al. found that cardiovascular morbidity and mortality rates were higher in
the COPD cohort than in the general population (standardized rate ratios of 1.9 and
2.0, respectively) [29]. Also, CVD and specifically ischemic heart disease were
more commonly reported as a cause of death, rather than COPD (19.6 vs. 15.5 per
1000 person-years). However, longer-term mortality due to cardiac disease may not
significantly differ between CAD and non-CAD-designated recipients, once
selected candidates undergo transplantation [30].
Using the Kaiser Permanente Medical Care Program, Sidney et al. studied the
relationship between COPD and hospitalization and mortality events due to CVD
end points. In their study, CVD study end points included cardiac arrhythmias,
angina pectoris, acute myocardial infarction, congestive heart failure (CHF), stroke,
pulmonary embolism, and a composite of the previously mentioned end points [31].
Mean follow-up time was 2.75 years for case patients and 2.99 years for control
patients. The relative risk (RR) for hospitalization for the composite of all study end
points was 2.09 (95% CI, 1.99–2.20), after adjustment for confounding variables
that included gender, preexisting CVD end points, hypertension, hyperlipidemia,
and diabetes. Moreover, the adjusted RR for mortality for the composite measure of
all study end points was 1.68 (95% CI, 1.50–1.88).
Patients with fibrotic lung disease, which since 2007 has been the most common
indication for lung transplantation, may also be at increased risk for CAD. Kizer
et al. found that the fibrotic lung diseases were associated with an increased preva-
lence of CAD as compared to the nonfibrotic diseases, after adjustment for tradi-
tional CV risk factors (OR 2.18; 95% CI, 1.17–4.06) [32]. However, this association
appeared to be driven largely by non-granulomatous fibrotic disease (particularly
IPF). Notably, the association between the fibrotic disorders and CAD strengthened
when multivessel disease was examined (OR 4.16; 95% CI, 1.46–11.9). In a series
of 243 LT candidates, Snell et al. analyzed 85 patients who underwent coronary
angiography and found that 32 had CAD [33]. The degree of obstruction was sig-
nificant (>50% stenosis) in 16 patients and 8 patients required intervention. The
incidence of CAD in patients >50 years old who were being considered for LT was
17%. Ben-Dor et al. reported a 17.8% incidence of significant CAD (defined as
>70% stenosis) and a 17.8% incidence of nonsignificant CAD in their cohort of 118
patients [22]. There were no differences in demographic or CV risk factors among
patients with or without significant CAD, and severity of CAD was not related to
posttransplant survival over short-term follow-up. As demonstrated by this study,
cardiac risk factors do not identify all LT candidates with significant CAD.
CAD is a relative contraindication to LT. However, heart-lung transplantation

can be considered in select patients with both end-stage lung disease and advanced
coronary disease with left ventricular dysfunction [5]. In the setting of preserved
ventricular function, obstructive CAD may be addressed by percutaneous or surgi-
cal revascularization [34]. Studies have reported acceptable outcomes following
percutaneous coronary intervention before transplant or simultaneous bypass graft-
ing during the transplant procedure; however, the latter approach may not be offered
to all patients, or available at all centers [22, 27, 34]. In a recent single-center retro-
spective study of 333 patients from 2004 to 2013, Halloran et al. found that the
presence of CAD and coronary artery bypass grafting (CABG) at the time of lung
transplantation did not impact overall retransplant-free survival [35].
Historically, prior CABG has been considered a contraindication to LT due to
CAD severity and the technical surgical challenges of chest reentry; however, post-
CABG patients are now increasingly being considered for and in select instances
undergoing LT. McKellar et al. identified 292 (1.97%) out of 14,791 LT patients
with a pretransplant CABG using data from the United Network for Organ Sharing
Registry between 2004 and 2013. Patients most commonly underwent single right
LT (n = 181), followed by single left LT (n = 68) and bilateral LT (n = 43).
Pretransplant CABG predicted mortality at 30 days and at 1, 3, and 5 years, with
hazard ratios ranging from 1.97 (95% CI, 1.23–3.16; p < 0.01) at 30 days to 1.38
(95% CI, 1.12–1.69; p < 0.01) at 5 years. However, this finding was driven princi-
pally by the increased mortality in patients that received bilateral LT [36].
Noncontrast cardiac computed tomography (CT) has received increasing atten-
tion as a less invasive method for detecting coronary artery calcification, and this
technique may be helpful in select patient groups [37]. However at this time, cardiac
CT has not been adequately studied in LT candidates, and therefore, its utility
remains uncertain. Using a patient registry, Gaisl et al. matched 81 COPD patients
with 81 non-COPD patients with a smoking history. There was no difference in
coronary artery calcium scores between COPD patients (Global Initiative for
Chronic Obstructive Lung Disease classification I, 5%; II, 23%; III, 16%; and IV,
56%) and controls (median difference: 68 Agatston units [95% CI, 176.5–192.5],
p = 0.90). However, there was a higher incidence of major adverse cardiac events in
the COPD cohort (RR = 2.80, p = 0.016) compared with controls over a median
follow-up duration of 42.6 months. Cardiac ischemia and coronary artery calcifica-
tion score were identified by proportional hazards modeling as independent predic-
tors for adverse cardiac events. Another study by Nathan et al. found that CT
performs moderately well for predicting CAD in IPF patients. In 57 patients with
CAD (significant disease in 28.1%, mild disease in 40.3%, and none in 31.6%), the
sensitivity of moderate to severe calcification for significant CAD was 81% and
specificity was 85%, with an associated odds ratio of 25.2 (95% CI, 4.64–166;
p < 0.005). There was also excellent interobserver agreement among reviewers
grading the coronary calcification. CT has been studied as part of the cardiac evalu-
ation in candidates for liver and renal transplantation with similar results [21, 38,
39]. Nevertheless, additional prospective data are needed before considering CT in
place of angiography in LT candidates.
Use of extracorporeal life support, including extracorporeal membrane oxygen-

ation (ECMO), as a bridge to lung or heart-lung transplantation has increased in
recent years [40–45]. However, ECMO may limit the ability to perform a more
thorough cardiac evaluation due to the underlying disease severity, inability to
access the pulmonary circulation or accurately perform right heart catheterization
(particularly when the internal jugular vein is accessed using a dual-lumen cannula),
or inability to transport the patient for other logistic reasons. There is growing expe-
rience with ambulation while on ECMO support, which allows for more aggressive
physical rehabilitation while awaiting transplantation [46–52]. Cardiac catheteriza-
tions and percutaneous intervention procedures have been performed in pediatric
and adult ECMO patients, with acceptable outcomes [53–60].
In terms of management, patients with CAD may be candidates for percutaneous
coronary intervention or CABG preoperatively or, in some instances, combined
lung transplant and CABG. Successful revascularization of CAD has been well
documented [25, 27, 34, 61, 62]; however, the type of coronary stent used in trans-
plant candidates (bare metal or drug-eluting) and severity of CAD considered
acceptable vary among transplant centers. Additionally, the timing of registration of
candidates onto the transplant waiting list (and consequently the timing of trans-
plantation) may be impacted by use of several medications common in CAD man-
agement, including the novel oral anticoagulants (NOACs), direct oral anticoagulants
(DOACs), and various antiplatelet agents [63–67]. A case illustrating the ability to
perform LT in a patient receiving Rivaroxaban has been reported [68]. Direct oral
anticoagulant therapy was also well tolerated in heart and lung transplant recipi-
ents, but drug interactions and dosing adjustment for renal function were com-
mon [69].
In the future, expanded use of genome-wide association studies (GWAS) may
one day help identify novel single-nucleotide polymorphisms (SNP) associated
with CAD in patients with advanced lung disease. In a recent study that included
more than 88,000 CAD cases and 162,000 controls, 25 new SNP-CAD associations
were identified (p < 5 × 10−8, in fixed-effects meta-analysis) from 15 genomic
regions, including SNPs in or near genes involved in cellular adhesion, leukocyte
migration and atherosclerosis (PECAM1, rs1867624), coagulation and inflamma-
tion (PROCR, rs867186 [p.Ser219Gly]), and vascular smooth muscle cell differen-
tiation (LMOD1, rs2820315) [70].
Diastolic Dysfunction
Poor cardiac function is generally considered a contraindication to LT. However,

given the propensity for right ventricular (RV) function to improve following LT, it
is typically the left ventricle (LV) that determines LT eligibility. Nevertheless, there
has been increasing interest in how the presence and severity of diastolic dysfunc-
tion may affect perioperative outcomes, early graft function, and long-term survival
in LT candidates.
Kato et al. studied the echocardiograms of 67 recipients before and after LT [71].
They found that RV parameters improved in all patients after LT (RV fractional area
change, 36.7 ± 5.6% to 41.5 ± 2.7%; RV strain, −15.5 ± 2.9% to −18.0 ± 2.1%; RV
E/e’, 8.4 ± 1.8 to 7.7 ± 1.8; all p < 0.05). Left ventricular ejection fraction (LVEF)
did not change (58.7 ± 6.0% to 57.5 ± 9.7%, p = 0.39); however, 20 patients (30%)
had >10% LVEF decline after LT (61.5 ± 6.1% to 47.3 ± 4.2%, p < 0.001) and an
increase in LV E/e’ (11.8 ± 1.8 to 12.9 ± 2.2, p = 0.05). Pre-LT LV E/e’ (OR 1.38,
[95% CI, 1.01–1.95], p = 0.043) and lower pre-LT LV strain (OR 1.29, [95% CI,
1.09–1.61], p = 0.002) were associated with LVEF decrease after LT. The authors
concluded that some recipients may experience worsening of both LV systolic and
diastolic function following LT and that pretransplant LV diastolic dysfunction may
increase the risk of LVEF deterioration post-LT. In a study of 65 lung transplant
candidates, Nowak et al. found that mortality was higher in patients with smaller left
ventricular end-systolic (LVESD) and end-diastolic (LVEDD) diameters (HR 3.03,
[95% CI, 1.16–7.69], p = 0.023; and HR 2.9, [95% CI 1.16–7.14], p = 0.022, respec-
tively) [72]. This finding was most relevant for patients with IPF, where a worse
prognosis was previously related to increased pulmonary arterial pressures [73].
Pretransplant diastolic dysfunction may also be associated with an increased risk
for primary graft dysfunction (PGD) following LT. In a retrospective cohort study
of patients with ILD, COPD, and PAH enrolled in the Lung Transplant Outcomes
Group (LTOG), Porteous et al. examined whether a higher ratio of early mitral
inflow velocity (E) to early diastolic mitral annular velocity (é), which suggests
worse LV diastolic function, was associated with a higher PGD risk [74]. They
found that a higher E/é and E/é >8 were associated with increased PGD risk (E/é
OR, 1.93 [95% CI, 1.02–3.64]; p = 0.04; E/é >8 OR, 5.29 [95% CI, 1.40–20.01];
p = 0.01). In a separate study, Perez-Teran et al. used both conventional and speckle-
tracking echocardiography to examine RV function and PGD risk [75]. Patients who
developed severe PGD had higher systolic pulmonary arterial pressure (48 ± 20 vs.
41 ± 18 mm Hg; p = 0.048), longer ischemia time (349 ± 73 vs. 306 ± 92 minutes;
p < 0.01), and better RV function as estimated by basal free wall longitudinal strain
(BLS; −24% ± 9% vs. –20% ± 6%; p = 0.039). In a multivariate analysis adjusted
for potentially confounding variables, basal free wall longitudinal strain
(BLS) ≥ −21.5% was independently associated with severe PGD (OR 4.56 [95%
CI, 1.20–17.38]; p = 0.026). More recently, Li et al. studied 330 bilateral lung trans-
plant recipients and found that mean left ventricular end-diastolic pressure (LVEDP)
was higher in patients with Grade 3 PGD (16 ± 7 vs. 12 ± 5 mmHg, p < 0.0001).
Elevation of either LVEDP >15 mmHg or mean pulmonary capillary wedge pres-
sure >15 mmHg was associated with severe PGD (adjusted OR 3.83 [95% CI,
1.90–7.73]; p < 0.0001 for LVEDP and adjusted OR 4.25 [95% CI, 1.83–9.86];
p = 0.0008 for mean pulmonary capillary wedge pressure) [76].
Avriel et al. examined LT outcomes for patients with PAH with preoperative LV
diastolic dysfunction with that of patients without diastolic dysfunction [77].
Fourteen of 44 patients (31.8%) with pretransplant diastolic dysfunction had a higher
mean pulmonary arterial pressure (54.6 ± 10 mmHg vs. 47 ± 11.3 mmHg) and right
atrial pressure (16.5 ± 5.2 mmHg vs. 10.6 ± 5.2 mmHg). Patients with diastolic dys-
function required extracorporeal life support more often (33% vs. 7%; p = 0.02), had
higher APACHE II scores (21.7 ± 7.4 vs. 15.3 ± 5.3; p = 0.02), and trended toward
fewer ventilator-free days (2.5 [IQR 6.5–32.5] vs. 17 [IQR 3–23]; p = 0.08). One-
year survival was worse (hazard ratio [HR] 4.45; 95% CI, 1.3–22; p = 0.02), and
diastolic dysfunction correlated with overall survival (HR 5.4; 95% CI, 1.3–22;
p = 0.02). The authors concluded that diastolic dysfunction leads to worse survival
in PAH patients following LT. However, Yadlapati et al. reported opposite findings.
They studied the effect of pretransplant diastolic dysfunction on LT outcome in 111
patients at a single institution [78]. They found that echocardiographic findings of
abnormal diastolic function, including A’ > E’ and A > E, did not predict adverse
events (p = 0.49). Mildly elevated pretransplant pulmonary capillary wedge pressure
(16–20 mmHg) and moderately or severely elevated pulmonary capillary wedge
pressure (>20 mmHg) were not associated with adverse events following LT.
Atrial Arrhythmias
Atrial arrhythmias are common both in the general population and after LT. Atrial
fibrillation (AF) is the most common atrial arrhythmia observed in Europe and the
United States. In these regions, the estimated prevalence of AF is 1–2% in the gen-
eral population; however, AF may be observed in >10% of individuals above the age
of 80 years [79]. Notably, AF has been associated with poorer outcomes in preop-
erative patients undergoing cardiac and valvular heart surgery, and liver transplanta-
tion candidates with AF may be at an increased risk for posttransplant mortality
[80–83].
Atrial arrhythmias may portend a poorer outcome in affected LT patients [84]. In
a meta-analysis that included 2094 patients from 11 studies, Fan et al. found that the
pooled incidence of any postoperative atrial arrhythmia following LT was 31% (95%
CI, 25–37%) [85]. This prevalence is consistent with that reported in several other
studies describing atrial arrhythmias post-lung transplant [86–90]. Risk factors asso-
ciated with the development of a postoperative atrial arrhythmia included: age (>50
vs. ≤50 years, OR 2.73 [95% CI, 1.86–4.00], p < 0.001), history of atrial arrhythmia
(OR 1.76 [95% CI, 1.34–2.32], p = 0.002), vasopressor use (OR 1.76 [95% CI,
1.34–2.32], p < 0.001), ILD (OR of 1.85 [95% CI, 1.27–2.71], p = 0.001), hyperten-
sion (OR 1.49 [95% CI, 1.12–1.97], p = 0.006), CAD (OR 1.58 [95% CI, 1.20–2.08],
p = 0.001), hyperlipidemia (OR 1.52 [95% CI, 1.06–2.20], p = 0.025), and left atrial
enlargement (OR 2.99 [95% CI, 1.91–4.67], p < 0.001). Female recipients (female
vs. male, OR 0.44 [95% CI, 0.35–0.56], p < 0.001) and those with cystic fibrosis
(OR 0.32 [95% CI, 0.18–0.59], p < 0.001) were less likely to develop a postoperative
atrial arrhythmia. A separate meta-analysis of 2653 patients from 9 studies (7 of
which were included in the above study) found that a postoperative atrial arrhythmia
occurred in 29.8% of patients [91]. The authors concluded that atrial arrhythmias
were associated with significantly higher perioperative mortality (OR 2.70 [95% CI,
1.73–4.19], p < 0.0001), a more frequent need for tracheostomy (OR 4.67 [95% CI,
2.59–8.44], p < 0.0001), and higher midterm mortality (OR 1.71 [95% CI, 1.28–2.30],
p < 0.001). A similar review of 12 studies, published a year later, drew the same
conclusion [92]. Chaikriangkrai et al. found that a new atrial arrhythmia was most
likely to occur within 30 days of LT [87]. Of patients who underwent
electrophysiologic studies, 80% had multiple mechanisms accounting for the atrial
arrhythmia, including peri-tricuspid flutter (48%), peri-mitral flutter (36%), right
atrial incisional reentry (24%), focal tachycardia from recipient pulmonary vein
antrum (32%), focal pulmonary vein fibrillation (24%), and left atrial roof flutter
(20%). Left atrial mechanisms were observed in 80% of electrophysiologic study
patients and typically originated from the anastomotic pulmonary vein antrum [87].
LT recipients with preoperative atrial fibrillation may be at increased risk of
poorer cardiovascular outcomes. In a single-center study of 235 lung transplant
recipients from 2013 to 2015, Yerasi et al. found that AF patients were older (64.1 ± 9
vs. 58.3 ± 8.3 years, p < 0.001), had a longer ischemic time (520 ± 188 vs. 305 ± 83,
p < 0.001), had more postoperative arrhythmias (73.7% vs. 20.8%, p = 0.01), and
had a longer median postoperative length of stay (16 vs. 13 days, p = 0.02) [93].
Median total hospital length of stay during the first posttransplant year was longer
for the AF patients (27 vs. 21 days, p = 0.25). Moreover, AF, along with pneumonia
and any infection, was associated with 30-day readmission after LT [94]. Elevated
pulmonary arterial pressure was associated with a lower occurrence of AF in a study
of 174 patients, of whom 16% developed AF at a median 6 days posttransplant [95].
In this study, every 10-mmHg increase in pulmonary artery systolic pressure was
associated with a 31% reduction in the odds of postoperative AF (OR 0.69 [95% CI,
0.49–0.98], p = 0.035). Bilateral LT, as opposed to single LT, may protect against
long-term paroxysmal AF [96]. Garcia et al. [97] found that AF was associated with
lower posttransplant survival; however, other studies of LT recipients with AF have
not identified a similar association [86, 98, 99]. Pharmacologic treatment and abla-
tion procedures have been performed following LT, with successful arrhythmia con-
trol [100–104]. However, there is one case report describing pulmonary toxicity
following treatment with amiodarone for atrial arrhythmias after LT [105]. The
study by Fan et al. also demonstrated an association between atrial arrhythmia and
length of stay (weighted mean difference 9.72, 95% CI 5.07–14.38, p < 0.001) and
overall survival after LT (HR 1.72, [95% CI, 1.39–2.12], p < 0.001).
PAH in Advanced Lung Diseases
Pulmonary arterial hypertension (PAH) secondary to advanced lung disease is asso-

ciated with both disease severity and survival in LT candidates. PAH occurs in
COPD, but the prevalence varies according to disease severity and the definition of
PAH utilized – up to 90% of GOLD stage IV COPD patients had a mean pulmonary
arterial pressure (mPAP) >20 mm Hg, and about 3–5% had a mPAP >35–40 mm Hg
[106, 107]. Patients with IPF may have an even higher prevalence of PH, with 8.1%
and 14.9% of IPF patients having mPAP >25 mm Hg in published series [108, 109].
The 5-year survival for COPD patients with PAH was 36% in one study [110], and
IPF survival worsens in the presence of PAH [111–114].
The 6-minute walk test (6MWT) has long been recognized as a useful diagnostic
tool for the assessment of PAH and the LT candidate [115, 116]. Walk distance and
oxygen desaturation have been associated with lung function in ILD patients [117,
118]. More notably, the 6MWT has prognostic value for patients with group 1 PAH
[119, 120], non-group 1 PAH [121], ILD [122–124], cystic fibrosis [125–127], and
COPD [128–132]. In a cross-sectional analysis, Porteous et al. studied the determi-
nants of 6-minute walk distance in 130 IPF patients undergoing lung transplant
evaluation [133]. After adjustment for age, sex, race, height, and weight, the pres-
ence of right ventricular dilation was associated with a decrease of 50.9 m (95%CI,
8.4–93.3; p = 0.02) in walk distance. Additionally, for every 1 Wood unit increase in
pulmonary vascular resistance, walk distance decreased by 17.3 m (95% CI,
5.1–29.5; p = 0:006). A pretransplant 6MWT >750 ft. (229 m) was associated with
a shorter length of hospitalization (37 vs. 20 days, p = 0.03) in pediatric LT recipi-
ents [134]. The 6-minute walk distance has also been associated with recipient sur-
vival following lung transplant [135].
Doppler echocardiography (DE) has been evaluated as a surrogate for RHC for
the detection of PAH. Balci et al. [136] studied 103 lung transplantation candidates
who underwent both DE and RHC within a 72-hour period. Almost 90% of patients
were able to undergo pulmonary artery systolic pressure (PASP) evaluation by
DE. Median PASP was 45 (12–145) mm Hg by RHC and 45 (20–144) mm Hg by
DE. PASP estimated by DE correlated with that measured by RHC (r = 0.585,
p < 0.0001). Sensitivity, specificity, and positive and negative predictive values of
PASP for the diagnosis of PAH were 85%, 67%, 87%, and 61%, respectively. PAH
was present in 57% of their lung transplantation candidates.
In another study comparing echocardiography and cardiac catheterization to
diagnose PAH, Nowak et al. [137] found that right ventricular systolic pressure
(RVSP) ≥43 mm Hg predicted the presence of PAH (sensitivity 92.3%, specificity
81.8%, area under curve [AUC] 0.84 [95% CI, 0.67–1.0]; p = 0.019). Right ven-
tricular outflow tract (RVOT) diameter ≥34 mm and tricuspid annular plane systolic
excursion (TAPSE) ≤18 mm had adequate sensitivity, specificity and AUC for PAH
(62.2%, 89.3%, 0.77 [95% CI, 0.66–0.89], p = 0.01, and 77.1%, 66.7%, 0.74 [95%
CI, 0.61–0.87], p = 0.027, respectively). The combined use of RVSP, RVOT, and
TAPSE increased both sensitivity and negative predictive value of PAH detection to
100%. PAH, defined by PASP >25 mm Hg on cardiac catheterization, was observed
in 67.6% of IPF patients, 30% of COPD patients, and 75% of patients with other
ILDs. Exercise pulmonary hemodynamic response has also predicted adverse clini-
cal outcomes in patients with fibrotic lung disease [138].
Patients with PAH undergoing LT may be at risk for transient LV dysfunction in
the immediate postoperative period. In a single-center study, Gupta et al. described
their experience in 16 patients with World Health Organization (WHO) Group 1
PAH who underwent LT between 2008 and 2012 [139]. Five of 16 patients (31%)
developed LV dysfunction after transplantation. Mean time to LV dysfunction onset
was 4.2 days. Patients with dysfunction had lower right and left ventricular ejection
fraction with higher LV end-diastolic volume before LT. However, all patients
recovered LV function within 4 months of LT.
PAH is common in end-stage lung disease and associated with poorer short-term
and intermediate-term LT outcomes. In a study of 518 patients, Andersen et al.
found that 58 (11%) had postcapillary PAH, while 211 (41%) had precapillary PAH
and 249 (48%) had no PAH [140]. Precapillary and postcapillary PAH were associ-
ated with worse 90-day outcomes compared to non-PAH patients (p = 0.003 and
0.043, respectively). However, survival beyond 1 year was not altered by PAH. Using
Organ Procurement and Transplant Network data, Singh et al. studied 2025 COPD,
2304 IPF, and 866 CF patients. The authors found that 1-year posttransplant sur-
vival for COPD patients with vs. without PAH was 76.9% vs. 86.2% (p = 0.001).
COPD patients with PAH had a 1.74 (95% CI, 1.3–2.3; p = 0.001) times higher risk
of mortality at 1 year post-LT. The presence of PAH did not influence post-LT sur-
vival for IPF and CF patients.
Valvular Heart Disease
The presence of significant valvular heart disease may preclude the possibility of
LT, although the degree of valvular dysfunction considered significant likely dif-
fers among transplant centers and by surgical assessment. There is little published
data evaluating the assessment of valvular heart disease prior to LT, and the
ISHLT candidate selection guidelines do not specifically address valvular heart
disease, outside of that contributing to “significant” heart dysfunction as a
contraindication.
In a small series (5 patients), progression of mitral regurgitation following LT
was not associated with 1-year or 5-year mortality [141]. However, the authors
acknowledge that in some instances, MR progression may become clinically sig-
nificant. LT may also unmask severe mitral regurgitation, as described in a patient
transplanted for severe PAH, possibly due to ventricular remodeling and subsequent
change in the mitral valve apparatus [142]. Aortic valve replacement has been per-
formed for critical aortic stenosis after bilateral LT [143]. Transcatheter aortic valve
implantation has been reported in a LT recipient, though this procedure may also be
associated with a risk of exacerbation in IPF pretransplant [144, 145]. Valves have
also been replaced for posttransplant infective endocarditis [146].
Conclusion
Lung transplantation remains an important treatment option for patients with

advanced or end-stage lung disease; however, careful candidate selection is impor-
tant for optimizing perioperative and long-term outcomes. The cardiac evaluation is
a critical element of the pretransplant assessment. Disorders such as significant
CAD, arrhythmias, PAH, and valvular heart disease should be readily identified and
managed so that the chance for a successful transplant outcome is not adversely
affected. Several current and emerging diagnostic techniques can assess for the
presence of cardiac disease, and future research will focus on novel methods of
detection and intervention to optimize the heart for LT.
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Index
A clinical presentation and

Abdominal aortic aneurysms (AAA), 216 management, 29, 30
Aclidinium, 172 and CVD, 27–29
Acute exacerbations of COPD diagnosis, 27
(AECOPD), 37, 38 general population studies, 26, 27
atrial fibrillation, 238, 239 prevalence of CVD, 30, 31
cardiovascular events, 231 during pregnancy, 26
causes, 231 Atherosclerosis Risk in Communities (ARIC)
definition, 230 Study, 27
etiology, 232 Azoles, 195
heart failure, 237, 238
incidence, 230
ischemic heart disease, 236, 237 B
mechanism, 234 Beclomethasone dipropionate, 166, 169, 176
myocardial infarction and stroke, 233, 234 Bergen Clinical Blood Pressure Survey, 6
non-pharmacologic therapy, 239, 240 Borg breathless scale, 220
pathophysiology, 232
prevention, 235, 236
risk factors, 234, 235 C
Adenine trinucleotide phosphates (ATP), 221 Canadian Community Health Survey, 27
Aerobic metabolism, 221 Cardiac imaging
Aerosol particles, 164, 179 cardiovascular disease, 109
Albuterol, 169 computed tomography, 98, 101
American College of Sports Medicine, 217 connective tissue diseases, 108
American Heart Association guidelines, 215 COPD, 105, 106
Aminophylline, 173 coronary artery disease, 102, 103
Amiodarone, 196 echocardiography, 98
Anaerobic threshold, 221 MRI, 101
Angiotensin enzyme convertor (ACE) peripheral arterial disease, 109
inhibitors, 196 pulmonary hypertension, 103, 104
Anti-arrhythmics, 196, 197 right ventricular dysfunction, 104, 105
Antibiotics, 180, 181 sarcoid, 106, 108
ASCENT study, 192 Cardiac rehabilitation (CR)
Asthma, 52 phases, 215
with cardiovascular disease, 26 See also Pulmonary rehabilitation (PR)

Respiratory Medicine, https://doi.org/10.1007/978-3-030-43435-9
268 Index
Cardiopulmonary disease, 20–22 cerebrovascular disease, 5, 6

Cardiopulmonary exercise testing (CPET), 218 clinical manifestations and diagnosis, 9–11
atrial fibrillation, 142 epidemiology, 1, 2
cardiovascular responses, 119, 120 heart failure, 7, 8
in combined COPD-heart failure peripheral arterial disease, 6, 7
anaerobic threshold, 120 Chronic Respiratory Questionnaire
central and peripheral (CRQ), 219
hemodynamics, 133–138 Ciclesonide, 166, 169, 176
cerebral blood flow, 138, 139 Ciprofloxacin, 179–181, 193
critical mechanical constraints, Cobicistat, 175
120, 123 COPD and Systemic Consequences–
disturbed pulmonary gas exchange, Comorbidities Network
123, 124 (COSYCONET), 6
impaired SV, 124, 125 Coronary artery disease (CAD), 3–5
increased ventilatory demand, 120, Coronary Artery Risk Development in Young
124, 125 Adults (CARDIA) cohort
lung mechanics, 129–133 study, 20, 21
poor O2 delivery, 124, 125 Corticosteroids, 175, 176
prevalence, 126 CredibleMeds, 188
prognosis, 126 Critical power, 221
reduced ventilatory reserve, 120 Cycling, 223, 224
ventilatory control and gas CYP2D6 enzymes, 163, 170–172, 177, 181
exchange, 126–130 CYP3A4 enzyme, 165, 166, 175–181,
in combined lungs-heart disease, 140, 141 187, 194
in isolated COPD, 117 CYP450 enzymes, 163, 165, 170
Kaplan-Meier survival curves, 141
in pulmonary hypertension, 140
rapidly-incremental CPET, 118 D
respiratory responses, 118 Dexamethasone sodium phosphate, 168
Cardiovascular disease (CVD) Drug disposition, COPD/CVD
and lung diseases, 17, 18 CHF, 167
and lung function, 46 drug-drug interactions (see Drug-drug
epidemiology, 46 interactions (DDIs), in COPD)
heart failure, 51 furosemide, 167
pathobiologic processes by inhalational route, 164–167
accelerated aging, 47, 48 inhaled antimuscarinics
arterial abnormalities, 46, 47 aclidinium, 172
hypercoagulability, 50 glycopyrrolate, 172
hypoxia, 50 ipratropium, 171
oxidative stress, 49 revefenacin, 172, 173
protease/antiprotease imbalance, 49, 50 tiotropium, 171, 172
renin-angiotensin system, 50 umeclidinium, 172
sympathetic nervous system, 51 inhaled β2-agonists
systemic inflammation, 48, 49 albuterol, 169, 170
pre-cardiovascular disease, 18, 19 formoterol, 170
Carotid intimal medial thickness (CIMT), 47 indacaterol, 170
Cerebrovascular and peripheral artery levalbuterol, 170
disease, 52 olodaterol, 171
Cerebrovascular disease, 5, 6 salmeterol, 170
Chlamydiae, 195 vilanterol, 171
Chronic Heart Questionnaire (CHQ), 219 inhaled corticosteroid, 168, 169
Chronic obstructive pulmonary roflumilast, 173
disease (COPD) by systemic circulation, 162–164
CAD, 3–5 systemic corticosteroids, 168
Index 269
theophylline, 173 Fluconazole, 175, 177

tobacco smoking, 167 Fluoroquinolones, 180, 181, 187, 193
Drug-drug interactions (DDIs), in COPD Formoterol, 170
antibiotics, 180, 181 Frailty, 220
classification, 174 Framingham Heart Study, 20
corticosteroids, 175, 176 Furosemide, 167
inhaled antimuscarinics, 178, 179
inhaled β2-agonists, 177, 178
lung transplantation, 174 G
medications, 174 Gender differences
pulmonary hypertension, 175 airways disease, 39
roflumilast, 180 asthma (see Asthma)
systemic corticosteroid therapy, 175, 177 in COPD
theophylline, 179, 180 cardiovascular mortality, 32
Dyspnea-12 questionnaire, 220 cardiovascular risk, 38, 39
Dyspnea threshold, 123 chronic bronchitis, 32
cigarette smoking, 33
clinicians response to men and
E women, 36
EMA post-authorization safety studies COPD-related hospitalizations, 33
(PASS), 189 CVD clinical manifestations and
Endurance shuttle walk test (ESWT), 218, risk, 36–38
219, 223 Finnish analysis of medical records, 33
Enterocytes, 164 prevalence and impact, 32, 33
Erythromycin, 177 risk factors, 32
EuroQol (EQ-5D), 219 in Scandinavian studies, 32
Exercise intolerance, 117 susceptibility of women to tobacco and
Exercise training biomass smoke inhalation, 34
anxiety and depression, 219 symptom profile and burden in men and
benefits, 216 women, 35
cardiopulmonary exercise test, 218 in women, 33
dyspnea, 219, 220 General Practice Research Database
endurance shuttle walk test, 218, 219 (GPRD), 233
exercise assessment, 217 Glycopyrrolate, 172
frailty, 220
frequency, 222
health-related quality of life, 219 H
incremental shuttle walk test, 218 Heart failure with reduced ejection fraction
inspiratory muscle training, 225 (HFrEF), 237, 238
intensity, 222, 223 Heart Failure: A Controlled Trial Investigating
peripheral muscle strength, 219 Outcomes of Exercise Training
physiological aerobic training, 220, 221 (HF-ACTION) trial, 215
principles of aerobic exercise, 221, 222 Heart-lung interactions
rehabilitation team, 225 cardiopulmonary physiology, 150
setting, 225 cardiovascular effects
six minute walk test, 218 of changing lung volume, 153, 154
strength training, 224 passive ventilation, 152
time (duration), 223 spontaneous breathing, 150, 152
type, 223 fluid-responsiveness prediction, 156, 157
gas exchange, 154, 155
mechanical ventilation, 156
F nocturnal non-invasive ventilation,
FITT method, 222 155, 156
Flow mediated dilation (FMD), 47 pulmonary function alterations, 155
270 Index
Hepatocytes, 164 pulmonary arterial hypertension, 256–258

High intensity exercise session, 221 survival rates, 247
High intensity lower limb training, 222 valvular heart disease, 258
Hospital Anxiety and Depression scale, 219 Lymphangioleiomyomatosis (LAM), 91, 92
Hypercoagulability, 50
M
I Major adverse cardiovascular and
Ideal cardiovascular health, 18 cerebrovascular events
Idiopathic pulmonary fibrosis (IPF), 52 (MACCE), 250
Incremental shuttle walk test (ISWT), 218, Major cardiovascular adverse events
222, 223 (MACE), 192
Indacaterol, 170, 178 Maximal exercise test, 221
Inhaled antimuscarinics, 171–173, 178, 179 Medical Research Council (MRC) dyspnea
Inhaled β2-agonists, 169–171, 177, 178 scale, 217, 219
Inhaled corticosteroid (ICS), 166–169, 174, Medicare beneficiary database, 234
175, 183, 186, 189–192, 236 Medication safety, in heart disease
Inhaled drug therapy, 164, 165 anti-infectives
Inhaled fluticasone furoate, 164 azoles, 195
Inspiratory muscle training, 225 fluoroquinolones, 193
INTERHEART study, 18 macrolides, 193, 194
International Society of Heart and Lung inhaled bronchodilators
Transplantation (ISHLT), 249 anti-muscarinics, 191, 192
Intravenous methylprednisolone sodium clinical trials, 189
succinate, 168 β2-agonits, 190, 191
Ipratropium, 171 Medications effects on heart disease
Ischemic heart disease, 236, 237 antimicrobials, 187, 188
Isokinetic dynamometry, 219 anti-muscarinics, 186
Itraconazole, 175–177, 180, 181, 187, 195 B2-agonists, 184–186
glucocorticoids, 183
inhaled corticosteroid, 183
K mineralocorticoid effects, 182
Ketoconazole, 175, 177 systemic corticosteroids, 182, 183
theophylline, 186, 187
Medications effects on pulmonary arterial
L hypertension, 198–200
Levalbuterol, 170 Medications effects on respiratory tract
Levofloxacin, 181, 193, 194 angiotensin enzyme convertor
Lipophilicity, 164 inhibitors, 196
Lipopolysaccharide (LPS) stimulation, 235 anti-arrhythmics, 196, 197
Long-acting beta-2 agonist (LABA), 168, 170, β-blockers, 197, 198
177, 178, 183, 186, 189–192, Methylprednisolone, 168, 175, 176, 181–183
200, 235 Moxifloxacin, 181, 186, 188, 193
Long-acting muscarinic antagonist Multi-Dimensional Dyspnea Profile
(LAMA), 235 questionnaire (MDP), 220
Lung Allocation Score (LAS), 248 Myocardial extracellular volume (ECV), 106
Lung transplantation (LT) Myocardial infarction (MI), 28
atrial arrhythmias, 255, 256
characteristics, 249
chronic lung allograft dysfunction, 247 N
coronary artery disease, 250–253 National Emphysema Treatment Trial, 51
development and refinement, 247 National Health and Nutrition Examination
diastolic dysfunction, 253–255 Survey (NHANES), 5
Lung Allocation Score, 248 National Health Interview Survey (NHIS), 5
Index 271
Nocturnal Oxygen Therapy Trial, 81 sarcoidosis-associated PH, 90

N-terminal pro b-type natriuretic peptide symptoms and exercise intolerance, 80
(NT-proBNP), 232 treatment, 80
Pulmonary rehabilitation (PR)
abdominal aortic aneurysms, 216
O aerobic exercise, 222
Obstructive and restrictive lung physiology, 17 anxiety and depression, 219
Olodaterol, 169, 171, 177, 178, 186 assessment, 217
benefits, 215
breathlessness, 214
P cardiopulmonary exercise test, 218
Peripheral arterial disease, 6, 7 dyspnea, 219
Peripheral muscle strength, 219 endurance shuttle walk test, 218, 219
P-gp inhibitor, 163, 164, 166, 168–175, exercise training, 216
177–179, 181 effects, 220, 221
Pharmacogenomics, 163 inspiratory muscle training, 225
Phenobarbital, 175 intensity, 222, 223
Prednisone, 168, 175, 176, 182, 183 principles, 221, 222
Pre-lung disease, 19, 20 rehabilitation team, 225
Pulmonary arterial hypertension strength training, 224
(PAH), 198–200 time (duration), 223
Pulmonary hypertension (PH) type, 223
causes, 80 frailty measures, 220
with COPD health-related quality of life, 219
calcium channel blockers, 82 incremental shuttle walk test, 218, 223
epoprostenol, 85 multiple comorbidities, 216
inhaled vasodilators, 82, 83 peripheral muscle strength, 219
long-term oxygen treatment, 81 setting, 225
medications, 82 six minute walk test, 218
mPAP and pulmonary vascular See also Cardiac rehabilitation (CR)
resistance, 81
Nocturnal Oxygen Therapy Trial, 81
PAH therapies, 81 R
phosphodiesterase-5 inhibitor, 83, 84 Renin angiotensin aldosterone system (RAAS)
pulmonary vasodilator therapies, 82 activation, 64, 65
definition, 80 Renin-angiotensin system (RAS), 50, 51
with interstitial lung diseases Resistance training, 216, 223–225
ARTEMIS-IPF trial, 88, 89 Revefenacin, 167, 172, 173, 192
bosentan, 86 Rifampin, 175
clinical efficacy, 86 Right heart dysfunction
endothelin receptor antagonists, 88 in chronic lung disease, 61–62
epoprostenol, 89 clinical management, 59
oxygen and anti-fibrotic agents, 89 diagnosis, 71–73
PAH therapies, 85, 86, 88, 89 disease-specific pathophysiologic
pre-clinical studies, 86–88 responses, 70
randomized controlled trials, 86–88 glucose oxidation, 63
riociguat, 89 hypoxia and right ventricular
sildenafil, 89 dysfunction, 70
STEP-IPF trial, 88 hypoxia inducible factor transcription
treprostinil, 89 factor, 63, 64
lymphangioleiomyomatosis, 91, 92 inflammatory pathways, 62–63
medical therapies, 80 metabolic alterations, 68, 69
pulmonary Langerhans cell mitochondrial metabolic remodeling, 63
histiocytosis, 91 neurohormonal activation, 67, 68
272 Index
Right heart dysfunction (cont.) Sulfotranferase enzymes (SULTIA3), 170

neurohormonal dysregulation, 64–66 Systemic corticosteroids, 168, 176, 177
normal right ventricle anatomy and
physiology, 60, 61
oxidative phosphorylation, 63 T
pathophysiology, 59 Theophylline, 167, 173, 179, 180
pulmonary hypertension, 66, 72 Timed up and Go (TUG), 220
pulmonary vascular remodeling, 62 Tiotropium, 171, 172
RA pressure estimation, 72 Tobacco smoking, 165, 167, 173, 179
reference limits, 71 TORCH study, 183, 190
renin-angiotensin system, 68 Torsades de pointes. (TdP), 187, 188,
right ventricular response, 67 193–195
Riociguat, 198 Torsemide, 167
Ritonavir, 175 Trepostinil, 199
Roflumilast, 173, 180 Triazoles, 175, 180, 181
S U
Salmeterol, 170, 178 UK national audit of cardiac rehabilitation
Secondary prevention in cardiovascular (NACR), 215
disease, 215 Umeclidinium, 172
Selexipag, 198 Understanding Potential Long-Term Impacts
Short-form 36 (SF-36), 219 on Function with Tiotropium
Short Physical Performance Battery (UPLIFT) trial, 38, 191, 235
(SPPB), 220
Sildenafil Trial of Exercise Performance in
Idiopathic Pulmonary Fibrosis V
(STEP-IPF) study, 88 Vilanterol, 167, 169–171, 178, 181, 189,
Six minute walk test (6MWT), 218 190, 192
ST-elevation myocardial infarction Voriconazole, 175, 181
(STEMI), 28, 232
Strength training, 224
Study to Understand Mortality and MorbidITy W
(SUMMIT) trial, 38, 183, 189, 190 Walking speed, 214, 218, 220, 221, 223

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Respiratory Medicine

Series Editors: Sharon I.S. Rounds · Anne Dixon · Lynn M. Schnapp

More information about this series at http://www.springer.com/series/7665

ISSN 2197-7372 ISSN 2197-7380 (electronic)

© Springer Nature Switzerland AG 2020

With the reduction in mortality attributable to cardiovascular disease in the devel-

be treated regardless of the presence of heart-lung comorbidity. A number of cardiac

Birmingham, AL, USA Surya P. Bhatt, MD

1 Cardiovascular Comorbidity in Chronic Lung Disease:

10 Medication Safety in Chronic Lung Disease with Cardiac

Deepak Acharya, MD, MSPH Division of Cardiovascular Diseases, Sarver Heart

Faculty of Medicine, UNSW Sydney, Sydney, NSW, Australia

Victoria Rusanov, MD Department of Medicine, University of Alabama at

© Springer Nature Switzerland AG 2020 1

lung diseases include chronic obstructive pulmonary disease (COPD), bronchial

Cardiovascular risk factors

Coronary Artery Disease (CAD)

controls without pulmonary fibrosis [21]. On follow-up over approximately

Given the similarities in pathophysiologic processes between CAD and ischemic

Peripheral Arterial Disease

diastolic dysfunction [45]. In a nested case-control study of 115 individuals with

Clinical Manifestations and Diagnosis

correlation between reported symptoms and objective findings (either on clinical

25. Finkelstein J, Cha E, Scharf SM. Chronic obstructive pulmonary disease as an independent

Lung Disease and Cardiovascular Disease

M. J. Cuttica · R. Kalhan (*)

© Springer Nature Switzerland AG 2020 17

The Paradigm: Identification of Pre-cardiovascular Disease

 he Paradigm Shift: Loss of Lung Health and Identification

 o-evolution of Lung and Heart Disease: The Birth

Declining FEV1 (and FVC) Declining FVC (and FEV1)

Decreased left heart Increased LV wall thickness

“Small heart, low output “Hypertrophic, high output

Cardio pulmonary disease states

There are substantial gender differences in chronic respiratory diseases as well as

© Springer Nature Switzerland AG 2020 25

What Do We Mean by Sex and Gender?

Asthma, Cardiovascular Disease, and Sex Differences

What Can We Learn from General Population Studies?

In a large population-based cohort of men and women in Northern California, with

The Atherosclerosis Risk in Communities (ARIC) Study in four US communities

Asthma and CVD in Case-Control Studies

In a US cohort of 203,595 adults with asthma and a parallel asthma-free cohort

 ender Effects on Outcomes in Asthma

myocardial infarction (STEMI or non-STEMI), OR 0.24, 95% CI 0.21–0.28 and

 ender-Related Factors Affect the Presentation

In relation to the impact of CVD in asthma, an analysis of sex differences in health

Mechanisms for the Increased Prevalence of CVD in Asthma

 re There Sex Differences in the Mechanisms Underlying

 ex Differences in Chronic Obstructive Pulmonary Disease

Sex Differences in COPD Prevalence and Impact

 isk of Developing COPD Differs by Dose and Type

I ncreased Susceptibility of Women to Tobacco and Biomass

 ifferent Symptom Profile and Burden in Men and Women

 ifferent Responses of Clinicians to Men and Women

 otential Mechanisms for Sex Differences in Increased Risk

Gender differences are especially prevalent in cardiovascular disease. Males tend to

COPD, CVD Clinical Manifestations, and Sex Differences

detected in up to 55% of patients admitted with AECOPD, suggesting that up to

 otential Mechanisms for Sex Differences Affecting

Birmingham, AL, USA Surya P. Bhatt, MD

1 Cardiovascular Comorbidity in Chronic Lung Disease:

10 Medication Safety in Chronic Lung Disease with Cardiac

Coronary Artery Disease (CAD)

Peripheral Arterial Disease

Clinical Manifestations and Diagnosis

Lung Disease and Cardiovascular Disease

The Paradigm: Identification of Pre-cardiovascular Disease

he Paradigm Shift: Loss of Lung Health and Identification

o-evolution of Lung and Heart Disease: The Birth

What Do We Mean by Sex and Gender?

Asthma, Cardiovascular Disease, and Sex Differences

What Can We Learn from General Population Studies?

Asthma and CVD in Case-Control Studies

ender Effects on Outcomes in Asthma

ender-Related Factors Affect the Presentation

Mechanisms for the Increased Prevalence of CVD in Asthma

re There Sex Differences in the Mechanisms Underlying

ex Differences in Chronic Obstructive Pulmonary Disease

Sex Differences in COPD Prevalence and Impact

isk of Developing COPD Differs by Dose and Type

I ncreased Susceptibility of Women to Tobacco and Biomass

ifferent Symptom Profile and Burden in Men and Women

ifferent Responses of Clinicians to Men and Women

otential Mechanisms for Sex Differences in Increased Risk

COPD, CVD Clinical Manifestations, and Sex Differences

otential Mechanisms for Sex Differences Affecting

ummary: Cardiovascular Comorbidity in Airway Disease:

Epidemiology of COPD and CVD

Relationship Between Lung Function and CVD

Pathobiologic Processes Underlying CVD Risk in COPD

Hypoxia and Sympathetic Nervous System Activation

Cerebrovascular and Peripheral Artery Disease

Idiopathic Pulmonary Fibrosis and Asthma

Normal Right Ventricular Anatomy and Physiology

Right Heart Dysfunction in Chronic Lung Disease

Pathophysiology of the Pulmonary Vasculature

ulmonary Vascular Remodeling in PH Due to Chronic

ontribution of Inflammatory Pathways to PH in Chronic

itochondrial Structural and Metabolic Alterations

Neurohormonal Dysregulation in the Pulmonary Circulation

Pulmonary Hypertension and the Right Ventricle

Pathophysiology of the Right Ventricle

Right Ventricular Response

Role of Renin-Angiotensin System

Metabolic Alterations in the Right Ventricle

Hypoxia and Right Ventricular Dysfunction

Disease-Specific Pathophysiologic Responses

Diagnosis of Right Heart Dysfunction in Chronic Lung Disease

PH Associated with Chronic Obstructive Pulmonary Disease

Calcium Channel Blockers

Phosphodiesterase-5 Inhibitors in COPD-Associated PH