Pulmonary Function in Patients With Reduced Left Ventricular Function: Influence of Smoking and Cardiac Surgery

doi:10.1378/chest.120.6.1869

Chest

Volume 120, Issue 6, December 2001, Pages 1869-1876

https://doi.org/10.1378/chest.120.6.1869 Get rights and content

Study objective

The impact of stable, chronic heart failure on baseline pulmonary function remains controversial. Confounding influences include previous coronary artery bypass or valve surgery (CABG), history of obesity, stability of disease, and smoking history.

Design

To control for some of the variables affecting pulmonary function in patients with chronic heart failure, we analyzed data in four patient groups, all with left ventricular (LV) dysfunction (LV ejection fraction [LVEF] ≤ 35%): (1) chronic heart failure, nonsmokers, no CABG (n = 78); (2) chronic heart failure, nonsmokers, CABG (n = 46); (3) chronic heart failure, smokers, no CABG (n = 40); and (4) chronic heart failure, smokers, CABG (n = 48). Comparisons were made with age- and gender-matched patients with a history of coronary disease but no LV dysfunction or smoking history (control subjects, n = 112) and to age-predicted norms.

Results

Relative to control subjects and percent-predicted values, all groups with chronic heart failure had reduced lung volumes (total lung capacity [TLC] and vital capacity[VC]) and expiratory flows (p < 0.05). CABG had no influence on lung volumes and expiratory flows in smokers, but resulted in a tendency toward a reduced TLC and VC in nonsmokers. Smokers with chronic heart failure had reduced expiratory flows compared to nonsmokers (p < 0.05), indicating an additive effect of smoking. Diffusion capacity of the lung for carbon monoxide (Dlco) was reduced in smokers and in subjects who underwent CABG, but not in patients with chronic heart failure alone. There was no relationship between LV size and pulmonary function in this population, although LV function (cardiac index and stroke volume) was weakly associated with lung volumes and Dlco.

Conclusions

We conclude that patients with chronic heart failure have primarily restrictive lung changes with smoking causing a further reduction in expiratory flows.

Section snippets

Subjects

A retrospective analysis was performed on data from heart failure patients obtained from databases maintained by the Cardiovascular Health Clinic (a preventive and rehabilitative cardiac clinic of the Mayo Clinic) and the Heart Failure Clinic at the Mayo Clinic, Rochester, from 1994 to 1998. Heart failure included patients with histories of dilated and ischemic pathologic conditions and with ejection fractions ≤ 35% with and without a history of CABG. A body mass index (BMI) of > 35 kg/m² was

Subject Characteristics

Mean characteristics of the five groups are shown in Table 1. No significant differences were observed among the groups for age, height, weight, or BMI. LVEF did not differ among the groups with chronic heart failure (averaging 23%), but as designed was significantly reduced relative to the CAD control subjects. Smoking history was not different between smokers with previous CABG vs smokers with no previous CABG (p > 0.05). There was a tendency for a greater number of female patients (percent)

Discussion

We were interested in the changes in baseline pulmonary function induced by stable chronic heart failure independent of smoking history, history of thoracic surgery, and morbid obesity. As summarized in Figure 4, we found that patients with chronic heart failure alone develop only mild restrictive changes in PFT results relative to control subjects and predictive values. Although these changes were significant, in most routine clinical laboratories the spirometric values would most likely be

Acknowledgment

The authors thank Becky Hughes-Borst and Sue Nelson, LPN, for help in data collection, and Audrey Schroeder for help with manuscript preparation.

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Moreover, the observed flow limitation and lung restriction may increase the work of breathing, which, in combination with weak respiratory muscles, may increase the sensation of dyspnea in patients with HF.8 Bronchial flow limitation has been attributed to airway compression (by pulmonary edema) and/or mucosal edema caused by bronchial congestion (Fig. 1),1,8–10 which may develop from either an increase in blood flow or an increase in blood volume without a change of flow caused by increased cardiac filling pressure or pulmonary artery hypertension.1 Several factors may influence bronchial blood flow in patients with HF, including increased left atrial pressure causing greater pulmonary vascular pressure and bronchial vessel stasis11; stretching of the left heart chambers, which may lead to increased bronchial conductance12; increase in levels of inflammatory and vasoactive mediators, which may influence vasomotor tone and lead to vasodilatation and congestion of bronchial vessels13,14; and chronic hypocapnia, which is a common manifestation of increased left ventricular filling pressures in patients with HF15 and may also lead to vasodilatation.16
Sex differences in leptin modulate ventilation in heart failure
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Leptin modulates ventilation and circulating levels are higher in normal women than men.
The aim of this study was to compare exercise ventilation and gas exchange in men and women with heart failure (HF) and their relation to circulating leptin concentration.
Consecutive HF patients were studied by cardiopulmonary exercise testing and assay of circulating leptin concentration.
Fifty-seven men and 20 women were similar with respect to age, BMI, NYHA class, left ventricular ejection fraction, and peak oxygen consumption (all p > 0.05). Leptin concentration was lower (10.3 ± 10 vs. 25.3 ± 16 ng/mL; p < 0.01) and peak exercise ventilatory efficiency (V_E/VCO₂) was higher (43 ± 10 vs. 36 ± 5; p < 0.01) in men. Leptin concentration was associated with peak exercise V_E/VCO₂ (b = −0.35; F = 5.6; p = 0.02).
Men have significantly lower circulating leptin concentration and increased ventilatory drive during exercise than women with comparable HF. In men with HF, lower leptin concentration may account for an increased ventilatory drive.
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This has been suggested as a screening method to identify those in need of further assessment by right heart catheterisation [66]. Lung restriction is found in PH due to left heart disease with reductions in both TLC and FVC, while airway obstruction is uncommon [67,68]. Heart size measured by echocardiography correlates with lung volume reductions as determined by spirometry and radiological evidence [26].
Breathlessness is a common symptom in pulmonary hypertension (PH) and an important cause of morbidity. Though this has been attributed to the well described pulmonary vascular abnormalities and subsequent cardiac remodelling, changes in the airways of these patients have also been reported and may contribute to symptoms. Our understanding of these airway abnormalities is poor with conflicting findings in many studies. The present review evaluates these studies for the major PH groups. In addition we describe the role of cardiopulmonary exercise testing in the assessment of pulmonary arterial hypertension (PAH) by evaluating cardiopulmonary interaction during exercise. As yet, the reasons for the abnormalities in lung function are unclear, but potential causes and the possible role of inflammation are discussed. Future research is required to provide a better understanding of this to help improve the management of these patients.
Pulmonary function impairment in patients with chronic heart failure: Lower limit of normal versus conventional cutoff values
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To determine the prevalence of pulmonary function abnormalities in patients with chronic heart failure (HF) according to recent American Thoracic Society/European Respiratory Society (ATS/ERS) guidelines using the lower limit of normal (LLN) compared to conventional cutoff values.
Recent ATS/ERS guidelines recommend the use of the LLN instead of the conventional cutoff values to define pulmonary function impairment to avoid misclassification of patients. However, studies addressing the prevalence of pulmonary function abnormalities according to both definitions in patients with chronic HF are lacking.
In this prospective cross-sectional study, 164 chronic HF outpatients (age 68 ± 10 years, 78% men, 88% New York Heart Association class I–II) with left ventricular ejection fraction < 40% underwent spirometry and measurement of diffusing capacity. Body plethysmography was performed in patients with abnormal spirometry results.
Diffusion impairment and airway obstruction were found in 44–58% and 26–37% of the patients, respectively, depending on the definition used (LLN versus conventional cutoff values, p < 0.05). However, restriction was infrequent, irrespective of the definition used (7% versus 5%, respectively, p > 0.05). The LLN identified fewer patients with abnormal lung function, whereas the conventional cutoff values classified more patients with diffusion impairment, airway obstruction, or a mixed category. Twenty-seven percent of patients were misclassified by the conventional cutoff values.
Pulmonary function abnormalities, especially diffusion impairment and airway obstruction, were highly prevalent in patients with chronic HF. Conventional cutoff values classified more patients with diffusion impairment, airway obstruction, or a mixed category compared to the LLN.
Effect of cardiac resynchronization therapy on pulmonary function in patients with heart failure
2013, American Journal of Cardiology
Pulmonary congestion due to heart failure causes abnormal lung function. Cardiac resynchronization therapy (CRT) is a proven effective treatment for heart failure. The aim of this study was to test the hypothesis that CRT promotes increased lung volumes, bronchial conductance, and gas diffusion. Forty-four consecutive patients with heart failure were prospectively investigated before and after CRT. Spirometry, gas diffusion (diffusing capacity for carbon monoxide), cardiopulmonary exercise testing, New York Heart Association class, brain natriuretic peptide, the left ventricular ejection fraction, left atrial volume, and right ventricular systolic pressure were assessed before and 4 to 6 months after CRT. Pre- and post-CRT measures were compared using either paired Student's t tests or Wilcoxon's matched-pair test; p values <0.05 were considered significant. Improved New York Heart Association class, left ventricular ejection fraction, left atrial volume, right ventricular systolic pressure, and brain natriuretic peptide were observed after CRT (p <0.05 for all). Spirometry after CRT demonstrated increased percentage predicted total lung capacity (90 ± 17% vs 96 ± 15%, p <0.01) and percentage predicted forced vital capacity (80 ± 19% vs 90 ± 19%, p <0.01). Increased percentage predicted total lung capacity was significantly correlated with increased peak exercise end-tidal carbon dioxide (r = 0.43, p = 0.05). Increased percentage predicted forced vital capacity was significantly correlated with decreased right ventricular systolic pressure (r = −0.30, p = 0.05), body mass index (r = −0.35, p = 0.02) and creatinine (r = −0.49, p = 0.02), consistent with an association of improved bronchial conductance and decreased congestion. Diffusing capacity for carbon monoxide did not significantly change. In conclusion, increased lung volumes and bronchial conductance due to decreased pulmonary congestion and increased intrathoracic space contribute to an improved breathing pattern and decreased hyperventilation after CRT. Persistent alveolar-capillary membrane remodeling may account for unchanged diffusing capacity for carbon monoxide.
Diagnosis and prognostic value of restrictive ventilatory disorders in the elderly: A systematic review of the literature
2012, Experimental Gerontology
Citation Excerpt :
Indeed, pulmonary fibrosis and reduced lung compliance secondary to chronic pulmonary oedema, competition between heart enlargement and lung parenchyma within the chest wall (Hosenpud et al., 1990; Olson et al., 2006; Agostoni et al., 2000) and respiratory muscle weakening (Walsh et al., 1996; Evans et al., 1995; Mancini et al., 1992) variously contribute to explain RLD in CHF patients. However, most of the studies on pulmonary function in CHF took place among middle-age populations (e.g. 60 years in the study by Wassermann Wasserman et al. (1997), with the exception of that by Johnson and colleagues (Johnson et al., 2001) which involved patients of a mean age of over 65 years. However, all these studies based the diagnosis of RLD on VC as a proxy for TLC and, thus, might have produced an overestimation of the true prevalence of RLD.
Although less extensively studied compared to pulmonary obstructive diseases, restrictive lung disease (RLD) is highly prevalent and frequently disabling in the adult and, more, the elderly population. The underlying conditions may be either primarily pulmonary diseases, such as idiopathic pulmonary fibrosis, or non respiratory conditions secondarily affecting the lung, e. g. congestive heart failure, or else conditions affecting the lung expansion, e. g. obesity or rib cage deformity. The diagnosis is frequently based on the measurement of surrogate indexes such as the forced vital capacity (FVC) used as a proxy for total lung capacity (TLC). As a consequence, diagnosis of RLD is often characterized by poor specificity. In the elderly, worsening in the quality of life and poor prognosis are variably, but significantly, associated to RLD, being the underlying condition an important source of variability. Several causes of RLD are preventable and treatable conditions. A prompt identification of these conditions may allow to slow the decline of respiratory reserve and, thus, to preserve both personal independence and resistance to acute respiratory infections.
This review gives an update on the latest evidence available on the prevalence and the prognosis of RLD in the elderly. Studies were identified through systematic searches of the electronic database MEDLINE. Reference list of eligible papers were also manually searched.

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: This work was supported in part by the Mayo Clinic and Foundation, and Human Health Services grant MO1-RR00585, General Clinical Research Centers, Division of Research Resources, National Institutes of Health.

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Chest

Clinical InvestigationsPULMONARY FUNCTIONPulmonary Function in Patients With Reduced Left Ventricular Function: Influence of Smoking and Cardiac Surgery

Study objective

Design

Results

Conclusions

Section snippets

Subjects

Subject Characteristics

Discussion

Acknowledgment

Prog Cardiovasc Dis

Clin Chest Med

J Am Coll Cardiol

Chest

Respir Med

Am J Med

Am J Cardiol

Int J Cardiol

Chest

Am Heart J

Chest

Chest

Chest

Chest

Chest

Am J Med Sci

Chest

J Am Coll Cardiol

Chest

Chest

J Cardiothorac Vasc Anesth

Evolution of resting lung function in the first year after cardiac transplantation

Eur Respir J

Vital capacity and congestive heart failure: the Framingham study

Circulation

Serial pulmonary function in patients with acute heart failure

Arch Intern Med

Pulmonary function tests in patients with congestive heart failure: effects of medical therapy

Cardiology

Pulmonary function tests in the detection of left heart failure: correlation with pulmonary artery wedge pressure

Respiration

Rapid decline in FEV1: a new risk factor for coronary heart disease mortality

Am J Respir Crit Care Med

Clinical Investigations
PULMONARY FUNCTION
Pulmonary Function in Patients With Reduced Left Ventricular Function: Influence of Smoking and Cardiac Surgery

Rapid decline in FEV₁: a new risk factor for coronary heart disease mortality