الفهرس 
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Abstract
Chronic Obstructive Pulmonary Disease (COPD) represents an important public health challenge and is a major cause of chronic morbidity and mortality throughout the world. In recent years, COPD has been considered a global problem, predicted to be the third most common cause of death by 2030 and ranked fifth in the global disease burden. COPD is also characterized by extra pulmonary comorbidities such as muscle wasting, underweight, osteoporosis, and cardiovascular disease. Cardiac manifestations are the most common extra pulmonary effects in COPD patients. COPD affects pulmonary blood vessels, right ventricle leading to development of pulmonary hypertension, cor-pulmonale, right ventricular dysfunction. PHTN is defined as an increase in mean pulmonary arterial pressure (PAPm) ≥25 mmHg at rest as assessed by right heart catheterization (RHC). In patients with COPD, whether mild or more severe, the presence of pulmonary hypertension (PHTN) is associated with an increase in hospitalization & a poorer prognosis. Indeed in some studies the degree of PHTN is more powerful indicator of prognosis than the measure of airflow limitation. Abnormal right ventricular function is also associated with poorer prognosis in patients with COPD. Echocardiography provides a non-invasive method to evaluate cardiac status like – right ventricular (RV) function, RV filling pressure, tricuspid regurgitation and left ventricular function. Many studies have confirmed that echocardiographic ally derived estimates of pulmonary artery pressure (PAP) correlate closely with those derived by cardiac catheterization. Multiple blood biomarkers have been investigated for the risk prediction of patients with PHTN. Brain natriuretic peptides remain the most promising blood biomarkers. N-terminal-pro hormone brain natriuretic peptide (NT-proBNP) or brain natriuretic peptide (BNP) are secreted by cardiomyocytes due to excessive stretching of the ventricles. In PHTN, increased myocardial stress and right ventricular hypertrophy due to an increase in pulmonary vascular resistance and pulmonary arterial pressure might cause a rise in (NT-pro) BNP.
Our study aimed to assess the role of transthoracic echocardiography in evaluating pulmonary artery pressure and right ventricular parameters in chronic obstructive pulmonary disease patients of different severity and its correlation with serum biomarker pro BNP. This randomized controlled study was carried out at Tanta university hospital, chest department on 100 subjects using transthorancic echocardiography. The duration of the study was twelve months from November 2022 to November 2023. Subjects were divided into 3 groups: group I: control group.(20 healthy smokers) group II: mild/moderate COPD group.(40 patients) group III: severe COPD group.(40 patients) Summary of our results: There was significant increase in age in severe COPD group as compared with control group and mild/moderate COPD group (P=0.001) and there was no significant difference between control group and MILD/MODERATE group. There was significant increase in smoking index in mild/moderate COPD group as compared with control group (P=0.001) and there was significant increase in smoking index in severe COPD group as compared with control group and mild/moderate COPD group (P=0.001). All patients were males. There was significant increase in symptoms of COPD (productive cough, dyspnea and wheezing and chest tightness) in Severe COPD group as compared with Mild/moderate COPD group (P value<0.001) There was significant increase in symptoms of pulmonary hypertension (dyspnea on exertion, fatigue and rapid exhaustion, palpitations and exercise- induced abdominal distension and nausea) and signs of pulmonary hypertension (accentuated pulmonary component of second heart sound and systolic murmur of tricuspid regurgitation) in Severe COPD group as compared with Mild/moderate COPD group (P value<0.05). There was no significant difference regarding symptoms of pulmonary hypertension (dyspnea when bending forward (bendopnoea), heaemoptysis, weight gain due to fluid retention, syncope, exertional chest pain and hoarseness of voice between) and signs of pulmonary hypertension (central or peripheral cyanosis and diastolic murmur of pulmonary regurgitation) between mild/moderate COPD group and Severe COPD group. There was significant increase in CAT assessment score in severe COPD group as compared with Mild/moderate COPD group (P value=0.001).
There was significant increase in MRC dyspnea scale 0,1 in Mild/moderate COPD group as compared with Severe COPD group.There was significant increase in MRC dyspnea scale 3,4 in Severe COPD group as compared with Mild/moderate COPD group(P value =0.004). Regarding GOLD ABE assasement tool ,there was significant increase in Class A in mild/moderate COPD group as compared with severe COPD group and there was significant increase in Class E in severe COPD group as compared with mild/moderate COPD group (P= 0.001). There was significant increase in SBP, DBP and HR in mild/moderate COPD group as compared with control group and in severe COPD group as compared with control group and mild/moderate COPD group. (P=0.001) There was significant increase in CRP and ESR levels in Severe COPD group as compared with Mild/moderate COPD group and Control group (P value<0.05). Regarding ABG: there was no significant difference regarding pH between both groups (P value =0.104). There was significant increase in CO2 and HCO3 in Severe COPD group as compared with mild/moderate COPD group (P value=0.001).There was significant deccrease in PaO2 and O2 saturation in Severe COPD group as compared with Mild/moderate COPD group(P value =0.001).ABG was normal in control group. There was significant increase in Pro BNP in Severe COPD group as compared with Mild/moderate COPD group and Control group (P value =0.001) and there was no significant difference between Control group and Mild/moderate COPD . Regarding CHEST X-RAY: In mild/moderate COPD group 8 patients shoewed increased bronchovascular marking,10(25%) patients showed lung hyperinflation in the form of flattened diaphragm, hyper lucency of the lungs and .In severe COPD group 32(80%) patients showed signs of lung hyperinflation in the form of flattened diaphragm and hyper lucency of the lungs rapid tapering of vascular markings. FEV1/FVC, FEV1 % and FVC were significantly different among the three groups. There was significant decrease in FEV1/FVC, FEV1 % and FVC in mild/moderate COPD group as compared with control group and in severe COPD group as compared with control group and mild/moderate COPD group. (P value=0.001)
Regarding ECG : In MILD/MODERATE COPD group abnormal ECG in the form of sinus tachycardia was found in 20% of patients (8 patients),P Pulmonale was found in 5% of patients (2 patient). Right axis deviation was found in 2.5 % of patients (1 patient).In severe COPD group abnormal ECG in the form of sinus tachycardia was found in 50% of patients (20patients), P Pulmonale was found in 10% of patients (4 patient), Right axis deviation was found in 50% of patients (20 patient), Right ventricular hypertrophy was found in 40% of patients (16 patients) and RBBB was found in 10% of patients (4 patients).
Regarding the incidence of pulmonary hypertension in studied COPD patients, it was found in 77.5 %. of patients categorized into mild, moderate. severe without right sided heart failure and severe with right sided heart failure with the following percentages respectively 33.75%,35%,5% and 3.75%. In Mild/moderate COPD group pulmonary hypertension was found to be present in 26(65%) patients. It was found to be mild in 14(35%) patients, moderate in 10(25%) patients and severe in 2(5%) patients. In Severe COPD group pulmonary hypertension was found to be present in 30(90%) patients. It was found to be mild in 13(32.5%) patients, moderate in 18(45%) patients, severe without right sided heart failure in 2(5%) patients and severe with right sided heart failure in 3(7.5%) patients There was significant increase in SPAP and MPAP in mild/moderate COPD group as compared with control group and in severe COPD group as compared with control group and mild/moderate COPD group.(P value=0.001) There was significant increase in RVMD, RVBD, RVLD, RVOT above pulmonary valve and RVOT above aortic valve in mild/moderate COPD group as compared with control group and in severe COPD group as compared with control group and mild/moderate COPD group.(P value=0.001) There was significant decrease in TAPSE and RVEF in mild/moderate COPD group as compared with control group and in severe COPD group as compared with control group and mild/moderate COPD group.(P value=0.001) There was a negative correlation between FEV1% and (SPAP and MPAP). There was a positive correlation between FEV1 % and (TAPSE and RVEF). There was a negative correlation between FEV1% and (RVMD and RVBD).
There was a positive correlation between Pro BNP and (SPAP and MPAP). There was a negative correlation between Pro BNP and (TAPSE and RVEF).