心力衰竭对 COPD 严重程度分类的影响。

The impact of heart failure on the classification of COPD severity.

机构信息

Comprehensive Heart Failure Center, University of Würzburg, Würzburg, Germany.

出版信息

J Card Fail. 2012 Aug;18(8):637-44. doi: 10.1016/j.cardfail.2012.05.008. Epub 2012 Jul 13.

DOI:10.1016/j.cardfail.2012.05.008

PMID:22858080

Abstract

BACKGROUND

Pulmonary restriction-a reduction of lung volumes-is common in heart failure (HF), rendering severity grading of chronic obstructive pulmonary disease (COPD) potentially problematic in subjects with both diseases. We compared pulmonary function in patients with either HF or COPD, or the combination to assess whether grading of COPD using the Global Initiative of Chronic Obstructive Lung Disease classification is hampered in the presence of HF.

METHODS AND RESULTS

In 2 cohorts involving 591 patients with established HF and 405 with a primary care diagnosis of COPD, the presence of HF and COPD was assessed according to guidelines. HF severity was staged according to the NYHA classification system into Classes I-IV. COPD was diagnosed if the ratio of post-bronchodilator forced expiratory volume in 1 second and forced vital capacity (FEV1/FVC) was <0.70, and categorized in GOLD stages I-IV according to post-bronchodilator-predicted FEV1 levels (FEV1% ≥80%; 50-79%; 30-49%; <30%). In total, 557 patients with HF only, 108 with HF+COPD, and 194 with COPD only were studied. Patients, who had neither HF nor COPD according to definition, or HF with reversible obstruction in post-bronchodilator pulmonary function tests were excluded from this analysis (n = 137). Compared with COPD only, patients with HF plus COPD had higher levels of post-bronchodilator FEV1/FVC (median [quartiles] 0.57 [0.47-0.64] vs 0.62 [0.55-0.66] and lower total lung capacity % (115 [104-126]% vs 105 [95-117]%, P < .001) P < .001), but comparable levels of post-bronchodilator FEV1% (70 [56-84]% vs 68 [54-80]%, P = .22) and thus similar distributions of GOLD stages I-IV in both groups (24/56/19/4% vs 31/50/19/1%, P = .57). In patients with HF only, 25% exhibited pre-bronchodilator FEV1% levels of <80% (FEV1% 94 [80-108]%), despite a pre-bronchodilator FEV/FVC ratio ≥0.7 in this group. The reduction of FEV1 in patients with HF only was associated with HF severity.

CONCLUSIONS

In stable HF, FEV1 may be significantly reduced even in the absence of "real" airflow obstruction. In this situation, diagnosing COPD according to GOLD criteria (based on FEV1/FVC) still seems feasible, because both FEV1 and FVC are usually decreased to an equal extent in HF. However, classifying COPD based on FEV1 levels may overrate obstruction severity in patients with combined disease (HF plus COPD), and thus may lead to unjustified use of bronchodilators.

摘要

背景

肺部限制（肺容积减少）在心力衰竭（HF）中很常见，这使得在同时患有这两种疾病的患者中，COPD 的严重程度分级变得复杂。我们比较了仅患有 HF、仅患有 COPD 或同时患有这两种疾病的患者的肺功能，以评估在存在 HF 的情况下，使用全球慢性阻塞性肺疾病倡议（GOLD）分类对 COPD 进行分级是否受到阻碍。

方法和结果

在涉及 591 例确诊 HF 患者和 405 例初级保健诊断为 COPD 的患者的 2 个队列中，根据指南评估 HF 和 COPD 的存在。HF 严重程度根据 NYHA 分类系统分为 I-IV 级。如果支气管扩张后用力呼气量占用力肺活量的比值（FEV1/FVC）<0.70，且支气管扩张后预测的 FEV1 水平（FEV1%≥80%；50-79%；30-49%；<30%）根据 GOLD 分期为 I-IV 期，则诊断为 COPD。共有 557 例仅患有 HF、108 例 HF+COPD 和 194 例仅患有 COPD 的患者符合研究条件。根据定义，既无 HF 也无 COPD 或支气管扩张后肺功能检查有可逆性阻塞的患者（n=137）被排除在本分析之外。与仅患有 COPD 的患者相比，同时患有 HF 和 COPD 的患者支气管扩张后 FEV1/FVC 更高（中位数[四分位数]：0.57[0.47-0.64]比 0.62[0.55-0.66]，总肺容量%更低（115[104-126]%比 105[95-117]%，P<0.001），P<0.001），但支气管扩张后 FEV1%相似（70[56-84]%比 68[54-80]%，P=0.22），因此两组的 GOLD 分期 I-IV 分布相似（24/56/19/4%比 31/50/19/1%，P=0.57）。在仅患有 HF 的患者中，尽管该组的支气管扩张前 FEV/FVC 比≥0.7，但仍有 25%的患者表现出支气管扩张前 FEV1%水平<80%（FEV1% 94[80-108]%）。仅患有 HF 的患者 FEV1 的减少与 HF 的严重程度有关。

结论

在稳定的 HF 中，即使没有“真正的”气流阻塞，FEV1 也可能显著降低。在这种情况下，根据 GOLD 标准（基于 FEV1/FVC）诊断 COPD 似乎仍然可行，因为在 HF 中，FEV1 和 FVC 通常都会同等程度地降低。然而，基于 FEV1 水平对 COPD 进行分类可能会高估合并疾病（HF+COPD）患者的阻塞严重程度，从而导致不合理地使用支气管扩张剂。