"Natural History" of pulmonary hypertension in a series of 131 patients with chronic obstructive lung disease
"Natural History" of pulmonary hypertension in a series of 131 patients with chronic obstructive lung disease
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DOI：
10.1164/ajrccm.164.2.2006129
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发表时间：
2001-07-15
影响因子：
24.7
通讯作者：
Oswald-Mammosser, M
中科院分区：
文献类型：
--
作者：
Kessler, R;Faller, M;Oswald-Mammosser, M
患有明显低氧血症的慢性阻塞性肺病 (COPD) 患者（无论是否接受长期氧疗 (LTOT)）的预后价值和肺动脉高压 (PH) 的演变已得到广泛研究。然而，对于不需要 LTOT 的轻度或中度低氧性 COPD 患者知之甚少。因此，我们通过平均 (SID) 时间间隔为 6.8 +/- 2.9 年进行两次右心导管插入术，评估了 131 名稳定期 COPD 患者的肺血流动力学演变。纳入时 (T0)，没有患者出现 PH（即静息时平均肺动脉压 [Ppa] < 20 mm Hg）。第 I 组包括 55 名未进行 PH 锻炼的患者，第 2 组包括 76 名进行 PH 锻炼的患者，定义为在稳态 40 W 锻炼期间肺动脉压 (Ppa) > 30 mm Hg。与第 I 组患者相比，第 2 组患者的静息 Ppa 显着更高（16 +/- 3 mm Hg 对比 14 +/- 2 mm Hg，p = 0.001）。在第二次导尿时，33 名 (25%) 患者（第 1 组 55 名患者中的 9 名，第 2 组 76 名患者中的 24 名，p = 0.048）显示静息 Ppa > 20 mm Hg，但 PH 通常较轻，范围为 20 至 42.5 mm Hg。第二次评估时，第 1 组的平均 Ppa 为 16 +/- 5 mm Hg，第 2 组为 19 +/- 7 mm Hg (p = 0.01)。在第二次导管插入术 (TI) 时出现静息 PH 的患者在 TO 时具有较高的静息和运动 Ppa（分别为 p = 0.001 和 p = 0.002），并且显着较低的静息和运动 Pa-O2（分别为 p = 0.005 和 p = 0.012）。 Logistic 回归分析显示，休息和运动 Ppa 是随后发生 PH 的独立预测因子（TO）（分别为 p = 0.029 和 p = 0.027）。出现静息 PH (TI) 的患者 Pa-O2 显着恶化（从 T0 时的 63.5 mm Hg 降至 T1 时的 60 mm Hg，p = 0.047），而其余患者的 Pa-O2 平均值保持稳定（TO 和 T1 时为 69.5 mm Hg）。这些结果表明以下内容。患有轻度至中度低氧血症的 COPD 患者的 Ppa 随着时间的推移进展相当缓慢，整个组的平均变化为 + 0.4 mm Hg/年。只有约 25% 患有轻度至中度低氧血症且发病时没有静息 PH 的 COPD 患者会在 6 年随访期间出现 PH。刚开始锻炼的 PH 患者随着时间的推移，发生 PH 的风险显着增加。只有发病时的休息和运动Ppa与PH的后续发展独立相关。然而，在个别情况下，线性或逻辑回归模型无法对第二次右心导管插入术时的 Ppa 水平或 PH 的存在进行相关预测。
The prognostic value and the evolution of pulmonary hypertension (PH) in patients with markedly hypoxemic chronic obstructive pulmonary disease (COPD), treated or not with long-term oxygen therapy (LTOT), has been extensively investigated. However, little is known in patients with mildly or moderately hypoxemic COPD not requiring LTOT. Therefore, we assessed the evolution of pulmonary hemodynamics in 131 patients with stable COPD by performing two right heart catheterizations at a mean ( SID) time interval of 6.8 +/- 2.9 yr. At inclusion (T0), no patient had PH (i.e., the mean pulmonary artery pressure [Ppa] at rest was < 20 mm Hg). Group I included 55 patients without exercising PH and group 2 included 76 patients with exercising PH, defined by a pulmonary arterial pressure (Ppa) > 30 mm Hg during a steady-state 40-W exercise. Group 2 patients compared with group I patients had a significantly higher resting Ppa (16 +/- 3 mm Hg versus 14 +/- 2 mm Hg, p = 0.001). At the second catheterization, 33 (25%) patients (9 of 55 in group 1, 24 of 76 in group 2, p = 0.048) showed a resting Ppa > 20 mm Hg, but PH was generally mild, ranging from 20 to 42.5 mm Hg. The mean Ppa at second evaluation was 16 +/- 5 mm Hg in group 1 and 19 +/- 7 mm Hg in group 2 (p = 0.01). The patients who developed resting PH at the second catheterization (TI) had higher resting and exercising Ppa (p = 0.001 and p = 0.002, respectively), and significantly lower resting and exercising Pa-O2 (p = 0.005 and p = 0.012, respectively) at TO. Logistic regression analysis showed that resting and exercising Ppa were independent predictors (at TO) for the subsequent development of PH (p = 0.029 and p = 0.027, respectively). The patients who developed resting PH (TI) had a significantly worsening of Pa-O2 (from 63.5 mm Hg at T0 to 60 mm Hg at T1, p = 0.047), whereas the Pa-O2 as a mean was stable in the remainder (69.5 mm Hg at TO and T1). These results show the following. The progression of Ppa over time in patients with COPD with mild to moderate hypoxemia is rather slow, the average change for the group as a whole being of + 0.4 mm Hg/yr. Only about 25% of patients with COPD with mild to moderate hypoxemia and without resting PH at the onset will develop PH during a 6-yr follow-up. The patients with exercising PH at the onset have a significantly increased risk of developing PH over time. Only resting and exercising Ppa at the onset are independently related to the subsequent development of PH. However, in individual cases, the models of linear or logistic regression do not allow a pertinent prediction of the level of Ppa or the presence of PH at the second right heart catheterization.