What echocardiographic findings should I assess in a 74‑year‑old woman with chronic obstructive pulmonary disease presenting with dyspnea?

Echocardiographic Assessment in a 74-Year-Old Woman with COPD Presenting with Dyspnea

In this patient, you should systematically assess for right ventricular dysfunction, pulmonary hypertension, left ventricular diastolic dysfunction, and valvular abnormalities, as cardiac complications are present in approximately 64% of COPD patients and significantly impact prognosis. 1

Right Ventricular Assessment (Priority #1)

The right ventricle is critically affected in COPD and requires comprehensive evaluation:

Structural Changes

• Right ventricular enlargement – present in 30% of COPD patients at first severe exacerbation 1
• Right atrial enlargement – assess right atrial area and volume 2
• Right ventricular wall thickness – measure for evidence of hypertrophy 3

Functional Parameters

• Tricuspid annular plane systolic excursion (TAPSE) – reduced values indicate RV systolic dysfunction and have prognostic significance 4, 3
• RV fractional area change – quantifies RV systolic function 3
• Tissue Doppler imaging of lateral tricuspid annulus (S') – peak systolic velocity <10 cm/s indicates RV dysfunction 4, 3
• RV myocardial performance index (Tei index) – shows the largest difference between COPD patients and controls 5
• RV basal strain by speckle tracking – demonstrates significant impairment and shows largest difference from controls 5

Clinical significance: Patients with three or more abnormal RV systolic function parameters have significantly worse prognosis, with all deaths in one study occurring in this group 5

Pulmonary Hypertension Assessment (Priority #2)

Pulmonary hypertension is present in approximately 19-63% of COPD patients and correlates with disease severity:

Estimation of Pulmonary Artery Pressure

• Measure tricuspid regurgitation velocity – obtainable in 67.5% of COPD patients 2
• Calculate systolic pulmonary artery pressure (sPAP) using the modified Bernoulli equation plus estimated right atrial pressure 2, 3
• Define pulmonary hypertension as sPAP >30 mmHg 2
• Assess right atrial pressure – typically 10 mmHg in 82.5% of cases, 15 mmHg in 17.5% 2

Severity Classification

• Mild PH: sPAP 30-40 mmHg (58.82% of PH cases) 2
• Moderate PH: sPAP 40-50 mmHg (23.53% of PH cases) 2
• Severe PH: sPAP >50 mmHg (17.65% of PH cases) 2

Critical finding: The prevalence of PH increases linearly with COPD severity (mild COPD 16.67%, very severe COPD 83.33%), and severe PH is almost always associated with cor pulmonale 2

Additional PH Parameters

• Pulmonary vascular resistance – can be estimated noninvasively using newer echocardiographic parameters 3
• Inferior vena cava diameter and collapsibility – assess for elevated right atrial pressure 4

Cor Pulmonale Detection

• Look for RV dilatation with RV dysfunction in the presence of pulmonary hypertension – present in 41.17% of COPD patients with PH 2
• Assess interventricular septal flattening or paradoxical motion – indicates RV pressure/volume overload 3

Prognostic importance: Clinical deterioration is significantly more common in patients with RV systolic pressure ≥35 mmHg (P = 0.018) 5

Left Ventricular Assessment (Priority #3)

Left heart abnormalities are present in 27% of COPD patients and often unrecognized:

Systolic Function

• Measure left ventricular ejection fraction – systolic dysfunction present in 7.5-13% of COPD patients 2, 1
• Assess for regional wall motion abnormalities – may indicate coexisting ischemic heart disease 4
• Left ventricular enlargement – present in 6% of patients 1

Diastolic Function (Critical in Elderly)

• Mitral inflow pattern (E/A ratio) – diastolic dysfunction (A ≥ E) present in 47.5% of COPD patients 2
• Tissue Doppler imaging of lateral mitral annulus (e') 4
• E/e' ratio – estimates left ventricular filling pressure; significantly higher in elderly patients 4
• Left atrial volume index – has greatest value in diagnosing HFpEF (sensitivity 77%, specificity 81%) 4
• Duration difference between pulmonary vein atrial reversal flow and mitral A wave 4

Key consideration: Diastolic dysfunction is a major cause of dyspnea in elderly patients, with 12% having unrecognized HFpEF versus only 3% having HFrEF 4

Valvular Assessment

Tricuspid Valve

• Assess tricuspid regurgitation severity – functional TR is common in COPD with PH 3
• Measure tricuspid annular diameter – assess for dilatation 3

Left-Sided Valves

• Evaluate for aortic stenosis/insufficiency – causes dyspnea and is age-related 4
• Assess mitral valve for stenosis/regurgitation 4
• Left atrial dilatation – present in 29% of COPD patients 1

Additional Assessments

Pericardial Evaluation

• Rule out pericardial effusion or constrictive pericarditis – both cause dyspnea 4

Left Ventricular Hypertrophy

• Measure interventricular septal and posterior wall thickness – LVH present in 22.5% of COPD patients 2

Advanced Techniques When Available

• Speckle tracking echocardiography for strain analysis – detects subclinical LV systolic dysfunction in HFpEF and early RV dysfunction 4, 3
• 3-D echocardiography – provides more accurate RV volume and ejection fraction assessment 4
• LA strain rate – significantly reduced in both HFrEF and HFpEF 4

Critical Clinical Pitfalls

• Do not assume dyspnea is purely pulmonary – cardiac abnormalities are present in 63% of COPD patients even without known cardiac disease or cardiovascular risk factors other than smoking 1
• Echocardiographic abnormalities are unrelated to COPD severity – even mild COPD can have significant cardiac involvement 1
• Standard echocardiography may be suboptimal in 45% of COPD patients due to hyperinflation and poor acoustic windows 6
• Right-sided hemodynamics and pulmonary function tests do not predict RV function – direct echocardiographic assessment is essential 6

Prognostic Implications

Clinical deterioration at 6 months is significantly more common (89%) in patients with baseline abnormal RV function 5. Considering the prognostic and therapeutic implications of cardiac comorbidity, echocardiography should be performed in all patients with clinically significant COPD 1. The American Thoracic Society recommends echocardiography for COPD patients with signs of congestive heart failure and/or concerning symptoms such as exertion-related dizziness or chest pain 4.