dr. Andrianto, Sp.

JP(K)
Dr.Aprihati
 Introduction
Chronic
Obstructive Local pulmonary manifestations +
Pulmonary systemic effects + comorbidities
Disease
(COPD)

A two- to three-fold higher risk of

Associated with increased developing CVD
cardiovascular morbidity and 37,6% of COPD deaths can be
mortality attributed to CVD

Lahousse, 2015; Zaghla, 2013; Huaiart, 2005

 Arrhythmias

Right CVD in Coronary

Ventricular Artery
Dysfunction COPD Diseases

Pulmonary
hypertension
Falk, 2008
Occurrence of Arrhythmias in
COPD Patients
Incidence and prevalence varies widely among reported studies
Atrial fibrillation/flutter are the most frequent arrhythmias in
COPD patient in some studies

Konecny, 2014; Hanrahan, 2008; Wilchesky, 2012

COPD is an independent risk factors
for atrial fibrillation/flutter and
nonsustained VT

Severity of COPD
increase the
likelihood of
developing AF/AFL,
NSVT, sust. VT
Konecny, 2014
 Saskatchewan Cohort Study
& Quebec Cohort Study

10.3 arrythmias per 1,000 per year

1.37 arrythmias per 100 per year.

Atrial fibrillation/flutter are the most

common arrhythmias found in COPD
patients

Wilchesky, 2012
Hanrahan, 2008
 COPD and Sudden Cardiac
Death
COPD was a risk factor for SCD both in cardiovascular patient groups
and incommunity-based studies, independent from cardiovascular
risk profile
The risk particularly increased in the period 2000 days (5.48 years)
after the diagnosis of COPD
COPD was associated with a prolonged and shortened QT interval

Lahousse, 2014; Van den berg, 2016

Possible mechanisms of
the association
between COPD and
SCD.

Vandenberg, 2016
Potensial Contribution Factors
Autonomic
neuropathy
Shared risk COPD
factors & medication
comorbid
Arrythmias
in COPD
 shares risk
Shared factors
Comorbid

Risk
age Coronary heart disease
Factors
and smooking Hypertensive heart disease
Comorbid Right and/or left ventricular
failure

Hypokalemia and hypomagnesia

Respiratory failure
Falk, 2008
 Autonomic Neuropathy
Common in COPD, even in early stages of the disease

Stimulus reception
Afferent nerve Sympathetic
conduction activity
Central processing
Efferent nerve
conduction
Neuromuscular response Parasympathetic
activity
Van Gestel, 2010
Van Gestel, 2012
 Hypoxemia & Hypercapnia

Hypoxemia Hypercapnia

stimulate arterial stimulate central

chemoreceptors chemoreceptors

Increase
sympathetic activity
Van Gestel, 2010
 Hypoxia

Altered cardiac repolarization and

increased dispersion of
repolarization

Malignant ventricular
arrhythmias and SCD

Sievi, 2014
 COPD Medication
New use of short-acting and long-acting b agonist increase the
risk of cardiac arrhythmia
Bronchodilator
The rate was slightly elevated, although not statistically significant,
with new use of ipratropium bromide and methylxanthines

Long term use hypertension, Diabetes Mellitus, Left atrial

enlargement, HF and ischemic heart disease AF
Corticosteroid
inhaled steroids were not associated with an increased risk of AF
or arrhythmias

Wilchesky, 2012; Shah, 2016; Falk, 2008; Huerta, 2005

 Management of Arrythmias in COPD
Correction of hypoxemia, respiratory acidosis, electrolyte abnormalities
and cardiac ischemia
Discontinue or decrease in dose of medications that can prolong the QT
interval and arrhythmogenic drugs
For patients with tachyarrhythmias, the dose of Short-acting selective
beta-2 adrenergic agents should be titrated to provide adequate
bronchodilation and relief of dyspnea without excess cardiac
chronotropic effects

ESC guidelines of AF, 2010; ACC/AHA guideline of AF, 2014

 Urgent electrical cardioversion of supraventricular tachyarrhythmias is
indicated in instable hemodynamic
A non-dihydropyridine CCB (diltiazem or verapamil) should be
considered to control the ventricular rate in AF
-1 selective blockers (e.g. bisoprolol) in small doses should be
considered as an alternative for ventricular rate control in AF

ESC guidelines of AF, 2010; ACC/AHA guideline of AF, 2014

ESC recommendation
for AF management
in pulmonary diseases
 Role of beta blocker in management of
arrhythmias with COPD
Risk Benefit
BB does not increase the risk of Reduces mortality and the
exaxerbation or inhospital risk of exacerbations
mortality

Therapy should be a empted with selec ve beta1 adrenergic blockade

Selective BB is recommended in patients with severe COPD or who have reversible
airway obstruction.

Luente-Maestu, 2015
 Forest plot
showing beta-
blockers use and
mortality risk in
COPD patients

Qingxia Du, 2014

 Prognosis
Depend on:
Clinical setting (eg, severity of COPD exacerbation)
Comorbidities :
Shock
Heart failure
Stroke
Renal insufficiency
Specific arrhythmia

Sterr, 2010; Fuso, 2005; Roberts, 2011

 Summary
COPD patients are at increased risk for developing arrhythmias
Atrial fibrillation are the most common arrhythmias in COPD
Shared risk factors, comorbid disorders, hypoxemia, hypercapnia, autonomic
dysfunction, and COPD medication have contribution in mechanism of
arrythmias in COPD
Comprehensive management is needed, while correcting the underlying
disorders are crucialS
Selective BB is recommended in patients with severe COPD or who have
reversible airway obstruction.