Download Relationships between Ischemic Heart Disease and Chronic Diffuse

Relationships between Ischemic Heart
Disease and Chronic Diffuse Pulmonary
Disease*
R. K. Bhargaua, M.D.,OV and C . R. Woolf, M.D.,F.C.C.P.t
The electrocardiograms of 389 patients over the age of 40 years have been
examined to determine the prevalence of myocardial ischemia and myocardial
infarction in relationship to chronic bronchitis, emphysema, asthma and pulmonary fibrosis, and to abnormalities of pulmonary function. Chronic diffuse
pulmonary disease was present in 322 patients, and in 67 (control group) there
was either local pulmonary disease or no significant pulmonary abnormality.
There was no significant difference in the prevalence of "ischemic changes" or
myocardial infarction when the chronic chest disease group were compared with
the control group. Sub-division of the chronic chest disease group into smaller
woups with more precise diagnoses did not change this findig. However,
patients with carbon dioxide retention had a significantly higher prevalence of
ischemic changes on the electrocardiogram than those with normal pulmonary
function. There was no relationship between the prevalence of myocardial
infarction and abnormality of pulmonary function. The results suggest that
patients with chronic diffuse pulmonary disease have neither a higher nor lower
prevalence of myocardial infarction when compared with individuals with localized chest disease or no significant chest abnormality.
n middle age, atherosclerotic ischemic heart dis-
I ease and many of the chronic disuse pulmonary
diseases (asthma, chronic bronchitis, emphysema,
-
.
pulmonary fibrosis) are common and these conditions tend to progress as individuals become older.
Some investigators have claimed that the presence
of chronic diffuse pulmonary disease predisposes to
or accelerates the development of coronary artery
disease. Others have suggested that myocardial
infarction is less frequent in association with chronic pulmonary disease, and others have stated that
the existence of the two types of disease is simply
coincidental. 1- 7
The present study has been designed to examine
the relationships between atherosclerotic ischemic
coronary artery disease and chronic diffuse pulmonary disease, both from an electrocardiographic and
pulmonary function point of view.
'From the Respiratory Research Laboratory, Toronto Genand the Department
University
of Toronto, Toronto, Ontario, Canada.
"Professor of Medicine, S. N. Medical College, Jodhpur,
Rajasthan, India.
+Associate Professor, Department of hledicine, University of
Toronto and Physician in Charge, Respiratory Research
Laboratory, Toronto General Hospital, Toronto, Ontario,
Canada.
All patients over the age of 40 years, who had performed
tests in the Routine Pulmonary Function Laboratory of the
Toronto General Hospital between July 1962 and November
1965, were considered for inclusion in the project. Patients
with hypertensive or valvular heart disease, those with diabetes, anemia, myocarditis, pericarditis, myxedema, hyperthyroidism and those with digitalis toxicity or electrolyte dish~rbances, were all excluded.
The patients were divided into nine groups:
Croup 1-chronic bronchitis
Group 2-chronic bronchitis with emphysema
Group 3-asthma
Group 4-asthma with emphysema
Group 5-pulmonary fibrosis
Group 6-pulmonary fibrosis with emphysema
Group 7-miscellaneons
Group 8-nonpulmonary disease
Group 9-localized pulmonary disease
The definition of each of these groups is shown in the
appendix. The patients in groups 8 and 9 were used as
- --.-.--- .
The pulmonary function tests performed were as follows:
forced vital capacity ( F V C ) , forced expiratory volume-one
second (FEVI ), maximum mid-expiratory flow rate
( MMFR ) and maximum voluntary ventilation ( hlVV ); using a waterless bellows type spirametero; pulmonary diffus'Jones Pulmonor, Jones Instrument Company, Chicago, 111.
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ISCHEMIC HEART DISEASE AND CHRONIC DIFFUSE PULMONARY DISEASE
255
Table 1--Criteria for Grading Results of Pulmonury Function Testa.
Grade
FVC
FEVI
MVV
(% of normal)
(% of FVC)
(% of normal)
>70
>80
71-80
5 1-70
Normal
Slight
Moderate
Moderately severe
Severe
>80
71-80
5 1-70
41-50
<41
6 1-70
51-60
41-50
<41
41-50
<41
ing capacity for carbon monoxide and fractional carbon
monoxide uptake by an end tidal steady state technique
performed at rest;B and arterial carbon dioxide tension by a
rebreathing method.8 The results of the pulmonary function
tests were graded as normals or as showing slight, moderate,
moderately severe or severe abnormalities (Table 1).
A restrictive respiratory function defect was considered
80 percent of normal; an obstrucpresent if the FVC was
70
tive respiratory defect was present if the FEVl was
percent of forced vital capacity, and the maximum midexpiratory flow rate was
three liters per second;lO,ll a
defect of pulmonary diffusing capacity was considered present if the DLCO was < 12 ml/min/mm Hg.
The electrocardiograms were analyzed for evidence of
"ischemic changes" and myocardial infarction. The diagnosis
of "ischemia" was based on depression of the ST segment and
or inyersion of waves. As this can occur in a variety of
conditions strict criteria were adhered to for including the
cases in the ischemic category. As mentioned earlier, cases
having associated hypertension, valvular heart disease, pericarditis, myocarditis, diabetes, anemia, myxedema and hyperthyroidism were not included in the present study. Those
cases showing S T and/or T wave changes due to digitalis,
electrolyte disturbances and tachycardia were also excluded.
Pseudodepression of ST segment was discarded. Cases showing right ventricular hypertrophy with strain, right bundle
branch block, left ventricular hypertrophy with strain were
also excluded. Of course, cases having a complete left bundle
branch block were this electrocardiographic finding was of
recent onset and where the other available tracings did not
show evidence of left ventricular hypertrophy were included
in the group with ischemia. Temporary ST, T changes later
<
<
<
Table %Age
Group
Sex
MMFR
(l/sec)
DLCO
(ml/min/mm Hg)
PC02
(mm)
>3
2-3
1-2
0.5-1
<0.5
> 12
10-12
8-9
5-7
<5
<44
44-50
5 1-70
71-80
>80
reverting to normal were not included in the group with
ischemia. Depression of 1 mm or more in the extremity
leads and 2 mm or more in the lateral precordial leads
(V4-Va) were considered abnormal and minor depressions
were disregarded. Thus before labelling any case in the
ischemic category all the above points were first considered
and ischemia was said to be present if there was ( 1 )
generalized ST depression and/or T wave inversion; ( 2 ) ST
depression and/or T inversion in precordial leads V4 to Ve
associated with similar changes in either leads 1 and aVL
(anterolateral ischemia) or in leads 11, 111, aVF (posterolatera1 ischemia). Thus it can be said that all possible care was
taken to include only genuine cases in the category showing
ischemic changes.
Infarction was considered to have occurred in the presence
of ( 1) Q waves, either of duration of 0.04 seconds or greater,
or where the depth was greater than 25 percent of the height
of the R wave in the same complex (provided the R wave
itself was 5 m m ) ; ( 2 ) ST segment elevation with a cove
plane T. These changes were seen in various leads, depending on the site of the infarction.
The pulmonary function tests and electrocardiograms used
were always from the same hospital admission, but where
more than one record was available, those with the greatest
abnormalities were recorded.
The study included 389 patients; the age, sex and distribution in clinical groups are shown in Table 2. There were 322
patients in the chronic diffuse pulmonary disease groups (251
men and 71 women ), and 67 in the control groups ( 56 men
and 11 women). The age distribution between the patients
with diffuse pulmonary disease and those in the control groups
was similar. Ten autopsy reports were available.
and Sex Distribution o f 389 Patient. under Study.
41-50 yrs.
51-60 yrs.
61-70 yrs.
1 Chronic bronchitis
2 Chronic bronchitis
with emphysema
3 Asthma
4 Asthma with emphysema
5 Pulmonary fibrosis
6 Pulmonary fibrosis
with emphysema
7 Pvliscellaneous
8 Nonpulmonary disease
9 Localized pulmonary disease
Total
CHEST, VOL. 59, NO. 3, MARCH 1971
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71-80 yrs.
Total
BHARGAVA AND WOOLF
Table 3--Prevalence of Electrocardiograpfaic Change
in t h e Nine Clinical Groups.
Ischemic Chances
Group
1 Chronic bronchitis
2 Chronic bronchitis
with emphysema
3 Asthma
4 Asthma with emphysema
5 Pulmonary fibrosis
6 Pulmonary fibroeis
with emphysema
7 Mieoellaneous
8 Nonpulmonary d h a
9 Localied
pulmonary dieease
Table %Average Age and Sex Distribution in Cases
Showing Ischemic Changes and Infarction in
the Various Groups.
Infarction
No.
No.
%
No.
%
83
11
13
6
7
120
44
12
30
19
4
0
2
16
9
0
7
7
4
2
2
6
9
17
7
14
19
37
0
2
1
2
1
11
1
0
11
3
30
2
7
2
7
Group
7
3
Table L P r e v a l e n c e of Electrocardiographic Change
in Various Combinations o f Clinical Groups.
- - -
1 and 2
3 and 4
5 and 6
7
8 and 9
2.4 and 6
1, 3 and 5
l to 7
Inclusive
Chronic bronchitis
f emphysema
Asthma
It emphysema
Pulmonary fibrosis
f emphysema
Mieoellaneous
Nonpulmonary and
local pulmonary
disease
Emphysema
Diffuse diaeaae
without
emphysema
Diffuse pulmonary
diaeaae
Infarction
*No.
%
No.
%
203
30
15
13
6
56
4
7
6
11
44
2
2
5
11
3
2
11
No.
19
6
7
3
5
3
Average
Age,
Total
The electrocardiographic changes in the nine
clinical groups are shown in Table 3. Ischemic
changes were most prevalent in the patients with
chronic bronchitis with emphysema (group 2 ) , but
analysis of variance showed no statistically signscant differences among all the groups ( p > 0.05).
The prevalence of myocardial infarction was greatest in the patients with asthma with emphysema
(group 4 ) , but the numbers were very small and
analysis of variance showed no statistically significant differences among all the groups ( p > 0.05).
Various combinations of the clinical groups are
shown in Table 4. Ischemic changes were most
frequent in the combined groups of the patients
with chronic bronchitis with or without emphysema
(groups 1 and 2 ) and least frequent in the group of
patients with pulmonary fibrosis with or without
emphysema (groups 5 and 6 ) and in the control
Group
Infarction
3
Cases Men Women Yra
RESULTS
Ischemic
Changes
Ischemic Changes
7
7
5
146
19
13
10
7
157
17
11
12
8
322
38
12
24
8
Chronic
bronchitis
Chronic
bronchitis
with
emphysema
Aathma
Asthma with
emphysema
Pulmonary
fibrosis
Pulmonary
fibrosis with
emphysema
Miscellaneous
Control series
7
Average
Total
Age,
Cases Men Women Yra
11
10
1
63.2
6
5
1
67.8
19
4
17
3
2
1
58.9
57.5
7
4
7
2
2
66.1
52.5
-
-
-
-
2
1
1
56.0
2
2
-
64.5
2
1
1
63.0
2
3
-
-
2
3
1
1
-
1
1
69
61.7
1
1
2
1
3
-
65.0
65.5
57.7
group (groups 8 and 9 ) . However, there were no
statistically significant differences in the incidence
of ischemic changes among these combinations of
groups ( p > 0.05 ) .
The prevalence of myocardial infarction was
greatest in the combined group of patients with
asthma with or without emphysema (groups 3 and
4 ) and in the miscellaneous group ( group 7 ) and
least frequent in the combined control group
(groups 8 and 9 ) . However, there were no statistically significant differences among any of these
combinations of groups ( p > 0.05).
When patients with emphysema (groups 2 , 4 and
6 ) were compared with those with diffuse pulmonary disease without emphysema (groups 1, 3 and
5 ) , there was no statistically significant difference in
the prevalence of ischemic changes or infarction on
the electrocardiogram ( p > 0.05). If all patients
with diffuse pulmonary disease (groups 1 to 7
inclusive) were compared with the nonpulmonary
and local pulmonary disease groups (groups 8 and
9 ) , there was no significant difference in the prevalence of ischemic changes or myocardial infarction
as judged by the electrocardiogram ( p > 0.05).
In the present study covering 389 patients either
suffering from chronic diffuse pulmonary diseases or
serving as controls there were 41 cases labelled as
having ischemic changes and 27 cases as having
myocardial infarction. Their distribution in various
groups is given in Table 5. Taken as a whole, the
number of women showing ischemic changes or
infarction were only 12 as compared to 56 men
showing these changes. The ratio of men to women
CHEST, VOL. 59, NO. 3, MARCH 1971
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257
ISCHEMIC HEART DISEASE AND CHRONIC DIFFUSE PULMONARY DISEASE
--
Table 6-Electrocardiographic Changes Related to
Pulnionary Function Abnormalities.
Pulmonary
Function
Ischemic Changes
No.
Normal
pulmonary
29
function
Restrictive defect
53
slight
moderate
66
moderate
severe
20
severe
10
Obstructive defect
92
slight
moderate
77
moderate
82
severe
severe
98
Diffusing capacity low
75
slight
moderate
74
moderate
severe
26
severe
3
Carbon dioxide retention
slight
52
moderate
59
moderate
severe
2
Infarction
No.
%
No.
%
10
11
20
19
5
2
10
3
1
50
0
0
in both the chronic pulmonary disease group and
the control series was roughly 5:l. The average age
in the various disease groups is also mentioned in
Table 5. It is quite interesting to note that the
patients suffering from asthma with or without
emphysema showed changes of ischemia or infarction at a much earlier age as compared to the other
groups.
The relationships between the electrocardiographic changes and the results of the pulmonary
function tests are shown in Tables 6 and 7.
In Table 6, the electrocardiographic abnormalities are related to the type and degree of abnormality of pulmonary function. There is possibly an
increased prevalence of ischemic changes with worsening of the tests of ventilation but this was not
apparent in relationship to worsening of the tests of
gas transfer. Nearly similar relationship was observed between the prevalence of myocardial infarction and the degree of abnormality of the various
pulmonary function tests. For purposes of statistical
analysis, patients with different types of respiratory
abnormality have been grouped together (Table 7 ) .
A comparison was made between the prevalence of
ischemic changes in the patients with all the pulmonary function tests normal, and the prevalence of
ischemic changes in those patients with abnormal
pulmonary function tests. There was a significantly
higher prevalence of ischemic changes in the patients with restrictive defects or carbon dioxide
retention or where there was a combination of
restriction, obstruction and carbon dioxide retention, or restriction, obstruction, low diffusing capacity and carbon dioxide retention ( p < 0.05).
There was a higher prevalence of ischemic changes
when only those patients with carbon dioxide
retention were compared with those patients with
normal pulmonary function ( p < 0.01 ). There was
no significant difference in the prevalence of myocardial infarction in any of the abnormal pulmonary
function groups compared with the normal pulmonary function groups ( p > 0.05 ) .
As shown in Table 8, the majority of the patients
in the present series were in the age group 51 to 70
years. Similar age distribution was seen in the
patients having various restrictive, obstructive and
diffusion defects and C 0 2 retention. Thus the cases
showing C 0 2 retention were not in the higher age
group as compared to the other groups. Moreover,
patients showing C 0 2 retention with changes of
ischemia or infarction on electrocardiograms also
belonged mainly to the age group 51 to 70 years.
There was no increase in the electrocardiographic
changes with increase in age; the average age of
the patients showing these changes was nearly
similar.
The autopsy findings in ten patients are shown in
Table 9. Seven patients had advanced emphysema
at autopsy. Of these, one had evidence of myocardial ischemia on the electrocardiogram and showed
marked coronary atherosclerosis at autopsy, and
another showed myocardial infarction on the electrocardiogram and this was confirmed at autopsy.
The other five patients had shown no changes of
ischemia or infarction on the electrocardiogram and
although these showed advanced emphysema at
Table 7-Electrocardiographic Change8 Related to
Pulmonary Function Abnormalities.
Ischemic Changea
Pulmonary
Function
No.
Normal function
Restrictive
defect (R)
Obstructive
defect ( 0 )
Diffusing
capacity
low (D)
Carbon dioxide
retention (C)
R+O+D
R+O+C
R+ O+ C+ D
CHEST, VOL. 59, NO. 3, MARCH 1971
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No.
%
Infarction
No.
%
BHARGAVA AND WOOLF
Table &Age
S. No.
and Sex Distribution in the 389 Cares of the Present Series According t o the T y p e and
Gradation o f the Various Pulmonary Function Tests.
Type of the
Pulmonary
Function
Defect
R
E
S
T
Gradation of the
Pulmonary
Function Defect
& No. of Cases in
Each Group.
Slight
+
I
C
T
4
1
44
9
Moderate (66)
M
P
6
2
22
3
19
5
8
1
55
11
++
+++
M
3
P
2
2
5
5
1
1
1
11
9
M
P
3
1
25
3
1
57
1
0
50
1
0
17
8
2
149
(92)
M
F
13
4
23
12
26
3
8
3
70
22
Moderate (77)
M
F
9
4
17
8
26
6
6
1
58
19
Moderately
Severe
(82)
M
P
9
6
23
5
22
5
11
1
65
17
Severe
M
F
12
3
60
37
6
131
21
6
115
13
0
43
83
15
349
(75)
M
F
6
4
19
8
22
6
8
2
55
20
Moderate (74)
M
F
5
3
22
4
21
7
12
0
60
14
Moderately
Severe
(26)
M
F
0
1
10
6
4
1
3
1
17
9
Severe
M
F
0
1
20
0
0
69
1
0
62
0
1
27
1
2
178
(52)
M
F
7
1
15
3
16
3
5
2
43
9
Moderate (59)
M
F
5
3
24
6
12
4
5
0
46
13
Moderately
Severe
(2)
M
P
0
0
1
0
1
0
0
0
2
0
Severe
(0)
Total (113)
M
0
16
0
49
0
36
0
12
0
113
No. of cases with
Normal Functions
Total (29)
M
F
8
3
11
7
3
10
6
0
6
1
22
7
29
++++
(10)
Total (149)
0
D
I
F
P
u
S
I
0
N
D
E
F
E
C
T
Slight
+
++
+++
++++
(98)
Total (349)
+
Slight
++
+++
++++
R
E
T
E
N
T
I
0
V
N
Normal
Pulmonary
Function
(3)
Total (178)
+
Slight
c02
Total
15
4
Severe
V
E
71-80
19
2
E
S
T
R
U
C
T
I
61-70
6
2
I
B
51-60
M
P
Moderately
Severe
(20)
v
.4ge Croup (in ycars)
41-50
(53)
R
I
Sex
++
+++
++++
1
2
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ISCHEMIC HEART DISEASE AND CHRONIC DIFFUSE PULMONARY DISEASE
Table 9-Relationships
between Autopsy Findings and Electrocardiographic and Pulmonary Function Abnormalities.
ECG
Age
Sex
Cliniral Diagnosis
1
60
iM
Bronchitis, emphysema
R
2
66
M
Bronchitis, emphysema,
pulmonary fibrosis.
R + O + C + D
0
3
66
M
Bronchitis, emphysema,
pulmonary fibrosis.
R + O + C + D
0
4
64
M
Bronchitis, emphysema
R + O + C + D
0
5
57
M
Bronchitis, emphysema
R + O + C + D
0
6
54
M
Bronchitis, emphysema
R + O + C + D
0
7
70
M
Bronchitis, emphysema
R + O + D
8
66
M
Bronchogenic carcinoma
9
79
F
Bronchitis
10
59
F
Bronchitis, emphysema
Patient
Pulmonary Function
+0+C +D
Ischemia
;\utopsy
Advanced emphysema,
marked coronarv
atherosclerosis.
0
Infarction
Ischemia
Infarction
R + O + C + D
autopsy, there was no significant coronary atherosclerosis. One elderly woman with bronchitis
showed a myocardial infarction on electrocardiogram and this was confirmed at autopsy. A man with
bronchogenic carcinoma showed ischemic changes
on the electrocardiogram and moderate coronary
atherosclerosis was found at autopsy. A woman of
59 was diagnosed clinically as having bronchitis and
emphysema but, at autopsy, had bronchiectasis and
pulmonary fibrosis. Her electrocardiogram showed
no evidence of ischemia or myocardial infarction
and there was no significant coronary atherosclerosis on postmortem examination. Therefore, four
patients who showed coronary atherosclerosis with
or without infarction at autopsy had electrocardiographic changes showing ischemia or myocardial
infarction; the six patients who did not have significant coronary atherosclerosis at autopsy had no
evidence of ischemic changes on the electrocardiograms.
DISCUSSION
In the present investigation, there was no statistically significant difference in the prevalence of
ischemic changes and myocardial infarction when
the patients with chronic chest disease were compared with the control group. Attempts to subdivide
0
Advanced emphysema,
no coronary
atherosclerosis.
Advanred emphysema,
no coronary
atherosclerosis.
. Advanced emphysema,
no coronary
atherosclerosis.
Advanced emphysema,
no coronary
atherosclerosis.
Advanced emphysema,
no coronary
atherosc~lerosis.
Advanced emphysema,
myocardial infarction.
Bronchogenic carcinoma,
moderate coronary
atherosclerosis.
N o emphysema,
advanced roronary
at herosrlerosis,
myocardial infarction.
Bronchiectasis, fihrosis,
no coronary
at herosclerosis.
the patients with chronic chest diseases according to
more precise diagnosis did not change this finding.
These results agree with the clinical studies of
Sanghvi and Kotia.7
However, some observations in the present study
appear to be quite significant. It was found that the
patients suffering from asthma with or without
emphysema showed changes of ischemia or infarction in electrocardiograms at a much earlier age as
compared to the control series and patients suffering from other chronic pulmonary diseases. How far
this observation is significant cannot be predicted
since in the present series there were only ten patients with asthma with or without emphysema who
showed changes of ischemia or infarction in the
electrocardiograms. Another observation worth comment was that there was an increased prevalence of
changes of ischemia and infarction with worsening
of the tests of ventilation, but this was not apparent
in relationship to worsening of the tests of gas transfer. In addition, those patients showing carbon
dioxide retention showed significantly greater prevalence of ischemic changes on the electrocardiograms, as compared to the patients showing other
types of pulmonary function defects and the control
group, though the age distribution in all these series
was nearly similar and there was no increase in the
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BHARGAVA AND WOOLF
electrocardiographic changes with increase in age.
However, this was not true with myocardial infarction for there was no change in the incidence of
myocardial infarction in patients showing either
normal pulmonary functions or various types of
restrictive, obstructive and diffusion capacity defects and C 0 2 retention.
It seems reasonable that the increased prevalence
of ischemic changes on the electrocardiogram
would correlate with the functional result of chronic
chest disease, namely the degree of arterial blood
gas abnormality, rather than the type of chronic
chest disease itself. Greggl:' has shown that hypoxia, which produces coronary vasodilation in a normal subject, does not produce vasodilatation with
compensatory increase of coronary blood flow in
patients with chronic chest disease and Moret and
his co-workersl-l have found an abnormally low
coronary blood flow in the majority of 32 patients
suffering from chronic pulmonary disease. They
showed that the coronary arteries were in a more
vasoconstrictive state in these patients than in
normal subjects. It is possible that changes in the
electrocardiogram interpreted as coronary atherosclerotic ischemic heart disease are really due to
coronary vasoconstriction and decreased coronary
blood flow. At least some of the electrocardiographic changes used in the diagnosis of atherosclerotic
ischemic heart disease are similar to those one
might expect in patients with chronic general hypoxia, and this is another possible source of error.
Though there was an increased incidence of ischemic changes in the electrocardiograms in patients
showing C 0 2 retention there was no increased
incidence of myocardial infarction in this group
with pulmonary function abnormality. Thus it is
suggested that, at least in some patients with severe
chronic chest disease, the electrocardiographic abnormalities might be due to chronic hypoxia and
coronary vasoconstriction, rather than to an increased prevalence of atherosclerotic coronary artery disease.
It is clear that there are difficulties in the electrocardiographic interpretation in a clinical study.
Reese and a s s o c i a t e s ~ a v eshown that coronary
heart disease was accurately diagnosed from the
electrocardiogram in 84 percent of patients showing
atherosclerotic lesions at autopsy, but when both
coronary and pulmonary heart disease were present,
the accuracy of the diagnosis was only 55 percent.
Coronary arteriograms should be an excellent method 1 1 %f detection, but Hale and his co-workers 15
found three patients with obvious angina pectoris
and electrocardiographic changes of myocardial
ischemia but all three had normal coronary arterio-
"
grams.
Even the use of autopsy material has given
conflicting results. In three reports, the prevalence
of myocardial infarction was found to be less in
patients with chronic obstructive lung disease compared with controls;4-6 in one of these reports, the
prevalence of coronary atherosclerosis without infarction was similar in the patients with chest
disease and the control subjects5 and in the other
reports, coronary atherosclerosis without infarction
appeared to be more frequent in the patients with
chronic obstructive lung disease.4.6 In three reports
of clinical and autopsy material, coronary artery
disease was more frequent in patients with various
types of chronic pulmonary disease. but there were
no control studies.'-" In the present series of ten
autopsies, two of the eight patients with severe
chronic chest disease had coronary atherosclerosis
and two patients without severe abnormalities of
pulmonary function had coronary atherosclerosis;
there was good correlation between the electrocardiographic findings and the presence or absence of
significant coronary atherosclerosis or myocardial infarction. The remaining six patients showing advanced chronic diffuse pulmonary diseases with
gross derangements in pulmonary function showed
no electrocardiographic changes of ischemia or infarction and their coronary vessels did not show
any atherosclerotic changes at autopsy. This also
confirms our observation that the presence of atherosclerotic heart disease in patients with chronic diffuse pulmonary disease is more of a coincidence
and the latter does not play any etiologic role in the
production of the former disease.
The clinical data presented in this paper suggest
that patients with chronic diffuse pulmonary disease
have neither a higher nor lower prevalence of myocardial infarction when compared with individuals
with either localized chest disease or no significant
chest disease. On the other hand, patients with chronic diffuse chest disease with severe abnormalities of
pulmonary function, especially where there is carbon
dioxide retention, have a higher prevalence of electrocardiographic abnormalities suggestive of myocardial ischemia. It remains open to question whether
these electrocardiographic changes are indicative of
true coronary atherosclerotic heart disease.
1 Thomas AJ: Coronary heart disease in the presence of
pulmonary disease. Brit Heart J 20:83, 1958
2 Gottsegen G, Torok E : A clinicopathologic study of cor
pulmonale with heart failure. Amer J Cardiol 2:441,
1958
3 Rees HA, Thomas AJ, Rossiter C: The recognition of
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ISCHEMIC HEART DISEASE AND CHRONIC DIFFUSE PULMONARY DISEASE
coronary heart disease in the presence of pulmonary
disease. Brit Heart J 26:233, 1964
4 Saniad IA, Noehren TH: Focal myocardial necrosis in cor
pulmonale of emphysema. Dis Chest 48:376, 1965
5 Nonkin Phl, Dick Mhl, Baum GL: hlyocardial infarction
in respiratory insufficiency. Arch Intern Sled 113:42,
1964
6 Samad IA, Noehren TH: hlyocardial infarction in pulmonary emphysema. Dis Chest 47:26, 1965
7 Sanghvi Lhl, Kotia KC: Heart failure in patients with
chronic pulmonary emphysema. Dis Chest 44:67, 1963
8 Woolf CR: The organization of a hospital routine pulmonary function laboratory. Canad Med Assoc J 98:30, 1968
9 Baldwin E de F, Cournand A, Richards DW, Jr: Pulmonary insufficiency. I Physiological classification, clinical
methods of analysis, standard values in normal subjects.
Medicine 27 :243, 1948
10 Gaensler EA: Analysis of the ventilatory defect by timed
capacity measurements. Amer Rev Ti~berc64:256, 1951
11 Bates DV, Woolf CR, Paul GI: Chronic bronchitis. A
report on the first two stages of the co-ordinated study of
chronic bronchitis in the Department of Veterans Affairs,
Canad Med Serv J 18:211,1962
12 Rotman Hhl, Woolf CR: The diffusing capacity of the
lungs at rest and on exercise in adults with atrial of
ventricular septa1 defect. Dis Chest 43:613, 1963
13 Gregg DE: Coronary Circulation in Health and Disease.
Philadelphia, Lea and Febiger, 1950
14 h4oret PM, Bopp P, Grousgurin J, et al: Comparative
study of electrocardiogram, vectorcardiogram, coronary
circulation and myocardial metabolism in chronic cor
pulmonale. Cardiologia 48:182, 1966
15 Hale G, Dexter D, Jefferson K, et al: Value of coronary
arteriography in the investigations of ischemic heart disease. Brit Heart J 28:40, 1966
16 Likoff W, Kasparian H, Segal BL, et al: Coronary arteriography: correlation with electrocardiographic response
to measured exercise. Amer J Cardiol 18: 160, 1966
Criteria for grouping patients according to type
of chest disease
1. Chronic bronchitis. Chronic cough for at least
three years; chronic dyspnea; pulmonary function studies either normal or with obstruction to
air flow, but diffusing capacity normal; only
slight response to bronchodilator aerosol; no
significant fibrosis on roentgenogram.
26 1
2. Chronic bronchitis with emphysema. The same
criteria as for chronic broichitis but with the
addition of an abnormally low pulmonary diffusing capacity.
3. Asthma. Asthmatic attacks for at least three
years (paroxysmal nature of dyspnea with periods of complete remission); pulmonary function tests either normal or with obstruction to air
flow but pulmonary diffusing capacity normal;
moderate to marked improvement after bronchodilator aerosol; no significant pulmonary fibrosis on roentgenogram.
4. Asthma with emphysema. Same criteria as for
asthma but with the addition of an abnormally
low pulmonary diffusing capacity.
5. Pulmonary fibrosis. Roentgenogram showing
diffuse bilateral reticulation, linear or nodular
shadows; pulmonary function tests either normal
or show restriction .to ventilation and/or '1 b normally low pulmonary diffusing capacity.
6. Pulmonary fibrosis with emphysema. Radiologic
evidence of fibrosis as defined above; pulmonary
function obstruction to air flow and abnormally
low pulmonary diffusing capacity. This is a
particularly difficult group to define as the above
criteria could be interpreted as air flow obstruction due to chronic bronchitis and the low
pulmonary diffusing capacity due to the pulmonary fibrosis, no emphysema necessarily being
present.
7. Miscellaneous. Patients showing various combinations of chronic bronchitis, asthma, pulmonary fibrosis and emphysema and which could
not be fitted in the above groups.
8. Nonpulmonary disease. This included neurologic
disorders and patients without obvious chest
disease being assessed for various types of
nonpulmonary surgery.
9. Localized pulmonary disease. This included patients with localized bronchiectasis, various lung
tumors and areas of localized pulmonary fibrosis.
Reprint requests: Dr. Woolf, Department of hledicine, Toronto General Hospital, Toronto 101, Ontario, Canatla
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