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Pulmonary Hypertension and Cardiac Function in Adult Cystic Fibrosis^*

Role of Hypoxemia

^* From St. Michael's Hospital, Wellesley Central Site, University of Toronto, Ontario, Canada. Supported by the Canadian Cystic Fibrosis Foundation and the Ontario Thoracic Society.

Correspondence to: Patrick J. Hanly, MD, FCCP, Room 6015, Bond Wing, St. Michael's Hospital, 300 Bond Street, Toronto, Ontario, Canada M5B1W8

Study objectives: To determine (1) the prevalence of pulmonary hypertension and cardiac dysfunction in adult cystic fibrosis (CF) patients with severe lung disease, (2) the relationship between these cardiovascular abnormalities and hypoxemia, and (3) the impact of subclinical pulmonary hypertension on survival.

Design: Single-blind, cross-sectional study.

Setting: Ambulatory clinic of the Adult CF program at a tertiary-level hospital.

Patients: Clinically stable patients with severe lung disease (FEV₁ < 40% of predicted normal value) who were not receiving supplemental oxygen. A second cohort of patients in stable condition with less severe lung disease (FEV₁ 40 to 65% predicted) was also recruited to enable multivariate analysis for the determinants of pulmonary hypertension.

Measurements and results: Eighteen patients with severe lung disease (FEV₁ 28 ± 7% of predicted normal value) were initially studied. Each patient had overnight polysomnography, pulmonary function tests, and Doppler echocardiography. Arterial oxygen saturation (SaO₂) was reduced during wakefulness (87.1 ± 6.1%) and fell during sleep (84.0 ± 6.6%) while transcutaneous PCO₂ was normal during wakefulness (41.1 ± 6.9 mm Hg) and increased during sleep (46.6 ± 4.7 mm Hg). Left ventricular size, systolic function, and diastolic function were normal except in one patient who had had a previous silent myocardial infarction due to coronary artery disease. Qualitative assessment of right ventricular function was normal in all patients. Pulmonary artery systolic pressure (PASP) was increased (> 35 mm Hg) in seven patients without clinical evidence of cor pulmonale. Regression analysis was performed by combining these data with data from an additional 15 CF patients with moderately severe lung disease (FEV₁ 56.3 ± 8.9% predicted normal) who were recruited to a modified study protocol that included overnight oximetry, pulmonary function tests, and Doppler echocardiography. None of these patients had evidence of hypoxemia and only three had mild elevation of PASP (36, 37, and 39 mm Hg). Linear regression analysis revealed that PASP was significantly correlated with FEV₁ (r = -0.44; p = 0.013), and SaO₂ during wakefulness (r = -0.60; p = 0.0003), during sleep (r = -0.56; p = 0.0008), and after 6 min of exercise (r = -0.75; p < 0.0001). Multivariate analysis revealed that awake SaO₂ was a significantly better predictor of PASP than FEV₁ (p = 0.0104). Clinical follow-up of the original cohort for up to 5 years revealed that mortality was significantly higher in those with pulmonary hypertension than those without pulmonary hypertension (p = 0.0129).

Conclusions: In adult CF patients with severe stable lung disease, left and right ventricular function is well maintained in the absence of significant coronary artery disease; pulmonary hypertension develops in a significant proportion of patients and is strongly correlated with oxygen status, independent of lung function; and subclinical pulmonary hypertension is associated with an increased mortality.

Key Words: cystic fibrosis • nocturnal hypoxemia • polysomnography • pulmonary hypertension • sleep

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