Manifestaciones extrapulmonares de epoc

Páginas: 15 (3556 palabras) Publicado: 19 de marzo de 2012
Clin Chest Med 28 (2007) 553–557

Other Systemic Manifestations of Chronic Obstructive Pulmonary Disease
Andrew C. Stone, MD, MPHa, Linda Nici, MDb,c,*
a Providence, RI, USA Brown University School of Medicine, Providence, RI, USA c Pulmonary and Critical Care Section, Providence Veterans Administration Medical Center, 830 Chalkstone Avenue, Providence, RI 02908, USA b

Clinically relevantsystemic effects of chronic obstructive pulmonary disease (COPD) include skeletal muscle, cardiovascular, neurologic, psychiatric, and endocrine system dysfunction. Systemic inflammation and skeletal muscle dysfunction in COPD are discussed in detail in the article by Remels and colleagues elsewhere in this issue. This article focuses on other systemic manifestations of COPD. Recognition andunderstanding of these extrapulmonary effects of COPD will point to additional areas for intervention, which should lead to improved functional status, performance, and enhanced quality of life for these patients. Inflammatory markers A large body of evidence now suggests the presence of systemic inflammation in COPD. There are many studies and reviews in the literature evaluating increased levels ofinflammatory cytokines, acute phase proteins, and markers of oxidant stress in patients who have COPD [1–5]. Increases in inflammatory cytokines are documented in sputum, exhaled breath condensate, bronchoalveolar lavage (BAL) fluid, and plasma in patients who have COPD. They include tumor necrosis factor a (TNF-a), transforming growth factorbeta, interferon-g, and interleukins (ILs) 6 and 8 [1]. Many ofthese inflammatory markers are elevated in patients who have clinically stable
* Corresponding author. Pulmonary and Critical Care Section, Providence Veterans Administration Medical Center, 830 Chalkstone Avenue, Providence, RI 02908. E-mail address: linda_nici@brown.edu (L. Nici).

COPD and increase further with exacerbations [2]. Increased inflammatory cytokines and C-reactive protein (CRP) alsoare associated with skeletal muscle dysfunction, heart disease, and atherosclerosis in patients who have COPD [1,2]. There is increased oxidant stress in the lungs of patients who have COPD as compared with healthy nonsmokers. This is demonstrated by measuring hydrogen peroxide and nitric oxide levels in BAL fluid and exhaled breath condensate [3]. These increases in oxidative burden arehypothesized as responsible for many of the systemic effects of COPD, including changes in fibrinolysis [6], which may contribute to atherosclerosis. Acute phase proteins, such as CRP and fibrinogen, are elevated in smokers [6], and increased plasma fibrinogen levels in smokers are associated with decreased lung function and increased risk for COPD [7]. Fibrinogen and IL-6 are elevated in patients who havestable COPD and rise with exacerbations [8]. Because CRP and fibrinogen are implicated in heart disease and atherosclerosis, it is postulated that reducing the number of COPD exacerbations might decrease these acute phase protein levels and, thus, reduce the risk for coronary artery disease. The association between COPD and cardiovascular disease is discussed later. Cardiovascular disease The previoussection introduced the concept that systemic inflammation occurs in COPD and may play a role in its pathogenesis. These inflammatory processes also may lead to cardiovascular pathology and dysfunction. Additionally,
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0272-5231/07/$ - see front matter Ó 2007 Elsevier Inc. All rights reserved. doi:10.1016/j.ccm.2007.06.005

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STONE & NICI

structural changes in thechest wall and lungs may affect cardiac performance independent of the systemic inflammatory response. In this section, cardiovascular dysfunction and pathology are discussed in relation to COPD. The cardiovascular system is affected by COPD in several ways, the most important being an increase in right ventricular afterload due to elevated pulmonary vascular resistance from direct vascular...
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