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The Interaction of HF and
COPD
Dr. J Mark FitzGerald
Dr. Sean Virani
Objectives:
 HF and COPD – a background
 Epidemiology
 Dealing with dyspnea
 Approach to the patient with COPD & HF
 The future…
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Prevalence – some considerations …
How do you estimate prevalence?
POPULATION
DEFINITION
Aging
Spirometry
Risk factors
Clinical coding
Smoking
Self reported
Disease burden
Medication
SPIROMETRY
SURVEILLANCE
Cut-offs
Awareness
Changing criteria
Screening
Pulmonary edema
Contact with Services
Technique
Reporting Bias
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Prevalence of COPD in HF
• The prevalence of COPD in
patients with HF increases
with age
• This has been
demonstrated in population
based studies from a
number of countries with
rates from 7.9% - 11.9%
• Some COPD may be
unrecognized
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Conclusions:
• COPD is common in HF
 and independently predicts mortality
• HF is common in COPD
 and independently predicts mortality
• Cardiovascular risk factors cluster in patients with
COPD
• Many symptomatic, diagnostic and therapeutic
challenges
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Clinical Approach:
 HF and COPD are common and they commonly coexist in the same patient
› (1) Diagnosis may be challenging due to similarities in
clinical presentation
› (2) Diagnostic tools exist which may help to differentiate
these disease entities in the dyspneic
patient
› (3) In general, traditional pharmacological and nonpharmacological therapies are well
tolerated and
may have benefit across
both disease states
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JAMA 2006
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Finding
Pooled
Sensitivity
Pooled
specificity
LR
LR
Positive
negative
0.61
0.86
4.4 (1.8-10.0)
0.45 (0.28-0.73)
Hx. of heart
failure
0.60
0.90
5.8 (4.1-8.0)
0.45 (0.38-0.53)
Myocardial
infarction
0.40
0.87
3.1(2.0-4.9)
0.69 (0.58-.82)
IHD
0.52
0.70
1.8 (1.1-2.8)
0.68(0.48-0.96)
COPD
0.34
0.57
0.81(0.60-1.1)
1.1 (0.95-1.4)
Initial clinical
judgment
JAMA 2006
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Symptoms
Pooled
Sensitivity
PND
0.41
Orthopnoea
0.51
Edema
0.51
Pooled
LR
LR
specificity Positive
negative
0.84
2.6 (1.5-4.5) .74 (0.540.91)
0.74
2.2 (1.2.65 (0.452.39)
0.92)
0.66
2.1 (0.92.64 (0.395.0)
1.11)
JAMA 2006
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Finding
Pooled
Sensitivity
Pooled
specificity
LR
LR
Positive
negative
Third heart sound
0.13
0.99
11 (4.9-25.0)
0.88(0.83-0.94)
Abdomino-jugular
reflex
0.24
0.96
6.4 (0.81-51.0)
0.79(0.62-1.0)
JVP elevated
0.39
0.92
5.1(3.2-7.9)
0.66(0.57-0.77)
Crackles
0.60
0.78
2.8(1.9-4.1)
0.51 (0.37-0.70)
Any murmur
0.27
0.90
2.6(1.74-4.1)
0.81(0.73-0.90)
Peripheral edema
0.50
0.78
2.3(1.5-3.7)
0.64(0.47-0.87)
Wheezing
0.22
0.58
0.52(0.38-0.71)
1.3 (1.1-1.7)
JAMA 2006
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Differentiating COPD and HF Clinically
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
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These may be difficult to differentiate
Overlap in signs
Overlap in symptoms
Overlap in investigations
 May be complicated in the face of an acute exacerbation of
either disease state
 Patient must have a ‘stable’ clinical status
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Differentiating HF and COPD using
diagnostics: Echocardiography
 Helpful in patients when there is clear evidence of either
systolic or diastolic dysfunction
 This may be difficult in patients with COPD
 Poor visualization (10-30%) of patients
 Concomitant atrial fibrillation precludes accurate
assessment of diastolic function
 Evidence of impaired systolic/diastolic function doesn’t
necessarily imply that the patient has clinical HF
 Nuclear medicine testing with MUGA or MIBI may be a
useful alternate mechanism for assessing LVEF
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Additional investigations to consider in the
“stable” patient
ECG
ECG
When “normal” HF < 10%
COPD
nT-pro-BNP
nT-pro-BNP
When “normal” HF < 10%
COPD
CXR
CXR
When “normal” HF < 12%
When “normal” HF < 9%
Low NPV and moderate PPV
COPD
Low NPV and low PPV
Davie et al., 1996; Rutten et al., 2005; Rutten et al., 2006; Fonseca et al., 2004; Fuat et al., 2006; Zaphiriou et
al., 2005.
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Why measure spirometry?





x COPD-6.
Diagnose COPD.
Confirm response to therapy.
Provide prognostic information for patients with CHF!
Assess relative contributions of COPD versus CHF to
dyspnea.
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Differentiating HF and COPD using
diagnostics: Spirometry
 COPD (GOLD-criteria)

Spirometry showing airflow obstruction:

FEV1/FVC <70% (or LLN) with or without complaints
 During HF exacerbations, FEV1 is more reduced than FVC

In stable HF, both FEV1 and FVC are reduced to the
same extent
 HF can distort grading of severity (FEV1 % predicted) in
COPD
 Fluid overload can cause a restrictive pattern in PFTs with
associated diffusion disturbances
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Int Heart Journal 2006
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 Spirometry strongest
predictors of mortality
 VC ≤ 81%
3.32)
2.5 (1.88-
 FEV1 ≤ 72% 2.02 (1.552.72)
Int Heart Journal 2006
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JACC 2002
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JACC 200228
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NEJM 2004
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Key messages:

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BNP guided therapy:
Shorter length of stay: media of 8 versus 11 days.
More cost effective $5.400 vs 7,200.
Less likely to be admitted to ICU.
Lower mortality.
NEJM 2004
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Non-Heart Failure Reasons for Elevation in
BNP
ACUTE HF
CHRONIC HF
Alternate Diagnoses to Consider
Alternate Diagnoses to Consider
Acute Coronary Syndromes
Advanced age ( > 75 years)
Pulmonary Embolism
Atrial Fibrillation
Acute Renal Insufficiency
Renal Dysfunction (eGFR < 45)
PAH
LVH
Sepsis
COPD
nT-pro-BNP > 400 pg/mL or BNP > 125 pg/mL
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Conclusions - Diagnostics
 Consider BNP/nT-pro-BNP to rule out the presence of HF
 Has good negative predictive value (NPV)
 Spirometry is useful when the patient’s volume status is
optimized
 During acute HF exacerbations, diagnostic accuracy may
be limited
 Echo may be helpful to rule out the presence of systolic or
diastolic dysfunction
 Poor echo windows and the presence of concomitant atrial
fibrillation is a co-founder
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AECOPD aka lung attacks have worse outcomes in
terms of in hospital and one year mortality compared
to heart attacks. Need integrated risk stratification and
Thorax 2011
better management of these events.
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COPD therapy bundle: post lung attack.
 Long acting anti-cholinergic
 LABA +/- ICS.
 Rehabilitation – smoking cessation, action plans
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Clinical trial results on the impact of an educational program
- 57%
Admissions
for other reasons
Patients who benefited from an
education program
Patients who only received
standard care
- 40%
Admissions
for exacerbations
0
- 59%
Non-scheduled
visits
Admissions the year
before the study
+ 4%
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100
150
Number of hospital admissions
- 23%
Emergencies for
other diseases
- 41%
Emergency for
exacerbations
0
50
100
150
200
Number of ER visits
Bourbeau J, Julien M, et al. (2003) Arch Intern Med / Vol. 163: 585-591).
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Pulmonary Rehabilitation
Study
(in rehabilitation/
usual care group)
Length of
follow-up
Risk ratio (95% CI)
Weight in %
18 months
0.29 (0.10 to 0.82)
37%
Man (20/21)
3 months
0.17 (0.04 to 0.69)
44%
Murphy (13/13)
6 months
0.40 (0.09 to 1.70)
19%
Behnke (14/12)
Overall (47/46)
0.26 (0.12 to 0.54)
Chi-Squared 0.70, p=0.71
.25
Favors rehabilitation
.5 .75 1 1.5
Risk of unplanned
hospital admission
Puhan MA, et al. Respir Res. 2005;6:54. Reproduced with permission from Biomed Central.
Favors usual care
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NEJM 1996
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NEJM 1996
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Therapeutic Considerations in HF and COPD
 Some therapies in COPD may be associated with
worsening cardiac events in HF patients:

(1) Oral steroids: increased sodium/fluid retention

(2) ß2 agonists: increase HR and increase MVO2
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(3) Aminophylline: increased risk of arrhythmias
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Therapeutic Considerations in HF and COPD
 HF drugs in COPD
› (1) ACE Inhibitors:
 increases respiratory muscle strength and
decrease pulmonary artery pressures
› (2) Beta-Blockers:
 Choose cardio-selective agents (e.g. bisoprolol) if
there
is a component of reactive airways
 BB use is associated with 22% reduction in mortality
and
a decreased risk of AECOPD
› (3) Aldosterone Blockers:
 Improves exercise tolerance
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Common interventions:
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Smoking cessation
Exercise prescription
Action plans
Comorbidities and overlap issues
Depression
End of life care
Control dyspnea
Potential therapeutic overlap
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Conclusions:
 HF and COPD are common and they commonly co-exist in
the same patient:
 The presence of both is associated with worse outcomes
 Diagnosis may be challenging due to similarities in clinical
presentation
 Diagnostic tools exist which may help to differentiate these
disease entities in the dyspneaic patient
 In general, traditional pharmacological and nonpharmacological therapies are well tolerated and may have
benefit across both disease states
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Next Steps and Evaluation
Next Steps and Evaluation
 Material is available on the psp website:
http://www.gpscbc.ca/psp/learning
 Monthly support call – September 11 from 12 to 1
 [email protected]
 Evaluation is critical!
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Break
Action Planning
Christina Southey
As Inspired by New Kids on the Block
Improvement
“ Step by Step, oh Baby, I’m gonna
get to you giiiiiiirl”
Goal
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What will lead to our success
 Clear Goals (written down)
 A way to measure our progress
 Defined changes to try
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Aim – Why are we here?
To collaborate to create a shared system to improve the
quality of care and experience for patients at risk for, and
living with, COPD and/or Heart Failure (HF):
 Reducing ER or unplanned GP visits
 Reducing unplanned hospital admissions
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What is Your Goal?
What do you want to focus on?
Smoking cessation
Medications
Patient education
Patients symptom self management
Screening and diagnosis
Referral and consult process
Working with community groups
Collaborating with allied health providers
Coordination of care for comorbid patients
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How will we monitor our progress?
For HF patients:
 % of patients with baseline assessment of ejection fraction
 % patients with HF who have been prescribed ACE/ARBS and
Beta Blockers.
 % patient with HF who bring at least one of the following at a
follow-up visit: Daily weight log, fluid intake log, sodium log, or
report physical activity changes.
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For HF and Comorbid Patients:
 % of smokers on with COPD and/or HF offered smoking
cessation support
 % patients with COPD and/or HF who have been referred to
pulmonary and/or cardiac rehab programs where available
 % of patients with COPD and or HF a coordinated care plan
amongst GPs, specialists, and/or community resources
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Are we impacting our goal?
 % of registry patients reporting an Emergency Department
visit or having an unplanned GP visit for COPD and/or HF since
their last appointment.
 % of registry patients reporting a hospital admission for
COPD and/or HF since their last appointment.
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As Inspired by New Kids on the Block
Improvement
“ Step by Step, oh Baby, I’m gonna
get to you giiiiiiirl”
Goal
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Thank you!