Download Module 3 chapter 1c - The Association of Physicians of India

MODULE 3 CHAPTER 2C
HYPERTENSION AND COPD
HYPERTENSION IS THE COMMONEST
CO MORBID CONDITION
HYPERTENSION AND COPD
• Systemic hypertension is a common comorbid
condition in patients with COPD, which may occur
in up to 65% of patients.
• At present, there are no specific guidelines for
the treatment of hypertension in patients with
COPD.
• In general, the recommendations for treatment in
uncomplicated hypertension may be followed in
patients with COPD. However, pulmonary effects
of antihypertensive agents may influence the
choice.
Hypertension and COPD
• Systemic effects of COPD not only predisposes
to hypertension but also to Cardiovascular
disease
• COPD patient most often die of CVD rather
than due to lung disease
• Using routine anti hypertensives also
problematic in COPD because some drugs
worsen COPD
SYSTEMIC
MANIFESTATIONS
OF COPD
Relationship between COPD and CVD
2.5
RR
2.0
1.5
1.0
0.5
0.0
109 %
96 %
88 %
80 %
63 %
FEV1
NHANES 1; N=1,861
DRUG SELECTION
WHICH DRUG?
• CCBs would be the preferred antihypertensive therapy in
patients with COPD, considering their potentially favorable
pulmonary effects: improvement in bronchial reactivity and
reduction of bronchoconstriction.
• Diuretics may be associated with theoretical safety concerns
of worsening hypokalemia when used with β2-adrenergic
receptor agonists and metabolic alkalosis in patients with
coexisting chronic hypercapnia.
• ACE inhibitor use may be associated with the development of
a dry cough that may exacerbate bronchial hyper
responsiveness.
• ARBs could be used as initial therapy as their use is not
associated with the dry cough seen with ACE inhibitors, but
they do not exhibit the favorable respiratory effects seen with
CCBs.
FIRST LINE
CALCIUM CHANNEL BLOCKERS
• CCBs have been shown to be effective in lowering
blood pressure in patients with COPD, and they are
generally well tolerated.
• They may also provide additional benefits in COPD
by virtue of their mechanism of action. These
agents block calcium entry into smooth muscle
cells, thereby causing relaxation.
• Thus, CCBs could oppose tracheobronchial smooth
muscle contraction in COPD and reinforce the
bronchodilator effect of β-agonists.
• Studies have shown a reduction in bronchial
reactivity and bronchoconstriction in patients with
COPD or asthma who are treated with CCBs.
WHICH IS THE SECOND DRUG?
• Based on the adverse effects, safety concerns,
and favorable pulmonary effects of
antihypertensive agents, a CCB (long-acting
dihydropyridine) would be the most
appropriate initial antihypertensive regimen
for a patient with COPD.
• An ARB would be the second-best choice after
the CCB.
WHAT ABOUT B BLOCKERS?
• β-blockers play a pivotal role in the management
of cardiovascular diseases.
• Physicians, however, tend to underuse β-blockers
in patients with COPD because there is a general
perception that these agents are contraindicated
in COPD patients.
• Considering that the majority of patients with
COPD die from cardiac and not respiratory
causes, the underuse of β-blockers is a significant
concern.
CARDIOSELECTIVE B BLOCKERS
• Cardio selective β-blockers are not associated
with respiratory adverse events in patients with
COPD comes from a large Cochrane database
review.
• No changes in FEV1 or respiratory symptoms, and
no effect on FEV1 treatment response to β-2
agonists were observed in patients taking cardio
selective β-blockers, irrespective of the severity
of their COPD, compared with those taking
placebo.
© 2005 Elsevier
COPD
DON’T BE RELUCTANT
• Taken together, these data suggest that cardio
selective β-blockers may be beneficial in patients
with COPD and pre-existing cardiac disease or
hypertension, contrary to physicians' general
reluctance to the use of these agents in COPD
patients.
• Based on these data, the Global Initiative for
Chronic Obstructive Lung Disease (GOLD) is not
opposed to using cardio selective β-blockers in
hypertensive COPD patients.
IMPROVE ENDOTHELIAL FUNCTION
• ARBs and β-blockers are not only effective as antihypertensive
agents but they have also been shown to improve endothelial
function, which is common to both COPD and hypertension.
• Blockade of AT1 receptor with ARBs has been shown to increase
nitric oxide release, thereby reducing vasoconstriction.
• Similar to ARBs, some β-blockers (bopindolol, celiprolol, and
nebivolol) have also been shown to possess vasodilator properties
mediated by increasing nitric oxide availability.
• However, the only β-blocker that has shown to cause apparent
increased endothelial nitric oxide release in humans has been
nebivolol, albeit in a very small study.
• So in this patient with COPD and hypertension, an ARB or a βblocker may provide additional benefits of improving endothelial
dysfunction when used to lower blood pressure.
COPD AND PULMONARY HYPERTENSION
COPD AND PULMONARY
HYPERTENSION
• Pulmonary hypertension in the setting of
COPD is a common occurrence, associated
with poor survival.
• It manifests initially during sleep and with
exercise, and in later stages it occurs at rest.
• In most cases PH is mild to moderate.
PULMONARY HYPERTENSION AND
COPD- NOT ALL ARE COR PULMONALE
NOT ALL PH ARE DUE TO COPD
OUT OF PROPOTION PH
• PULMONARY ARTERIAL HYPERTENSION (PAH)TYPE 1
• PULMONARY EMBOLISM
OUT OF PROPOTION PH
• There is a subpopulation of patients with COPD
with moderate obstruction, severe hypoxemia,
and a low DLCO who have significant PH and are
recently termed "out of proportion PH."
• Workup of patients with COPD and PH should
include a screening echocardiogram and
evaluation for PE.
• If PE is excluded PAH type 1 may be considered
and appropriate work should be done
OUT OF PROPOTION PH
• Patients with PH and COPD present with dyspnea
and hypoxemia out of proportion to the degree
of obstruction.
• Patients with COPD who develop signs of right
heart failure, have right ventricular dilatation on
echocardiogram, have dyspnea not fully
explained by the degree of obstruction, and/or
develop hypoxemia and a low DLCO out of
proportion for their obstruction, should be
suspected to be having out of proportion PH
OUT OF PROPOTION PH
• Pulmonary hypertension related to COPD is
characterized by a relatively normal systolic right
ventricular function (possibly diastolic
dysfunction) and preserved cardiac output
• PAH patients in Group I are characterized by
limitations in the right ventricular flow (cardiac
output) and in advanced stages by a hypo
contractile and dilated right ventricle. Although at
risk for increased mortality, COPD patients with
PH do not typically succumb to right ventricular
failure.
COPD,SYSTEMIC HYPERTENSION AND
PULMONARY HYPERTENSION
• TO R/O “OUT OF PROPOTION PH”
• CALCIUM CHANNEL BLOCKERS MAY HELP
BOTH
• SILDANAFIL WILL BENEFIT BOTH (IF TYPE 1 PH)
• ARB MAY HELP BOTH
• IF B BLOCKERS HAVE TO BE USED ALWAYS USE
NEBIVOLOL (NO DONOR)
CONCLUSIONS
• Hypertension is the commonest co morbid condition in
COPD
• COPD itself can produce lot of systemic effects
including systemic hypertension
• Ca channel antagonists are first choice
• ARB can be used as second line
• If indicated cardio selective b blockers should be used
• If associated with PH one should r/o “out of proportion
PH’
• All the drugs used for type 1 PH reduce systemic
hypertension
END OF MODULE 3 CHAPTER 2 C