The interaction of HF and COPD

J Mark FitzGeraldSean Virani

Objectives:

HF and COPD – a backgroundEpidemiologyDealing with dyspnea Approach to the patient with COPD & HFThe future …

Case :65 year old woman with a thirty pack year hx. of

smoking presents with progressive dyspnoea.

Five years previously there was a history of a AMI.

There is a reported history of chronic cough and clear sputum.

There is minimal peripheral edema.

Salbutamol PRN gives some relief but the symptoms have become progressive and more troublesome.

What next …?

BCMA

simplify this slide

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

Clinical Approach:

HF and COPD are common and they commonly co-exist 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 non-pharmacological therapies are well tolerated and may have benefit across both disease states

JAMA 2006

JAMA 2006

Finding Pooled Sensitivity

Pooled specificity

LR

Positive

LR

negative

Initial clinical

judgment

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)

JAMA 2006

Symptoms Pooled Sensitivity

Pooled specificity

LR

Positive

LR

negativePND 0.41 0.84 2.6 (1.5-4.5) .74 (0.54-

0.91)Orthopnoea 0.51 0.74 2.2 (1.2-

2.39).65 (0.45-0.92)

Edema 0.51 0.66 2.1 (0.92-5.0)

.64 (0.39-1.11)

JAMA 2006

Finding Pooled Sensitivity

Pooled specificity

LR

Positive

LR

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)

Differentiating COPD and HF Clinically

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

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

(1)Poor visualization (10-30%) of patients

(2)Concomitant atrial fibrillation precludes accurate assessment of diastolic function

(3)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

Additional investigations to consider in the “stable” patient

ECG When “normal” HF < 10%

ECG COPD When “normal” HF < 12%

nT-pro-BNP When “normal” HF < 10%

nT-pro-BNP COPD When “normal” HF < 9%

CXR Low NPV and moderate PPV

CXR 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.

Why measure spirometry?

x COPD-6. Diagnose COPD. Confirm response to therapy. Provide prognostic information for patients

with HF! Assess relative contributions of COPD versus

HF to dyspnea.

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

Int Heart Journal 2006

Spirometry strongest predictors of mortality

VC ≤ 81% 2.5 (1.88-3.32)

FEV1 ≤ 72% 2.02 (1.55-2.72)

Int Heart Journal 2006

JACC 2002

JACC 2002

NEJM 2004

NEJM 2004

Key messages:

BNP guided therapy:

• Shorter length of stay: median of 8 versus 11 days

• More cost effective $5.400 vs 7,200

• Less likely to be admitted to ICU

• Lower mortality

Non-Heart Failure Reasons for Elevation in BNP

ACUTE HF

Alternate Diagnoses to Consider

Acute Coronary Syndromes

Pulmonary Embolism

Acute Renal Insufficiency

PAH

Sepsis

CHRONIC HF

Alternate Diagnoses to Consider

Advanced age ( > 75 years)

Atrial Fibrillation

Renal Dysfunction (eGFR < 45)

LVH

COPD

nT-pro-BNP > 400 pg/mL or BNP > 125 pg/mL

Conclusions - Diagnostics

• Consider BNP/nT-pro-BNP to rule out the presence of HFHas 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

Thorax 2011Thorax 2011

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 better management of these events.

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 better management of these events.

Therapeutic Considerations in HF and COPDHF 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

Common interventions:Smoking cessation. Exercise prescription. Action plans. Co morbidities and over lap issues:

Depression.End of life care.Control of dyspnea.

Potential therapeutic overlap.

What’s Happening in HF at the Provincial Level

• Development of new patient and provider resources for HF through the Provincial HF Strategy

•Medications and Lifestyle Management

• Evaluation of existing resources with key stakeholder feedback and continued development

• Standardized reporting of cardiac imaging

• Development of Nursing standards and medication titration order sets for allied health

• End-of-life tools with HF focus in collaboration and alignment with existing PSP

•ICD management

What’s Happening in HF at the Provincial Level

PATIENT RESOURCES

MEDICATIONS

SODIUM

FLUID

EXERCISE

EXACERBATION PLAN

HF 101

PROVIDER RESOURCES

REFERRAL FORMS

PATIENT ASSESMENT FORMS

CARE MAPS & TX ALGORITHMS

MEDICATION TITRATION

PATIENT SYMPTOM STATUS

VISIT SNAP SHOT

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 dyspneic patient

• In general, traditional pharmacological and non-pharmacological therapies are well tolerated and may have benefit across both disease states

Back to the Case :• BNP elevated at 600 confirming the diagnosis of HF

associated with volume overload•Started on diuretics with some improvement in edema

and dyspnea, but persistent wheezing on exam

•Receives education regarding lifestyle management including sodium and fluid restriction

•Subsequent echocardiogram confirms LVEF 30%

•Started on ACEi for LV dysfunction and HF

•Given history of CAD and previous MI, patient is also started on statin

Back to the Case :• Patient symptomatically better after diuresis but

remains SOB.

• Spirometry shows an FEV1/FVC ratio of 65% predicted and an absolute FEV1 of 58%. There is no evidence of reversibility.

• The patients was prescribed a SABA for symptom relief and after two months using it frequently on a daily basis was started on tiotropium with symptom improvement.

• The patient is also started on a beta blocker.

• Advised to ensure immunizations are up to date and also referred to local cardio pulmonary rehab program.