HEART and LUNG. Heart failure and COPD Χ. ΑΔΑΜΟΠΟΥΛΟΣ ΓΝΘ «ΑΓΙΟΣ ΠΑΥΛΟΣ»

Transcription

1 HEART and LUNG Heart failure and COPD Χ. ΑΔΑΜΟΠΟΥΛΟΣ ΓΝΘ «ΑΓΙΟΣ ΠΑΥΛΟΣ»

2 Prevalence of concurrent HF and COPD 8 52 % of HF patients have concurrent COPD More common in male HF patients Prevalence increases until 75 years of age and declines thereafter Very few studies used spirometry

3 Prognosis of concurrent COPD in HF patients References n Study design Prevalence COPD (%) Spirometry Mean LVEF (%) Outcome Mean follow-up Adjusted risk (±95% CI) Macchia et al Retrospective 24 No Mortality 287 days 1.42 ( ) Staszewsky et al Prospective 13 No 27 Non-CV mortality 23 months 2.50 ( ) Mascarenhas et al Retrospective 39 Yes Death/hospitalization 433 days 2.10 ( ) Rusinaru et al Prospective 20 No 50 Mortality 5 years 1.53 ( ) Hawkins et al Prospective 9 No 35 Mortality 24.7 months 1.14 ( ) Lainscak et al Retrospective 17 Yes 43 Mortality 1062 days 1.38 ( ) Kwon et al Retrospective 37 Yes 49 Mortality GOLD III 731 days 3.20 ( ) De Blois et al Prospective 17 No 32 Mortality 13.3 months 1.19 ( ) Mentz et al Prospective 25 No 25 Mortality 60 days 0.97 ( ) Mentz et al Prospective 10 No 27 Mortality 9.9 months 1.17 ( ) Boschetto et al Prospective 30 Yes 40 Mortality 1029 days Non-significant Arnaudis et al Prospective 38 Yes 31 Mortality GOLD II 54.9 months 2.27 ( )

4 Prognosis of concurrent COPD in HF patients (2) The mortality is doubled Non-cardiovascular death predominates Sudden death is also increased

5 Diagnostic challenges: Symptoms and X-ray Patients with HF or COPD : dyspnea, orthopnea, cough, exercise intolerance, fatigue, muscle weakness, disturbed sleep, anorexia Neither symptoms nor signs are unique to either condition Chest radiograph may be misleading, as pulmonary vascular remodelling in those with COPD either mimics (upper lobe venous diversion) or masks pulmonary congestion and may falsely reduce heart size (overdistention)

6 Diagnosis of COPD in HF patients Pulmonary function tests COPD : FEV1/FVC < 0.7 In stable HF, both FEV1 and FVC are reduced on average by 20% not affecting the FEV1/ FVC ratio In acutely decompensated HF patients, and in HF patients with chronic pulmonary fluid overload, congestion of the lung may provoke mechanical obstruction of the bronchi by increased interstitial fluid pressure. Reduction of both FEV1 and FVC, but to a larger extent of FEV1, leads to reduction of the FEV1/FVC ratio

7 Diagnosis of COPD in HF patients Pulmonary function tests (2) Restrictive ventilation: Chronic stable HF Airflow obstruction: Decompensated HF Misdiagnosis or overestimation of COPD!!! but FEV1 improves by 11 34% with diuresis and often normalizes

8 Diagnosis of COPD in HF patients Pulmonary function tests (3) Alternatives to diagnose COPD in HF Ratio of residual volume and total lung capacity (RV/TLC) Hyperinflation ( RV/TLC) is a valid indicator of true COPD even in decompensated HF

9 Raised in pulmonary hypertension and RVF Diagnosis of HF in COPD Natriuretic peptides Typical COPD levels overlap with stable HF High negative predictive value (>0.85) BUT low specificity (0.6) and low positive predictive value (0.4)

10 Diagnosis of HF in COPD Echocardiography Echocardiographic acoustic windows: impeded by air trapping in pulmonary disease Unsatisfactory image quality: from 10% in stable patients with COPD to 35% in severe disease and 50% in very severe airflow obstruction Most studies utilizing echo do not report feasibility Echocardiography vs CMR: No studies

11 Uncovering CHF during COPD exacerbation

12 Evaluation of HF in Stable COPD Patients

13 Beta-blockers and COPD Effects on functional parameters Only 3 randomized controlled trials in patients with HF and COPD B-blockers induce bronchoconstriction (reduce FEV1 without an effect on FVC) and may contribute to overdiagnosis of COPD Bisoprolol better than carvedilol This reduction of FEV1 equals or exceeds the improvement of bronchodilators B-blockers are very well tolerated by COPD patients

14 Beta-blockers and COPD Effects on survival 10 retrospective cohort studies Strong protective effect across a broad spectrum of patients with COPD Pooled relative risk: 0.69 ( )

15 Bronchodilators and heart failure Symptom improvement reduction of exacerbations Anticholinergics or beta-2-agonists? The adverse effects of beta-agonists; ischemia, arrhythmias, tachycardia, hypokalemia, QT prolongation, disturbed autonomic modulation However, association is not causation: SUMMIT trial

16 SUMMIT TRIAL Mortality

17 Thank you