COPD Common disease associated with HF

Transcription

1 COPD Common disease associated with HF 경북대학교병원순환기내과양동헌

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3 호흡기 내과 vs 순환기 내과 3

4 Sliding doors concept Male patient, age 70y, with DOE Depending on whether the patient first sees: Pulmonologist Cardiologist procalcitonin Chest x-ray / CT PFT BNP/NTproBNP ECG Echocardiography Bronchodilator antibiotics HF treatment

5 Sliding doors concept Male patient, age 70y, with DOE Depending on whether the patient first sees: Pulmonologist CRP 46.5mg/L PCT 9.4ng/L procalcitonin Chest x-ray / CT PFT Cardiologist BNP/NTproBNP ECG Echocardiography Bronchodilator antibiotics HF treatment

6 Sliding doors concept Male patient, age 70y, with DOE Depending on whether the patient first sees: Pulmonologist procalcitonin Chest x-ray / CT PFT Cardiologist BNP/NTproBNP ECG Echocardiography NTproBNP 1347pg/mL TnI 0.13ng/mL Bronchodilator antibiotics HF treatment

7 Sliding doors concept Male patient, age 70y, with DOE Depending on whether the patient first sees: Pulmonologist Cardiologist Cardio-pulmonology procalcitonin Chest x-ray / CT PFT BNP/NTproBNP ECG Echocardiography interdisciplinary clinical units Bronchodilator antibiotics HF treatment

8 COPD and HF Prevalence COPD : 14 million Americans CHF : 5 million Tobacco as a common risk factor Coexistance of COPD and HF COPD in patients with CHF The one that most delays the diagnosis of CHF Cause of nonadherence to therapeutic guidelines, especially beta-blockade

9 Comorbidity in HF

10 COPD in HF Prevalence of COPD in HF North American : 11 52% European cohorts : 9 41% Population age, sex Risk factors : smoking Urban vs Rural area Awareness 219 patients with both HF and COPD 82% echocardiography vs 36% PFT

11 Risk of HF in COPD Prevalence of CHF in pt with COPD: 20-30%

12 COPD as a CVD risk COPD is an independent risk factor of mortality and CV comorbidity in HF FEV1 : good predictor of CV mortality as serum cholesterol Smoking CRP 증가 ( 배 ) role in pathogenesis of atherosclerosis LV systolic dysfunction

13 COPD CHF

14 COPD CHF

15 COPD 환자에서심부전진단 Diagnostic Difficulties similar in symptoms and physical findings 1. CXR: less sensitive CT ratio is adversely affected by hyperinflated lung LV dilatation is masked by RV enlargement Pulmonary congestion (even pulmonary edema) can be present in COPD 2. EKG abnormality: overlap with those seen in HF 3. BNP/pro-BNP: helpful 4. Echo / Cardiac MRI

16 Diagnostic Difficulties Chest X-ray Chest hyperinflation cardiothoracic ratio Pulmonary vascular remodelling and radiolucent lung fields mask the typical alveolar shadowing of pulmonary edema. pulmonary congestion (even pulmonary edema) can be present in COPD LV dilatation is masked by RV enlargement Emphysematous vascular bed loss upper lobe venous diversion, mimicking HF

17 Diagnostic Difficulties Echocardiography poor acoustic windows unsatisfactory in 10.4% of patients with COPD 35% in patients with severe COPD Contrast echo

18 Diagnostic Difficulties Cardiac MRI standard for measuring LV volumes and ejection fraction precise quantification of RV volumes, function, and transvalvular flow, Difficulties in breathing holding

19 Diagnostic Difficulties Natriuretic peptides

20 Diagnostic Difficulties Natriuretic peptides

21 HF in stable COPD

22 Therapeutic implications COPD CHF

23 Therapeutic implications -Pulmonary medication influencing cardiac function -CV medication influencing pulmonary function

24 Pulmonary medication influencing cardiac function 1. β2 receptor agonist 2. Anticholinergics

25 β2-receptor agonist β2 agonist - not highly selective activation of β1-receptor in myocardial tissue down regulation of β1-receptor increase myocardial O 2 consumption endogenous catecholamine production

26 beta2-receptor agonist inhalation of long acting β2-r agonist more quickly removed from myocardial betareceptor potential deleterious cardiac effects less likely

27 Anticholinergics Reduce acetylcholine release over short period Potentially exert (adverse) cardiac effects - atropine Until now, no adverse effect on cardiac function

28 CV medication influencing pulmonary function β-blocking agent ACE inhibitor / ARB Aldosterone antagonist Digitalis Diuretics

29 Underused beta-blocker

30 β-blocking agent Selective β1 blockade Respiratory symptoms and FEV1 are not significantly worsened by selective β1 blockade in COPD patients does not attenuate β2 receptor agonist-induced bronchodilatation

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34 Recommendation all CHF + stable COPD without reversible airway obstruction Selective or nonselective beta-blocker CHF + COPD with reversible airway obstruction Selective β1-blocker Nonselective β-blocker : no safety data COPD exacerbation avoid β-blocker until safety data are available

35 ACE inhibitor & ARB Angiotensin-II : potent pulmonary airway constrictor ACE inhibitor pulmonary inflammation pulmonary vascular constriction ameliorate the alveolar membrane gas conductance abnormality benefit in treating pt with COPD

36 Statin Inhibit development of emphysema, inflammation, pulmonary hypetension pleiotrophic effect anti-inflammatory action

37 ACEI/ARB and Statin

38 Diuretics & Digitalis high dose diuretics acid-base disturbance metabolic alkalosis blunt respiratory derive Normal dosage of diuretics No influence on pulmonary function Digitalis Pulmonary vasoconstriction reduce lung fx

39 Summary COPD in patients with HF is not uncommon. Early and appropriate diagnosis Proper management Selective and/or nonselective β-blocker ACEI / ARB Statin Proper bronchodilator Anticholinergic inhalation of long acting β2-r agonist

40 경청해주셔서감사합니다.

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44 Sliding doors concept Cardio-oncology interdisciplinary clinical units