Comorbidities in HF COPD Chronic Obstructive Pulmonary Disease Gerasimos Filippatos Athens, Greece

Transcription

1 Comorbidities in HF COPD Chronic Obstructive Pulmonary Disease Gerasimos Filippatos Athens, Greece

2 Epidemiology of heart failure in chronic obstructive pulmonary disease (COPD) patients and vice versa. Diagnostic, prognostic and treatment challenges of the co-existence of both syndromes.

3 Definition of COPD COPD is characterized by airflow limitation that is not fully reversible. The airflow limitation is usually progressive and associated with an abnormal inflammatory response of the lung. It has significant extrapulmonary effects that may contribute to the severity in individual patients.

4 Classification of COPD Severity by Spirometry Stage I: Mild FEV 1 /FVC < 0.70 FEV 1 > 80% predicted Stage II: Moderate FEV 1 /FVC < % < FEV 1 < 80% predicted Stage III: Severe FEV 1 /FVC < % < FEV 1 < 50% predicted Stage IV: Very Severe FEV 1 /FVC < 0.70 FEV 1 < 30% predicted or FEV 1 < 50% predicted plus chronic respiratory failure

5 Percent Change in Age-Adjusted Death Rates, U.S., Proportion of 1965 Rate Coronary Heart Disease Stroke Other CVD COPD All Other Causes % 64% 35% +163% 7% Source: NHLBI/NIH/DHHS

6 Number Deaths x 1000 COPD Mortality by Gender Men Women Source: US Centers for Disease Control and Prevention, 2002

7 COPD and Heart Failure Heart Failure COPD Filippatos G 2010

8 Prevalence of COPD in patients with heart failure The reported prevalence of COPD ranges from 11 to 52% in North American patients with HF, and from 9 to 41% in European cohorts Hawkins NM et al. EJHF 2009

9 Prevalence of COPD in heart failure trials Hawkins NM et al EJHF 2009 Reference n Prevalence COPD (%) LVEF (%) Trial Population Parker SOLVD Community Sharma ELITE II Community Staszewsky <40 Val-HeFT Community Massie WATCH Community Grancelli Any DIAL Community NETWORK Investigators NETWORK Mixed Gheorghiade ACTIV-CHF Cuffe <40 OPTIME-CHF HF hospitalization HF hospitalization

10 Prevalence of COPD in HF Clinic Data Presented by Stainacher, AT

11 Prevalence of heart failure in patients with COPD

12 0,6 Normal LV LVD 0,4 0,2 0 LVD Normal LV Distance walked on the flat without stopping LVD was found in 32% of patients with COPD presenting with symptomatic deterioration

13 Problems diagnosing heart failure in patients with COPD Clinical features Radiology Imaging (Echocardiography, CMR, Νuclear) Νatriuretic Peptides European Journal of Heart Failure (2009) 11, J Am Coll Cardiol 2007;49:171 80

14 Problems diagnosing heart failure in patients with COPD Clinical features. Pulmonary disease may produce or obscure every symptom and sign defined by Framingham Criteria Radiology. Imaging (Echo, CMR, Νuclear) Νatriuretic Peptides European Journal of Heart Failure (2009) 11, J Am Coll Cardiol 2007;49:171 80

15 Exam Variables by Diagnosis J Am Coll Cardiol 2010

16 Problems diagnosing heart failure in patients with COPD Clinical features Radiology Chest hyperinflation spuriously reduces the cardiothoracic ratio. Pulmonary vascular remodelling and radiolucent lung fields mask the typical alveolar shadowing of pulmonary oedema Asymmetric, regional, and reticular patterns of pulmonary oedema are common Emphysematous vascular bed loss causes upper lobe venous diversion, mimicking HF Imaging (Echo, CMR, Νuclear) Νatriuretic Peptides J Am Coll Cardiol 2007;49: European Journal of Heart Failure (2009) 11,

17 Relationship between LVEF and heart size on chest radiograph in patients with COPD. Chest 1995

18 A chest radiograph of a 50-year-old woman with chronic cough. Gehlbach B K, Geppert E Chest 2004;125:

19 Active transport is important for edema clearance Filippatos et al. In Vitro 1997 Voelker et al

20 Problems diagnosing heart failure in patients with COPD Clinical features Radiology Imaging (Echo, CMR, Νuclear) Echo images unsatisfactory in 10 to 50 % Νatriuretic Peptides

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22 Problems diagnosing heart failure in patients with COPD Clinical features Radiology Imaging (Echo, CMR, Νuclear) Νatriuretic Peptides Natriuretic peptides are elevated in both primary pulmonary hypertension and right HF secondary to chronic respiratory disease

23 ESC Guidelines for the Diagnosis and Treatment of Acute and Chronic Heart Failure

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25 Problems diagnosing COPD in patients with heart failure Airflow obstruction is common in ADHF and restriction in CHF Disparities in confirmatory testing. In a recent study among patients with both HF and COPD, 82% had echo vs 36% LFT. Respir Care 2006;51:

26 Cardiopulmonary abormalities responsible for restrictive and obstructive defects JACC 2004

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29 The percentage of fibrosis (stained blue) in the right venticle was significantly greater in CPD patients with right ventricular hypertrophy

30 Boudestein L C et al. Eur J Heart Fail 2009;11:1182 Kaplan Meier survival curves of 404 patients with a general practitioner's diagnosis of chronic obstructive pulmonary disease.

31 J Card Fail 2010

32 Challenges in management

33 Utilization of Evidence-based Therapies in Heart Failure History of HF and LVEF Documented and 0.40* *Excludes patients with documented contraindications. 2300/7883 Patients hospitalized with HF; prior known dx of systolic dysfunction HF; outpatient medical regimen. ADHERE Registry Report Q (4/01-3/02) of 180 US Hospitals Presented by GC Fonarow at the Heart Failure Society of America Satellite Symposium, September 23, 2002.

34 Therapeutic implications Pulmonary medication influencing cardiac function Oral and inhaled short-acting β2- adrenoreceptor agonists do seem to increase the risk of mortality and number of heart failure exacerbations in LVSD F. Rutten. Heart failure in COPD, Thesis 2005

35 Hawkins N M et al. Eur J Heart Fail 2010;12: Adjusted survival rate according to bronchodilator and beta-blocker use.

36 Therapeutic implications Cardiovascular medication influencing pulmonary function I Angiotensin-II is a potent pulmonary airway constrictor. Therefore, ACE-inhibitors and ARBs confer potential benefit in COPD. ACE-inhibitors may have additional beneficial effects because they can also decrease pulmonary inflammation Aldosterone antagonists can also have possibly positive effects on gas exchange, because aldosterone can damage the alveolar-capillary membrane F. Rutten. Heart failure in COPD, Thesis 2005

37 Changes in exercise tolerance measured in placebo and losartan groups by the mean number of shuttles completed in the shuttle walk test.

38 Therapeutic implications Cardiovascular medication influencing pulmonary function II High dosages of diuretics can cause acidbase disturbances (metabolic alkalosis) in COPD patients and this may blunt the respiratory drive Digitalis may reduce lung function because it can cause pulmonary vasoconstriction F. Rutten. Heart failure in COPD, Thesis 2005

39 Therapeutic implications Cardiovascular medication influencing pulmonary function III Until recently, experts advised not to use β- blockers in COPD, specially in the presence of bronchospasm. However, recent analyses have shown that cardioselective β-blockers do not produce clinically significant adverse respiratory effects in patients with mild to moderate reactive airway disease. The results were similar for patients with concomitant chronic airways obstruction

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41 Rutten et al. Arch Intern Med 2010; 170:880-

42 Differences Between B-Blockers in Patients With CHF Failure and COPD: A Randomized Crossover Trial Switching between β1-selective beta-blockers and the nonselective beta-blocker carvedilol is well tolerated but results in demonstrable changes in airway function, most marked in patients with COPD. Switching from β1-selective beta-blockers to carvedilol causes short-term reduction of central augmented pressure and NT-proBNP. JACC 2010

43 Public Health would benefit more from application of what is already known than from scientific breakthroughs. Lord Rosenheim

44 There are, in truth, no specialties in medicine, since to know fully many of the most important diseases a man must be familiar with their manifestations in many organs. William Osler, The Army Surgeon, Medical News, Philadelphia, 1894

45 WORLD COPD DAY November 14, 2007 Raising COPD Awareness Worldwide

46 IS YOUR HEART FAILING? Do you have unexplained shortness of breath, swollenankles? Go to If thisdoes not answeryour questions, please contact yourdoctor