COPD as a comorbidity of heart failure in elderly patients

COPD as a comorbidity of heart failure in elderly patients Professor Mitja Lainscak, MD, PhD, FESC, FHFA Departments of Cardiology and Research&Education, General Hospital Celje Faculty of Medicine, University of Ljubljana Heart Failure Association, Executive Committee member

Disclosures Honoraria, speakers fees: none. Research grants (Slovenian research Agency, FP7) International Journal of Cardiology Associate Editor Heart and Lung

Am J Respir Crit Care Med 2006;174:962-3. Anatomic and physiologic dependence Lungs hug the heart Lungs as a conduit for R and L heart O 2 and CO 2 exchange (2 organs, 1 function)

5 Heart failure definition HF is a clinical syndrome characterized by typical symptoms (e.g. breathlessness, ankle swelling and fatigue) that may be accompanied by signs (e.g. elevated jugular venous pressure, pulmonary crackles and peripheral oedema) caused by a structural and/or functional cardiac abnormality, resulting in a reduced cardiac output and/or elevated intracardiac pressures at rest or during stre EJHF 2016, in press

Lung disease Airway (narrowing/blockage of the airway) asthma, COPD (emphysema, chronic bronchitis), bronchiectasies Tissue (structure: inflammation/scarring) fibrosis, sarcoidosis, tuberculosis, cancer Vasculature (clotting/scarring/inflammation) pulmonary hypertension, pulmonary vasculitis

Global Strategy for Diagnosis, Management and Prevention of COPD Definition of COPD n n COPD, a common preventable and treatable disease, is characterized by persistent airflow limitation that is usually progressive and associated with an enhanced chronic inflammatory response in the airways and the lung to noxious particles or gases. Exacerbations and comorbidities contribute to the overall severity in individual patients. 2013 Global Initiative for Chronic Obstructive Lung Disease

ESC Heart Failure Guidelines: Ten Commandments 1. Apply a novel algorithm for the diagnosis of heart failure in the non-acute setting based on, i) clinical probability of the disease (derived from medical history, physical examination and resting ECG), ii) the assessment of circulating natriuretic peptides, and iii) transthoracic echocardiography.

PATIENT WITH SUSPECTED HF (non-acute onset) ASSESSMENT OF HF PROBABILITY 1. Clinical history: History of CAD (MI, revascularization) History of arterial hypertension Exposition to cardiotoxic drug/radiation Use of diuretics Orthopnoea / paroxysmal nocturnal dyspnoea 2. Physical examination: Rales Bilateral ankle oedema Heart murmur Jugular venous dilatation Laterally displaced/broadened apical beat 3. ECG: Any abnormality 9

PATIENT WITH SUSPECTED HF (non-acute onset) ASSESSMENT OF HF PROBABILITY 1. Clinical history; 2. Physical examination; 3. ECG Assessment of natriuretic peptides not routinely done in clinical practice 1 present NATRIURETIC PEPTIDES NT-proBNP 125 pg/ml BNP 35 pg/ml yes no all absent HF unlikely: consider other diagnosis ECHOCARDIOGRAPHY normal If HF confirmed (based on all available data): determine aetiology and start appropriate treatment 10

Global Strategy for Diagnosis, Management and Prevention of COPD Diagnosis of COPD SYMPTOMS shortness of breath chronic cough sputum EXPOSURE TO RISK FACTORS tobacco occupation indoor/outdoor pollution è SPIROMETRY: Required to establish diagnosis 2013 Global Initiative for Chronic Obstructive Lung Disease

Proportion of patients Heart failure and obstructive pulmonary disease Heart failure Chronic obstructive pulmonary disease Asthma 40 35 30 25 20 15 10 5 0 Prevalence Stable disease NA After hospitalizationna Mortality ESC Heart Failure 2015;2:103-7.

Prevalence of HF/COPD ESC Heart Failure 2015;2:103-7.

ESC Heart Failure Guidelines: Ten Commandments 16 7. Manage HF co-morbidities in all heart failure patients. In HFpEF, this is the only evidence based treatment approach.

Importance of co-morbidities in patients with HF

HF is a chronic condition with acute episodes Increasing frequency of acute events with disease progression leads to high rates of hospitalization and increased risk of mortality 1 5 Chronic decline Cardiac function and quality of life Hospitalizations for acute decompensation episodes Disease progression Adapted from Gheorghiade et al. 2005 2 18 HF=heart failure 1. Ahmed et al. Am Heart J 2006;151:444 50; 2. Gheorghiade et al. Am J Cardiol 2005;96:11G 17G 3. Gheorghiade, Pang. J Am Coll Cardiol 2009;53:557 73; 4. Holland et al. J Card Fail 2010;16:150 6 5. Muntwyler et al. Eur Heart J 2002;23:1861 6

Lainscak et al. Curr Opin Clin Nutr Metab Care 2013

Percent of patients COPD in AHF 35 30 25 20 15 10 5 0 EHF I EHF II HF LT registry ALARM-HF

Percent of patients Is it really COPD? 35 30 25 20 15 10 5 0 EHF I EHF II HF LT registry ALARM-HF

Percent of patients Is it really COPD? 35 30 25 History unreliable Smoking and COPD mismatch Respiratory therapy not reported 20 15 10 5 0 EHF I EHF II HF LT registry ALARM-HF

Pulmonary function in hypervolemia Normal subjects infused with 2L of saline 11% FEV1 reduction Clin Sci 1973;45:407-410. Hawkins N, et al, Eur Heart J 2013.

Natriuretic peptides in HF&COPD Hawkins N, et al, Eur Heart J 2013.

Causes of elevated concentrations of natriuretic peptides

NTpro-BNP [ng/ml] NT-proBNP 127 patients, clinically AE COPD 3500 3000 No Left ventricular dysfunction Left ventricular dysfunction 2500 2000 1500 1000 500 0 Admission Discharge 7-10 days postdischarge Lainscak M, unpublished.

Crit Care 2011:15:R114.

Patient with acute dyspnea NYHA I, LVEF 53%, COPD GOLD III, full pharmacological therapy NT-proBNP 3950ng/L (previously 350ng/L ) TnI <0.01μg/L CRP normal, procalcitonin not done Blood gas analysis (respiratory rate 25/min) ph = 7.36 O 2 = 9.13 kpa CO 2 = 4.60 kpa

Pulmonary embolism in HF/COPD 10% of HF patients Chest 2005;128:2576-80. Up to 25% of COPD patients Chest 2009;135:786-93. Geneva and Pisa risk stratification depends on comorbidity Am J Med 2006;119:851-8.

Pneumonia EHF II survey: infection 18%

Critical Care 2013;18:R4.

0.086 μg/l 0.192 μg/l 0.657 μg/l Critical Care 2013;18:R4.

Antibiotics cause for concern?! Eur J Heart Fail 2012:14:278-86.

GOLD guidelines: 1. Treatment of HF in COPD: HF should be treated according to usual HF guidelines as there is no evidence that HF should be treated differently in the presence of COPD. 2. Treatment of COPD in HF: COPD should be treated as usual as there is no direct evidence that COPD should be treated differently in the presence of HF.

Eur J Heart Fail 2011;13:670-80.

Average age 73y, 49% able to tolerate target dose Respir Med 2011;105(S1):S44-9.

Global Strategy for Diagnosis, Management and Prevention of COPD Manage Stable COPD: Pharmacologic Therapy RECOMMENDED FIRST CHOICE Exacerbations per year GOLD 4 GOLD 3 C ICS + LABA or LAMA ICS + LABA and/or LAMA D > 2 GOLD 2 GOLD 1 A SAMA prn or SABA prn LABA or LAMA B 1 0 mmrc 0-1 CAT < 10 mmrc > 2 CAT > 10 2013 Global Initiative for Chronic Obstructive Lung Disease

Cardiovascular safety of long acting bronchodilators Ontario, Canada; >66y; COPD database At least one prescription of LAB 191005 patients 53532 had CV event 26628 matched pairs (9 variables) Primary exposure: new use of LABA/LAA JAMA Intern Med 2013;173:1175-84.

JAMA Intern Med 2013;173:1175-84.

Lancet 2016;387:1817-26.

Arch Med Sci 2014;10:920-32.

Lainscak et al. Curr Opin Clin Nutr Metab Care 2013

Int J Cardiol 2008;125:209-15.

WKW 2011;125:384-7.

COPD and HF (in elderly) Coexist frequently Clinical suspicion confirm/rule-out individual disease Aetiology of acute dyspnoea Consider lung ultrasound Treat according to disease specific guidelines Side effects Interactions

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