The Interaction of HF and COPD

1. The Interaction of HF and COPD Dr. J Mark FitzGerald Dr. Sean Virani

2. Objectives: • HF and COPD – a background • Epidemiology • Dealing with dyspnea • Approach to the patient with COPD & HF • The future…

7. Prevalence – some considerations …How do you estimate prevalence?

9. Prevalence of COPD in HF The prevalence of COPD in patients with HF increases with age This has been demonstrated in population based studies from a number of countries with rates from 7.9% - 11.9% Some COPD may be unrecognized

14. 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

15. 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

16. JAMA 2006

17. JAMA 2006

18. JAMA 2006

19. JAMA 2006

20. 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

21. 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 • Poor visualization (10-30%) of patients • Concomitant atrial fibrillation precludes accurate assessment of diastolic function • 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

22. Additional investigations to consider in the “stable” patient Davie et al., 1996; Rutten et al., 2005; Rutten et al., 2006; Fonseca et al., 2004; Fuat et al., 2006; Zaphiriou et al., 2005.

23. Why measure spirometry? • x COPD-6. • Diagnose COPD. • Confirm response to therapy. • Provide prognostic information for patients with CHF! • Assess relative contributions of COPD versus CHF to dyspnea.

24. 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

25. Int Heart Journal 2006

26. 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

27. JACC 2002

28. JACC 2002

30. NEJM 2004

31. Key messages: • BNP guided therapy: • Shorter length of stay: media of 8 versus 11 days. • More cost effective $5.400 vs 7,200. • Less likely to be admitted to ICU. • Lower mortality. NEJM 2004

32. Non-Heart Failure Reasons for Elevation in BNP nT-pro-BNP > 400 pg/mL or BNP > 125 pg/mL

33. Conclusions - Diagnostics • Consider BNP/nT-pro-BNP to rule out the presence of HF • Has 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

34. 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. Thorax 2011

35. COPD therapy bundle: post lung attack. • Long acting anti-cholinergic • LABA +/- ICS. • Rehabilitation – smoking cessation, action plans

36. - - 57% 57% Admissions for other reasons - - 40% 40% Admissions for exacerbations - - 59% 59% Non-scheduledvisits Admissions the year before the study + 4% + 4% - - 23% 23% Emergencies forother diseases 0 0 50 50 100 100 150 150 Number of hospital admissions Patients who benefited from an education program - - 41% 41% Emergency for exacerbations Patients who only received standard care 0 0 50 50 100 100 150 150 200 200 Number of ER visits Clinical trial results on the impact of an educational program Bourbeau J, Julien M, et al. (2003) Arch Intern Med / Vol. 163: 585-591).

37. Pulmonary Rehabilitation Study(in rehabilitation/usual care group) Length offollow-up Risk ratio (95% CI) Weight in % Behnke (14/12) 18 months 0.29 (0.10 to 0.82) 37% Man (20/21) 3 months 0.17 (0.04 to 0.69) 44% Murphy (13/13) 6 months 0.40 (0.09 to 1.70) 19% Overall (47/46) 0.26 (0.12 to 0.54)Chi-Squared 0.70, p=0.71 .25 .5 .75 1 1.5 Favors rehabilitation Risk of unplannedhospital admission Favors usual care Puhan MA, et al. Respir Res.2005;6:54. Reproduced with permission from Biomed Central. 38

39. NEJM 1996

40. NEJM 1996

41. Therapeutic Considerations in HF and COPD • Some therapies in COPD may be associated with worsening cardiac events in HF patients: • (1) Oral steroids: increased sodium/fluid retention • (2) ß2 agonists: increase HR and increase MVO2 • (3) Aminophylline: increased risk of arrhythmias

42. Therapeutic Considerations in HF and COPD • HF 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

43. Common interventions: • Smoking cessation • Exercise prescription • Action plans • Comorbidities and overlap issues • Depression • End of life care • Control dyspnea • Potential therapeutic overlap

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

45. Next Steps and Evaluation

46. Next Steps and Evaluation • Material is available on the psp website: http://www.gpscbc.ca/psp/learning • Monthly support call – September 11 from 12 to 1 • l_hlth_psp_sharedcare@lists.gov.bc.ca • Evaluation is critical!

47. Break

48. Action Planning Christina Southey

49. As Inspired by New Kids on the Block “ Step by Step, oh Baby, I’m gonna get to you giiiiiiirl” Improvement Goal

50. What will lead to our success • Clear Goals (written down) • A way to measure our progress • Defined changes to try