1. www.pspbc.ca COPD or HF A Clinical Challenge Learning Session 3

2. 2  Sharing success and lessons learned (65):  Optional co-morbid Patient Story: (10)  Comorbidity patients (60 - 40 didactic, 20 discussion  Break (15)  Planning for Sustainability (30, 15 didactic + 15 discussion):  Wrap up (30 – mostly evaluation) Agenda

3. 3 Faculty/Presenter Disclosure Speaker’s Name: Speaker’s Name Relationships with commercial interests: -Grants/Research Support: PharmaCorp ABC -Speakers Bureau/Honoraria: XYZ Biopharmaceuticals Ltd -Consulting Fees: MedX Group Inc. -Other: Employee of XYZ Hospital Group

4. 4 Disclosure of Commercial Support This program has received financial support from [organization name] in the form of [describe support here – e.g. educational grant]. This program has received in-kind support from [organization name] in the form of [describe the support here – e.g. logistical support]. Potential for conflict(s) of interest: -[Speaker/Faculty name] has received [payment/funding, etc.] from [organization supporting this program AND/OR organization whose product(s) are being discussed in this program]. -[Supporting organization name] [developed/licenses/distributes/benefits from the sale of, etc.] a product that will be discussed in this program: [enter generic and brand name here].

5. 5 Mitigating Potential Bias [Explain how potential sources of bias identified in slides 1 and 2 have been mitigated]. Refer to “Quick Tips” document

6. Patients with Comorbidities

7. 7  HF and COPD – a background  Epidemiology  Dealing with dyspnea  Approach to the patient with COPD & HF  The future … Objectives

8. 8  65 year old woman with a thirty pack year hx. of smoking presents with progressive dyspnoea.  Five years previously there was a history of a AMI.  There is a reported history of chronic cough and clear sputum.  There is minimal peripheral edema.  Salbutamol PRN gives some relief but the symptoms have become progressive and more troublesome.  What next …? Case

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14. 14  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 Conclusions:

15. 15  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 Clinical Approach

16. 16 FindingPooled Sensitivity Pooled specificity LR Positive LR negative Initial clinical judgment 0.610.864.4 (1.8-10.0)0.45 (0.28-0.73) Hx. of heart failure 0.600.905.8 (4.1-8.0)0.45 (0.38-0.53) Myocardial infarction 0.400.873.1(2.0-4.9)0.69 (0.58-.82) IHD0.520.701.8 (1.1-2.8)0.68(0.48-0.96) COPD0.340.570.81(0.60-1.1)1.1 (0.95-1.4)

17. 17 SymptomsPooled Sensitivity Pooled specificity LR Positive LR negative PND0.410.842.6 (1.5-4.5).74 (0.54- 0.91) Orthopnoea0.510.742.2 (1.2- 2.39).65 (0.45- 0.92) Edema0.510.662.1 (0.92- 5.0).64 (0.39- 1.11)

18. 18 FindingPooled Sensitivity Pooled specificity LR Positive LR negative Third heart sound0.130.9911 (4.9-25.0)0.88(0.83-0.94) Abdomino-jugular reflex 0.240.966.4 (0.81-51.0)0.79(0.62-1.0) JVP elevated0.390.925.1(3.2-7.9)0.66(0.57-0.77) Crackles0.600.782.8(1.9-4.1)0.51 (0.37-0.70) Any murmur0.270.902.6(1.74-4.1)0.81(0.73-0.90) Peripheral edema0.500.782.3(1.5-3.7)0.64(0.47-0.87) Wheezing0.220.580.52(0.38-0.71)1.3 (1.1-1.7)

19. 19  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 Differentiating COPD and HF Clinically

20. 20  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 Differentiating HF and COPD using diagnostics: Echocardiography

21. 21 ECGWhen “normal” HF < 10% ECGCOPDWhen “normal” HF < 12% nT-pro-BNPWhen “normal” HF < 10% nT-pro-BNPCOPDWhen “normal” HF < 9% CXRLow NPV and moderate PPV CXRCOPDLow NPV and low PPV Davie et al., 1996; Rutten et al., 2005; Rutten et al., 2006; Fonseca et al., 2004; Fuat et al., 2006; Zaphiriou et al., 2005. Additional investigations to consider in the “stable” patient

22. 22  x COPD-6.  Diagnose COPD.  Confirm response to therapy.  Provide prognostic information for patients with HF!  Assess relative contributions of COPD versus HF to dyspnea. Why Measure Spirometry?

23. 23  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 Differentiating HF and COPD using diagnostics: Spirometry

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25. 25 NEJM 2004  BNP guided therapy:  Shorter length of stay: median of 8 versus 11 days  More cost effective $5.400 vs 7,200  Less likely to be admitted to ICU  Lower mortality Key messages:

26. 26 ACUTE HF Alternate Diagnoses to Consider Acute Coronary Syndromes Pulmonary Embolism Acute Renal Insufficiency PAH Sepsis Non-Heart Failure Reasons for Elevation in BNP CHRONIC HF Alternate Diagnoses to Consider Advanced age ( > 75 years) Atrial Fibrillation Renal Dysfunction (eGFR < 45) LVH COPD nT-pro-BNP > 400 pg/mL or BNP > 125 pg/mL

27. 27  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 Conclusions - Diagnostics

28. 28  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 Therapeutic Considerations in HF and COPD

29. 29  Smoking cessation.  Exercise prescription.  Action plans.  Co morbidities and over lap issues:  Depression.  End of life care.  Control of dyspnea.  Potential therapeutic overlap. Common interventions:

30. 30  Development of new patient and provider resources for HF through the Provincial HF Strategy › Medications and Lifestyle Management › Evaluation of existing resources with key stakeholder feedback and continued development › Standardized reporting of cardiac imaging › Development of Nursing standards and medication titration order sets for allied health › End-of-life tools with HF focus in collaboration and alignment with existing PSP › ICD management What’s Happening in HF at the Provincial Level

31. 31 PATIENT RESOURCES MEDICATIONS SODIUM FLUID EXERCISE EXACERBATION PLAN HF 101 What’s Happening in HF at the Provincial Level PROVIDER RESOURCES REFERRAL FORMS PATIENT ASSESMENT FORMS CARE MAPS & TX ALGORITHMS MEDICATION TITRATION PATIENT SYMPTOM STATUS VISIT SNAP SHOT

32. 32  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 dyspneic patient › In general, traditional pharmacological and non- pharmacological therapies are well tolerated and may have benefit across both disease states Conclusions:

33. 33  BNP elevated at 600 confirming the diagnosis of HF associated with volume overload  Started on diuretics with some improvement in edema and dyspnea, but persistent wheezing on exam  Receives education regarding lifestyle management including sodium and fluid restriction  Subsequent echocardiogram confirms LVEF 30%  Started on ACEi for LV dysfunction and HF  Given history of CAD and previous MI, patient is also started on statin Back to the Case

34. 34  Patient symptomatically better after diuresis but remains SOB.  Spirometry shows an FEV1/FVC ratio of 65% predicted and an absolute FEV1 of 58%. There is no evidence of reversibility.  The patients was prescribed a SABA for symptom relief and after two months using it frequently on a daily basis was started on tiotropium with symptom improvement.  The patient is also started on a beta blocker.  Advised to ensure immunizations are up to date and also referred to local cardio pulmonary rehab program. Back to the Case

35. 35  65-year old patient comes to your office with SOB  NYHA class II and stable  Major complain fatigue and lack of energy  Cough, mostly in am with some phlegm  Smoker  ? MI 10 years ago MR. B

36. 36  Jugular Venous Pressure (JVP) = 6 cm  Rales, S3 and S4 heart sounds  Lab values: › – Troponin: negative › – Serum creatinine: 132.6 µmol/L › – Na = 141.1 mmol/L: K = 4.7 mmol/L  No peripheral edema; chest x-ray suggests cardiomegaly, a bit venous congestion PE and labs

37. 37  COPD  End-stage emphysema  Reactive airway disease  AHF Q1. What diagnosis would you give this patient?

38. 38  Remote MI  Cough  Nocturnal cough  PND  Smoking  He does not have heart failure Q 2: Which of the Historical Features is Most Suggestive of HF as a Cause of his Dyspnea?

39. 39  High JVP  Presence of AF  S3  Holosystolic murmur  Quiet heart sounds  He does not have heart failure Q 3: Which Physical Exam Feature Best Supports a Diagnosis of HF?

40. 40  Prevalence of COPD ranges from 20 to 30% in patient with HF  The prevalence of HF is 3 times greater among patient discharge from the hospital with diagnosis of COPD  They are comorbidity for each other COPD and HF

41. 41  COPD patients are at increased risk of cardiovascular mortality or morbidity independent of other risk factor including smoking  The leading cause of death in COPD patients is Ischemic heart disease not respiratory failure  Low grade systemic inflammation causing atherosclerosis COPD as a Cardiovascular Risk

42. 42 Arnold JMO et al. Can J Cardiol 2006;22(1):23-45.  Elevated neck veins (jugular venous pressure)  Positive abdominojugular reflux  Rales or evidence of pleural effusion  S3  Ascites  Lower extremity edema Signs of Heart Failure

43. 43 Data from ADHERE database (Acute Decompensated Heart Failure National Registry in the US)  Dyspnea in 89% of patients at presentation  Rales in 68%  Peripheral edema in 66%  SBP <90 mm Hg in <3% Clinical Presentation of AHF Adams KF et al; ADHERE Scientific Advisory Committee and Investigators. Am Heart J 2005;149:209-16.

44. 44 Butman SM et al. J Am Coll Cardiol 1993;22(4):968-74.  Did careful physical exam on heart failure patients about to undergo a right heart catheterization  52 patients, mostly NYHA III, average EF 18% Bedside Cardiovascular Examination in Patient with HF

45. 45 Butman SM et al. J Am Coll Cardiol 1993;22(4):968-74.  If rales were present, all had a wedge pressure >18, very specific  However, only 9 of 37 with a wedge pressure >18 had rales, very insensitive  So…clear lung fields tell you very little about the fluid status in heart failure Bedside Cardiovascular Examination in Patient with HF

46. 46 Butman SM et al. J Am Coll Cardiol 1993;22(4):968-74.  Only 3 of 15 with a low PCWP had a high JVP or positive abdominojugular reflux test, spec of 80%  30 of 37 with a high wedge had either a high JVP or positive abdominojugular reflux test, sensitivity of 81%  So a careful examination of the neck veins is the best physical exam technique for determining the fluid status in heart failure Bedside Cardiovascular Examination in Patient with HF

47. 47  Past history HF5.8  PND2.6  S311  CXR venous congestion12  EKG AF3.8 Positive Likelihood Ratios for Heart Failure (in ER) Wang CS et al. JAMA 2005;294:1944-56.

48. 48  No rales (crackles)0.51  No past HF0.45  No SOB0.48  CXR without cardiomegaly0.33  EKG normal0.64 Negative Likelihood Ratios for Heart Failure (in ER) Wang CS et al. JAMA 2005;294:1944-56.

49. 49 Dao Q et al. J Am Coll Cardiol 2001;37:379-85. How Good are Existing Tools for Diagnosing Heart Failure? In ED, clinical misdiagnosis occurs in 25-50% of patients presenting with decompensating HF (Agency for Health Care and Research 1994)

50. 50 Arnold JMO et al. Can J Cardiol 2006;22(1):23-45.  Can be a wide range of presentations  Many of the symptoms of heart failure overlap with other disease states such as COPD, obesity, nephrotic syndrome, drug- induced edema, cirrhosis and sleep apnea Take home message in diagnosing “Heart Failure”

51. 51  85 year old female with SOBOE for 3 months  Flu (cough, SOB, fever, mild leg edema L>R)  Dx “viral pneumonia” in ER – antibiotics  CXR in ER ? nodule with subsequent CT 03/04 “fine interstitial pattern”  3 days ago: ER with progressive dyspnea NYD (seen and discharged with antibiotic and puffer)  Return to your office complaining of dyspnea Case Study 2 : Advanced age and SOB † † Fictitious patient profile. May not be representative of all patients with ADHF.

52. 52  PMH › Longstanding depression/ anxiety disorder › ? MI 1973 (never hospitalized)  Medication › Elavil and Clonazepam Case 2: Old and SOB

53. 53  BP=162/96 mm Hg  HR=102 beats/min; T=36.2 C; RR=26 breaths/min  Mild respiratory distress  JVP “not sure”  Chest a “few creps”  Normal heart sounds  Mild asymmetric edema R>L Examination

54. 54 1.Definitely yes 2.Possibly 3.Probably not 4.Definitely not Is this HF?

55. 55 Ankle edema Other causes Sacral edema Pulmonary findings non- specific Delirium Falls Functional decline Sleep disturbance Nocturia/ incontinence Dyspnea uncommon if sedentary Elderly: Clinical Features HF Arnold JMO et al. Can J Cardiol 2007;23(1):21-45.

56. 56  O2 sat 90% on RA  WBC 12 left shift, HB =110 NCNC  Cr 140 µmol/L  CK and Tn I normal Investigations

57. 57

58. 58 EKG

59. 59  pH: 7.50  pCO2: 28  pO2: 82  Bicarb.: 22  Saturation: 3 litres  Leg dopplers negative  Spirometry: “poor effort” Further Investigations

60. 60  Await response to clinical treatment (lasix, O2, antibiotics, heparin, steroids)?  BNP?  Spiral CT to R/O PE?  Echocardiogram?  Cardiology consult? What is the Next Most Appropriate Investigation?

61. 61  Best clinician diagnosis is about 80%1  Average time in ER before diuretic is 3 hours  Most common drugs in ER: Salbutamol, antibiotics, furosemide › Worsening renal function in hospital is associated with poor prognosis2 › So we wish to avoid inappropriate diuretic while maximizing use when indicated  Better diagnostic methods needed – BNP, NT- pro-BNP  IMPROVE- HF CANADA Study3 Diagnosis of HF 1. Maisel A. Rev Card Med 2002;3(Suppl 4):S10-7. 2. Arnold et al. Can J Cardiol 2006:22(1):23-45. 3. Moe GW et al. Circulation 2007;115:3103-10.

62. 62  32-amino acid peptide secreted primarily from the ventricles of the heart  Released in response to stretch and increased volume in the ventricles  BNP levels correlate with: › Left ventricular end-diastolic pressure and volume › New York Heart Association (NYHA) functional classification › Extent of reversible ischemia  Rapid, point-of-care assay for BNP now available to facilitate diagnosis of HF and use as a prognostic marker B-Type Natriuretic Peptide (BNP) Moe GW. Heart Fail Monitor 2005;4(4):116-22.

63. 63 Hino J et al. Biochem Biophys Res Comm 1990;167:693-700. Processing of the Human BNP Gene

64. 64 Physiology of BNP 1. Marcus LS, et al. Circulation 1996;94:3184-89. 2. Zellner C et al. Am J Physiol 1999;276(3 pt 2):H1049-57. 3. Tamura N et al. Proc Natl Acad Sci USA. 2000;97:4239-44. 4. Abraham WT et al. J Card Fail 1998;4:37-44. 5. Clemens LE et al. J Pharmacol Exp Ther 1998;287:67-71. 6. Rayburn BK, Bourge RC. Rev Cardiovasc Med 2001;2(Suppl 2):S25-31. 7. Akerman MJ et al. Chest 2006;130:66-72.

65. 65  LV systolic dysfunction  LVH with diastolic abnormalities  ACS (increase mortality)  Stable angina (prognostic factor)  Valvular disease (aortic stenosis)  Constrictive pericarditis  Significant pulmonary embolism  Cor pulmonale  Pulmonary HTN  Aging (modest increases)  Renal insufficiency  Malignancy  Sepsis Causes of Increased BNP Moe GW. Heart Fail Monitor 2005;4(4):116-22.

66. 66 BNP and NT-proBNP In HF Cut Points for HF Diagnosis Arnold JMO et al. Can J Cardiol 2007;23(1):21-45.

67. 67 BNP Concentration for the Prediction of Clinical Events Death or Heart Failure Hospitalization Harrison A et al. Ann Emerg Med 2001;39(2);131-38.

68. 68 The BNP Study: First Evidence that Adding BNP to Testing Improves Diagnostic Accuracy Strunk A et al. Am J Medic 2006;119:69. e1-11

69. 69  Breathing Not Properly Study1 › US sites with BNP >1000 patients › Improved diagnostic accuracy and AUC  BASEL study2 › Single centre Swiss study of BNP with 500 patients › Improved accuracy, shorter ER times, less cost  PRIDE3 › Single city Boston (US) study with NT-pro-BNP and approximately 1,000 patients › Improved diagnostic accuracy, age-related cutpoints Earlier BNP Studies 1. Maisel A et al. J Am Coll Cardiol 2003;41(11):2018-212. 2. Mueller C et al. N Engl J Med 2004;350(7):647-54. 3. Januzzi JL et al. Am J Cardiol 2005;95(8):948-54.

70. 70 Do BNP Levels Help Diagnose Those with Acute Dyspnea? Knudsen CW et al. Am J Med 2004;116(6):363-8..

71. 71  Practical Tips  Biomarkers such as BNP and NT-proBNP are complementary to, but do not replace, good clinical evaluation  No compelling factors favor the use of BNP versus NT-proBNP  The choice of assay is dictated by › availability › clinician’s familiarity and ability to interpret the results BNP/NT-proBNP in Heart Failure Arnold JMO et al. Can J Cardiol 2007;23(1):21-45.

72. 72  Recommendations:  BNP or NT-proBNP should be measured to help confirm or rule out a diagnosis of HF in the acute or ambulatory care setting in patients in whom the clinical diagnosis is in doubt (Class I, Level A)  Measurement may also be considered in patients with known HF for prognostic stratification (Class IIa, Level A)  Sequential measurement of BNP/NT-proBNP levels may be considered to guide therapy in HF patients (Class IIb, Level B) What Does the CCS Say about BNP Testing? Arnold JMO et al. Can J Cardiol 2007;23(1):21-45.

73. 73 Acute SOB

74. 74  20 to 25% of ambulatory and stable HF patient have BNP less than 100  Echocardiography appears to be more reliable than BNP levels to detect unsuspected LV systolic dysfunction in patient with stable COPD  Radionuclide ventriculography (MUGA) helps in patient with poor LV window Stable patient

75. 75

76. 76  Diagnosis of HF in multi-system disease is challenging.  Co-morbidities are common, mask the diagnosis of HF, limit therapeutic options, and negatively impact prognosis.  BNP and ECHO may aid in the diagnosis of HF in this patient population. Conclusions

77. 77  70-Year old male  PMHx of COPD  Stable with no new SOB  Echocardiogram shows EF of 38% CASE MR C.

78. 78  Beta blockers?  Ace inhibitors?  Statins? What medications will you consider?

79. 79  Selective B1 receptor blockers  Non selective beta blockers B1 and B2 Beta blockers

80. 80  Selectives › Metoprolol › Bisoprolol  Nonselectives › Carvedilol

81. 81  Few reports of acute bronchospasm after initiation of BB lead to exclusion of patients with coexistence HF and COPD from large BB trails  BB remains underprescribed for patient with COPD and HF

82. 82  Selective BB › Do not change the symptoms and FEV1 › Do not attenuate beta 2 agonist effect  Non selective BB › May increase the symptoms › Decrease beta agonist effect

83. 83  Both do not increase the exacerbation and hospitalization in COPD patients  Better to be controlled by a structured outpatient clinic  Acute vs. chronic  Using B agonists may change the response and it can increase the risk of de compensated HF Clinical Experience

84. 84  Non reversible COPD › Can use both B1 selective and B2 non selective with alpha blockers activity  Reversible disease › Selective B1 receptor  Acute COPD or HF › Do not use BB

85. 85  ACE › One of the first steps in HF treatment › Also prevents cachexia and muscle atrophy in COPD patients  ARB › No evidence ACE Inhibitors/ ARB

86. 86  Some suggestions of clinical improvement and even reduction in mortality Statins

87. Sustaining Your Gains

88. 88  Up to 70% of change initiatives fail, impacting: › Best possible care › Staff and provider frustration › Reluctance to engage in future Why Focus on Sustainability?

89. 89  Benefits for patients and staff are not clear  Changes are not credible  Changes are not part of the workflow  No one is monitoring over time  All staff have not be trained on changes  Key clinical leaders have not been engaged  The changes do not fit with the priorities of the clinic Why don’t changes sustain?

90. 90 1.Clarify what you are sustaining 2.Engage leaders 3.Involve and support front-line staff 4.Communicate the benefits of the improved process 5.Ensure the change is ready to be implemented and sustained 6.Embed the improved process in your electronic and human processes. 7.Build ongoing measurement What can you do?

91. 91 With your community team discuss what you would like to sustain in the practice and community, is it: › A specific change? › A measured outcome from your efforts? › An underlying culture of improvement? › Relationships established in the community? › A combination? › (5 min) What Are You Trying to Sustain? Source: NHS Improvement leader’s Guide: Sustainability, NHS Institute for Innovation and Improvement, 2007

92. 92  Staff, providers and patients can describe why they like the change and its impact  Providers and staff are confident and can assist in explaining to others  Job descriptions reflect new roles  Measurement is part of the practice and used to monitor progress  The change is no longer ‘new’, but ‘the way we do things around here’ Predictors of Sustainability Adapted from: NHS Improvement leader’s Guide: Sustainability, NHS Institute for Innovation and Improvement, 2007

93. 93  Using the PSP sustainability planner, reflect on the content of each section and identify some actions you might need to take to improve the chances of sustaining your changes. Group Reflection

94. Thank you!