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

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Presentation on theme: "The Interaction of HF and COPD Dr. J Mark FitzGerald Dr. Sean Virani."— Presentation transcript:

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

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

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7 7 Prevalence – some considerations … How do you estimate prevalence? SURVEILLANCE Awareness Screening Contact with Services Reporting Bias SPIROMETRY Cut-offs Changing criteria Pulmonary edema Technique DEFINITION Spirometry Clinical coding Self reported Medication POPULATION Aging Risk factors Smoking Disease burden

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9 9 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% % Some COPD may be unrecognized Prevalence of COPD in HF

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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 JAMA 2006

17 17 JAMA 2006 FindingPooled Sensitivity Pooled specificity LR Positive LR negative Initial clinical judgment ( )0.45 ( ) Hx. of heart failure ( )0.45 ( ) Myocardial infarction ( )0.69 ( ) IHD ( )0.68( ) COPD ( )1.1 ( )

18 18 JAMA 2006 SymptomsPooled Sensitivity Pooled specificity LR Positive LR negative PND ( ).74 ( ) Orthopnoea ( ).65 ( ) Edema ( ).64 ( )

19 19 JAMA 2006 FindingPooled Sensitivity Pooled specificity LR Positive LR negative Third heart sound ( )0.88( ) Abdomino-jugular reflex ( )0.79( ) JVP elevated ( )0.66( ) Crackles ( )0.51 ( ) Any murmur ( )0.81( ) Peripheral edema ( )0.64( ) Wheezing ( )1.3 ( )

20 20  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

21 21  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

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

23 23  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. Why measure spirometry?

24 24  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

25 25 Int Heart Journal 2006

26 26 Int Heart Journal 2006  Spirometry strongest predictors of mortality  VC ≤ 81% 2.5 ( )  FEV1 ≤ 72% 2.02 ( )

27 27 JACC 2002

28 28 JACC 2002

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30 30 NEJM 2004

31 31 NEJM 2004

32 32 NEJM 2004  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. Key messages:

33 33 Non-Heart Failure Reasons for Elevation in BNP ACUTE HF Alternate Diagnoses to Consider Acute Coronary Syndromes Pulmonary Embolism Acute Renal Insufficiency PAH Sepsis 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

34 34  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

35 35 Thorax 2011 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.

36 36  Long acting anti-cholinergic  LABA +/- ICS.  Rehabilitation – smoking cessation, action plans COPD therapy bundle: post lung attack.

37 37 Bourbeau J, Julien M, et al. (2003) Arch Intern Med / Vol. 163: ). Clinical trial results on the impact of an educational program Patients who benefited from an education program Patients who only received standard care Admissions the year before the study Admissions for exacerbations for other reasons Number of hospital admissions -40% -57% + 4% Admissions -40% -57% + 4% Emergencies for other diseases Emergency for exacerbations -41% -23% -59% Number of ER visits Non-scheduled visits -41% -23% -59%

38 38 Pulmonary Rehabilitation Puhan MA, et al. Respir Res. 2005;6:54. Reproduced with permission from Biomed Central. Overall (47/46) Risk ratio (95% CI) 0.17 (0.04 to 0.69) 0.40 (0.09 to 1.70) 1.5 Risk of unplanned hospital admission Favors usual careFavors rehabilitation.75 Study (in rehabilitation/ usual care group) Man (20/21) Murphy (13/13) Length of follow-up 3 months 6 months Weight in % 44% 19% 0.29 (0.10 to 0.82)Behnke (14/12)18 months37% 0.26 (0.12 to 0.54) Chi-Squared 0.70, p=

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40 40 NEJM 1996

41 41 NEJM 1996

42 42  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 Therapeutic Considerations in HF and COPD

43 43  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

44 44  Smoking cessation  Exercise prescription  Action plans  Comorbidities and overlap issues  Depression  End of life care  Control dyspnea  Potential therapeutic overlap Common interventions:

45 45  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 dyspneaic patient  In general, traditional pharmacological and non- pharmacological therapies are well tolerated and may have benefit across both disease states Conclusions:

46 Next Steps and Evaluation

47 47  Material is available on the psp website:  Monthly support call – September 11 from 12 to 1   Evaluation is critical! Next Steps and Evaluation

48 Break

49 Action Planning Christina Southey

50 50 “ Step by Step, oh Baby, I’m gonna get to you giiiiiiirl” As Inspired by New Kids on the Block Improvement Goal

51 51  Clear Goals (written down)  A way to measure our progress  Defined changes to try What will lead to our success

52 52 To collaborate to create a shared system to improve the quality of care and experience for patients at risk for, and living with, COPD and/or Heart Failure (HF):  Reducing ER or unplanned GP visits  Reducing unplanned hospital admissions Aim – Why are we here?

53 What is Your Goal?

54 54 Smoking cessation Medications Patient education Patients symptom self management Screening and diagnosis Referral and consult process Working with community groups Collaborating with allied health providers Coordination of care for comorbid patients What do you want to focus on?

55 55 For HF patients:  % of patients with baseline assessment of ejection fraction  % patients with HF who have been prescribed ACE/ARBS and Beta Blockers.  % patient with HF who bring at least one of the following at a follow-up visit: Daily weight log, fluid intake log, sodium log, or report physical activity changes. How will we monitor our progress?

56 56 For HF and Comorbid Patients:  % of smokers on with COPD and/or HF offered smoking cessation support  % patients with COPD and/or HF who have been referred to pulmonary and/or cardiac rehab programs where available  % of patients with COPD and or HF a coordinated care plan amongst GPs, specialists, and/or community resources

57 57  % of registry patients reporting an Emergency Department visit or having an unplanned GP visit for COPD and/or HF since their last appointment.  % of registry patients reporting a hospital admission for COPD and/or HF since their last appointment. Are we impacting our goal?

58 58 “ Step by Step, oh Baby, I’m gonna get to you giiiiiiirl” As Inspired by New Kids on the Block Improvement Goal

59 59

60 Thank you!


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