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

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

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

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

Conclusions: COPD is common in HF and independently predicts mortality HF is common in COPD Cardiovascular risk factors cluster in patients with COPD Many symptomatic, diagnostic and therapeutic challenges

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

JAMA 2006

JAMA 2006 Finding Pooled Sensitivity Pooled specificity LR Positive negative Initial clinical judgment 0.61 0.86 4.4 (1.8-10.0) 0.45 (0.28-0.73) Hx. of heart failure 0.60 0.90 5.8 (4.1-8.0) 0.45 (0.38-0.53) Myocardial infarction 0.40 0.87 3.1(2.0-4.9) 0.69 (0.58-.82) IHD 0.52 0.70 1.8 (1.1-2.8) 0.68(0.48-0.96) COPD 0.34 0.57 0.81(0.60-1.1) 1.1 (0.95-1.4) JAMA 2006

Symptoms Pooled Sensitivity Pooled specificity LR Positive negative PND 0.41 0.84 2.6 (1.5-4.5) .74 (0.54- 0.91) Orthopnoea 0.51 0.74 2.2 (1.2- 2.39) .65 (0.45- 0.92) Edema 0.66 2.1 (0.92- 5.0) .64 (0.39- 1.11) JAMA 2006

JAMA 2006 Finding Pooled Sensitivity Pooled specificity LR Positive negative Third heart sound 0.13 0.99 11 (4.9-25.0) 0.88(0.83-0.94) Abdomino-jugular reflex 0.24 0.96 6.4 (0.81-51.0) 0.79(0.62-1.0) JVP elevated 0.39 0.92 5.1(3.2-7.9) 0.66(0.57-0.77) Crackles 0.60 0.78 2.8(1.9-4.1) 0.51 (0.37-0.70) Any murmur 0.27 0.90 2.6(1.74-4.1) 0.81(0.73-0.90) Peripheral edema 0.50 2.3(1.5-3.7) 0.64(0.47-0.87) Wheezing 0.22 0.58 0.52(0.38-0.71) 1.3 (1.1-1.7) JAMA 2006

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

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

Additional investigations to consider in the “stable” patient ECG When “normal” HF < 10% COPD When “normal” HF < 12% nT-pro-BNP When “normal” HF < 9% CXR Low NPV and moderate PPV Low 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.

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.

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

Int Heart Journal 2006

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

JACC 2002

JACC 2002

NEJM 2004

NEJM 2004

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

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

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

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

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

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

Pulmonary Rehabilitation Study (in rehabilitation/ usual care group) Length of follow-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) Speaker Notes Respiratory rehabilitation may improve prognosis in these patients by addressing relevant risk factors for exacerbations such as low exercise capacity and this study evaluated this possibility via meta-analysis of published results. Combined analysis of results from six trials including 230 patients indicated that respiratory rehabilitation reduced the risk for hospital admissions (pooled relative risk = 0.26), and mortality (pooled relative risk = 0.45). Reference Puhan MA, Scharplatz M, Troosters T, Steurer J. Respiratory rehabilitation after acute exacerbation of COPD may reduce risk for readmission and mortality - a systematic review. Respir Res. 2005;6:54. 0.26 (0.12 to 0.54) Chi-Squared 0.70, p=0.71 .25 .5 .75 1 1.5 Favors rehabilitation Risk of unplanned hospital admission Favors usual care Puhan MA, et al. Respir Res. 2005;6:54. Reproduced with permission from Biomed Central. 38

NEJM 1996

NEJM 1996

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 oral catacosteroids

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

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

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

Next Steps and Evaluation

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!

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Action Planning Christina Southey

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

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

Aim – Why are we here? 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 Identifying patients earlier who have COPD using a case-finding approach Developing relationships and care plans amongst family physicians, specialists, patients, and community services  Implementing more standardized referral and consult letters, and improving  relationships, hand offs, and communication between GPs and specialists Improving the management of COPD by putting the GPAC guidelines into practice    

What is Your Goal?

What do you want to focus on? 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

How will we monitor our progress? 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.

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

Are we impacting our goal? % 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.

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

Thank you!