2. The interaction of HF and COPD J Mark FitzGerald Sean Virani

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

4. Case : 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 …?

10. 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

11. 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

12. JAMA 2006

13. 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)

14. JAMA 2006 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)

15. JAMA 2006 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)

16. 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

17. 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 (1)Poor visualization (10-30%) of patients (2)Concomitant atrial fibrillation precludes accurate assessment of diastolic function (3)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

18. 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 Davie et al., 1996; Rutten et al., 2005; Rutten et al., 2006; Fonseca et al., 2004; Fuat et al., 2006; Zaphiriou et al., 2005.

19. Why measure spirometry?  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.

20. Differentiating HF and COPD using diagnostics: Spirometry COPD (GOLD-criteria) Spirometry showing a irflow 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

21. Int Heart Journal 2006

22. 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

23. JACC 2002

26. NEJM 2004

27. Key messages: 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

28. 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

29. 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

30. 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.

31. 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

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

33. What’s Happening in HF at the Provincial Level 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

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

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

36. Back to the Case : 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

37. Back to the Case : 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.