7 Prevalence – some considerations … How do you estimate prevalence? POPULATIONAgingRisk factorsSmokingDisease burdenDEFINITIONSpirometryClinical codingSelf reportedMedicationSPIROMETRYCut-offsChanging criteriaPulmonary edemaTechniqueSURVEILLANCEAwarenessScreeningContact with ServicesReporting Bias
9 Prevalence of COPD in HF The prevalence of COPD in patients with HF increases with ageThis has been demonstrated in population based studies from a number of countries with rates from 7.9% %Some COPD may be unrecognized
14 Conclusions: COPD is common in HF and independently predicts mortality HF is common in COPDCardiovascular risk factors cluster in patients with COPDMany 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
20 Differentiating COPD and HF Clinically These may be difficult to differentiateOverlap in signsOverlap in symptomsOverlap in investigationsMay be complicated in the face of an acute exacerbation of either disease statePatient 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 dysfunctionThis may be difficult in patients with COPDPoor visualization (10-30%) of patientsConcomitant atrial fibrillation precludes accurate assessment of diastolic functionEvidence of impaired systolic/diastolic function doesn’t necessarily imply that the patient has clinical HFNuclear medicine testing with MUGA or MIBI may be a useful alternate mechanism for assessing LVEF
22 Additional investigations to consider in the “stable” patient ECGWhen “normal” HF < 10%COPDWhen “normal” HF < 12%nT-pro-BNPWhen “normal” HF < 9%CXRLow NPV and moderate PPVLow NPV and low PPVDavie 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 complaintsDuring HF exacerbations, FEV1 is more reduced than FVCIn stable HF, both FEV1 and FVC are reduced to the same extentHF can distort grading of severity (FEV1 % predicted) in COPDFluid overload can cause a restrictive pattern in PFTs with associated diffusion disturbances
32 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
33 Non-Heart Failure Reasons for Elevation in BNP ACUTE HFAlternate Diagnoses to ConsiderAcute Coronary SyndromesPulmonary EmbolismAcute Renal InsufficiencyPAHSepsisCHRONIC HFAlternate Diagnoses to ConsiderAdvanced age ( > 75 years)Atrial FibrillationRenal Dysfunction (eGFR < 45)LVHCOPDnT-pro-BNP > 400 pg/mL or BNP > 125 pg/mL
34 Conclusions - Diagnostics Consider BNP/nT-pro-BNP to rule out the presence of HFHas good negative predictive value (NPV)Spirometry is useful when the patient’s volume status is optimizedDuring acute HF exacerbations, diagnostic accuracy may be limitedEcho may be helpful to rule out the presence of systolic or diastolic dysfunctionPoor echo windows and the presence of concomitant atrial fibrillation is a co-founder
35 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
36 COPD therapy bundle: post lung attack. Long acting anti-cholinergicLABA +/- ICS.Rehabilitation – smoking cessation, action plans
37 Clinical trial results on the impact of an educational program 50100150Admissions the year before the studyAdmissionsfor exacerbationsfor other reasonsNumber of hospital admissions-40%57%+ 4%Patients who benefited from an education programPatients who only received standard care50100150200Emergencies for other diseasesEmergency for exacerbations-41%23%59%Number of ER visitsNon-scheduled visitsBourbeau J, Julien M, et al. (2003) Arch Intern Med / Vol. 163: ).
38 Pulmonary Rehabilitation Study (in rehabilitation/ usual care group)Length of follow-upRisk ratio (95% CI)Weight in %Behnke (14/12)18 months0.29 (0.10 to 0.82)37%Man (20/21)3 months0.17 (0.04 to 0.69)44%Murphy (13/13)6 months0.40 (0.09 to 1.70)19%Overall (47/46)Speaker NotesRespiratory 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).ReferencePuhan 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=0.71.25.5.7511.5Favors rehabilitationRisk of unplanned hospital admissionFavors usual carePuhan MA, et al. Respir Res. 2005;6:54. Reproduced with permission from Biomed Central.38
42 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 arrhythmiasoral catacosteroids
43 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 airwaysBB use is associated with 22% reduction in mortality and a decreased risk of AECOPD(3) Aldosterone Blockers:Improves exercise tolerance
44 Common interventions: Smoking cessationExercise prescriptionAction plansComorbidities and overlap issuesDepressionEnd of life careControl dyspneaPotential therapeutic overlap
45 Conclusions:HF and COPD are common and they commonly co-exist in the same patient:The presence of both is associated with worse outcomesDiagnosis may be challenging due to similarities in clinical presentationDiagnostic tools exist which may help to differentiate these disease entities in the dyspneaic patientIn general, traditional pharmacological and non- pharmacological therapies are well tolerated and may have benefit across both disease states
50 As Inspired by New Kids on the Block “ Step by Step, oh Baby, I’m gonna get to you giiiiiiirl”ImprovementGoal
51 What will lead to our success Clear Goals (written down)A way to measure our progressDefined changes to try
52 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 visitsReducing unplanned hospital admissionsIdentifying patients earlier who have COPD using a case-finding approachDeveloping 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 specialistsImproving the management of COPD by putting the GPAC guidelines into practice
54 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
55 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.
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 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.
58 As Inspired by New Kids on the Block “ Step by Step, oh Baby, I’m gonna get to you giiiiiiirl”ImprovementGoal