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

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

7. 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

9. 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% %
Some COPD may be unrecognized

14. 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

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

16. JAMA 2006

17. JAMA 2006 Finding Pooled Sensitivity Pooled specificity LR Positive
negative
Initial clinical
judgment
0.61
0.86
4.4 ( )
0.45 ( )
Hx. of heart failure
0.60
0.90
5.8 ( )
0.45 ( )
Myocardial infarction
0.40
0.87
3.1( )
0.69 ( )
IHD
0.52
0.70
1.8 ( )
0.68( )
COPD
0.34
0.57
0.81( )
1.1 ( )
JAMA 2006

18. Symptoms Pooled Sensitivity Pooled specificity LR Positive negative
PND
0.41
0.84
2.6 ( )
.74 ( )
Orthopnoea
0.51
0.74
2.2 ( )
.65 ( )
Edema
0.66
2.1 ( )
.64 ( )
JAMA 2006

19. JAMA 2006 Finding Pooled Sensitivity Pooled specificity LR Positive
negative
Third heart sound
0.13
0.99
11 ( )
0.88( )
Abdomino-jugular reflex
0.24
0.96
6.4 ( )
0.79( )
JVP elevated
0.39
0.92
5.1( )
0.66( )
Crackles
0.60
0.78
2.8( )
0.51 ( )
Any murmur
0.27
0.90
2.6( )
0.81( )
Peripheral edema
0.50
2.3( )
0.64( )
Wheezing
0.22
0.58
0.52( )
1.3 ( )
JAMA 2006

20. 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

21. 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

22. 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.

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 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

25. Int Heart Journal 2006

26. Spirometry strongest predictors of mortality VC ≤ 81% 2.5 (1.88-3.32)
FEV1 ≤ 72% ( )
Int Heart Journal 2006

27. JACC 2002

28. JACC 2002

30. NEJM 2004

31. NEJM 2004

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 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. 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

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-cholinergic
LABA +/- ICS.
Rehabilitation – smoking cessation, action plans

37. Clinical trial results on the impact of an educational program50
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: ).

38. 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

40. NEJM 1996

41. NEJM 1996

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 arrhythmias
oral 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 airways
BB use is associated with 22% reduction in mortality and a decreased risk of AECOPD
(3) Aldosterone Blockers:
Improves exercise tolerance

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

46. Next Steps and Evaluation

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

48. Break

49. Action Planning
Christina Southey

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

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

53. What is Your Goal?

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”
Improvement
Goal

60. Thank you!