Transcript The Interaction of HF & COPD

The interaction of HF and COPD
J Mark FitzGerald
Sean Virani
Objectives:
HF and COPD – a background
Epidemiology
Dealing with dyspnea
Approach to the patient with COPD & HF
The future …
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 …?
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
Clinical Approach:
HF and COPD are common and they commonly coexist 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 nonpharmacological therapies are well tolerated and
may have benefit across both disease states
JAMA 2006
Finding
Pooled
Sensitivity
Pooled
specificity
LR
LR
Positive
negative
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)
Initial clinical
judgment
JAMA 2006
Symptoms
Pooled
Sensitivity
PND
0.41
Orthopnoea
0.51
Edema
0.51
Pooled
LR
LR
specificity Positive
negative
0.84
2.6 (1.5-4.5) .74 (0.540.91)
0.74
2.2 (1.2.65 (0.452.39)
0.92)
0.66
2.1 (0.92.64 (0.395.0)
1.11)
JAMA 2006
Finding
Pooled
Sensitivity
Pooled
specificity
LR
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
0.78
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
(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
Additional investigations to consider
in the “stable” patient
ECG
ECG
When “normal” HF < 10%
COPD
nT-pro-BNP
nT-pro-BNP
When “normal” HF < 10%
COPD
CXR
CXR
When “normal” HF < 12%
When “normal” HF < 9%
Low NPV and moderate PPV
COPD
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 HF!
 Assess relative contributions of COPD versus
HF 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%
3.32)
2.5 (1.88-
FEV1 ≤ 72% 2.02 (1.552.72)
Int Heart Journal 2006
JACC 2002
JACC 2002
NEJM 2004
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
NEJM 2004
Non-Heart Failure Reasons for Elevation in BNP
ACUTE HF
CHRONIC HF
Alternate Diagnoses to Consider
Alternate Diagnoses to Consider
Acute Coronary Syndromes
Advanced age ( > 75 years)
Pulmonary Embolism
Atrial Fibrillation
Acute Renal Insufficiency
Renal Dysfunction (eGFR < 45)
PAH
LVH
Sepsis
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
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.
 Co morbidities and over lap issues:
 Depression.
 End of life care.
 Control of dyspnea.
 Potential therapeutic overlap.
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
What’s Happening in HF at the Provincial Level
PATIENT RESOURCES
PROVIDER RESOURCES
MEDICATIONS
REFERRAL FORMS
SODIUM
PATIENT ASSESMENT FORMS
FLUID
CARE MAPS & TX ALGORITHMS
EXERCISE
MEDICATION TITRATION
EXACERBATION PLAN
PATIENT SYMPTOM STATUS
HF 101
VISIT SNAP SHOT
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 nonpharmacological therapies are well tolerated and may have
benefit across both disease states
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
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.