Chronic obstructive pulmonary disease and heart failure in Europe-further evidence of the need for integrated care

Certainties fading away: β-blockers do not worsen chronic obstructive pulmonary disease

For many years, β-blockers have been considered contraindicated in patients with heart failure (HF) and in those with bronchial asthma or even chronic obstructive pulmonary disease (COPD) although without clear evidence of asthma. Today, despite overwhelming evidence of the usefulness of β-blockers, especially in HF with reduced left ventricular ejection fraction (HFrEF), and in ischaemic heart disease, some reluctance persists in using these drugs when COPD coexists. Such resistance is due to the fear that a possible worsening of bronchospasm induced by β-blockers could induce negative effects greater than the benefits. The Guidelines of the European Society of Cardiology clearly suggest that: (i) implantation of a cardiac defibrillator (ICD) are not contraindicated in COPD without clear evidence of bronchial asthma; (ii) β-blockers are only ‘relatively’ contraindicated when there is certainty of bronchial asthma with a documented bronchodilator response to the β2 stimulant. Therefore, bronchial asthma is not an absolute contraindication to β-blockers. The cardiologist should not limit the diagnosis of COPD to clinical suspicion, but should rely on a spirometry examination associated with any bronchodilation tests. In any case, selective β1 blockers are preferred, starting at a basic dose, which ensure a better dilator response to bronchodilators and in any case cause less bronchospasm than non-selective β-blockers. Unfortunately, there is still some reluctance to the use of β-blockers in patients with COPD associated with HF, which should be eliminated.

COPD and heart failure: differential diagnosis and comorbidity

Heart failure (HF) and chronic obstructive pulmonary disease (COPD) represent the most important differential diagnoses of dyspnea in elderly people. Heart failure is the inability of the heart to pump sufficient amounts of blood through the cardiovascular system. Pump failure is caused by compromised contractility and/or filling of the ventricles leading to forward and backward failure and subsequently to dyspnea. In COPD, the destruction and remodeling processes of the bronchiolar architecture inhibit proper exhalation of air, thereby leading to exhaustion of the thoracic muscles, insufficient oxygen diffusion, and dyspnea. Despite these fundamental differences in the pathophysiology of both disorders, their clinical presentation may be very similar. This renders accurate and timely diagnosis and therapy, especially in patients with coexisting disease, difficult. This clinical review summarizes typical problems in the diagnosis of COPD, HF, and coincident disease, and describes strategies that help avoid misdiagnosis and ineffective treatment.

Diagnostic and Therapeutic Gaps in Patients With Heart Failure and Chronic Obstructive Pulmonary Disease

Heart failure (HF) and chronic obstructive pulmonary disease (COPD) coincide in a significant number of patients. Recent population-based registries suggest that spirometry is largely underused in patients with HF to diagnose comorbid COPD and that patients with COPD frequently do not receive the recommended beta-blocker (BB) treatment. This state-of-the-art review summarizes: 1) current challenges in the implementation of recommended spirometry for COPD diagnosis in patients with HF; and 2) current underuse and underdosing of BBs in patients with HF and COPD despite guideline recommendations. Open issues in the therapeutic management of patients with HF and COPD are discussed in the third section, including the use of the nonselective BB carvedilol, target BB doses in patients with HF and COPD, BB and bronchodilator management during HF hospitalization with and without COPD exacerbation, and the use of BBs in patients with COPD with right HF or free from cardiovascular disease. The whole scenario described herein advocates for a bipartisan initiative to drive immediate attention to the translation of guideline recommendations into clinical practice for patients with HF with co-occurring COPD.

[Clinical features and prognosis in heart failure patients with chronic obstructive pulmonary diseases]

BACKGROUND

Multimorbidity is a specific characteristic of the modern patient with chronic heart failure (CHF) which significantly changes clinical course, prognosis of the syndrome, leads to socio‑economic losses and makes significant adjustments to treatment tactics. The goal is to study the clinical features and prognosis of patients with CHF in combination with chronic obstructive pulmonary disease (COPD).

MATERIALS AND METHODS

We studied 183 HF patients, including with stable CHF, including 105 with CHF combined with COPD. The clinical phenotype was assessed by its belonging to the functional class and the severity of COPD. A 6‑minute walk test (6‑MWT), spirometry, echocardioscopy, testing on a scale assessing the clinical condition, quality of life were studied. The end points during the year were: all‑cause mortality and cardiovascular mortality, myocardial infarction, stroke, pulmonary embolism, and hospitalization rates due to acute decompensation of CHF.

RESULTS

The clinical phenotype of CHF combined with COPD was characterized by a high frequency of smoking, low quality of life and exercise tolerance. Respiratory dysfunction in CHF in combination with COPD was characterized by mixed disorders (68.4%), in CHF without lung disease, restrictive (25.6%). Cardiovascular mortality in comorbid pathology was 4.0%, in CHF without COPD - 4.6%; myocardial infarction was observed 1.7 times more often with lung disease than in patients with CHF only (16.8% and 10.8%); stroke was observed exclusively in comorbid pathology (8.9%). The combined endpoint (all cardiovascular events) with CHF in combination with COPD was achieved 2.3 times more often in comparison with patients with COPD only (29.7% and 15.4%). Hospitalization due to acute decompensation of CHF occurred 2 times more often with CHF in combination with COPD than without it (32.7% and 15.4%) with a tendency to increase as the left ventricular ejection fraction decreased.

CONCLUSION

The results of the study demonstrate that COPD contributes to the formation of the clinical phenotype of CHF from the standpoint of the mutual influence of the characteristics of the cardiovascular and respiratory systems, and also aggravates the prognosis that requires an integrated approach to the differential diagnosis and individualization of pharmacotherapy.