Heart failure and chronic obstructive pulmonary disease: the challenges facing physicians and health services

Is 'Cardiopulmonary' the New 'Cardiometabolic'? Making a Case for Systems Change in COPD

Chronic obstructive pulmonary disease (COPD) and cardiovascular disease (CVD) have a syndemic relationship with shared risk factors and complex interplay between genetic, environmental, socioeconomic, and pathophysiological mechanisms. CVD is among the most common comorbidities in patients with COPD and vice versa. Patients with COPD, irrespective of their disease severity, are at increased risk of CVD morbidity and mortality, driven in part by COPD exacerbations. Despite these known interrelationships, CVD is underestimated and undertreated in patients with COPD. Similarly, COPD is an independent risk-enhancing factor for adverse cardiovascular (CV) events, yet it is not incorporated into current CV risk assessment tools, leading to under-recognition and undertreatment. There is a pressing need for systems change in COPD management to move beyond symptom control towards a comprehensive cardiopulmonary disease paradigm with proactive prevention of exacerbations and adverse cardiopulmonary outcomes and mortality. However, there is a dearth of evidence defining optimal cardiopulmonary care pathways. Fortunately, there is a precedent to support systems-level change in the field of diabetes, which evolved from glycemic control to comprehensive multi-organ risk assessment and management. Key elements included integrated multidisciplinary care, intensive risk factor management, coordination between primary and specialist care, care pathways and protocols, education and self management, and disease-modifying therapies. This commentary article draws parallels between the cardiometabolic and cardiopulmonary paradigms and makes a case for systems change towards multidisciplinary, integrated cardiopulmonary care, using the evolution in diabetes care as a potential framework.

Clinical features, management in the emergency department and mortality of acute heart failure episodes in patients with chronic obstructive pulmonary disease

OBJECTIVES

This study aims to analyse differences in clinical and therapeutic management for patients with chronic obstructive pulmonary disease (COPD) who present to the emergency department with acute heart failure (AHF). Additionally, it examines mortality rates during such episodes.

METHODS

We included patients diagnosed with AHF at 50 Spanish emergency departments from 2012 to 2022 who also had COPD. We compared their baseline characteristics, decompensation episodes, and emergency department management with those of AHF patients without COPD during the same period. We collected data on in-hospital and 30-day all-cause mortality, investigating differences between the two groups using crude and adjusted logistic regression models.

RESULTS

A total of 21,694 AHF patients were analysed (median age = 83 years, 56% female), including 4,942 (23%) with COPD. COPD patients were generally younger and more frequently male, with a higher prevalence of comorbidities (excluding valve disease and dementia, which were more common in non-COPD patients). They exhibited a worse respiratory functional class (NYHA) but a better overall functional capacity (Barthel Index). Decompensation in COPD patients was more often triggered by infection and less frequently by tachyarrhythmia, hypertensive crisis, or acute coronary syndrome. While there were differences in clinical findings in the emergency department, the severity assessed by the MEESSI-AHF Scale was similar across both groups. In terms of emergency department management, a higher proportion of COPD patients received oxygen therapy, non-invasive ventilation, bronchodilators, corticosteroids, and antibiotics, while fewer received intravenous nitroglycerin, and they were hospitalized more frequently. In-hospital mortality rates were 8.1% for patients with COPD and 7.5% for those without (OR = 1.088, 95% CI = 0.968-1.224), with 30-day mortality rates of 11.0% and 10.0%, respectively (OR = 1.111, 95% CI = 1.002-1.231). After adjusting for clinical characteristics, decompensation episodes, and emergency department management, these odds ratios decreased to 1.040 (95% CI = 0.905-1.195) and 1.080 (95% CI = 0.957-1.219), respectively.

CONCLUSION

Patients with AHF and COPD exhibit distinct clinical and therapeutic management characteristics in the emergency department and require more frequent hospitalization. Although they show higher crude 30-day mortality, this is attributable to their differing clinical profiles rather than the presence of COPD itself.

Heart failure with preserved ejection fraction

Heart failure with preserved ejection fraction (HFpEF) accounts for nearly half of all heart failure cases and has a prevalence that is expected to rise with the growing ageing population. HFpEF is associated with significant morbidity and mortality. Specific HFpEF risk factors include age, diabetes, hypertension, obesity and atrial fibrillation. Haemodynamic contributions to HFpEF include changes in left ventricular structure, diastolic and systolic dysfunction, left atrial myopathy, pulmonary hypertension, right ventricular dysfunction, chronotropic incompetence, and vascular dysfunction. Inflammation, fibrosis, impaired nitric oxide signalling, sarcomere dysfunction, and mitochondrial and metabolic defects contribute to the cellular and molecular changes observed in HFpEF. HFpEF impacts multiple organ systems beyond the heart, including the skeletal muscle, peripheral vasculature, lungs, kidneys and brain. The diagnosis of HFpEF can be made in individuals with signs and symptoms of heart failure with abnormality in natriuretic peptide levels or evidence of cardiopulmonary congestion, facilitated by the use of HFpEF risk scores and additional imaging and testing with the exclusion of HFpEF mimics. Management includes initiation of guideline-directed medical therapy and management of comorbidities. Given the significant impact of HFpEF on quality of life, future research efforts should include a particular focus on how patients can live better with this disease.

Chronic Obstructive Pulmonary Disease in Heart Failure: Challenges in Diagnosis and Treatment for HFpEF and HFrEF

PURPOSE OF REVIEW

Chronic obstructive pulmonary disease (COPD) is common in heart failure (HF), and it has a significant impact on the prognosis and quality of life of patients. Additionally, COPD is independently associated with lower adherence to first-line HF therapies. In this review, we outline the challenges of identifying and managing HF with preserved (HFpEF) and reduced (HFrEF) ejection fraction with coexisting COPD.

RECENT FINDINGS

Spirometry is necessary for COPD diagnosis and prognosis but is underused in HF. Therefore, misdiagnosis is a concern. Also, disease-modifying drugs for HF and COPD are usually safe but underprescribed when HF and COPD coexist. Patients with HF-COPD are poorly enrolled in clinical trials. Guidelines recommend that HF treatment should be offered regardless of COPD presence, but modern registries show that undertreatment persists. Treatment gaps could be attenuated by ensuring an accurate and earlier COPD diagnosis in patients with HF, clarifying the concerns related to pharmacotherapy safety, and increasing the use of non-pharmacologic treatments. Acknowledging the uncertainties, this review aims to provide key clinical resources to support better physician-patient co-decision-making and improve collaboration between health professionals.

Diagnostic accuracy of prehospital lung ultrasound for acute decompensated heart failure: A systematic review and Meta-analysis

BACKGROUND

Lung ultrasound (LUS) reduces time to diagnosis and treatment of acute decompensated heart failure (ADHF) in emergency department (ED) patients with undifferentiated dyspnea. We conducted a systematic review to evaluate the diagnostic accuracy and clinical impact of LUS for ADHF in the prehospital setting.

METHODS

We performed a keyword search of multiple databases from inception through June 1, 2023. Included studies were those enrolling prehospital patients with undifferentiated dyspnea or suspected ADHF, and specifically diagnostic studies comparing prehospital LUS to a gold standard and intervention studies with a non-US comparator group. Title and abstract screening, full text review, risk of bias (ROB) assessments, and data extraction were performed by multiple authors. and adjudicated. The primary outcome was pooled sensitivity, specificity, and diagnostic likelihood ratios (LR) for prehospital LUS. A test-treatment threshold of 0.7 was applied based on prior ADHF literature in the ED. Intervention outcomes included mortality, mechanical ventilation, and time to HF specific treatment.

RESULTS

Eight diagnostic studies (n = 691) and two intervention studies (n = 70) met inclusion criteria. No diagnostic studies were low-ROB. Both intervention studies were critical-ROB, and not pooled. Pooled sensitivity and specificity of prehospital LUS for ADHF were 86.7% (95%CI:70.8%-94.6%) and 87.5% (78.2%-93.2%), respectively, with similar performance by physician vs. paramedic LUS and number of lung zones evaluated. Pooled LR+ and LR- were 7.27 (95% CI: 3.69-13.10) and 0.17 (95% CI: 0.06-0.34), respectively. Area under the summary receiver operating characteristic curve was 0.922. At the observed 42.4% ADHF prevalence (pre-test probability), positive pre-hospital LUS exceeded the 70% threshold to initiate treatment (post-test probability 84%, 80-88%).

CONCLUSIONS

LUS had similar diagnostic test characteristics for ADHF diagnosis in the prehospital setting as in the ED. A positive prehospital LUS may be sufficient to initiate early ADHF treatment based on published test-treatment thresholds. More studies are needed to determine the clinical impact of prehospital LUS.

Traditional and Advanced Echocardiographic Evaluation in Chronic Obstructive Pulmonary Disease: The Forgotten Relation

Chronic obstructive pulmonary disease (COPD) is a significant preventable and treatable clinical disorder defined by a persistent, typically progressive airflow obstruction. This disease has a significant negative impact on mortality and morbidity worldwide. However, the complex interaction between the heart and lungs is usually underestimated, necessitating more attention to improve clinical outcomes and prognosis. Indeed, COPD significantly impacts ventricular function, right and left chamber architecture, tricuspid valve functionality, and pulmonary blood vessels. Accordingly, more emphasis should be paid to their diagnosis since cardiac alterations may occur very early before COPD progresses and generate pulmonary hypertension (PH). Echocardiography enables a quick, noninvasive, portable, and accurate assessment of such changes. Indeed, recent advancements in imaging technology have improved the characterization of the heart chambers and made it possible to investigate the association between a few cardiac function indexes and clinical and functional aspects of COPD. This review aims to describe the intricate relation between COPD and heart changes and provide basic and advanced echocardiographic methods to detect early right ventricular and left ventricular morphologic alterations and early systolic and diastolic dysfunction. In addition, it is crucial to comprehend the clinical and prognostic significance of functional tricuspid regurgitation in COPD and PH and the currently available transcatheter therapeutic approaches for its treatment. Moreover, it is also essential to assess noninvasively PH and pulmonary resistance in patients with COPD by applying new echocardiographic parameters. In conclusion, echocardiography should be used more frequently in assessing patients with COPD because it may aid in discovering previously unrecognized heart abnormalities and selecting the most appropriate treatment to improve the patient's symptoms, quality of life, and survival.

The role of multimorbidity in patients with heart failure across the left ventricular ejection fraction spectrum: Data from the Swedish Heart Failure Registry

AIMS

The aim of this analysis was to provide data on the overall comorbidity burden, both cardiovascular (CV) and non-CV, in a large real-world heart failure (HF) population across the ejection fraction (EF).

METHODS AND RESULTS

Patients with HF from the Swedish HF Registry between 2000 and 2021 were included. Of 91 463 patients (median age 76 years [interquartile range 67-82]), 98% had at least one among the 17 explored comorbidities (94% at least one CV and 85% at least one non-CV comorbidity). All comorbidities, except for coronary artery disease (CAD), were more frequent in HF with preserved EF (HFpEF). Patients with multiple comorbidities were older, more likely female, inpatients, with HFpEF, worse New York Heart Association class and higher N-terminal pro-B-type natriuretic peptide levels. In a multivariable Cox model, 12 comorbidities were independently associated with a higher risk of death from any cause. The highest risk was associated with dementia (hazard ratio [HR] 1.55, 95% confidence interval [CI] 1.45-1.65), chronic kidney disease (HR 1.37, 95% CI 1.34-1.41), chronic obstructive pulmonary disease (HR 1.32, 95% CI 1.28-1.35). Obesity was associated with a lower risk of all-cause death (HR 0.81, 95% CI 0.79-0.84). CAD and valvular heart disease were associated with a higher risk of all-cause and CV mortality, but not non-CV mortality, whereas cancer and musculo-skeletal disease increased the risk of non-CV mortality. A significant interaction with EF was observed for several comorbidities. Occurrence of CV and non-CV outcomes was related to the number of CV and non-CV comorbidities, respectively.

CONCLUSION

The burden of both CV and non-CV comorbidities was high in HF regardless of EF, but overall higher in HFpEF. Multimorbidity was associated with a high risk of death with a different burden on CV or non-CV outcomes.

Implementation of the Care Bundle for the Management of Chronic Obstructive Pulmonary Disease with/without Heart Failure

Chronic obstructive pulmonary disease (COPD) is often part of a more complex cardiopulmonary disease, especially in older patients. The differential diagnosis of the acute exacerbation of COPD and/or heart failure (HF) in emergency settings is challenging due to their frequent coexistence and symptom overlap. Both conditions have a detrimental impact on each other's prognosis, leading to increased mortality rates. The timely diagnosis and treatment of COPD and coexisting factors like left ventricular overload or HF in inpatient and outpatient care can improve prognosis, quality of life, and long-term outcomes, helping to avoid exacerbations and hospitalization, which increase future exacerbation risk. This work aims to address existing gaps, providing management recommendations for COPD with/without HF, particularly when both conditions coexist. During virtual meetings, a panel of experts (the authors) discussed and reached a consensus on the differential and paired diagnosis of COPD and HF, providing suggestions for risk stratification, accurate diagnosis, and appropriate therapy for inpatients and outpatients. They emphasize that when COPD and HF are concomitant, both conditions should receive adequate treatment and that recommended HF treatments are not contraindicated in COPD and have favorable effects. Accurate diagnosis and therapy is crucial for effective treatment, reducing hospital readmissions and associated costs. The management considerations discussed in this study can potentially be extended to address other cardiopulmonary challenges frequently encountered by COPD patients.

Lack of Evidence Regarding Markers Identifying Acute Heart Failure in Patients with COPD: An AI-Supported Systematic Review

Background

Due to shared symptoms, acute heart failure (AHF) is difficult to differentiate from an acute exacerbation of COPD (AECOPD). This systematic review aimed to identify markers that can diagnose AHF underlying acute dyspnea in patients with COPD presenting at the hospital.

Methods

All types of observational studies and clinical trials that investigated any marker's ability to diagnose AHF in acutely dyspneic COPD patients were considered eligible for inclusion. An AI tool (ASReview) supported the title and abstract screening of the articles obtained from PubMed, Scopus, Web of Science, the Cochrane Library, Embase, and CINAHL until April 2023. Full text screening was independently performed by two reviewers. Twenty percent of the data extraction was checked by a second reviewer and the risk of bias was assessed in duplicate using the QUADAS-2 tool. Markers' discriminative abilities were evaluated in terms of sensitivity, specificity, positive and negative predictive values, and the area under the curve when available.

Results

The search identified 10,366 articles. After deduplication, title and abstract screening was performed on 5,386 articles, leaving 153 relevant, of which 82 could be screened full text. Ten distinct studies (reported in 16 articles) were included, of which 9 had a high risk of bias. Overall, these studies evaluated 12 distinct laboratory and 7 non-laboratory markers. BNP, NT-proBNP, MR-proANP, and inspiratory inferior vena cava diameter showed the highest diagnostic discrimination.

Conclusion

There is not much evidence for the use of markers to diagnose AHF in acutely dyspneic COPD patients in the hospital setting. BNPs seem most promising, but should be interpreted alongside imaging and clinical signs, as this may lead to improved diagnostic accuracy. Future validation studies are urgently needed before any AHF marker can be incorporated into treatment decision-making algorithms for patients with COPD.

Protocol Registration

CRD42022283952.

The Interplay of Comorbidities in Chronic Heart Failure: Challenges and Solutions

BACKGROUND

Chronic heart failure (HF) is frequently associated with various comorbidities. These comorbid conditions, such as anemia, diabetes mellitus, renal insufficiency, and sleep apnea, can significantly impact the prognosis of patients with HF.

OBJECTIVE

This review aims to synthesize current evidence on the prevalence, impact, and management of comorbidities in patients with chronic HF.

METHODS

A comprehensive review was conducted, with a rigorous selection process. Out of an initial pool of 59,030 articles identified across various research modalities, 134 articles were chosen for inclusion. The selection spanned various research methods, from randomized controlled trials to observational studies.

RESULTS

Comorbidities are highly prevalent in patients with HF and contribute to increased hospitalization rates and mortality. Despite advances in therapies for HF with reduced ejection fraction, options for treating HF with preserved ejection fraction remain sparse. Existing treatment protocols often lack standardization, reflecting a limited understanding of the intricate relationships between HF and associated comorbidities.

CONCLUSION

There is a pressing need for a multidisciplinary, tailored approach to manage HF and its intricate comorbidities. This review underscores the importance of ongoing research efforts to devise targeted treatment strategies for HF patients with various comorbid conditions.

Exploring Patterns of COPD Exacerbations and Comorbid Flare-Ups

Background

Comorbidities are known to complicate disease management in patients with Chronic Obstructive Pulmonary Disease (COPD). This is partly due to lack of insight into the interplay of acute exacerbations of COPD (AECOPD) and comorbid flare-ups. This study aimed to explore patterns of AECOPDs and comorbid flare-ups.

Methods

Data of increased symptoms were extracted from a 12-month daily symptom follow-up database including patients with COPD and comorbidities (chronic heart failure (CHF), anxiety, depression) and transformed to visualizations of AECOPDs and comorbid flare-up patterns over time. Patterns were subsequently categorized using an inductive approach, based on both predominance (ie, which occurs most often) of AECOPDs or comorbid flare-ups, and their simultaneous (ie, simultaneous start in ≥ 50%) occurrence.

Results

We included 48 COPD patients (68 ± 9 years; comorbid CHF: 52%, anxiety: 40%, depression: 38%). In 25 patients with AECOPDs and CHF flare-ups, the following patterns were identified: AECOPDs predominant (n = 14), CHF flare-ups predominant (n = 5), AECOPDs nor CHF flare-ups predominant (n = 6). Of the 24 patients with AECOPDs and anxiety and/or depression flare-ups, anxiety and depression flare-ups occurred simultaneously in 15 patients. In 9 of these 24 patients, anxiety or depression flare-ups were observed independently from each other. In 31 of the included 48 patients, AECOPDs and comorbid flare-ups occurred mostly simultaneously.

Conclusion

Patients with COPD and common comorbidities show a variety of patterns of AECOPDs and comorbid flare-ups. Some patients, however, show repetitive patterns that could potentially be used to improve personalized disease management, if recognized.

A Literature Review on the Coexisting Chronic Obstructive Pulmonary Disease and Heart Failure

The convergence of chronic obstructive pulmonary disease (COPD) and heart failure (HF) is a prevalent yet often overlooked medical scenario. This coexistence poses diagnostic challenges due to symptom similarities. This comprehensive review extensively examines the impact of COPD and HF on pharmacological management. Furthermore, the concurrent presence of these conditions amplifies both mortality rates and societal financial strain. Addressing these intertwined ailments necessitates a multidisciplinary approach. Within this review, we delve into the foundational mechanisms, diagnostic intricacies, and available management choices for these closely related conditions.

Animal models and mechanisms of tobacco smoke-induced chronic obstructive pulmonary disease (COPD)

Chronic obstructive pulmonary disease (COPD) is the third leading cause of death worldwide, and its global health burden is increasing. COPD is characterized by emphysema, mucus hypersecretion, and persistent lung inflammation, and clinically by chronic airflow obstruction and symptoms of dyspnea, cough, and fatigue in patients. A cluster of pathologies including chronic bronchitis, emphysema, asthma, and cardiovascular disease in the form of hypertension and atherosclerosis variably coexist in COPD patients. Underlying causes for COPD include primarily tobacco use but may also be driven by exposure to air pollutants, biomass burning, and workplace related fumes and chemicals. While no single animal model might mimic all features of human COPD, a wide variety of published models have collectively helped to improve our understanding of disease processes involved in the genesis and persistence of COPD. In this review, the pathogenesis and associated risk factors of COPD are examined in different mammalian models of the disease. Each animal model included in this review is exclusively created by tobacco smoke (TS) exposure. As animal models continue to aid in defining the pathobiological mechanisms of and possible novel therapeutic interventions for COPD, the advantages and disadvantages of each animal model are discussed.

PrehospitaL Ultrasound in Undifferentiated DyspnEa (PreLUDE): a prospective, clinical, observational study

BACKGROUND

Diagnostic uncertainty in patients with dyspnea is associated with worse outcomes. We hypothesized that prehospital point-of-care ultrasound (POCUS) can improve diagnostic accuracy.

METHODS

Prospective observational study of adult patients suffering dyspnea. Prehospital critical care physicians registered a suspected diagnosis based on clinical examination alone, performed POCUS of the heart and lungs, and finally registered suspected diagnoses based on their clinical examination supplemented with POCUS. Pre- and post-POCUS diagnoses were compared to endpoint committee adjudicated diagnoses. The primary outcome was improved sensitivity for diagnosing acute heart failure. Secondary outcomes included other diagnostic accuracy measures in relation to acute heart failure and other causes of dyspnea.

RESULTS

In total, 214 patients were included. The diagnosis of acute heart failure was suspected in 64/214 (30%) of patients before POCUS and 64/214 (30%) patients after POCUS, but POCUS led to reclassification in 53/214 (25%) patients. The endpoint committee adjudicated the diagnosis of acute heart failure in 87/214 (41%) patients. The sensitivity for the diagnosis of acute heart failure was 58% (95% CI 46%-69%) before POCUS compared to 65% (95% CI 53%-75%) after POCUS (p = 0.12). ROC AUC for the diagnosis acute heart failure was 0.72 (95% CI 0.66-0.78) before POCUS compared to 0.79 (0.73-0.84) after POCUS (p < 0.001). ROC AUC for the diagnosis acute exacerbation (AE) of chronic obstructive pulmonary disease (COPD) or asthma was 0.87 (0.82-0.91) before POCUS and 0.93 (0.88-0.97) after POCUS (p < 0.001). A POCUS finding of any of severely reduced left ventricular function, bilateral B-lines or bilateral pleural effusion demonstrated the highest sensitivity for acute heart failure at 88% (95% CI 79%-94%), whereas the combination of all of these three findings yielded the highest specificity at 99% (95% CI 95%-100%).

CONCLUSION

Supplementary prehospital POCUS leads to an improvement of diagnostic accuracy of both heart failure and AE-COPD/-asthma overall described by ROC AUC, but the increase in sensitivity for the diagnoses of acute heart failure did not reach statistical significance. Tailored use of POCUS findings optimizes diagnostic accuracy for rule-out and rule-in of acute heart failure.

TRIAL REGISTRATION

Registered in Clinical Trials, 05.04.2019 (identifier: NCT03905460) https://clinicaltrials.gov/ct2/show/study/NCT03905460?term=NCT03905460&cond=Dyspnea&cntry=DK&draw=2&rank=1 .

Impact of COPD and asthma on in-hospital mortality and management of patients with heart failure in England and Wales: an observational analysis

OBJECTIVE

To evaluate the association between having concomitant chronic obstructive pulmonary disease (COPD) or asthma, and in-patient mortality and post-discharge management among patients hospitalised for acute heart failure (HF).

SETTING

Data were obtained from patients enrolled in the National Heart Failure Audit.

PARTICIPANTS

217 329 patients hospitalised for HF in England-Wales between March 2012 and 2018.

OUTCOMES

In-hospital mortality, referrals to cardiology follow-up and prescriptions for HF medications were compared between patients with comorbid COPD (COPD-HF) or asthma (asthma-HF) versus HF-alone using mixed-effects logistic regression.

RESULTS

Patients with COPD-HF were more likely to die during hospitalisation, and those with asthma-HF had a reduced likelihood of death, compared with patients who had HF-alone ((adjusted)OR_adj, 95% CI: 1.10, 1.06 to 1.14 and OR_adj, 95% CI: 0.84, 0.79 to 0.88). In patients who survived to discharge, referral to HF follow-up services differed between groups: patients with COPD-HF had reduced odds of cardiology follow-up (OR_adj, 95% CI 0.79, 0.77 to 0.81), while cardiology referral odds for asthma-HF were similar to HF-alone. Overall, proportions of HF medication prescriptions at discharge were low for both COPD-HF and asthma-HF groups, particularly prescriptions for beta-blockers.

CONCLUSIONS

In this nationwide analysis, we showed that COPD and asthma significantly impact the clinical course in patients hospitalised for HF. COPD is associated with higher in-patient mortality and lower cardiology referral odds, while COPD and asthma are both associated with lower use of prognostic HF therapies on discharge. These data highlight therapeutic gaps and a need for better integration of cardiopulmonary services to improve healthcare provision for patients with HF and coexisting respiratory disease.

Effects of mineralocorticoid receptor antagonists in heart failure with reduced ejection fraction patients with chronic obstructive pulmonary disease in EMPHASIS-HF and RALES

AIMS

Heart failure with reduced ejection fraction (HFrEF) and chronic obstructive pulmonary disease (COPD) individually cause significant morbidity and mortality. Their coexistence is associated with even worse outcomes, partly due to suboptimal heart failure therapy, especially underutilisation of beta-blockers. Our aim was to investigate outcomes in HFrEF patients with and without COPD, and the effects of mineralocorticoid receptor antagonists (MRAs) on outcomes.

METHODS AND RESULTS

We studied the effect of MRA therapy in a post-hoc pooled analysis of 4397 HFrEF patients in the RALES and EMPHASIS-HF trials. The primary endpoint was the composite of heart failure hospitalisation or cardiovascular death. A total of 625 (14.2%) of the 4397 patients had COPD. Patients with COPD were older, more often male, and smokers, but less frequently treated with a beta-blocker. In patients with COPD, event rates (per 100 person-years) for the primary endpoint and for all-cause mortality were 25.2 (95% confidence interval 22.1-28.7) and 17.2 (14.9-19.9), respectively, compared with 19.9 (18.8-21.1) and 12.8 (12.0-13.7) in participants without COPD. The risks of all-cause hospitalisation and sudden death were also higher in patients with COPD. The benefit of MRA, compared with placebo, was consistent in patients with or without COPD for all outcomes, e.g. hazard ratio for the primary outcome 0.66 (0.50-0.85) for COPD and 0.65 (0.58-0.73) for no COPD (interaction p = 0.93). MRA-induced hyperkalaemia was less frequent in patients with COPD.

CONCLUSIONS

In RALES and EMPHASIS-HF, one-in-seven patients with HFrEF had coexisting COPD. HFrEF patients with COPD had worse outcomes than those without. The benefits of MRAs were consistent, regardless of COPD status.

Responses to incremental exercise and the impact of the coexistence of HF and COPD on exercise capacity: a follow-up study

Our aim was to evaluate: (1) the prevalence of coexistence of heart failure (HF) and chronic obstructive pulmonary disease (COPD) in the studied patients; (2) the impact of HF + COPD on exercise performance and contrasting exercise responses in patients with only a diagnosis of HF or COPD; and (3) the relationship between clinical characteristics and measures of cardiorespiratory fitness; (4) verify the occurrence of cardiopulmonary events in the follow-up period of up to 24 months years. The current study included 124 patients (HF: 46, COPD: 53 and HF + COPD: 25) that performed advanced pulmonary function tests, echocardiography, analysis of body composition by bioimpedance and symptom-limited incremental cardiopulmonary exercise testing (CPET) on a cycle ergometer. Key CPET variables were calculated for all patients as previously described. The [Formula: see text]E/[Formula: see text]CO2 slope was obtained through linear regression analysis. Additionally, the linear relationship between oxygen uptake and the log transformation of [Formula: see text]E (OUES) was calculated using the following equation: [Formula: see text]O2 = a log [Formula: see text]E + b, with the constant 'a' referring to the rate of increase of [Formula: see text]O2. Circulatory power (CP) was obtained through the product of peak [Formula: see text]O2 and peak systolic blood pressure and Ventilatory Power (VP) was calculated by dividing peak systolic blood pressure by the [Formula: see text]E/[Formula: see text]CO2 slope. After the CPET, all patients were contacted by telephone every 6 months (6, 12, 18, 24) and questioned about exacerbations, hospitalizations for cardiopulmonary causes and death. We found a 20% prevalence of HF + COPD overlap in the studied patients. The COPD and HF + COPD groups were older (HF: 60 ± 8, COPD: 65 ± 7, HF + COPD: 68 ± 7). In relation to cardiac function, as expected, patients with COPD presented preserved ejection fraction (HF: 40 ± 7, COPD: 70 ± 8, HF + COPD: 38 ± 8) while in the HF and HF + COPD demonstrated similar levels of systolic dysfunction. The COPD and HF + COPD patients showed evidence of an obstructive ventilatory disorder confirmed by the value of %FEV1 (HF: 84 ± 20, COPD: 54 ± 21, HF + COPD: 65 ± 25). Patients with HF + COPD demonstrated a lower work rate (WR), peak oxygen uptake ([Formula: see text]O2), rate pressure product (RPP), CP and VP compared to those only diagnosed with HF and COPD. In addition, significant correlations were observed between lean mass and peak [Formula: see text]O2 (r: 0.56 p < 0.001), OUES (r: 0.42 p < 0.001), and O2 pulse (r: 0.58 p < 0.001), lung diffusing factor for carbon monoxide (DLCO) and WR (r: 0.51 p < 0.001), DLCO and VP (r: 0.40 p: 0.002), forced expiratory volume in first second (FEV1) and peak [Formula: see text]O2 (r: 0.52; p < 0.001), and FEV1 and WR (r: 0.62; p < 0.001). There were no significant differences in the occurrence of events and deaths contrasting both groups. The coexistence of HF + COPD induces greater impairment on exercise performance when compared to patients without overlapping diseases, however the overlap of the two diseases did not increase the probability of the occurrence of cardiopulmonary events and deaths when compared to groups with isolated diseases in the period studied. CPET provides important information to guide effective strategies for these patients with the goal of improving exercise performance and functional capacity. Moreover, given our findings related to pulmonary function, body composition and exercise responses, evidenced that the lean mass, FEV1 and DLCO influence important responses to exercise.

Differences in Outcomes between Heart Failure Phenotypes in Patients with Coexistent COPD: A Cohort Study

RATIONALE

Differences in clinical presentation and outcomes between HF phenotypes in patients with COPD have not been assessed.

OBJECTIVES

The aim of this study was to compare clinical outcomes and healthcare resource use (HRU) between patients with COPD and HF with preserved (HFpEF), mildly-reduced (HFmrEF), and reduced ejection fraction (HFrEF).

METHODS

Patients with COPD and HF were identified in the United States (US) administrative claims database OptumLabs® DataWarehouse between 2008-2018. All-cause and cause-specific (HF) hospitalization, acute exacerbation of COPD (AECOPD, severe and moderate combined), mortality and HRU were compared between HF phenotypes.

RESULTS

From 5,419 patients with COPD, 70% had HFpEF, 20% had HFrEF and 10% had HFmrEF. All-cause hospitalization did not differ across groups, however patients with COPD and HFrEF had a greater risk of HF-specific hospitalization (HR 1.54, 95%CI 1.29-1.84) and mortality (HR: 1.17, 95%CI 1.03-1.33) compared to patients with COPD and HFpEF. Conversely, patients with COPD and HFrEF had a lower risk of AECOPD compared with those with COPD and HFpEF (HR 0.75, 95%CI 0.66-0.87). Rates of long-term stays (in skilled-nursing facilities) and emergency room visits were lower for those with COPD and HFrEF than for those with COPD and HFpEF.

CONCLUSION

Outcomes in patients with comorbid COPD and HFpEF are largely driven by COPD. Given the paucity in treatments for HFpEF, better differentiation between cardiac and respiratory symptoms may provide an opportunity to reduce the risk of AECOPD. Risk of death and HF hospitalization were highest among patients with COPD and HFrEF, emphasizing the importance of optimizing guideline-recommended HFrEF therapies in this group.

Relação da Função Pulmonar e da Força Inspiratória com Capacidade Aeróbica e com Prognóstico na Insuficiência Cardíaca

Fundamento

A espirometria é subutilizada na insuficiência cardíaca (IC) e não está claro o grau de associação de cada defeito com a capacidade de exercício e com o prognóstico desses pacientes.

Objetivo

Determinar a relação da %CVF prevista (ppCVF) e do VEF₁/CVF contínuos com: 1) pressão inspiratória máxima (PImáx), fração de ejeção do ventrículo esquerdo (FEVE) e desempenho ao exercício; e 2) prognóstico, para o desfecho composto de morte cardiovascular, transplante cardíaco ou implante de dispositivo de assistência ventricular.

Métodos

Coorte de 111 participantes com IC (estágios AHA C/D) sem pneumopatia; foram submetidos a espirometria, manovacuometria e teste cardiopulmonar máximo. As magnitudes de associação foram verificadas por regressões lineares e de Cox (HR; IC 95%), ajustadas para idade/sexo, e p <0,05 foi considerado significativo.

Resultados

Com idade média 57±12 anos, 60% eram homens, 64% em NYHAIII. A cada aumento de 10% no VEF₁/CVF [β 7% (IC 95%: 3-10)] e no ppCVF [4% (2-6)], foi associado à reserva ventilatória (VRes); no entanto, apenas o ppCVF associado à PImáx [3,8cmH₂O (0,3-7,3)], à fração de ejeção do ventrículo esquerdo (FEVE) [2,1% (0,5-3,8)] e ao VO₂ pico [0,5mL/kg/min (0,1-1,0)], considerando idade/sexo. Em 2,2 anos (média), ocorreram 22 eventos; tanto FEV1/FVC (HR 1,44; IC 95%: 0,97-2,13) quanto ppCVF (HR 1,13; 0,89-1,43) não foram associados ao desfecho. Apenas no subgrupo FEVE ≤50% (n=87, 20 eventos), VEF₁/CVF (HR 1,50; 1,01-2,23), mas não ppCVF, foi associado a risco.

Conclusão

Na IC crônica, ppCVF reduzido associou-se a menor PImáx, FEVE, VRes e VO₂ pico, mas não distinguiu pior prognóstico em 2,2 anos de acompanhamento. Entretanto, VEF₁/CVF associou-se apenas com VRes, e, em participantes com FEVE ≤50%, o VEF₁/CVF reduzido mostrou pior prognóstico proporcional. Portanto, VEF₁/CVF e ppFVC contribuem para melhor fenotipagem de pacientes com IC.

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.

Prognosis of Laboratory-Confirmed Influenza and Respiratory Syncytial Virus in Acute Heart Failure

Concomitant respiratory viral infections may influence clinical outcomes of acute decompensated heart failure (ADHF) but this association is based on indirect observation. The aim of this study was to evaluate the prevalence and impact of laboratory-confirmed influenza or respiratory syncytial virus (RSV) infection on outcomes in patients hospitalised for ADHF. Prospective cohort of patients hospitalised for ADHF with systematic influenza and RSV screening using real-time PCR on nasopharyngeal swabs. The primary outcome was all-cause mortality or readmission at 90 days. Among 803 patients with ADHF, 196 (24.5%) patients had concomitant flu-like symptoms of influenza. PCR was positive in 45 patients (27 for influenza, 19 for RSV). At 90 days, PCR positive patients had lower rates of all-cause mortality or readmission as compared to patients without flu-like symptoms (HR 0.40, 95% CI 0.18–0.91, p = 0.03), and non-significantly less all-cause mortality (HR 0.30, 95% CI 0.04–2.20, p = 0.24), or HF-related death or readmission (HR 0.36, 95% CI 0.13–0.99, p = 0.05). The prevalence of influenza or RSV infection in patients admitted for ADHF was low and associated with less all-cause mortality and readmission. Concomitant viral infection with ADHF may not in itself be a predictor of poor outcomes. (ClinicalTrials.gov NCT02444416).

Health expenditures after first hospital admission for heart failure in Nova Scotia, Canada: a retrospective cohort study

BACKGROUND

Although the frequency of heart failure makes it among the costliest of illnesses, there are scant Canadian data on annual costs of treatment or the costs as the condition advances. Our objective was to estimate mean prevalence- and incidence-based direct medical costs among older adults discharged alive after a first hospital admission for heart failure.

METHODS

We conducted a retrospective cohort study using population-based administrative health databases for Nova Scotia. The cohort comprised persons 50 years of age or older with an incident hospital admission for heart failure between 2009 and 2012. We considered the costs (expressed as 2020 Canadian dollars) of hospital admissions, physician visits and, for patients 65 years of age or older, outpatient cardiac medications. We estimated costs for calendar years, longitudinally and in the last 2 years of life. We analyzed costs from the perspective of a third-party public payer.

RESULTS

The cohort consisted of 3327 patients (mean age 77.6 yr; 1605 [48.2%] women). Median survival was 2.5 and 2.2 years among men and women, respectively. Annual prevalence-based costs were about $7100. Mean incidence-based costs ranged between $65 000 and $164 000 in the year after diagnosis and decreased by 90% subsequently. Costs were 4 to 7 times higher in the year before death than in the period from 1 to 2 years before death.

INTERPRETATION

The direct medical costs of treating patients with heart failure in Nova Scotia displayed a reverse J shape, with costs highest after diagnosis, declining subsequently and then increasing during the final year of life. Strategies designed to improve the quality of care immediately after diagnosis and during more advanced stages of disease might reduce these costs.

Impact of beta-blocker use on the long-term outcomes of heart failure patients with chronic obstructive pulmonary disease

AIMS

The number of patients with both chronic obstructive pulmonary disease (COPD) and heart failure (HF) is increasing in Asia, and these conditions often coexist. We previously revealed a tendency of beta-blocker underuse among patients with HF with reduced ejection fraction (HFrEF) and COPD in Asian countries other than Japan. Here, we evaluated the impact of cardio-selective beta-blocker use on the long-term outcomes of patients with HF and COPD.

METHODS AND RESULTS

Among the 5232 patients with HFrEF (left ventricular ejection fraction of <40%) prospectively enrolled from 11 Asian regions in the ASIAN-HF registry, 412 (7.9%) had a history of COPD. We compared the clinical characteristics and long-term outcomes of the patients with HF and COPD according to the use and type of beta-blockers used: cardio-selective beta-blockers (n = 149) vs. non-cardio-selective beta-blockers (n = 124) vs. no beta-blockers (n = 139). The heart rate was higher, and the outcome was poorer in the no beta-blocker group than in the beta-blocker groups. The 2 year all-cause mortality was significantly lower in the non-cardio-selective beta-blocker group than in the no beta-blocker group. Further, the cardiovascular mortality significantly decreased in the non-cardio-selective beta-blocker group before (hazard ratio: 0.36; 95% confidence interval: 0.18-0.73; P = 0.004) and after adjustments (hazard ratio: 0.37; 95% confidence interval: 0.19-0.73; P = 0.005), but not in the cardio-selective beta-blocker group.

CONCLUSIONS

Beta-blockers reduced the all-cause mortality of patients with HFrEF and COPD after adjusting for age and heart rate, although the possibility of selection bias could not be completely excluded due to multinational prospective registry.

Epidemiological and clinical boundaries of heart failure with preserved ejection fraction

Heart failure with preserved ejection fraction (HFpEF) is highly prevalent and is associated with relevant morbidity and mortality. However, an evidence-based treatment is still absent. The heterogeneous definitions, differences in aetiology/pathophysiology, and diagnostic challenges of HFpEF made it difficult to define its epidemiological landmarks so far. Several large registries and observational studies have recently disclosed an increasing incidence/prevalence, as well as its prognostic significance. An accurate definition of HFpEF epidemiological boundaries and phenotypes is mandatory to develop novel effective and rational therapeutic approaches.

Metabolism and Chronic Inflammation: The Links Between Chronic Heart Failure and Comorbidities

Heart failure (HF) patients often suffer from multiple comorbidities, such as diabetes, atrial fibrillation, depression, chronic obstructive pulmonary disease, and chronic kidney disease. The coexistance of comorbidities usually leads to multi morbidity and poor prognosis. Treatments for HF patients with multi morbidity are still an unmet clinical need, and finding an effective therapy strategy is of great value. HF can lead to comorbidity, and in return, comorbidity may promote the progression of HF, creating a vicious cycle. This reciprocal correlation indicates there may be some common causes and biological mechanisms. Metabolism remodeling and chronic inflammation play a vital role in the pathophysiological processes of HF and comorbidities, indicating metabolism and inflammation may be the links between HF and comorbidities. In this review, we comprehensively discuss the major underlying mechanisms and therapeutic implications for comorbidities of HF. We first summarize the potential role of metabolism and inflammation in HF. Then, we give an overview of the linkage between common comorbidities and HF, from the perspective of epidemiological evidence to the underlying metabolism and inflammation mechanisms. Moreover, with the help of bioinformatics, we summarize the shared risk factors, signal pathways, and therapeutic targets between HF and comorbidities. Metabolic syndrome, aging, deleterious lifestyles (sedentary behavior, poor dietary patterns, smoking, etc.), and other risk factors common to HF and comorbidities are all associated with common mechanisms. Impaired mitochondrial biogenesis, autophagy, insulin resistance, and oxidative stress, are among the major mechanisms of both HF and comorbidities. Gene enrichment analysis showed the PI3K/AKT pathway may probably play a central role in multi morbidity. Additionally, drug targets common to HF and several common comorbidities were found by network analysis. Such analysis has already been instrumental in drug repurposing to treat HF and comorbidity. And the result suggests sodium-glucose transporter-2 (SGLT-2) inhibitors, IL-1β inhibitors, and metformin may be promising drugs for repurposing to treat multi morbidity. We propose that targeting the metabolic and inflammatory pathways that are common to HF and comorbidities may provide a promising therapeutic strategy.

Relationship between heart failure and the risk of acute exacerbation of COPD

RATIONALE

Heart failure (HF) management in chronic obstructive pulmonary disease (COPD) is often delayed or suboptimal.

OBJECTIVES

To examine the effect of HF and HF medication use on moderate-to-severe COPD exacerbations.

METHODS AND MEASUREMENTS

Retrospective cohort studies from 2006 to 2016 using nationally representative English primary care electronic healthcare records linked to national hospital and mortality data. Patients with COPD with diagnosed and possible HF were identified. Possible HF was defined as continuous loop diuretic use in the absence of a non-cardiac indication. Incident exposure to HF medications was defined as ≥2 prescriptions within 90 days with no gaps >90 days during ≤6 months of continuous use; prevalent exposure as 6+ months of continuous use. HF medications investigated were angiotensin receptor blockers, ACE inhibitors, beta-blockers, loop diuretics and mineralocorticoid receptor antagonists. Cox regression, stratified by sex and age, further adjusted for patient characteristics, was used to determine the association of HF with exacerbation risk.

MAIN RESULTS

86 795 patients with COPD were categorised as no evidence of HF (n=60 047), possible HF (n=8476) and newly diagnosed HF (n=2066). Newly diagnosed HF (adjusted HR (aHR): 1.45, 95% CI: 1.30 to 1.62) and possible HF (aHR: 1.65, 95% CI: 1.58 to 1.72) similarly increased exacerbation risk. Incident and prevalent use of all HF medications were associated with increased exacerbation risk. Prevalent use was associated with reduced exacerbation risk compared with incident use.

CONCLUSIONS

Earlier opportunities to improve the diagnosis and management of HF in the COPD population are missed. Managing HF may reduce exacerbation risk in the long term.

Update on the Impact of Comorbidities on the Efficacy and Safety of Heart Failure Medications

PURPOSE OF REVIEW

Multiple newer medications benefit patients with heart failure with reduced ejection fraction (HFrEF). While these therapies benefit the broad population with HFrEF, the efficacy and safety of these therapies have been less well characterized in patients with significant comorbidities.

RECENT FINDINGS

Common comorbidities of high interest in heart failure (HF) include diabetes mellitus, chronic kidney disease (CKD), atrial fibrillation, and obesity, and each has potential implications for clinical management. As the burden of comorbidities increases in HF populations, risk-benefit assessments of HF therapies in the context of different comorbidities are increasingly relevant for clinical practice. This review summarizes data regarding the core HFrEF therapies in the context of comorbidities, with specific attention to sodium-glucose cotransporter 2 inhibitors, sacubitril/valsartan, mineralocorticoid receptor antagonists (MRAs), and beta-blockers. In general, studies support consistent treatment effects with regard to clinical outcome benefits in the presence of comorbidities. Likewise, safety profiles are relatively consistent irrespective of comorbidities, with the exception of heightened risk of hyperkalemia with MRA therapy in patients with severe CKD. In conclusion, while HF management is complex in the context of multiple comorbidities, the totality of evidence strongly supports guideline-directed medical therapies as foundational for improving outcomes in these high-risk patients.

The role of imaging in characterizing the cardiac natural history of Duchenne muscular dystrophy

Duchene muscular dystrophy (DMD) is a rare but devastating disease resulting in progressive loss of ambulation, respiratory failure, DMD-associated cardiomyopathy (DMD-CM), and premature death. The use of corticosteroids and supportive respiratory care has improved outcomes, such that DMD-CM is now the leading cause of death. Historically, most programs have focused on skeletal myopathy with less attention to the cardiac phenotype. This omission is rather astonishing since patients with DMD possess an absolute genetic risk of developing cardiomyopathy. Unfortunately, heart failure signs and symptoms are vague due to skeletal muscle myopathy leading to limited ambulation. Traditional assessment of cardiac symptoms by the New York Heart Association American College of Cardiology/American Heart Association Staging (ACC/AHA) classification is of limited utility, even in advanced stages. Echocardiographic assessment can detect cardiac dysfunction late in the disease course, but this has proven to be a poor surrogate marker of early cardiovascular disease and an inadequate predictor of DMD-CM. Indeed, one explanation for the paucity of cardiac therapeutic trials for DMD-CM has been the lack of a suitable end-point. Improved outcomes require a better proactive treatment strategy; however, the barrier to treatment is the lack of a sensitive and specific tool to assess the efficacy of treatment. The use of cardiac imaging has evolved from echocardiography to cardiac magnetic resonance imaging to assess cardiac performance. The purpose of this article is to review the role of cardiac imaging in characterizing the cardiac natural history of DMD-CM, highlighting the prognostic implications and an outlook on how this field might evolve in the future.

Distinct Mechanical Properties of the Respiratory System Evaluated by Forced Oscillation Technique in Acute Exacerbation of COPD and Acute Decompensated Heart Failure

Discriminating between cardiac and pulmonary dyspnea is essential for patients’ management. We investigated the feasibility and ability of forced oscillation techniques (FOT) in distinguishing between acute exacerbation of COPD (AECOPD), and acute decompensated heart failure (ADHF) in a clinical emergency setting. We enrolled 49 patients admitted to the emergency department (ED) for dyspnea and acute respiratory failure for AECOPD, or ADHF, and 11 healthy subjects. All patients were able to perform bedside FOT measurement. Patients with AECOPD showed a significantly higher inspiratory resistance at 5 Hz, Xrs₅ (179% of predicted, interquartile range, IQR 94–224 vs. 100 IQR 67–149; p = 0.019), and a higher inspiratory reactance at 5 Hz (151%, IQR 74–231 vs. 57 IQR 49–99; p = 0.005) than patients with ADHF. Moreover, AECOPD showed higher heterogeneity of ventilation (respiratory system resistance difference at 5 and 19 Hz, Rrs_5-19: 1.49 cmH₂O/(L/s), IQR 1.03–2.16 vs. 0.44 IQR 0.22–0.76; p = 0.030), and a higher percentage of flow limited breaths compared to ADHF (10%, IQR 0–100 vs. 0 IQR 0–12; p = 0.030). FOT, which resulted in a suitable tool to be used in the ED setting, has the ability to identify distinct mechanical properties of the respiratory system in AECOPD and ADHF.

Clinical heterogeneity of a population of patients admitted to the Emergency Department with a diagnosis of COPD-exacerbation: Relevance of cardiovascular comorbidities

FEV1-based Chronic Obstructive Pulmonary Disease (COPD) severity does not account for the complexity of the disease. Recent studies point to the high frequency of comorbidities responsible for unfavorable outcomes. There is a lack of data on this concerning the patient evaluated in the emergency setting. Aim of the study was to prospectively evaluate patients admitted to the ED for “exacerbated COPD” to describe their clinical heterogeneity and the influence that it may have on outcomes: death, length of hospitalization, exacerbation recurrence. The following data were recorded: history, symptoms, blood gas analysis, laboratory and radiological findings and comorbidities. Each patient underwent electrocardiography, echocardiography and spirometry. In order to identify a correlation between these variables and the selected outcomes, a multivariate linear logistic regression analysis was carried out. This study was conducted on 41 eligible patients consecutively admitted to the emergency room for exacerbated COPD. A consistent proportion showed ECG, Echocardiographic and laboratory abnormalities. At spirometry a FEV1 <30% of predicted was detected in 37% of patients. Cardiovascular comorbidities came out to be very frequent (hypertension, heart failure and coronary artery disease in particular). The history of heart failure was related to the risk of re-hospitalization within three months, while pneumonia, a low pH and a low FEV1 predicted a hospital stay >7 days. Our study shows that the term “exacerbated COPD” underscores a heterogeneous population, with a high prevalence of cardiovascular comorbidities, which significantly influence outcomes. Multicenter studies are needed to better investigate the clinical relevance of these findings.

Cardiac biomarkers and long-term outcomes of exacerbations of COPD: a long-term follow-up of two cohorts

Background

COPD patients often have cardiac comorbidities. Cardiac involvement at the time of a COPD exacerbation is associated with a high short-term mortality, but whether this influences long-term outcomes is unknown. We explored whether biomarkers of cardiac dysfunction at the time of a COPD exacerbation predict long-term outcomes.

Methods

Two prospective cohorts of patients admitted to Waikato Hospital for exacerbations of COPD were recruited during 2006-2007 and 2012-2013. N-terminal pro-B-type natriuretic peptide (NT-proBNP) and troponin T were measured on admission and were used to indicate cardiac stretch and myocardial injury, respectively. 5-year survival after discharge and subsequent admissions for cardiac disease and COPD exacerbations were analysed using Kaplan-Meier and Cox proportional hazards tests.

Results

The overall 5-year mortality was 61%. Patients with high NT-proBNP on admission had higher mortality than those with normal cardiac biomarkers (adjusted hazard ratio (aHR) 1.76, 95% CI 1.18-2.62). High NT-proBNP was also associated with a higher risk of future cardiac admissions (aHR 1.75, 95% CI 1.2-2.55). Troponin T levels were not associated with long-term survival (aHR 0.86, 95% CI 0.40-1.83) or future cardiac admissions (aHR 0.74, 95% CI 0.34-1.57). Neither biomarker predicted future COPD exacerbations.

Conclusion

The long-term prognosis following a hospitalisation for an exacerbation of COPD is poor with less than half of patients surviving for 5 years. Elevated NT-proBNP at the time of a COPD exacerbation is associated with higher long-term mortality and a greater likelihood of future cardiac admissions, but not future COPD exacerbations.

Systemic Galectin-3 in Smokers with Chronic Obstructive Pulmonary Disease and Chronic Bronchitis: The Impact of Exacerbations

PURPOSE

The carbohydrate-binding protein Galectin-3 is increased in several inflammatory diseases and has recently been forwarded as a systemic biomarker in chronic obstructive pulmonary disease (COPD). In this longitudinal study, we characterized the level of systemic Galectin-3 using blood from smokers with a history of COPD and chronic bronchitis (COPD-CB), during stable clinical conditions and exacerbations.

PATIENTS AND METHODS

The study population comprised 56 long-term smokers with COPD-CB, 10 long-term smokers without lung disease (LTS) and 10 clinically healthy never-smokers (HNS). Blood samples were analyzed for levels of Galectin-3, leukocyte populations and C-reactive protein (CRP). In addition, sputum samples from the COPD-CB group were analyzed for bacterial growth.

RESULTS

When comparing stable clinical conditions and exacerbations in the COPD-CB group, we found that the level of Galectin-3, just like that of CRP, leukocytes and neutrophils, respectively, was increased during exacerbations. However, this exacerbation-associated increase of Galectin-3 was modest. During stable clinical conditions of COPD-CB, the level of Galectin-3 was not elevated in comparison with HNS or LTS. Nor did this level of Galectin-3 distinguish patients that remained in a clinically stable condition throughout the study to those that developed an exacerbation. In addition, neither during stable clinical conditions nor during exacerbations, did the presence of bacterial growth in sputum alter Galectin-3 levels. In contrast to Galectin-3, the level of CRP, leukocytes and neutrophils, respectively, were increased during clinical stable conditions in the COPD-CB group compared with the other groups and were further enhanced during exacerbations.

CONCLUSION

Systemic Galectin-3 is increased in a reproducible but modest manner during exacerbations in smokers with COPD-CB. During stable clinical conditions, the level of systemic Galectin-3 does not distinguish patients that remain clinically stable from those that develop exacerbations. This makes it less likely that systemic Galectin-3 may become a clinically useful biomarker in the current setting.

Cardiopulmonary Telerehabilitation

Cardiopulmonary telerehabilitation is a safe and effective alternative to traditional center-based rehabilitation. It offers a sustainable solution to more conveniently meet the needs of patients with acute or chronic, preexisting or newly acquired, cardiopulmonary diseases. To maximize success, programs should prioritize basic, safe, and timely care options over comprehensive or complex approaches. The future should incorporate new strategies learned during a global pandemic and harness the power of information and communication technology to provide evidence-based patient-centered care. This review highlights clinical considerations, current evidence, recommendations, and future directions of cardiopulmonary telerehabilitation.

Eccentric Left Ventricular Hypertrophy and Left and Right Cardiac Function in Chronic Heart Failure with or without Coexisting COPD: Impact on Exercise Performance

AIM

Our aim was to assess: 1) the impact of the eccentric left ventricular hypertrophy (ELVH) on exercise performance in patients diagnosed with chronic heart failure (CHF) alone and in patients with co-existing CHF and chronic obstructive pulmonary disease (COPD) and 2) the relationship between left and right cardiac function measurements obtained by doppler echocardiography, clinical characteristics and primary measures of cardiorespiratory fitness.

METHODS

The current study included 46 patients (CHF:23 and CHF+COPD:23) that performed advanced pulmonary function tests, echocardiography and symptom-limited, incremental cardiopulmonary exercise testing (CPET) on a cycle ergometer.

RESULTS

Patients with CHF+COPD demonstrated a lower work rate, peak oxygen uptake (VO2), oxygen pulse, rate pressure product (RPP), circulatory power (CP) and ventilatory power (VP) compared to those only diagnosed with CHF. In addition, significant correlations were observed between VP and relative wall thickness (r: 0.45 p: 0.03),VE/VCO2 intercept and Mitral E/e' ratio (r: 0.70 p: 0.003) in the CHF group. Significant correlations were found between indexed left ventricle mass and RPP (r: -0.47; p: 0.02) and relative VO2 and right ventricle diameter (r: -0.62; p: 0.001) in the CHF+COPD group.

CONCLUSION

Compared to a diagnosis of CHF alone, a combined diagnosis of CHF+COPD induced further impairments in cardiorespiratory fitness. Moreover, echocardiographic measures of cardiac function are related to cardiopulmonary exercise performance and therefore appear to be an important therapeutic target when attempting to improve exercise performance and functional capacity.

Cardiovascular safety of mometasone/indacaterol and mometasone/indacaterol/glycopyrronium once-daily fixed-dose combinations in asthma: pooled analysis of phase 3 trials

OBJECTIVE

To evaluate cardiovascular safety of two new inhaled fixed-dose combinations for treatment of asthma: (i) the inhaled corticosteroid/long-acting beta2-agonist (ICS/LABA) mometasone furoate/indacaterol acetate (MF/IND), (ii) the ICS/LABA/long-acting muscarinic antagonist (LAMA) MF/IND/glycopyrronium bromide (GLY).

METHODS

Patient-level data were pooled from four randomized trials, including 52-week studies PALLADIUM (n = 2216) and IRIDIUM (n = 3092), 24-week study ARGON (n = 1426), and 12-week study QUARTZ (n = 802). Cardio-/cerebrovascular (CCV) event frequencies were examined in the following comparisons: (1) LABA effect: pooled-dose MF/IND vs. pooled-dose MF; (2) LAMA effect: pooled-dose MF/IND/GLY vs. pooled-dose MF/IND; (3) ICS-dose effects: (a) high-dose MF/IND vs. medium-dose MF/IND, (b) high-dose MF/IND/GLY vs. medium-dose MF/IND/GLY; (4) intra-class effects: (a) high-dose MF/IND vs. Fluticasone/Salmeterol (F/S), (b) high-dose MF/IND/GLY vs. F/S + Tiotropium (TIO). Risk estimates (percentage of patients with ≥1 CCV event) and risk differences (RDs) with 95% confidence intervals (CIs) were calculated for each comparison.

RESULTS

The frequency of CCV events was low, without notable differences between comparison groups. Risk estimates and corresponding RDs (95% CIs) were as follows: (1) pooled-dose MF/IND = 2.35%, pooled-dose MF = 2.18%, RD = 0.17% (-1.00%, 1.34%); (2) pooled-dose MF/IND/GLY = 3.65%, pooled-dose MF/IND = 3.77%, RD = -0.12% (-1.63%, 1.39%); (3a) high-dose MF/IND = 3.69%, medium-dose MF/IND = 3.35%, RD = 0.34% (-1.25%, 1.94%); (3b) high-dose MF/IND/GLY = 2.84%, medium-dose MF/IND/GLY = 2.02%, RD = 0.82% (-0.49%, 2.13%); (4a) high-dose MF/IND = 3.69%, F/S = 2.82%, RD = 0.87% (-0.66%, 2.40%); (4b) high-dose MF/IND/GLY = 1.26%, F/S + TIO = 1.05%, RD = 0.21% (-1.26%, 1.68%).

CONCLUSIONS

There was no evidence of increased cardiovascular risk attributable to the addition of IND to MF or addition of GLY to MF/IND. Similarly, no evidence of increased cardiovascular risk was observed with an increase in the ICS-dose or relative to F/S ± TIO.

Active screening for COPD among hospitalized smokers - a feasibility study

BACKGROUND

Spirometry is a primary tool for early chronic obstructive pulmonary disease (COPD) detection in patients with risk factors, for example, cigarette smoking. The aim of this study was to evaluate the strategy of an active screening for COPD among smokers admitted to the pulmonary and cardiology department.

METHODS

This prospective study was conducted between February and March 2019. All hospitalized smokers aged 40 years and older completed an original questionnaire and had spirometry measurement with a bronchial reversibility test (if applicable) performed by medical students using a portable spirometer.

RESULTS

One hundred and eighty-eight patients were eligible to participate in the study. Seventy (37%) subjects refused to participate. Eventually, 116 (62%) patients were included in the final analysis and 94 (81%) performed spirometry correctly. In total, 32 (34 %) patients were found to have COPD. Nine (28%) of these patients were newly diagnosed, 89% of them had mild-to-moderate airway obstruction. Patients with newly diagnosed COPD were significantly younger [age 63 (56-64) versus 69 (64-78) years], had a longer smoking-free period [17 (13-20) versus 9 (2-12) years], had fewer symptoms and had a better lung function compared with patients with a previous diagnosis of COPD (p < 0.05 for all comparisons).

CONCLUSION

The proposed diagnostic strategy can be successfully used to improve COPD detection in the inpatient setting. The majority of the newly diagnosed COPD patients had mild-to-moderate airway obstruction. Patients who should be particularly screened for COPD include ex-smokers with less pronounced respiratory symptoms.

Association of β-blocker use with survival and pulmonary function in patients with chronic obstructive pulmonary and cardiovascular disease: a systematic review and meta-analysis

AIMS

The aim of this study was to clarify the effect of β-blockers (BBs) on respiratory function and survival in patients with chronic obstructive pulmonary disease with cardiovascular disease (CVD), as well as the difference between the effects of cardioselective and noncardioselective BBs.

METHODS AND RESULTS

We searched for relevant literature in four electronic databases, namely, PubMed, EMBASE, Cochrane Library, and Web of Science, and compared the differences in various survival indicators between patients with chronic obstructive pulmonary disease taking BBs and those not taking BBs. Forty-nine studies were included, with a total sample size of 670 594. Among these, 12 studies were randomized controlled trials (RCTs; seven crossover and five parallel RCTs) and 37 studies were observational (including four post hoc analyses of data from RCTs). The hazard ratios (HRs) of chronic obstructive pulmonary disease exacerbation between patients with chronic obstructive pulmonary disease who were not treated with BBs and those who were treated with BBs, cardioselective BBs, and noncardioselective BBs were 0.77 [95% confidence interval (CI) 0.67, 0.89], 0.72 [95% CI 0.56, 0.94], and 0.98 [95% CI 0.71, 1.34, respectively] (HRs <1 indicate favouring BB therapy). The HRs of all-cause mortality between patients with chronic obstructive pulmonary disease who were not treated with BBs and those who were treated with BBs, cardioselective BBs, and noncardioselective BBs were 0.70 [95% CI 0.59, 0.83], 0.60 [95% CI 0.48, 0.76], and 0.74 [95% CI 0.60, 0.90], respectively (HRs <1 indicate favouring BB therapy). Patients with Chronic obstructive pulmonary disease treated with cardioselective BBs showed no difference in ventilation effect after the use of an agonist, in comparison with placebo. The difference in mean change in forced expiratory volume in 1 s was 0.06 [95% CI -0.02, 0.14].

CONCLUSION

The use of BBs in patients with chronic obstructive pulmonary disease is not only safe but also reduces their all-cause and in-hospital mortality. Cardioselective BBs may even reduce chronic obstructive pulmonary disease exacerbations. In addition, cardioselective BBs do not affect the action of bronchodilators. Importantly, BBs reduce the heart rate acceleration caused by bronchodilators. BBs should be prescribed freely when indicated in patients with chronic obstructive pulmonary disease and heart disease.

Heart failure with preserved ejection fraction: strategies for disease management and emerging therapeutic approaches

Approximately 50% of patients with heart failure (HF) have a preserved ejection fraction (HFpEF), and the incidence of HFpEF is increasing relative to HF with reduced ejection fraction (HFrEF). Both types of HF are associated with reduced survival and increased risk for hospitalization. However, in contrast to HFrEF, there are no approved treatments specifically indicated for HFpEF, and current therapy is largely focused on management of symptoms and comorbidities. Diagnosis of HFpEF in the outpatient setting also presents unique challenges compared with HFrEF because of factors including a high burden of comorbidities in HFpEF and difficulties in distinguishing HFpEF from normal aging. Primary care providers (PCPs) play a pivotal role in the delivery of holistic, patient-centric care from diagnosis to management and palliative care. As the prevalence of HF continues to rise in an aging population, PCPs will need to play a greater role in HFpEF care. This article will review HFpEF etiology and pathophysiology, diagnostic workup, and management of symptoms and comorbidities, with a focus on the critical role of PCPs throughout the clinical course of HFpEF.

Adherence to COPD free triple inhaled therapy in the real world: a primary care based study

INTRODUCTION

The development of new pharmacological treatments for chronic obstructive pulmonary disease (COPD) has improved health-related quality of life of patients. However, suboptimal adherence may limit its potential.

OBJECTIVE

The aim of the present study was to assess the adherence to free triple inhaled therapy and to investigate poor adherence determinants among primary care patients.

METHODS

Data were derived from a primary care database in Italy. Patients aged 40+ affected by COPD and prescribed with inhaled corticosteroids, long-acting beta agonists and long-acting muscarinic antagonists (N = 3177) were enrolled. Low adherence was defined as a proportion of days covered (PDC) by medications prescription lower than 80%. Predictors of low adherence were tested using logistic regression models.

RESULTS AND CONCLUSIONS

The 85% of enrolled patients showed poor adherence to free triple inhaled therapy. Comorbidities, such as heart failure (OR 1.78, 95%CI 1.19-2.75), depression (OR 1.41, 95%CI 1.06-1.88) and peripheral vascular disease (OR 1.32, 95%CI 1.01-1.74) were associated with poor adherence. Former (OR 0.52, 95%CI 0.34-0.78) or current smokers (OR 0.61, 95%CI 0.41-0.93) and patients with more severe airways obstruction or history of severe exacerbations (OR 0.64, 95%CI 0.52-0.79) were less likely to exhibit poor adherence. Real-world adherence to triple inhaled therapy with different inhalers is generally low. Higher GOLD airways obstruction stage and current or former smoking status are associated with increased adherence to treatment. Reduced perceived benefit on symptoms control is probably linked to poorer adherence to free triple therapy.

The role of pulmonary function in patients with heart failure and preserved ejection fraction: Looking beyond chronic obstructive pulmonary disease

Background

The prognostic value of chronic obstructive pulmonary disease (COPD) as a comorbidity in heart failure has been well documented. However, the role of pulmonary function indices in patients with heart failure and preserved ejection fraction (HFpEF) remains to be elucidated.

Methods

Subjects with HFpEF received pulmonary function tests and echocardiogram. Total lung capacity (TLC), residual volume (RV), forced expiratory flow rate between 25% and 75% of vital capacity (FEF25-75), forced expiratory volume in the 1^st second (FEV1), forced vital capacity (FVC), and vital capacity (VC) were measured. Echocardiographic indices, including pulmonary artery systolic pressure (PASP), the ratio of early ventricular filling flow velocity to the septal mitral annulus tissue velocity (E/e’), and left ventricular mass (LVM), were recorded. National Death Registry was linked for the identification of mortality.

Results

A total of 1194 patients (72.4±13.2 years, 59% men) were enrolled. PASP, E/e’ and LVM were associated with either obstructive (RV/TLC, FEV1 and FEF25-75) or restrictive (VC and TLC) ventilatory indices. During a mean follow-up of 23.0±12.8 months, 182 patients died. Subjects with COPD had a lower survival rate than those without COPD. While VC, FVC, RV/TLC, and FEV1 were all independently associated with all-cause mortality in patients without COPD, only FEF25-75 was predictive of outcomes in those with COPD.

Conclusions

The abnormalities of pulmonary function were related to the cardiac hemodynamics in patients with HFpEF. In addition, these ventilatory indices were independently associated with long-term mortality, especially in those without COPD.

Coexisting Morbidities in Heart Failure: No Robust Interaction with the Left Ventricular Ejection Fraction

PURPOSE OF REVIEW

Heart failure (HF) patients often present with multiple coexisting morbidities. In this review, we contend that coexisting morbidities are highly prevalent and clinically important regardless of the left ventricular ejection fraction (LVEF).

RECENT FINDINGS

Multimorbidity is prevalent in the ambulatory subjects of the community and increases with age. Differences in the prevalence of coexisting morbidities between HF with preserved LVEF (> 50%), mid-range LVEF (40-50%), and reduced LVEF (< 40%) are either not demonstrable or whenever present are small and unrelated to morbidity and mortality. The constellation of coexisting morbidities together with the disease modifiers (age, sex, genes, other) defines the HF phenotype and outcome. There is no robust evidence supporting an interaction in HF patients between the prevalence and clinical significance of coexisting morbidities and the LVEF.

Adequacy of Therapy for People with Both COPD and Heart Failure in the UK: Historical Cohort Study

Purpose

Chronic obstructive pulmonary disease (COPD) and heart failure (HF) often occur concomitantly, presenting diagnostic and therapeutic challenges for clinicians. We examined the characteristics of patients prescribed adequate versus inadequate therapy within 3 months after newly diagnosed comorbid COPD or HF.

Patients and Methods

Eligible patients in longitudinal UK electronic medical record databases had pre-existing HF and newly diagnosed COPD (2017 GOLD groups B/C/D) or pre-existing COPD and newly diagnosed HF. Adequate COPD therapy was defined as long-acting bronchodilator(s) with/without inhaled corticosteroid; adequate HF therapy was defined as beta-blocker plus angiotensin-converting enzyme inhibitor and/or angiotensin receptor blocker.

Results

Of 2439 patients with HF and newly diagnosed COPD (mean 75 years, 61% men), adequate COPD therapy was prescribed for 726 (30%) and inadequate for 1031 (42%); 682 (28%) remained untreated for COPD. Adequate (vs inadequate) COPD therapy was less likely for women (35%) than men (45%), smokers (36%) than ex-/non-smokers (45%), and non-obese (41%) than obese (47%); spirometry was recorded for 57% prescribed adequate versus 35% inadequate COPD therapy. Of 12,587 patients with COPD and newly diagnosed HF (mean 75 years, 60% men), adequate HF therapy was prescribed for 2251 (18%) and inadequate for 5332 (42%); 5004 (40%) remained untreated for HF. Adequate (vs inadequate) HF therapy was less likely for smokers (27%) than ex-/non-smokers (32%) and non-obese (30%) than obese (35%); spirometry was recorded for 65% prescribed adequate versus 39% inadequate HF therapy.

Conclusion

Many patients with comorbid COPD/HF receive inadequate therapy after new diagnosis. Improved equity of access to integrated care is needed for all patient subgroups.

Effects of β2-receptor stimulation by indacaterol in chronic heart failure treated with selective or non-selective β-blockers: a randomized trial

Alveolar β₂-receptor blockade worsens lung diffusion in heart failure (HF). This effect could be mitigated by stimulating alveolar β₂-receptors. We investigated the safety and the effects of indacaterol on lung diffusion, lung mechanics, sleep respiratory behavior, cardiac rhythm, welfare, and exercise performance in HF patients treated with a selective (bisoprolol) or a non-selective (carvedilol) β-blocker. Study procedures were performed before and after indacaterol and placebo treatments according to a cross-over, randomized, double-blind protocol in forty-four patients (27 on bisoprolol and 17 on carvedilol). No differences between indacaterol and placebo were observed in the whole population except for a significantly higher VE/VCO₂ slope and lower maximal P_ETCO₂ during exercise with indacaterol, entirely due to the difference in the bisoprolol group (VE/VCO₂ 31.8 ± 5.9 vs. 28.5 ± 5.6, p < 0.0001 and maximal P_ETCO₂ 36.7 ± 5.5 vs. 37.7 ± 5.8 mmHg, p < 0.02 with indacaterol and placebo, respectively). In carvedilol, indacaterol was associated with a higher peak heart rate (119 ± 34 vs. 113 ± 30 bpm, with indacaterol and placebo) and a lower prevalence of hypopnea during sleep (3.8 [0.0;6.3] vs. 5.8 [2.9;10.5] events/hour, with indacaterol and placebo). Inhaled indacaterol is well tolerated in HF patients, it does not influence lung diffusion, and, in bisoprolol, it increases ventilation response to exercise.

Beta Adrenergic Blocker Use in Patients With Chronic Obstructive Pulmonary Disease and Concurrent Chronic Heart Failure With a Low Ejection Fraction

Chronic heart failure (CHF) and chronic obstructive pulmonary disease (COPD) often coexist and present clinicians with diagnostic and therapeutic challenges. Beta-blockers are a cornerstone of CHF treatment, in patients with a low ejection fraction, while beta-agonists are utilized for COPD. These 2 therapies exert opposing pharmacological effects. COPD patients are at an increased risk of mortality from cardiovascular events. In addition to CHF, beta-blockers are used in a number of cardiovascular conditions because of their cardioprotective properties as well as their mortality benefit. However, there is reluctance among physicians to use beta-blockers in patients with COPD because of fear of inducing bronchospasms, despite increasing evidence of their safety and mortality benefits. The majority of this evidence comes from observational studies showing that beta-blockers are safe and well tolerated, with minimal effect on respiratory function. Furthermore, beta-blockers have been shown to lower the mortality risk in patients with COPD alone, as well as in those with COPD and CHF. Large clinical trials are needed in order to dispel the mistrust of beta-blocker use in COPD patients. The current evidence supports the use of cardioselective beta-blockers in patients with COPD. As the population continues to live longer, comorbidities become ever more present, and cardioselective beta-blockers should not be withheld from patients with COPD and coexistent CHF, because the benefits outweigh the risks.

Heart failure and chronic obstructive pulmonary disease: a review

Heart failure (HF) and chronic obstructive pulmonary disease (COPD) are important causes of morbidity and mortality worldwide. The association between the two conditions have significant systemic effects and a chronic, progressive evolution, affecting exercise tolerance and quality of life. The diseases share common risk factors, such as smoking, advanced age, and low-grade systemic inflammation. The majority of symptoms and physical signs, such as dyspnoea, orthopnea, nocturnal cough, exercise intolerance, muscle weakness may coexist in both pathologies. Thus, the differential clinical diagnosis between exacerbation of COPD and HF decompensation may be difficult. Natriuretic peptides are sensitive biomarkers of HF, used mostly to exclude HF if their values are less than 100 pg/mL for Brain Natriuretic Peptide (BNP), respectively less than 300 pg/mL for N-terminal-pro Brain Natriuretic Peptide (NT-proBNP). Natriuretic peptides are very useful in emergency, for the differential diagnosis of acute dyspnoea. Echocardiography is the standard imaging technique of HF diagnosis and should be performed in all patients with potential HF. Treatment of patients with both HF and COPD should include drugs that prolong survival in HF, such as angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, cardioselective beta1-blockers, aldosterone antagonists, and long-acting bronchodilators (an antimuscarinic rather than a beta2-agonist). The prognosis of patients with both diseases is worse than in patients with only one of the two conditions. These patients represent a continuous challenge of diagnosis and treatment for the clinicians and require a close monitoring of cardiopulmonary function.

The Value of Cardiopulmonary Exercise Testing in Determining Severity in Patients with both Systolic Heart Failure and COPD

Our aim was to identify optimal cardiopulmonary exercise testing (CPET) threshold values that distinguish disease severity progression in patients with co-existing systolic heart failure (HF) and chronic obstructive pulmonary disease (COPD), and to evaluate the impact of the cut-off determined on the prognosis of hospitalizations. We evaluated 40 patients (30 men and 10 woman) with HF and COPD through pulmonary function testing, doppler echocardiography and maximal incremental CPET on a cycle ergometer. Several significant CPET threshold values were identified in detecting a forced expiratory volume in 1 second (FEV₁) < 1.6 L: 1) oxygen uptake efficiency slope (OUES) < 1.3; and 2) circulatory power (CP) < 2383 mmHg.mlO₂.kg⁻¹. CPET significant threshold values in identifying a left ventricular ejection fraction (LVEF) < 39% were: 1) OUES: < 1.3; 2) CP < 2116 mmHg.mlO₂.kg⁻¹.min⁻¹ and minute ventilation/carbon dioxide production (V̇_E/V̇CO₂) slope>38. The 15 (38%) patients hospitalized during follow-up (8 ± 2 months). In the hospitalizations analysis, LVEF < 39% and FEV₁ < 1.6, OUES < 1.3, CP < 2116 mmHg.mlO₂.kg⁻¹.min⁻¹ and V̇_E/V̇CO₂ > 38 were a strong risk predictor for hospitalization (P ≤ 0.050). The CPET response effectively identified worsening disease severity in patients with a HF-COPD phenotype. LVEF, FEV_1, CP, OUES, and the V̇_E/V̇CO₂ slope may be particularly useful in the clinical assessment and strong risk predictor for hospitalization.