Co-morbidities in AHF : Pulmonary disease.

1. Comorbidities in acute heart failure-
pulmonary disease
Frans H. Rutten, MD, PhD, general practitioner
Frans H. Rutten, MD, PhD, general practitioner
Julius Center, University Medical Center Utrecht,
Netherlands

2. No conflict of interest on this topic

3. 40% ‘COPD’ aged 65 yrs or over: NO COPD1
78% ‘COPD’ hospitalized acute systolic HF: NO COPD 2
20.5% ‘COPD’: unrecognized HF 1
20.5% real COPD: unrecognized HF 1
1. Rutten FH et al. EHJ 2005;26:1887-94
2. Brenner S et al. Int J Card 2013;168:1910-6.
Doubt diagnosis of COPD!!
cardiologists afraid to overdiagnose HF..
pulmonologist/GPs are not afraid to overdiagnose COPD..

4. Background
heart and lungs ‘tandem’ in providing oxygen saturated blood
both share tobacco smoking as important risk factor:
- lung destruction (Western world >90% COPD by smoking)
- endothelial dysfunction atherosclerosis and IHD
- first/second/third hand smoke plaque rupture/erosion
risk of acute MI , also in non-smokers
- cause of death in COPD patients often cardiovascular

5. Observed and modelled rates for all myocardial infarction
admissions in Liverpool, 2004–2012, divided by gender
Liu A et al. BMJ Open 2013;3:e003307
©2013 by British Medical Journal Publishing Group

6. smoking ban resulted in reduction in acute MI
• Flanders Belgium Heart 2014;100:1430-5
before and after smoking ban in public places, work places,
restaurants
women < 60 jr - 33.8% > 60 jr - 9.0%
men < 60 jr - 13.1% > 60 jr - 7.0%
• Schmucker Germany Eur J Prev Cardiol 2014;9:1180-6
+4% smokers
16% reduction STEMI
-26% non smokers

7. Also in patients with COPD:
Heart failure ‘always’ left sided
Only ≈ 1% cor pulmonale (SPAP > 50mmHg)
Naeije R et al Proc Am Thorac Soc 2005;2:20-2

8. To whom should GP refer?
pulmologist or cardiologist
75 yrs old female
Obese, 30 pack yrs of smoking
20 yrs hypertension, 5 yrs coxartritis, 3 yrs diabetes
15 yrs COPD GOLD II (FEV1/FVC 65%, FEV1%pred 65%)
Primary care: 2 days more severe breathlessness,
coughing, last night orthopnoea.
Drugs: enalapril 20 mg bd, hydrochlorothiazide 25 mg od,
simvastin 40mg od, metformin 850mg bd,
tiotropium bromide inhalation18mcg bd
PE: 96 kg, 1,70m, BMI 33 kg/m2, temp 38.3 Celcius, RR 164/86 mmHg,
pulse 104 regular, 24 breaths/min, oxygen saturation 86%, lungs: rattling
breathing sounds with wheezing. JVP ?, murmurs? Apical impulse?
Is pulmonary infection the single cause?

9. respiratory symptoms ≠ pulmonary disease
Does wheezing fit with asthma or COPD?
35% of elderly with AHF wheeze at initial
presentation
Risk of overdiagnosing COPD
Jorge S et al. BMC Cardiovasc Disord 2007;7:16

10. (luckily) referred to cardiologist
ECG: SR, 104 bpm, ‘normal’
Echo: hypertrophic LV (wall thickness 13 mm)
LVEF >55%,
valves ‘normal’, indexed LA volume 40 ml/m2,
E/e’ 18, septal e’ 4 cm/s, Systolic PAP 35 mmHg.
Chest X-ray: CTR 0.49, no infiltrate or pleural fluid, however, cephalization.
Lab: Hb 8.0 mmol/l (13.6 mg/ml), leucocytes 13.3/l, creatinine 50 μmol/l
(eGFR>60 ml/min) , glucose 14.0 mmol/l,
NTproBNP 1620 pg/ml, hs-troponine I 0.043
Conclusion cardiologist: acute HFpEF triggered by pulmonary infection
Pulmonologist: exacerbation COPD ? Antibiotics, oral prednisolone, ß2-mimetics ?

11. diagnostic pitfalls with spirometry in HF
COPD (GOLD-criteria) = Obstruction on spirometry
= FEV1/FVC <70% (or LLN)
acute HF (fluid overload): FEV1 more reduced than FVC
elevated interstitial pulmonary fluid pressure 
pulmonary obstruction with spirometry !!
better to (also) perform bodyplethysmography (RV/TLC)
Gueder G, et al. J Card Fail 2012;18:637-644

12. diagnostic pitfalls with spirometry in HF (2)
Should be done when ‘dry’: 3 months after hospitalization
stable non-acute HF: both FEV1 and FVC reduced with 20%, but
FEV1/FVC ratio may be used
(over-rating FEV1%pred !)
619 SHF (LVEF <40%) admitted for acute HF, 23% labeled COPD
After 6 months when ‘dry’: in 9% COPD (5% known, 4% new cases)
Brenner S et al. Int J Card 2013;168:1910-6. J Card Fail 2012;18:637-644

13. Therapeutic challenges in our case

14. Pre-hospital treatment options
• measure oxygen saturation
• 5 l/min oxygen (2 l/min in COPD patients)
• when systolic >90 mmHg; nitroglycerine sublingual
• furosemide 40 mg iv
• 2.5-5 mg morphine slowly iv (severe dyspnoea/agitation)

16. Other options for our case?
–

17. Any other options in our case?
- antibiotics for pulmonary infection
- Short acting beta2 mimetic inhalation for the first minutes???
• …on the short run…it may reduce pulmonary congestion by increasing
transepithelial sodium and chloride transport (shown in animal models)!
• …on the short run.. in small sized studies increased FEV1, improved
peripheral oxygen delivery, increased cardiac index, and decreased
systemic vascular resistance
• On the other hand: positive chronotropic effects; increased heart rates and
decreased potassium levels; facilitating hypo-potassemia -induced
arrhythmias and tachycardias.
Maak CA, et al. J Emerg Med 2013;40:135-145, Mutlu GM. Crit Care Med 2004;32:1607-1608,
Singer AJ et al ADHERE-EM Ann Emerg Med 2008

18. When stable again; beta-blockers allowed?
practice study UK: >80% of HFrEF patients with COPD
managed in HF outpatient clinic tolerated beta-blockers
Shelton RJ, et al. Heart 2006;92:331-36.
But,
Beta-blockers might slightly reduce FEV1
- clinically irrelevan, but ….
another risk of overdiagnosing COPD
Gueder G et al EJHF 2014

19. Association between beta-blockers and mortality in
COPD patients (observational studies)
Etminan M, et al. BMC 2012; 12:48

20. Other cardiovascular drugs in COPD
Same story as for beta-blockers.
Also statins and ACEi and ARBs may reduce all-cause mortality
But, observational studies !!
Risk of (residual) confounding
1. Mancini GBJ et al. JACC 2006;47:2554-60 (ACE-i/ARBs, statins)
2. Soyeth V et al. Eur Resp J 2007;29:279-83 (statins)

21. Conclusions
• a label of COPD ≠ true COPD
• HF treatment on the first place before inhalers
• spirometry should be done when stable/euvolemic
• shortacting beta2-mimetics in acute HF (those wheezing)??
• near future; RCTs with CV drugs in COPD??
• when stabilised: not withhold HF patients from beta-blockers

22. Thank you for your attention