Challenges in the Management of Patients with Chronic Obstructive Pulmonary Disease and Heart Failure With Reduced Ejection Fraction

Abstract

Chronic obstructive pulmonary disease (COPD) and heart failure with reduced ejection fraction (HFrEF) commonly coexist in clinical practice. The prevalence of COPD among HFrEF patients ranges from 20 to 32 %. On the other hand; HFrEF is prevalent in more than 20 % of COPD patients. With an aging population, the number of patients with coexisting COPD and HFrEF is on rise. Coexisting COPD and HFrEF presents a unique diagnostic and therapeutic clinical conundrum. Common symptoms shared by both conditions mask the early referral and detection of the other. Beta blockers (BB), angiotensin-converting enzyme inhibitors, and aldosterone antagonists have been shown to reduce hospitalizations, morbidity, and mortality in HFrEF while long-acting inhaled bronchodilators (beta-2-agonists and anticholinergics) and corticosteroids have been endorsed for COPD treatment. The opposing pharmacotherapy of BBs and beta-2-agonists highlight the conflict in prescribing BBs in COPD and beta-2-agonists in HFrEF. This has resulted in underutilization of evidence-based therapy for HFrEF in COPD patients owing to fear of adverse effects. This review aims to provide an update and current perspective on diagnostic and therapeutic management of patients with coexisting COPD and HFrEF.

National Heart Foundation of Australia and Cardiac Society of Australia and New Zealand: Guidelines for the Prevention, Detection, and Management of Heart Failure in Australia 2018

“…Inhaled salmeterol improved forced expiratory volume (FEV) 1 in a small study in eight patients with NYHA II or III heart failure [439]. Inhaled corticosteroids have a better side effect profile than oral steroids [440]. Use of oral corticosteroids can increase fluid retention, and doses over 20 mg/day have been associated with acute decompensated heart failure [440].…”

“…Inhaled corticosteroids have a better side effect profile than oral steroids [440]. Use of oral corticosteroids can increase fluid retention, and doses over 20 mg/day have been associated with acute decompensated heart failure [440].…”

Management protocols for chronic heart failure in India

“…Other common co-morbidities in HF patients include iron deficiency (serum ferritin <100 μg/L or ferritin between 100 and 299 μg/L and transferrin saturation <20%) and anemia, CKD (eGFR <60 mL/min/1.73 m 2 and/or presence of albuminuria, i.e., high 30–300 or very high >300 mg albumin/1 g of urine creatinine) and COPD 8, 9. Key considerations regarding the management of these patients are outlined in Box 23, Box 24, Box 25 8, 67, 74Key considerations in HF patients with iron deficiency/anemiaPatients should be screened for potentially treatable/reversible causes such as gastrointestinal sources of bleeding.Treatment with IV ferric carboxymaltose is effective in HFrEF patients with iron deficiency.In case of anemia, evaluate and rectify the cause, e.g., occult blood loss, iron deficiency, B 12 /folate deficiency, blood dyscrasias, etc.ESA have been shown to increase hemoglobin levels.…”

Chronic Respiratory Abnormalities in the Multi-Morbid Frail Elderly

“…Because of the potential adverse effect of cardiovascular drugs, and particularly the BB, the prevalence and impact of COPD has been more frequently investigated in cardiovascular diseases 33,39 .…”

“…This is particularly true for patients with HF with reduced ejection fraction 39 , whereas it remains to be properly investigated for the 50% of patients with HF and preserved ejections fraction who are treated like the former but without any evidence of efficacy and safety 15 .…”