Chronic Obstructive Pulmonary Disease in Elderly Patients with Acute and Advanced Heart Failure: Palliative Care Needs—Analysis of the EPICTER Study

Abstract

Introduction: There are studies that evaluate the association between chronic obstructive pulmonary disease (COPD) and heart failure (HF) but there is little evidence regarding the prognosis of this comorbidity in older patients admitted for acute HF. In addition, little attention has been given to the extracardiac and extrapulmonary symptoms presented by patients with HF and COPD in more advanced stages. The aim of this study was to evaluate the prognostic impact of COPD on mortality in elderly patients with acute and advanced HF and the clinical manifestations and management from a palliative point of view. Methods: The EPICTER study (“Epidemiological survey of advanced heart failure”) is a cross-sectional, multicenter project that consecutively collected patients admitted for HF in 74 Spanish hospitals. Demographic, clinical, treatment, organ-dependent terminal criteria (NYHA III-IV, LVEF <20%, intractable angina, HF despite optimal treatment), and general terminal criteria (estimated survival <6 months, patient/family acceptance of palliative approach, and one of the following: evidence of HF progression, multiple Emergency Room visits or admissions in the last six months, 10% weight loss in the last six months, and functional impairment) were collected. Terminal HF was considered if the patient met at least one organ-dependent criterion and all the general criteria. Both groups (HF with COPD and without COPD) were compared. A Kaplan–Meier survival analysis was performed to evaluate the presence of COPD on the vital prognosis of patients with HF. Results: A total of 3100 patients were included of which 812 had COPD. In the COPD group, dyspnea and anxiety were more frequently observed (86.2% vs. 75.3%, p = 0.001 and 35.4% vs. 31.2%, p = 0.043, respectively). In patients with a history of COPD, presentation of HF was in the form of acute pulmonary edema (21% vs. 14.4% in patients without COPD, p = 0.0001). Patients with COPD more frequently suffered from advanced HF (28.9% vs. 19.4%; p < 0.001). Consultation with the hospital palliative care service during admission was more frequent when patients with HF presented with associated COPD (94% vs. 6.8%; p = 0.036). In-hospital and six-month follow-up mortality was 36.5% in patients with COPD vs. 30.7% in patients without COPD, p = 0.005. The mean number of hospital admissions during follow-up was higher in patients with HF and COPD than in those with isolated HF (0.63 ± 0.98 vs. 0.51 ± 0.84; p < 0.002). Survival analysis showed that patients with a history of COPD had fewer survival days during follow-up than those without COPD (log Rank chi-squared 4.895 and p = 0.027). Conclusions: patients with HF and COPD had more severe symptoms (dyspnea and anxiety) and also a worse prognosis than patients without COPD. However, the prognosis of patients admitted to our setting is poor and many patients with HF and COPD may not receive the assessment and palliative care support they need. Palliative care is necessary in chronic non-oncologic diseases, especially in multipathologic and symptom-intensive patients. This is a clinical care aspect to be improved and evaluated in future research studies.

Does Hospitalist Care Enhance Palliative Care and Reduce Aggressive Treatments for Terminally Ill Patients? A Propensity Score-Matched Study

“…A routine and early palliative care initiation to deal with the burden of physical and psychological symptoms of patients with malignant disease has become the standard of care [23]. Furthermore, the importance of palliative care intervention for patients with end-stage organ dysfunction, such as kidney injury [24,25], advanced heart failure [26], and chronic obstructive pulmonary disease [27], has been increasingly addressed. Discussions of EOL care preferences and modalities of life-sustaining treatments are challenging [28].…”

The impact of secondary pulmonary hypertension in elderly patients with chronic obstructive pulmonary disease

“…COPD complications increase the risk of death due to other comorbidities; therefore, the health impact of COPD may be underestimated, considering that 50% of mortality in COPD patients is caused by non-respiratory diseases [5,11,12]. Specific to COPD in geriatrics are: (1) higher prevalence in the elderly; (2) higher severity of the disease; (3) a silent clinical picture in the early stages, with the disease being unrecognized and untreated until it progresses to a more severe degree; (4) the association with a large number of comorbidities (average of 9); (5) a higher mortality rate; (6) reduced therapeutic efficacy and (7) a significant quality of life impact [13][14][15][16][17][18]. Exacerbation of COPD in the elderly consisted of aggravation of the disease, the apparition of other symptoms and worsening of the pre-existing ones, a significant decline in functional and cognitive performance, a reduction in quality of life, and a poor prognosis.…”

“…Exacerbation of COPD in the elderly consisted of aggravation of the disease, the apparition of other symptoms and worsening of the pre-existing ones, a significant decline in functional and cognitive performance, a reduction in quality of life, and a poor prognosis. As a result, determining the evolution characteristics of COPD in elderly patients is regarded as critical for early COPD diagnosis, assessment of COPD secondary hemodynamic disorders, implementation of effective therapeutic interventions, and reduction of the economic impact on the public health system [11,14,19].…”