Coexisting chronic obstructive pulmonary disease and cardiovascular disease in clinical practice: a diagnostic and therapeutic challenge

Abstract

C hronic obstructive pulmonary disease (COPD) is the cardinal smoking-related respiratory illness. 1,2 Diagnosis requires exposure to noxious inhalants, respiratory symptoms, and spirometry demonstrating airflow obstruction, defined by a post-bronchodilator forced expiratory volume in one second (FEV 1 ) divided by forced vital capacity ratio < 0.70. 1,2 COPD is the fifth leading cause of disability-adjusted life-years worldwide, affecting about 14% of Australians above the age of 40 years. 2 COPD has a profound impact on the Australian hospital system. In 2015-16, it was the most common cause of potentially preventable hospitalisations related to chronic conditions in Australia; it was followed by heart failure. 3 In Australian general practice, both respiratory presentations and cardiovascular issues are common, so co-occurrence is frequent. 4 Cardiovascular disease (CVD) has compelling links to COPD. Individuals with COPD have a nearly 2.5-fold risk of CVD in comparison with controls. 5 Moreover, patients with comorbid COPD and CVD report more breathlessness and worse quality of life, are more frequently hospitalised and have higher mortality than those with COPD alone. 6 More than a quarter of patients with COPD will die from a cardiovascular event, and 40% of patients with COPD and a cardiovascular history will die following a cardiovascular event. 6Despite this, under-diagnosis of CVD in patients with COPD is frequent. For example, in patients with COPD and electrocardiographic evidence of myocardial infarction, less than one-third had been diagnosed with CVD. 7 COPD and CVD share risk factors and symptoms with significant overlap in clinical presentations. Determining the presence and contributions of the individual diseases can help clinicians prognosticate and manage this complex population.We searched PubMed for COPD and cardiovascular terms. We examined clinically relevant aspects of their relationship, diagnostic challenges and current and future therapeutic strategies. COPD and CVD: shared pathophysiologyDisease processes in COPD and CVD overlap, and salient clinical aspects are outlined below. Shared risk factorsPatients with COPD generally have multiple major risk factors for CVD. They have almost invariably smoked, and tend to be older, male and less physically active (Box 1). Hypertension is highly prevalent and present in up to 77% of some COPD cohorts. 1,5 However, these are insufficient to explain the excess CVD prevalence seen in COPD. 6 1

Treatable cardiac disease in hospitalised COPD exacerbations

“…The accurate bedside differentiation of pulmonary and cardiac diagnoses during AECOPD can be difficult. Clinical features such as dyspnoea and chest discomfort overlap and although evidence of missed ischaemic events can be found on ECGs, in the acute setting, these remain mostly nonspecific [ 2 , 14 ]. Standard cardiac imaging modalities have substantive limitations during AECOPD that render them inaccurate or impractical [ 2 , 14 ].…”

“…Clinical features such as dyspnoea and chest discomfort overlap and although evidence of missed ischaemic events can be found on ECGs, in the acute setting, these remain mostly nonspecific [ 2 , 14 ]. Standard cardiac imaging modalities have substantive limitations during AECOPD that render them inaccurate or impractical [ 2 , 14 ]. For example, transthoracic echocardiography suffers from limited acoustic windows, and cardiac magnetic resonance imaging is typically not feasible in acutely dyspnoeic individuals [ 2 ].…”

<p>Different Clusters in Patients with Chronic Obstructive Pulmonary Disease (COPD): A Two-Center Study in Brazil</p>

“…This cluster presented the higher proportion of metabolic comorbidities associated to COPD and can be related to higher risk of cardiovascular events. 46,47 In clinical practice, the identification of these patients should always be considered to receive appropriate treatment and better control of the disease. 44,46,47 In the current study, cluster 3 identified high levels of CRP and neutrophils, with moderate airflow limitation, suggesting the association of the systemic inflammatory process and the systemic manifestation of disease (lower BMI values and lower physical performance).…”

“…46,47 In clinical practice, the identification of these patients should always be considered to receive appropriate treatment and better control of the disease. 44,46,47 In the current study, cluster 3 identified high levels of CRP and neutrophils, with moderate airflow limitation, suggesting the association of the systemic inflammatory process and the systemic manifestation of disease (lower BMI values and lower physical performance). 48,49 The literature is consistent to demonstrate an increased risk of mortality in COPD patients with cachexia.…”

The untreated treatable trait: Cardiovascular disease in COPD exacerbations

“…Furthermore, during AECOPD, a slew of intercurrent, superimposed factors may influence COPD and cardiovascular disease—these include viral and bacterial infections, inflammation, hyperinflation and pharmaco‐therapeutic effects 4 . Consequently, cardiovascular disease and COPD may be present independently, coexist or masquerade as the other during AECOPD 5 . Deciphering this complicated disease network 6,7 during a time of acute illness can be difficult.…”