Treatable cardiac disease in hospitalised COPD exacerbations

Abstract

IntroductionAcute exacerbations of COPD (AECOPD) are accompanied by escalations in cardiac risk superimposed upon elevated baseline risk. Appropriate treatment for coronary artery disease (CAD) and heart failure with reduced ejection fraction (HFrEF) could improve outcomes. However, securing these diagnoses during AECOPD is difficult, so their true prevalence remains unknown, as does the magnitude of this treatment opportunity. We aimed to determine the prevalence of severe CAD and severe HFrEF during hospitalised AECOPD using dynamic computed tomography (CT).MethodsA cross-sectional study of 148 patients with hospitalised AECOPD was conducted. Dynamic CT was used to identify severe CAD (Agatston score ≥400) and HFrEF (left ventricular ejection fraction ≤40% and/or right ventricular ejection fraction ≤35%).ResultsSevere CAD was detected in 51 of 148 patients (35%), left ventricular systolic dysfunction was identified in 12 cases (8%) and right ventricular systolic dysfunction was present in 18 (12%). Clinical history and examination did not identify severe CAD in approximately one-third of cases and missed HFrEF in two-thirds of cases. Elevated troponin and brain natriuretic peptide did not differentiate subjects with severe CAD from nonsevere CAD, nor distinguish HFrEF from normal ejection fraction. Undertreatment was common. Of those with severe CAD, only 39% were prescribed an antiplatelet agent, and 53% received a statin. Of individuals with HFrEF, 50% or less received angiotensin blockers, beta blockers or antimineralocorticoids.ConclusionDynamic CT detects clinically covert CAD and HFrEF during AECOPD, identifying opportunities to improve outcomes via well-established cardiac treatments.

The untreated treatable trait: Cardiovascular disease in COPD exacerbations

“…Our data complement this notion: 55% of individuals with hospitalized AECOPD had sufficiently severe coronary atherosclerosis to warrant aspirin and lipid‐lowering therapy but most were not treated 18 . Thus, it would be common for patients with AECOPD to have some degree of coronary atherosclerosis that is undertreated 11 . In addition, emerging data suggest that therapeutic responses may vary according to cardiac imaging phenotype 19 …”

“…To examine this question, we recently employed a novel dynamic (i.e. video) cardiac computed tomography (CT) protocol, examining the prevalence of severe heart failure with reduced ejection fraction and severe calcific coronary atherosclerosis in hospitalized AECOPD 11 . Briefly, dynamic CT can assess multiple important parameters which were previously difficult to assess including coronary atherosclerosis, atrial, ventricular, pulmonary and systemic vascular function in addition to pulmonary pathologies 8 …”

“…The Global Initiative for Chronic Obstructive Lung Disease (GOLD) 15 and COPD‐X 16 suggest a clinically directed approach to detection of cardiovascular disease during AECOPD, using descriptors such as ‘alternative’, 16 ‘complications’ 16 (COPD‐X) and ‘differential’ 15 (GOLD) to frame cardiovascular disease. Such terminology would imply that AECOPD and cardiovascular disease are mutually exclusive; however, it is clear that both diseases can be simultaneously present 10,11 . An additional conundrum for the clinician is that these influential documents acknowledge that the conventional clinical cardiovascular diagnostic armamentarium is blunted in COPD, but still suggest a clinically directed approach.…”

Contemporary Concise Review 2020: Chronic obstructive pulmonary disease

“…3). 54 Among 148 hospitalized AECOPD, dynamic cardiac CT frequently identified severe coronary artery disease and left ventricular systolic dysfunction, conditions that were otherwise clinically covert 55 . Given that mortality in COPD is closely linked to both lung and cardiac diseases, 53 this field merits further intensive research.…”

Statistical Validation of Cardiovascular Digital Biomarkers Towards Monitoring the Cardiac Risk in COPD: A Lyfas Case Study

“…It is characterized by persistent and progressive respiratory difficulties, especially exhalation (evident by lower FEV 1 values), and excessive mucous production in the respiratory passage. As the condition progresses (i.e., FEV 1 values diminishes), it poses a high risk of (i) right ventricular failure, clinically called Cor Pulmonale [6], and finally, (ii) Bi-Ventricular Failure [7], where the respiratory distress is even worse characterized by orthopnoea (severe respiratory distress while lying, which is relieved with sitting posture) [8], (iii) increased blood-tinged mucous production due to rupture of the bronchial vessels as a consequence of strenuous breathing, (iv) deep cyanosis due to lack of oxygen in the tissues, (v) cardiac edema leading to fluid accumulation in the dependent part of the body, (vi) paroxysmal nocturnal dyspnea (also known as the cardiac COPD), and finally (vii) respiratory muscle failure [9]. Therefore, FEV 1 is a critical pathophysiological parameter to assess the cardiac risk in COPD patients [10].…”