A yearly influenza vaccine reduces serious illness and death in COPD patients by nearly 50%. Pneumococcal polysaccharide vaccine is also recommended for COPD patients aged 65 years and older or those younger than age 65 years with an FEV1 <40% predicted.1
Long-term oxygen therapy is indicated for patients with chronic respiratory failure and has been shown to increase survival rates. The primary goal is to increase the baseline PaO2 to at least 60 mm Hg at rest and SaO2 to at least 90%.1
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Nonpharmacologic considerations include reduction or elimination of exposure to tobacco smoke, occupational dust and chemicals, and air pollutants. For patients with COPD, health education is essential to effective treatment, as it plays a vital role in smoking cessation, medication compliance, and the ability to cope with illness.1
Pharmacologic and nonpharmacologic HF treatment
The cornerstones of pharmacologic therapy for HF are ACE inhibitors and beta blockers. Unless contraindicated, an ACE inhibitor should be started in all patients with symptomatic HF and left-ventricle EF (LVEF) <40%.
Beta blockers should be used in all patients with symptomatic HF and LVEF <40%. Both treatment modalities will improve ventricular function and patient well-being, reduce hospitalizations, and increase survival rates.3
Angiotensin II receptor blockers (ARBs) are recommended as an alternative for those who cannot tolerate ACE inhibitors (LVEF <40%, NYHA class III-IV). Another indication for use of an ARB is persistent symptoms despite treatment with an ACE inhibitor and beta blocker.
Consider aldosterone antagonists for all patients with EF <35%, NYHA class III-IV with moderate-to-severe symptoms, and after optimal dose of beta blocker and ACE inhibitor or ARB.
Used in combination, hydralazine and isosorbide dinitrate are an alternative when an ACE inhibitor or ARB is not tolerated. They can be used as an add-on therapy to an ACE inhibitor if an ARB or aldosterone antagonist is not tolerated. The evidence for such use is strongest in African-Americans.
Diuretics are recommended in HF patients with clinical signs and symptoms of pulmonary congestion. Since diuretics can activate the renin-angiotensin-aldosterone system in patients with mild symptoms of HF, they should be used in combination with an ACE inhibitor or ARB. Loop diuretics are recommended for moderate or severe HF. A thiazide diuretic may be used in combination with loop diuretics for resistant edema.
Digoxin may be necessary in patients with HF and atrial fibrillation and may be used to slow a rapid ventricular rate. In patients with AF and LVEF <40%, digoxin should be used to control heart rate in addition to or prior to a beta blocker.
Nonpharmacologic recommendations for treatment of HF include revascularization, valvular surgery, cardiac resynchronization therapy, pacemaker and/or implantable cardioverter defibrillator (ICD), left ventricular assist devices or heart transplantation.
Influenza vaccine and pneumococcal vaccine are also important considerations. Vigilance in terms of anemia, cachexia and gout are recommended as well.
Integrating HF and COPD guidelines in clinical practice
The detection and treatment of pulmonary congestion is the highest priority for patients with combined HF and COPD. The presence of pulmonary congestion is best established through a combination of objective and subjective exam findings, laboratory data, and imaging. Specifically, BNP >500 ng/mL, orthopnea, S3 gallop, rales and interstitial pulmonary infiltrates on chest x-ray are suggestive of fluid overload.
Agents with documented effects on morbidity and mortality such as ACE inhibitors, beta blockers, and ARBs should be continued in patients with comorbid COPD and HF. The majority of patients with HF and COPD can safely tolerate beta blockers, especially when initiated at a low dose and gradually titrated up.
Mild deterioration of pulmonary function and symptoms should not lead to prompt discontinuation of beta blockers. If symptoms worsen, a reduction of the dosage or withdrawal may be necessary. Selective beta blockers are preferred to nonselective beta blockers in patients with coexisting COPD and HF.
Similarly, inhaled beta-agonists should be administered in accordance with the established guidelines in patients with COPD in the presence of HF.3
Adjustments in medication should be based on assessment findings, laboratory tests, imaging, and whether a patient is at maximum levels of established pharmacologic therapy. For patients who are on maximum therapeutic doses of medications, the addition of hydralazine and isosorbide dinitrate is considered prudent. Similarly, adjustments to diuretic therapy may be beneficial by means of up-titration or changing from a thiazide-type diuretic to a loop diuretic.
These recommendations are not as firmly established as the existing guidelines for the management of the diseases as they occur separately. The management of patients with coexisting COPD and HF should include input from pulmonology and cardiology.
Case study outcome
Table 3 summarizes of the exam findings and treatment plan of the patient described at the beginning of this article. Because pulmonary function testing had not been performed for several years, a referral to a pulmonologist was recommended.
Likewise, a referral to an interventional cardiologist was made to discuss combination bi-ventricular pacemaker/ICD placement. Combined cardiac and pulmonary rehabilitation was also recommended.
Hydralazine was added to his existing medications in an attempt to confront hypertension and decreased EF. A chest x-ray, ECG, CBC, electrolytes, BNP, LFTs, and a renal panel were obtained. Follow-up in two weeks was advised to evaluate the effectiveness of the interventions.
Conclusions
Medical specialties have traditionally separated HF and COPD into distinct components, even when they coexist in the same patient. This compartmentalization of disease processes makes it difficult for PCPs to manage individuals who have these diseases comorbidly, because the varying disciplines often have differing opinions on the management of the patient.
This forces the PCP to become the mediator for appropriate management of these patients. The lack of guidance on these comorbid disease processes further complicates matters for PCPs and points to the need for further interdisciplinary dialogue and research.
Maija Bamford, ANP, is a registered nurse at Ohio State’s Ross Heart Hospital in Columbus. Matthew R. Paulus, ANP-BC, is a Federal Nurse Practitioner Fellow in Columbus. The authors have no relationships to disclose regarding the content of this article.
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References
2. The Criteria Committee of the New York Heart Association. Nomenclature and Criteria for Diagnosis of Diseases of the Heart and Great Vessels. 9th ed. Boston, Mass: Little, Brown & Co; 1994:253-256.
5. Gonzales R, Nadler PL. Common symptoms. In: McPhee SJ, Papadakis MA, eds. Current Medical Diagnosis & Treatment. 49th ed. New York, N.Y.: McGraw-Hill; 2010:22-30.
6. Ferri FF. Ferri’s Clinical Advisor. Philadelphia, Pa.: Elsevier Mosby:439.
8. Simon PM, Schwartzstein RM, Weiss JW et al. “Distinguishable types of dyspnea in patients with shortness of breath.” Am Rev Respir Dis. 1990;142:1009-1014.
9. Chernecky CC, Berger BJ. Laboratory Tests and Diagnostic Procedures. 5th ed. St. Louis, Mo.: Saunders Elsevier; 2008:808.
10. Le Jemtel TH, Padeletti M, Jelic S. Diagnostic and therapeutic challenges in patients with coexistent chronic obstructive pulmonary disease and chronic heart failure. J Am Coll Cardiol. 2007;49:171-180.
All electronic documents accessed October 11, 2011.
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