Greater chronic obstructive pulmonary disease (COPD) severity was linked in a British study to increased mortality and hospitalizations in patients with comorbid heart failure, researchers said.
Their conclusion: optimal care of patients with both conditions requires accurate diagnosis and targeting of severe COPD markers.
Among 50,114 patients with newly diagnosed HF (median age 79; 46% female), those with COPD were significantly more likely to die during follow-up (adjusted odds ratio 1.31; 95% CI 1.26-1.36) and hospitalization (aOR 1.33; 95% CI 1.26-1.39), reported Claire Lawson, PhD, of the University of Leicester in England, and colleagues in JAMA Network Open.
The increased risks were seen primarily in patients who were prescribed the most intense COPD medications, including triple inhaler therapy, oral corticosteroids, and/or oxygen therapy.
Other main findings included:
- The three most severe medication intensity levels showed significantly increasing mortality associations: full inhaler therapy (aOR 1.17; 95% CI 1.06-1.29) to oral corticosteroids (aOR 1.69; 95% CI 1.57-1.81) to oxygen therapy (aOR 2.82; 95% CI 2.42-3.28).
- The respective estimates for medication intensity and hospitalization were similar: 1.17 (95% CI 1.03-1.33), 1.75 (95% CI 1.59-1.92), and 2.84 (95% CI 1.22-3.63).
- Availability of spirometry data was limited but showed that increasing airflow limitation was associated with increased risk of mortality: forced expiratory volume in one second (FEV1) 80% or more, aOR 1.63 (95% CI 1.42-1.87); FEV1 50% to 79%, aOR 1.69 (95% CI 1.56-1.83); FEV1 30% to 49%, aOR 2.21 (95% CI 2.01-2.42); FEV1 less than 30%, aOR 2.93 (95% CI 2.49-3.43).
Associations between FEV1 and hospitalization risk, on the other hand, were similar among COPD severity stages, with adjusted odds ratios ranging only from 1.48 for FEV1 80% or more to 1.73 for FEV1 less than 30%.
Lawson and colleagues said the study is the largest to date to examine the impact of COPD severity on outcomes in patients with heart failure. They added that while there is some evidence that COPD severity is an independent risk factor for heart failure death and hospitalization, the research has been limited.
Using the U.K. Clinical Practice Research Datalink (CPRD), the researchers identified hospitalized patients with a newly diagnosed HF from 2002 through 2013. Heart failure patients with COPD were compared to patients without COPD, and international COPD GOLD guidelines were used to stratify patients with COPD into seven medication intensity levels and four airflow limitation severity stages.
A major study limitation cited by the researchers was the lack of recorded spirometry data for half of the patients with HF and COPD.
In patients without spirometry readings, COPD was found to be protective against death and was associated with a lower risk for hospitalizations.
The researchers hypothesized that the group without spirometry may have had milder severity COPD, or may not have had COPD at all.
“The diagnosis of COPD in patients with HF is complicated by nonspecific shared symptoms such as breathlessness and spirometry is required for accurate diagnosis, which can be particularly challenging in the community setting,” Lawson and colleagues wrote. “While we used specific clinical COPD diagnostic codes that have demonstrated high precision in CPRD, this study highlights an urgent need to improve routine assessment of lung function for all patients with HF and COPD in the community.”
Another significant finding was that use of short-acting beta-agonist inhalers in patients with HF but without COPD was associated with a 30% increased risk in all-cause hospitalizations.
In an editorial published with the study, Frans Rutten, MD, PhD, and Berna Broekhuizen, MD, PhD, of the Netherlands’ Utrecht University Medical Center, wrote that this finding confirms that use of short-acting beta-agonists should be limited in HF.
“Moreover, this finding may also be explained by inadequate management of exacerbations of HF, misinterpreted as COPD symptoms, and treated by inhaled β-mimetics instead of up-titration of diuretics,” they wrote.
The editorialists noted that the study findings “clearly highlighted that concurrent COPD is associated with poor outcome, which is worse in severe cases.”
“The finding that short-acting inhaled β-mimics may be deleterious in patients with HF is a crucial finding and in line with literature, and should urge clinicians to refrain from prescribing these drugs that are not obligatory in COPD, but instead use inhaled long-acting β-mimetics and muscarin antagonists,” Rutten and Broekhuizen said.
“In addition, we need valid diagnoses of both COPD and HF, and notably the diagnosis in the presence of the other is a challenge, even when a patient receives noninvasive diagnostic tests available for such cases,” they concluded.
Funding for this research was provided by the National Institute for Health Research, the University of Leicester, and others.