Awareness of pulmonary hypertension in patients with COPD growing

Key takeaways:

• Pulmonary hypertension appears in 25% to 30% of patients with COPD.
• There are no approved therapies for patients with this disease combination.
• Two trials assessing different treatments are ongoing.

PHILADELPHIA — With the 2025 GOLD report newly featuring a section dedicated to pulmonary hypertension, it is important that clinicians expand their knowledge of this comorbidity, according to a presentation.

“If you want to understand COPD as a whole, you also need to pay attention to smaller details like the pulmonary vasculature,” Gabor Kovacs, MD, of the division of pulmonology in the department of internal medicine at Medical University of Graz, said during his presentation at the 2024 GOLD COPD International Conference.

“There are some pathophysiologic mechanisms which are common in COPD and in pulmonary hypertension that affect the lung parenchyma, the airways and the lung vessels,” Kovacs said.

To gain a better understanding of pulmonary hypertension (PH) and the different forms it can take, Kovacs highlighted the five PH classifications/groups and noted that most patients with COPD belong to group 3, or severe pulmonary hypertension associated with lung diseases and/or hypoxia.

Importantly, patients with COPD and PH could also be classified with PAH (group 1), PH associated with left heart disease (group 2) and PH associated with pulmonary artery obstructions including chronic thromboembolic pulmonary hypertension (group 4), Kovacs said.

“According to the current definition of pulmonary hypertension, which is about 20 mm of mercury in the mean pulmonary arterial pressure address, we have to state that patients with COPD very frequently have pulmonary hypertension, especially if they have severe COPD,” Kovacs said. “If COPD is not specifically severe, even then, we believe that 25% to 30% of patients have pulmonary hypertension.”

On the topic of COPD severity, Kovacs also pointed out the existence of patients with COPD with the “pulmonary vascular phenotype,” meaning they have lower COPD severity but significant pulmonary vascular disease.

With respect to patient outcomes, one factor negatively impacted by a diagnosis of both COPD and pulmonary hypertension is survival, according to the presentation.

Using data from a study published in CHEST that he was first author on, Kovacs showed that when patients with COPD are divided based on GOLD stage plus severe vs. nonsevere PH, those with GOLD 3 to 4 plus severe PH had worse survival than those with GOLD 1 to 2 plus nonsevere PH. Survival of patients with GOLD 1 to 2 plus severe PH or GOLD 3 to 4 plus nonsevere PH fell in between the above groups.

When presented with the question of which patients with COPD should be diagnosed with PH, Kovacs said to concentrate on those with severe PH.

Additionally, severe pulmonary vascular disease should be considered in patients with COPD if airflow obstruction/limitation do not explain all their symptoms, Kovacs said.

“In the first step, echocardiography should be done,” Kovacs said. “If echocardiography suggests the presence of severe pulmonary hypertension, then it’s important to investigate these patients in expert centers with right heart catheterization.”

Unfortunately, there are no approved therapies for patients with this disease combination; however, Kovacs highlighted that there have been studies performed in this population showing treatment potential with sildenafil (studied in patients with moderate COPD and severe PH) and phosphodiestrerase-5 inhibitors.

Clinicians managing these patients should turn to the 2022 ESC/ERS PH guidelines, as there are four recommendations that mention patients with PH plus lung disease. According to Kovacs’s presentation, these include:

• “In patients with lung disease and suspected PH, it is recommended to optimize treatment of the underlying lung disease and, where indicated, hypoxemia, sleep-disordered breathing and/or alveolar hypoventilation;
• In patients with lung disease and suspected severe PH, or where there is uncertainty regarding the treatment of PH, referral to a PH center is recommended;
• In patients with lung disease and severe PH, an individualized approach to treatment is recommended; and
• The use of PAH medication is not recommended in patients with lung disease and non-severe PH.”

Notably, a figure in the 2025 GOLD report indicates that the 2022 ESC/ERS PH guidelines should be used when treating patients with COPD and PAH (group 1), as well as when treating patients with COPD and chronic thromboembolic PH (group 4). However, the suggested management is different for patients with COPD and severe PH associated with lung diseases and/or hypoxia (group 3): “Individualized treatment approach in PH center with experience in respiratory diseases.”

Looking ahead, Kovacs said there are two ongoing trials of treatment for PH-COPD, one investigating MK-5475, an inhaled soluble guanylate cyclase stimulator (INSIGNIA-PH-COPD), and one investigating tadalafil (ERASE PH-COPD).

“We hope that we will have positive results, and in the future, we will then recommend treatment based on the respective data,” Kovacs said.

References:

• Global initiative for chronic obstructive lung disease 2025 report. https://goldcopd.org/wp-content/uploads/2024/11/GOLD-2025-Report-v1.0-12Nov2024_WMV-Draft.pdf. Accessed Nov. 13, 2024.
• GOLD report 2025 key changes summary. https://goldcopd.org/wp-content/uploads/2024/11/KEY-CHANGES-GOLD-2025-11Nov2024.pdf. Accessed Nov. 13, 2024.
• Kovacs G, et al. CHEST. 2022;doi:10.1016/j.chest.2022.01.031.