Misdiagnosis of heart failure possible in patients with COPD

Key takeaways:

• Systemic inflammation and endothelial dysfunction are some mechanisms linking COPD to heart failure with preserved ejection fraction (HFpEF).
• In a HFpEF risk scoring system, COPD is not a considered variable.

PHILADELPHIA — Heart failure with preserved ejection fraction may be misdiagnosed in patients with COPD due to symptoms/signs being misinterpreted as COPD, according to a presentation at the 2024 GOLD COPD International Conference.

“Cardiovascular disease is extremely common in [the] COPD patient population, and we’ve been very good at describing this for decades now, but I think what we’ve been less good at doing is looking at how we might change that paradigm and change the overlap between heart failure and COPD,” Jennifer Quint, MSc, PhD, FHEA, FRCP, professor of respiratory epidemiology in the School of Public Health at Imperial College London, said.

As Healio previously reported, outcomes differ in patients with coexisting COPD and heart failure (HF) based on type of HF: HF with preserved ejection fraction (HFpEF), HF with reduced ejection fraction (HFrEF) and HF with midrange ejection fraction (HFmEF).

During her presentation, Quint focused specifically on HFpEF and what that diagnosis can mean in patients with COPD.

Key characteristics of this HF type, according to Quint, include a left ventricular ejection fraction more than 50%, left ventricular diastolic dysfunction, elevated left ventricular filling pressures and elevated natriuretic peptides.

Notably, this type of HF has been observed in patients with obesity, hypertension, kidney impairment and several other diseases/conditions, meaning there is not one treatment that works across all patient populations, Quint said.

“We need to be thinking about the other conditions that are associated with [HFpEF], and think much more about personalized treatment,” Quint said.

According to Quint’s presentation, systemic inflammation, endothelial dysfunction and lung hyperinflation are some of the mechanisms linking COPD to HFpEF.

“Symptoms [of COPD and HFpEF] might mimic each other and therefore increase the chance of misdiagnosis, and I think that’s something that we probably need to get better at thinking about,” Quint said.

Among patients with HF, Quint highlighted that older age, male sex and GOLD stage 3 to 4 COPD have been revealed as frequent demographics.

Moving away from diagnosis and onto how having both COPD and HF impacts hospitalization, exacerbations and mortality rates, Quint shared results from the study previously referenced above regarding outcomes differing by HF type.

In this study, a greater proportion of patients with HFpEF experienced an acute exacerbation of COPD (38%) vs. HFmEF (29.9%) and HFrEF (29.4%), but in terms of HF-specific hospital admissions, more patients with HFrEF had this outcome (20%) than patients with HFpEF (15.5%) or HFmEF (15.8%).

Quint emphasized the importance of the exacerbation finding during her presentation. As Healio previously reported, experiencing an acute COPD exacerbation raised the risk for acute cardiovascular events, including acute heart failure.

Based on recommendations from the European Society of Cardiovascular guidelines on heart failure, which note that patients with HFpEF plus COPD have a heightened risk for mortality, Quint said, “We need to be thinking about COPD more independently as a risk factor for poor prognosis amongst our heart failure population.”

When delving into how to treat patients with both COPD and HF, Quint highlighted two main ideas.

“We need to remember that treatment for heart failure is well tolerated in the COPD patient population,” Quint said. “[Additionally,] beta-blockers are absolutely not contraindicated in the COPD patient population.”

“[A study published in Thorax suggests] when you diagnose, treat and manage the heart failure appropriately, you reduce exacerbation risk in the COPD patient population,” Quint added. “Yet another reason to more aggressively diagnose and treat heart failure in the COPD patient population.”

According to Quint, there is not enough current evidence on how inhaled corticosteroids impact cardiovascular disease.

Lastly, Quint highlighted that in the H₂FPEF scoring system used to determine HFpEF risk, COPD is not a considered variable.

“Some of the risk scoring systems may need to take COPD into account,” Quint said.

References:

• Axson EL, et al. Thorax. 2021;doi:10.1136/thoraxjnl-2020-216390.
• Gulea C, et al. Ann Am Thorac Soc. 2022;doi:10.1513/AnnalsATS.202107-823OC.