Clinicians should be doing more to screen for and manage cardiovascular risk in their patients with COPD.

New Zealand’s Professor Robert Hancox told the Respiratory Insights Forum in Melbourne that cardiovascular disease was present in 25-50% of patients hospitalised for exacerbations.

Despite contributing to poorer outcomes in COPD patients, cardiovascular disease remained under-recognised in this patient group.

Professor Hancox, from the University of Otago and Waikato Hospital, said findings from the Atherosclerosis Risk in Communities Cohort (ARIC) study^[1] highlighted the importance of cardiovascular disease in COPD.

“Unless they are Gold 3 or 4, patients with COPD are much more likely to die of cardiovascular disease than respiratory disease.”

Yet COPD guidelines focused on respiratory failure and airway treatment, he said.

“Cardiovascular disease is a major cause of morbidity and mortality amongst our COPD patients. We should be more aware of it, looking for it and trying to manage it.”

Evidence on treatment lacking

Professor Hancox said there were only a few clinical trials to guide management, with COPD patients often excluded from trials of cardiovascular agents such as beta-blockers.

A 2012 meta-analysis^[2] favoured the use of beta-blockers to prevent all-cause mortality but relied on observational studies. However a 2013 study suggested β-blockers reduced survival in oxygen-dependent patients with COPD^[3].

The same study also found antiplatelet drugs could improve survival in COPD – a finding further supported by a 2016 meta-analysis^[4].

Professor Hancox said evidence for the effectiveness of statins was equivocal with a recent trial of rosuvastatin in patients with co-existing COPD and heart failure finding no benefit in mortality or all-cause hospitalisation[5].

“How we actually treat or prevent cardiac mortality is not that clear yet and that’s what we need to work on,” he said.

A recent attempt to recruit exacerbating COPD patients into a study of beta-blockers in New Zealand[6] screened 572 patients but had to exclude 549 for reasons including prior use of beta-blockers, discharge before the first dose of medication, and pneumonia.

He said randomised controlled trials were urgently needed, with a Trans-Tasman study proposed.

Cardiac dysfunction difficult to detect

 Professor Hancox told the meeting that cardiac biomarkers N-terminal pro-brain natriuretic peptide (NT-proBNP) and troponin T were strong predictors of early mortality among patients admitted to hospital with COPD exacerbations^[7].

“If both NT-proBNP and troponin are elevated, patients are 15 times more likely to die in the first 30 days than patients with normal levels,” he said.

“What we have established is that the cardiac biomarkers are strong predicators of mortality in people with exacerbations of COPD. What we don’t yet know is what the mechanisms underlying the biomarkers’ derangement are.”

Professor Hancox said standard tests such as ECG and chest X-rays were not very helpful in predicting risk.

Respiratory physicians should be making appropriate referrals to cardiology colleagues if they felt they were unable to manage cardiovascular risk in their patients, he said.

References

[1] Mannino DM, Doherty DE & Buist AS. Global Initiative on Obstructive Lung Disease (GOLD) classification of lung disease and mortality: findings from the Atherosclerosis Risk in Communities (ARIC) study. Resp Med. 2006;100:115-22.

http://www.resmedjournal.com/article/S0954-6111(05)00141-1/pdf

[2] Etminan M, Jafari S, et al. Beta-blocker use and COPD mortality: a systematic review and meta-analysis. BMC Pulmonary Medicine. 2012:12:48. https://bmcpulmmed.biomedcentral.com/articles/10.1186/1471-2466-12-48

[3] Ekström M, Hermannson AB & Strom KE. Effects of Cardiovascular Drugs on Mortality in Severe Chronic Obstructive Pulmonary Disease: A Time-Dependent Analysis. Am J Respir Crit Care Med. 2013;187:715-720. http://www.atsjournals.org/doi/abs/10.1164/rccm.201208-1565OC

[4] Pavasini R, Biscaglia S, et al. Antiplatelet Treatment Reduces All-Cause Mortality in COPD Patients: A Systematic Review and Meta-Analysis. Journal of Chronic Obstructive Pulmonary Disease. 2016; 13(4):509-14.  http://www.tandfonline.com/doi/abs/10.3109/15412555.2015.1099620?journalCode=icop20

[5] Rossi A, Inciardi RM, et al. Prognostic effects of rosuvastatin in patients with co-existing chronic obstructive pulmonary disease and chronic heart failure: A sub-analysis of GISSI-HF trial. Pulm Pharm & Therapeutics. 2017;33:16-23. https://www.ncbi.nlm.nih.gov/pubmed/28263812

[6] Chang CL, Wong C, et al.  β-blockers in exacerbations of COPD: feasibility of a randomised controlled trial. ERJ Open. 2017;3(1):00090.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5279067/#__ffn_sectitle

[7] Chang CL, Robinson SC, et al. Biochemical markers of cardiac dysfunction predict mortality in acute exacerbations of COPD. Thorax. 2011; 66:764-68. https://www.ncbi.nlm.nih.gov/pubmed/21474497