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COPD Increases Risk of Death in Patients With Heart Failure

Allison Inserro
Increased severity of chronic obstructive pulmonary disease (COPD) was associated with an increased risk of mortality and hospitalization in patients with heart failure, according to a recent study published in JAMA Open.
Increased severity of chronic obstructive pulmonary disease (COPD) was associated with an increased risk of mortality and hospitalization in patients with heart failure (HF), according to a recent study published in JAMA Open.

HF and COPD are common comorbidities in the elderly. Prevalence of COPD affects about one-third of patients with HF, and it is already known that COPD is associated with a higher risk of death for patients with HF. What isn’t as well known is whether or not any higher risk of hospitalization or death associated with COPD in patients with HF differs according to the severity of COPD.

The UK study looked to see which factors of COPD could be identified in order to better target high-risk patients. Researchers used data from the Clinical Practice Research Datalink linked to Hospital Episode Statistics between January 1, 2002, and January 1, 2014. There were 50,114 patients with HF; 46% were women and the median age was 79 years. The patients were newly diagnosed with HF.

In patients with HF, those with COPD were compared with those without it. Researchers conducted 2 separate nested case-control studies within the HF group for the main outcome of first all-cause admission or all-cause death.

Researchers used the Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines to segment patients with COPD, using 7 medication intensity levels and airflow limitation severity stages using prescriptions and forced expiratory volume in 1 second (FEV1) data. The 4 GOLD severity stages were mild, moderate, severe, and very severe.

Researchers conducted 2 separate nested case-control studies within the HF group for the main outcome of first all-cause admission or all-cause death in patients with HF. 

Medication severity levels ranged from the least severe levels that included short-acting anticholinergics or β-antagonists only, or monotherapy (GOLD A group); dual therapy (GOLD group B or C); or triple therapy (GOLD group B) using a combination of long-acting anticholinergics, β-antagonists, and inhaled corticosteroids. Researchers also added 2 more medication intensity levels that included oral corticosteroids and oxygen therapy.

In patients with HF, COPD (18,478 [13.8%]) was significantly associated with increased mortality (adjusted odds ratio [AOR], 1.31; 95% CI, 1.26-1.36) and hospitalization (AOR, 1.33; 95% CI, 1.26-1.39).

The 3 most severe medication intensity levels showed significantly increasing mortality associations from 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 hospitalization were AORs of 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, with the following AORs: FEV80% or more, 1.63 (95% CI, 1.42-1.87); FEV1 50% to 79%, 1.69 (95% CI, 1.56-1.83); FEV1 30% to 49%, 2.21 (95% CI, 2.01-2.42); and FEV1 less than 30%, 2.93 (95% CI, 2.49-3.43).

The strengths of associations between FEV1 and hospitalization risk were similar among stages ranging from FEV1 80% or more (AOR, 1.48; 95% CI, 1.31-1.68) to FEV1 less than 30% (AOR, 1.73; 95% CI, 1.40-2.12).

The authors said that to their knowledge, this study was the largest population-based study to investigate the links between COPD and outcomes in a group of patients with HF.  There are 4 clinical implications from this study, they wrote. To improve HF prognosis, identifying and effectively managing comorbidities is important. The findings show that 1 in 7 patients with HF also have COPD, which carries a 30% risk of death and hospitalization compared with patients with HF who do not have COPD.

Second, COPD medication intensity could be a warning of progressive disease in patients with HF.

Third, more studies may be needed to determine the value of FEV1 for hospital admissions, since the risk of death increased with more severe airflow limitation.

Lastly, COPD and women with HF was linked to a 15% higher risk of death than in men. The researchers said this finding adds new evidence to what is known about women with COPD: namely, that they suffer from higher death rates from COPD than men, possibly because of genetics, physiology, delayed diagnosis, and poor treatment responses.

Reference

Lawson CA, Mamas MA, Jones PW, et al. Association of medication intensity and stages of airflow limitation with the risk of hospitalization or death in patients with heart failure and chronic obstructive pulmonary disease [published online December 14, 2018]. JAMA Netw Open. doi: 10.1001/jamanetworkopen.2018.5489.

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