A consensus statement outlining strategies for the identification and management of cardiopulmonary risk in chronic obstructive pulmonary disease has been developed by a global expert working group. Co-chair Professor Chris Gale discusses the findings and highlights the importance of a shared understanding and multidisciplinary teamwork in addressing the challenges.
There is good evidence from historical and recent multinational observational studies for the association of acute exacerbations of chronic obstructive pulmonary disease (COPD) and a range of cardiovascular events. The cardiovascular events that occur with a greater magnitude of risk in individuals with COPD following an exacerbation compared with individuals with COPD who have not had an exacerbation include myocardial infarction, decompensated heart failure, arrhythmias and stroke.
It is not fully understood why acute exacerbations of COPD are associated with higher risk of cardiovascular events. Presently, there are three proposed mechanisms: systemic inflammation triggered by lung inflammation that triggers atherothrombosis; hyperinflation that reduces cardiac output; and hypoxaemia, which causes pulmonary hypertension and right heart failure.
Of note is that many individuals with COPD have underlying cardiovascular disease or are at higher risk of cardiovascular disease. As such, they have an underlying substrate that is catalysed into an acute event by way of an exacerbation.
The rationale behind the cardiopulmonary risk in COPD consensus
Our earlier work had identified gaps in the knowledge base about cardiopulmonary risk in COPD, and we were aware that the literature did not provide detailed guidance on this topic. In particular, we noted an absence of dedicated clinical practice guidelines about cardiovascular disease and risk in individuals with COPD from national and international respiratory and cardiovascular organisations.
Our aim was to write a paper that would help pulmonologists, cardiologists, primary care physicians and other healthcare professionals understand, identify and manage cardiopulmonary risk in patients with COPD.
We invited 100 clinical and academic experts in cardiovascular disease and COPD from around the world from the Global Working Group in Cardiopulmonary Risk in COPD to contribute to the consensus statement.
The final consensus statement is: ‘Given the high burden of fatal and non-fatal major cardiovascular and respiratory events in patients with COPD, it is important that cardiopulmonary risk is assessed and managed’.
The statement should be viewed as a pragmatic guide for clinicians and a call to action to better understand and treat COPD-associated cardiopulmonary risk rather than a definitive set of evidence-based guidelines.
In addition to the consensus statement and clinical guide, we developed internationally agreed definitions of cardiopulmonary events and cardiopulmonary risk in COPD.
Improving early detection and intervention for cardiopulmonary risk
We propose that people with COPD be thoroughly evaluated for cardiovascular disease. At a minimum, a cardiovascular disease history and, as necessary, additional investigations should be performed annually as dictated.
Evaluation should include any history of chest pain/tightness, orthopnoea, paroxysmal nocturnal dyspnoea, palpitations, syncope and disproportionate dyspnoea. In addition, a full lipid profile, haemoglobin a1c, complete blood count, urea and electrolytes, estimated glomerular filtration rate, thyroid function, liver function (collectively representing a basic metabolic panel), N-terminal pro-B-type natriuretic peptide, blood pressure and a 12-lead electrocardiogram should be taken.
Individuals with cardiovascular risk factors or disease who have a regular cough or expectoration, recurrent ‘chest infections’, a significant smoking history, or breathlessness should complete spirometry to confirm the presence of COPD.
We have provided a blueprint for the identification and management of cardiopulmonary risk in people with COPD. Implementation of the consensus recommendations will be achieved through education and awareness campaigns, shared understanding and improved interdisciplinary working, outputs from research about cardiopulmonary risk in COPD, and adoption into national guidelines.
What cardiologists and respiratory physicians should prioritise in their practice
It is important to be aware that individuals with COPD have, or are at risk of, cardiovascular disease and adverse cardiovascular events. When COPD co-exists with cardiovascular disease, it carries a worse prognosis – about one in five of these individuals will die from cardiovascular disease.
There are evidence-based treatments for cardiovascular disease, and these should not be withheld in individuals with COPD. Equally, optimising lung health with inhaled therapies to reduce acute exacerbations offers the potential to reduce the burden of cardiovascular events.
Interdisciplinary working across pulmonology and cardiovascular medicine is required to better identify disease – be it incident cases of COPD or cardiovascular disease within prevalent COPD – estimate risk and deliver optimal care.
Discrete models of parallel referrals from primary care to separate cardiology and pulmonology specialists may impede optimal care. Alternative care models could comprise multidisciplinary team discussions and virtual review, multispeciality clinics for people presenting with undifferentiated breathlessness, inclusion (and contracting) of cardiopulmonary risk assessment in the annual COPD review, early cardiopulmonary review following a moderate or severe COPD exacerbation and dedicated cardiopulmonary risk clinics.
Allied health professionals, including pharmacists, specialist nurses and certified respiratory educators could be upskilled to enable the identification and initial management of cardiopulmonary risk in the community as well as at cardiology and respiratory clinics. Indeed, it has been shown that a COPD care pathway can successfully be embedded in an existing cardiology outpatient clinic infrastructure.
Conclusion
The consensus paper provides a comprehensive yet pragmatic approach to tackling cardiopulmonary events in individuals with COPD. It is written by clinical experts, with input from 100 contributors from around the world, for healthcare professionals. The paper also highlights areas where there remain knowledge gaps and scientific uncertainty.
Adopting the consensus recommendations, novel research into the interplay between cardiovascular disease and COPD and its treatment and integrating these findings into clinical guidelines will improve cardiopulmonary outcomes in COPD.
Author
Chris P Gale MBBS PhD Med MSc FESC FRCP
Professor of cardiovascular medicine and honorary consultant cardiologist, Leeds Teaching Hospitals NHS Trust and the Leeds Institute for Cardiovascular and Metabolic Medicine, University of Leeds, UK
