Clinical Investigation
The Impact of Heart Failure on the Classification of COPD Severity

https://doi.org/10.1016/j.cardfail.2012.05.008Get rights and content

Abstract

Background

Pulmonary restriction—a reduction of lung volumes—is common in heart failure (HF), rendering severity grading of chronic obstructive pulmonary disease (COPD) potentially problematic in subjects with both diseases. We compared pulmonary function in patients with either HF or COPD, or the combination to assess whether grading of COPD using the Global Initiative of Chronic Obstructive Lung Disease classification is hampered in the presence of HF.

Methods and Results

In 2 cohorts involving 591 patients with established HF and 405 with a primary care diagnosis of COPD, the presence of HF and COPD was assessed according to guidelines. HF severity was staged according to the NYHA classification system into Classes I–IV. COPD was diagnosed if the ratio of post-bronchodilator forced expiratory volume in 1 second and forced vital capacity (FEV1/FVC) was <0.70, and categorized in GOLD stages I–IV according to post-bronchodilator–predicted FEV1 levels (FEV1% ≥80%; 50–79%; 30–49%; <30%). In total, 557 patients with HF only, 108 with HF+COPD, and 194 with COPD only were studied. Patients, who had neither HF nor COPD according to definition, or HF with reversible obstruction in post-bronchodilator pulmonary function tests were excluded from this analysis (n = 137). Compared with COPD only, patients with HF plus COPD had higher levels of post-bronchodilator FEV1/FVC (median [quartiles] 0.57 [0.47–0.64] vs 0.62 [0.55–0.66] and lower total lung capacity % (115 [104–126]% vs 105 [95–117]%, P < .001) P < .001), but comparable levels of post-bronchodilator FEV1% (70 [56–84]% vs 68 [54–80]%, P = .22) and thus similar distributions of GOLD stages I–IV in both groups (24/56/19/4% vs 31/50/19/1%, P = .57). In patients with HF only, 25% exhibited pre-bronchodilator FEV1% levels of <80% (FEV1% 94 [80–108]%), despite a pre-bronchodilator FEV/FVC ratio ≥0.7 in this group. The reduction of FEV1 in patients with HF only was associated with HF severity.

Conclusions

In stable HF, FEV1 may be significantly reduced even in the absence of “real” airflow obstruction. In this situation, diagnosing COPD according to GOLD criteria (based on FEV1/FVC) still seems feasible, because both FEV1 and FVC are usually decreased to an equal extent in HF. However, classifying COPD based on FEV1 levels may overrate obstruction severity in patients with combined disease (HF plus COPD), and thus may lead to unjustified use of bronchodilators.

Section snippets

Population and Study Design

Data from selected patients of 2 prospective cohort studies entered the present analysis.

Patients with an established diagnosis of either COPD (according to the GOLD criteria using post-dilatory measurements of FEV and FVC), or with established HF according to European Society of Cardiology (ESC) criteria18 were eligible, and in these 2 patient groups the presence of the respective other disease, HF or COPD, was assessed. COPD severity was classified according to GOLD, and HF severity was

Results

Patients were categorized and analyzed in 3 groups according to the presence or absence of HF or COPD as defined by the GOLD definition. Baseline characteristics are shown in Table 1.

Discussion

The present study combined 2 carefully characterized complementary cohorts with the aim to understand the intricate bidirectional relations between COPD and HF and their individual effects on pulmonary function testing and, consecutively, classification of pulmonary obstruction. We found that a substantial proportion (12%) of patients with HF only received antiobstructive treatment without established objective evidence of obstruction in pulmonary function testing. About one fifth of patients

Conclusion

In patients with stable HF, lung volumes such as FEV1 and FVC or TLC can be reduced also in the absence of obvious airflow limitation. Because levels of these parameters are frequently reduced to a similar extent, the diagnosis of COPD according to GOLD (using the ratio of FEV1 and FVC) is usually not compromised. However, the current GOLD classification based on FEV1 tends to overrate the severity of obstruction in COPD patients with coexisting HF. In patients with COPD and HF severity grading

Acknowledgments

We thank all patients, physicians, and study nurses that contributed to the studies.

Disclosure

None.

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    The Dutch study was supported by a grant (number 904-61-144) from the Netherlands Organization for Scientific Research. The German study was supported by the German Ministry of Education and Research (FKZ 01GI0205) and the German Competence Network Heart Failure. Study analysis (grant for G. Güder) was supported by the German Competence Network Heart Failure funded by the German Ministry of Education and Research (FKZ 01GI0205), the German Heart Foundation (Deutsche Herzstiftung), and the Comprehensive Heart Failure Center (funded by the German Ministry of Education and Research FKZ 01EO1004). Funding sources did not influence design of the study, data analysis, manuscript preparation, review, or authorization for submission.

    See page 643 for disclosure information.

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