Coexisting chronic obstructive pulmonary disease and heart

failure: implications for treatment, course and mortality

Joana Mascarenhasa,b, Ana Azevedoa,b,c and Paulo Bettencourta,b
a

Servico de Medicina Interna, Hospital S. Joao,

Unidade de Investigacao e Desenvolvimento
Cardiovascular do Porto and cServico de Higiene e
Epidemiologia, Faculdade de Medicina da Universidade
do Porto, Instituto de Saude Publica da Universidade
do Porto (ISPUP), Porto, Portugal
b

Correspondence to Dr Joana Mascarenhas, Servico de

Medicina Interna, Hospital S. Joao, Alameda Prof.
Hernani Monteiro, 4200-319 Porto, Portugal
Tel: +351 966104032; fax: +351 225513653;
e-mail: joanamaspinto@gmail.com
Current Opinion in Pulmonary Medicine 2010,
16:106111

Purpose of review
Chronic obstructive pulmonary disease (COPD) and heart failure are prevalent
comorbidities affecting a huge proportion of the world population, responsible for
significant morbidity and mortality. Their coexistence is more frequent than previously
recognized and poses important diagnostic and therapeutic challenges. Prognosis of
patients with concurrent heart failure and COPD has not been comprehensively
addressed. With this review, we intend to emphasize the diagnosis and prognosis
implications of the two coexisting conditions and to highlight the therapeutic constraints
posed by the combination.
Recent findings
Progressively, more attention has been given to the interplay between COPD and heart
failure. The combination is frequent, but largely unrecognized due to overlapping clinical
manifestations. Patients presenting with both conditions seem to have an ominous
course. Despite the overwhelming evidence supporting cardioselective b-blockade
safety and tolerability in COPD patients, b-blockers are underprescribed to heart failure
patients with concomitant COPD.
Summary
COPD and heart failure coexistence is often overlooked. COPD diagnosis can remain
unsuspected in heart failure patients due to similar symptoms. Although b-blockers are
well tolerated in COPD patients, they are overall less prescribed in this challenging
population. COPD, at least at severe degrees of airflow obstruction, predicts a worse
prognosis in heart failure patients.
Keywords
b-blockers, chronic obstructive pulmonary disease, heart failure, prognosis
Curr Opin Pulm Med 16:106111
2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
1070-5287

Introduction
Heart failure and chronic obstructive pulmonary disease
(COPD) are major public health epidemics, with increasing prevalence [1,2,3]. Although both conditions
have been extensively studied separately, clinicians
often fail to recognize one syndrome in the presence
of the other, mainly due to the similarities in clinical
presentation and additionally due to scarcity of reports
specifically addressing the combination [4]. According to
available evidence, COPD and heart failure often coexist, and the prevalence of the combination is variable,
depending on the population studied (community, outpatient or hospitalized) and on the diagnostic criteria
applied [4,5]. The coexistence of the two conditions is
further supported by shared risk factors, notably age and
smoking [1,5,6].
Since the publication of several trials demonstrating the
efficacy and the survival benefits of b-blockers, these
1070-5287 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

agents are considered the cornerstone of systolic heart

failure management [79]. Although extensive evidence
concerning safety of selective b-1 blockade in respiratory
disease has accumulated [10,11], COPD is commonly
advocated as the principal cause for nonadherence to
heart failure therapeutic guidelines because it is generally perceived as a contraindication to b-blockers use
[12,13]. Indeed, patients with coexisting heart failure
and COPD are often deprived of the long-term benefits
of this intervention [12,14]. Apart from these therapeutic
issues, the prognosis of patients with concomitant heart
failure and COPD is not completely understood. In an
increasing number of studies [15,16,17], COPD has
been found to adversely impact on prognosis of heart
failure patients, being an independent predictor of
mortality and hospitalization.
The present review focuses on the therapeutic dilemmas
and prognostic impact of coexisting COPD and heart
failure and outlines the diagnostic challenges presented
DOI:10.1097/MCP.0b013e328335dc90

Coexisting COPD and heart failure Mascarenhas et al. 107

by the combination. The prevalence of the two coexisting

syndromes will be addressed briefly.

concerning the diagnosis of the two coexisting syndromes.

Coexisting chronic obstructive pulmonary

disease and heart failure: epidemiology and
the interplay

Diagnostic challenges presented by the

chronic obstructive pulmonary disease/heart
failure combination

There are several observations reporting a high rate of

coexistence of COPD and heart failure, particularly in
the elderly population [1,2,3,5]. The prevalence
of heart failure in COPD patients varies between 7.2
and 20.9% [1821], with the highest estimates coming
from studies that have used standardized heart failure
diagnostic criteria [20,21]. Considerable variation of
COPD prevalence in patients with heart failure is also
found across studies, with estimates ranging from
approximately 10.0 to 39.0% [2226,27,28]. In these
investigations, the diagnosis of COPD was almost
always based on clinical data or on self-reported information [2226], with the exception of two studies
[27,28] that have evaluated the prevalence of physiologically defined disease according to Global Initiative
for Chronic Obstructive Lung Disease (GOLD)
criteria. In light of previous observations showing poor
agreement between self-reported and objectively
defined COPD [29], the higher prevalence of COPD
observed in these two studies, 39.2% in a cohort of
elderly stable patients with chronic heart failure and
35% in patients consecutively admitted with heart
failure, is not surprising. Noteworthy, using selfreported information may leave COPD diagnosis unrevealed in a considerable number of heart failure
patients [28] or, alternatively, may label with the
diagnosis of COPD patients not fulfilling the criteria
for airflow obstruction [30]. In patients with preserved
left ventricular ejection fraction (LVEF), some degree
of misdiagnosis probably occurs, and the finding of a
higher prevalence of COPD can be at least partially
explained by the inaccurate attribution of heart failure
diagnosis to patients who actually have COPD [28]. At
last, given the strict selection of patients included in
heart failure trials, the reported prevalence of COPD in
this setting is lower than in population-based studies
(713%, with only one study reporting a prevalence of
23%), reflecting a selection bias [5,3134].

The diagnostic assessment of concomitant COPD and

heart failure is demanding and requires a high level of
expertise from the involved physician. First, both conditions usually present with similar nonspecific symptoms and signs (exertion dyspnoea, functional disability,
nocturnal cough, peripheral oedema, pulmonary crackles
and jugular venous distension, among others), and there
is no distinctive feature exclusive to each of them.
Second, these characteristic clinical features are frequently masked by or attributed to additional comorbidities [37], present mainly in the elderly [3]. Moreover,
the absence of an objective definition of heart failure,
whose diagnosis requires the typical clinical picture as
well as objective evidence of cardiac dysfunction [2],
can compromise the correct recognition of this entity
when echocardiography is not available, as other conditions can mimic the clinical syndrome of heart failure
[38].

In order to explain the high rate of coexistence of these

two a etiologically distinct conditions, several plausible
theories have been proposed, namely, the sharing of
smoking as a major risk factor [5] and the association
of low-grade systemic inflammation present in COPD
patients with the development and progression of atherosclerosis [35,36]. Regardless of the potential mechanisms underlying the combination, current estimates of
COPD and heart failure concurrence are worrisome and
underscore the need for greater physicians awareness

To assist in the diagnosis of each disease, a number of

complementary tests can be performed. However, the
coexistence of COPD and heart failure can interfere with
the quality of the information obtained. Although a
normal electrocardiogram is useful to exclude heart failure, this tool lacks specificity to undoubtedly assert that
diagnosis because abnormalities found frequently overlap with those seen in other conditions, including COPD
[39]. The interpretation of chest radiography may be
misleading because chest hyperinflation present in
COPD patients can mask an increased cardiothoracic
ratio and right ventricular enlargement can obscure left
ventricular dilation [40]. Also, whereas extra shadows
commonly seen in lung disease can suggest spurious
pulmonary oedema, the remodelling of pulmonary vascular bed may hide the typical alveolar pattern found in
acute heart failure [5,40]. Poor acoustic window caused
by pulmonary air trapping may hinder accurate echocardiographic assessment of LVEF in 1035% of COPD
patients, particularly in those with more severe degrees of
airflow obstruction [41,42]. To overcome this limitation,
the use of cardiac MRI (CMRI) is currently being advocated as an alternative. Apart from providing accurate and
reproducible measurements of left ventricular volumes
and LVEF that are not affected by lung hyperinflation,
this technique is also valuable in the correct evaluation of
right ventricular volume and function [43]. The usefulness of natriuretic peptides to reliably diagnose or rule
out heart failure as the cause of acute dyspnoea is well
established in patients without COPD [44]. Although at

108 Obstructive, occupational and environmental diseases

higher thresholds, natriuretic peptides remain accurate in

the diagnosis of heart failure in COPD patients, mainly
during acute exacerbation [45]. Finally, notwithstanding
restrictive defects that are commonly encountered in
stable heart failure patients, the finding of airflow
obstruction should not necessarily be attributed to coexistent COPD in the acute setting, as an obstructive
pattern is frequently found in decompensated heart
failure [5].

Therapeutic dilemmas of coexisting chronic

obstructive pulmonary disease and heart
failure
Despite the publication and regular update of guidelines
to assist physicians on the management of COPD and
heart failure [1,2], the coexistence of both diseases
creates important therapeutic dilemmas that lead to
suboptimal treatment of patients. In fact, several surveys
conducted in order to address clinicians compliance with
guidelines have consistently shown underutilization of
heart failure evidence-based treatment, namely b-blockers, and prescription of lower than recommended dosages
of these agents, especially in patients with concurrent
COPD [12,14,46]. The available evidence regarding
heart failure treatment derives from randomized clinical
trials from which COPD patients have been frequently
excluded [5]. Therefore, the best management strategy
to treat patients with both conditions is uncertain, as it is
based on retrospective studies and on subgroup analysis
of heart failure trials [47].
b-blockers have been shown to improve heart failure
prognosis across the entire spectrum of disease severity
[79], being recommended in all patients with systolic
dysfunction [2]. Regardless of their unequivocal morbidity and mortality benefits, these agents remain underused and are frequently withdrawn in heart failure
patients with concomitant COPD due to fear of precipitating bronchospasm [12]. In a recently published European survey, COPD was the most powerful predictor of
b-blockers underprescription in heart failure patients
and was identified as a cause of poor target dose achievement [46]. The same report pointed out that, even
though b-blocker prescription increased significantly
after the publication of updated guidelines in 2005, the
percentage of heart failure patients on these agents is still
far from ideal [46]. According to current evidence, stable
COPD should not be considered a valid contraindication
to b-blocker therapy because these agents have proved to
be safe and generally well tolerated in patients with
pulmonary disease [11,48]. In brief, selective b1 blockade
does not significantly affect short-term pulmonary function and also does not attenuate b2-induced bronchodilation [49]. As a result, selective b-1-blocking agents
can be safely used in all heart failure patients with

respiratory disease [49,50], even in those with reversible

obstruction [11]. Although nonselective b-blockade combined with a-blockade is also well tolerated in COPD
patients without reactive airway component, the safety
profile of these drugs is not as well established in patients
with reactive airway disease [10,51]. Consistent with
these data, the recommendations of Heart Failure
Society of America advocate b-blocker therapy in all
patients with coexistent COPD and heart failure [52].
However, a recently published randomized controlled
study [53] found a reduction in forced expiratory
volume in 1 s (FEV1), but not impaired reversibility or
quality of life, after initiation of bisoprolol in heart failure
patients with concomitant moderate-to-severe COPD.
These apparent conflicting findings underscore the need
of additional randomized controlled trials addressing the
real impact of b-blocker therapy in heart failure patients
with concurrent COPD. Although the controversy regarding this issue is ongoing, it seems advisable to use these
agents in patients with both conditions, provided that
adverse effects are regularly monitored.
Additional therapeutic modalities used in heart failure
may also carry particular problems in COPD patients.
The metabolic alkalosis caused by intensive diuretic
therapy may interfere with the respiratory drive of COPD
patients, causing hypoventilation with subsequent worsening of hypercapnia, although this theoretical effect is
rarely reported at standard doses [4]. A potential
beneficial role to angiotensin-converting enzyme
(ACE) inhibitors and angiotensin-II receptor blockers
(ARBs) has been claimed in heart failure patients with
concurrent COPD due to their effects in decreasing
pulmonary inflammation and vascular constriction [54].
Finally, concerns regarding the use of inhaled bronchodilators [anticholinergics and b2-adrenoreceptor (B2R)
agonists] in COPD patients with concomitant heart failure have always been manifested by physicians. Whereas,
till the present, no adverse effect has been reported in
heart failure patients treated with anticholinergics [4,55],
short-acting B2R agonists were found to increase the risk
of mortality and heart failure exacerbations in a restricted
number of studies [56,57]. These agents were pointed to
as potentially deleterious for cardiac muscle because they
can increase myocardial oxygen consumption through the
induction of tachycardia [56,58]. Since the publication of
a recent randomized study [59] that failed to show
increased occurrence of adverse cardiovascular events
with the use of long-acting B2R agonists, these agents
are the preferred treatment option in the majority of
COPD patients, namely, in those with cardiovascular
comorbidities.
The analysis of these data, in addition to guidelines on
the pharmacological approach of heart failure patients

Coexisting COPD and heart failure Mascarenhas et al. 109

with COPD, suggests that patients with both conditions

should be able to profit from the therapies known to
improve prognosis of heart failure patients.

Figure 1 KaplanMeier event-free survival curves according to

chronic obstructive pulmonary disease coexistence

1.0

Prognostic implications of concurrent chronic

obstructive pulmonary disease and heart
failure
The association between COPD and several cardiovascular endpoints has been previously suggested [18,19].
COPD patients, notably those with concomitant heart
failure [19], were found to be at an increased risk for
hospitalization and death due to cardiovascular diseases,
independently of the presence of traditional cardiovascular risk factors [19,60]. In patients with heart failure,
the presence of noncardiac comorbidities, including
COPD, has been strongly associated with adverse
clinical outcomes [16,25,31,37]. The prognostic impact
of COPD was observed in patients with both preserved
and reduced LVEF [15]. A recently published review
[5] concluded that, across several studies using multivariable models, COPD was consistently an independent predictor of death and hospitalization in patients
with heart failure. Its coexistence prolongs time to
discharge, promotes frequent readmissions and incurs
significant additional costs in patients hospitalized due
to decompensated heart failure. The specific cause of
death was ascertained only in one study [32], in which
COPD was found to independently predict noncardiac
mortality and hospitalizations but not cardiovascular
events.
Contrasting with these observations, we found, in a
cohort of elderly stable patients with chronic heart failure
[27], that only severe COPD (stages III and IV as
defined by GOLD criteria) was associated with an
adverse course (Figs 1 and 2). Differences in our results
can be partially attributed to the adopted COPD definition because the diagnosis of COPD based on objective
measurements of respiratory function identifies patients
across all degrees of disease severity, even those minimally symptomatic who generally do not seek medical
attention.

++
+++
+
+
+++

0.8

++
++++
++
++ +
++ +

+ ++
++
+
+
+
++ +

0.6

+
+
++ +
+
++ +
+

P = 0.16

+
++
+

0.4

COPD

0.2

No
Yes

0.0
0.00

200.00

400.00

600.00

800.00

Time (days)
COPD, chronic obstructive pulmonary disease. Reproduced with permission from [27].

Figure 2 KaplanMeier curves comparing event-free survival

according to chronic obstructive pulmonary disease stages

1.0

++
+++
+

++ ++
+++
+
+ +++
+

0.8

+ + +
+ ++
++

+
+

+
++
+++

0.6

++ +

+ ++
+
++

0.4

The mechanisms underlying increased cardiovascular

risk in patients with COPD are yet to be completely
understood [3]. Although impaired pulmonary function,
as expressed by reduced FEV1, has been shown to be a
strong independent predictor of cardiovascular mortality
[61], the relationship between COPD and cardiovascular
events remains unclear. Recent investigations have
focused on the interplay between systemic inflammation
and airflow obstruction as a potential explanation for the
development of cardiac injury in COPD patients [35].
Apart from the mechanism(s) involved, cardiovascular
conditions are the leading cause of morbidity and

+ ++

GOLD stages
0
I
II
III/IV

0.2

0.036

0.0
0.00

200.00

400.00

600.00

800.00

Time (days)
Stage I: HR 1.06 (95% CI 0.472.37); stage II: HR 1.31 (95% CI 0.72
2.38); stages III and IV: HR 2.10 (95% CI 1.054.22). CI, confidence
interval; GOLD, Global Initiative for Chronic Obstructive Lung Disease;
HR, hazard ratio. Reproduced with permission from [27].

110 Obstructive, occupational and environmental diseases

mortality in COPD patients, independently of other risk

factors including smoking [10].
The prognostic implications of COPD in heart failure
patients and vice-versa remain, however, largely undefined due to the limited number of studies specifically
addressing the prognosis of patients presenting with both
diseases and due to the short follow-up of the majority of
the existing reports.

Conclusion
The coexistence of COPD and heart failure is frequent,
but commonly ignored. The diagnosis of one condition
in the presence of the other is challenging and requires
objective evidence of pulmonary and cardiac dysfunction, apart from the appropriate clinical picture.
Although long-term effects of b-blockers need to be
further assessed in COPD patients, these agents are
currently recommended in all heart failure patients
with concurrent COPD. Despite this, prescription
rates remain disappointingly low mainly because of
concerns related to bronchospasm. It is generally
acknowledged that COPD adversely affects heart
failure prognosis, although more conclusive studies
are still needed.
Considering the expanding mortality and the profound
impact on quality of life and performance status imposed
by each disease, it is crucial to diagnose these two
coexistent conditions and to establish a management
strategy that simultaneously addresses both comorbidities in order to alleviate symptoms, delay progression and
improve prognosis.

References and recommended reading

Papers of particular interest, published within the annual period of review, have
been highlighted as:

of special interest
 of outstanding interest
Additional references related to this topic can also be found in the Current
World Literature section in this issue (p. 165).
1

GOLD, Global Initiative for Chronic Obstructive Lung Disease. Global strategy for the diagnosis, management and prevention of chronic obstructive
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Dickstein K, Cohen-Solal A, Filippatos G, et al. ESC guidelines for the

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therapy.

2


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