European Heart Journal Advance Access originally published online on December 5, 2005
European Heart Journal 2006 27(3):372; doi:10.1093/eurheartj/ehi676
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Unrecognized heart failure in elderly patients with stable chronic obstructive pulmonary disease
Medical Division
Manchester Medical Society
1 The Lodge
842 Wilmslow Road
Didsbury
Manchester
Lancashire M20 2RN
UK
Tel: +44 1614489034
E-mail address: oscarjolobe{at}yahoo.co.uk
The documentation of a 20.5% prevalence of heart failure (with ischaemic heart disease as the underlying cause in 20.2%) in stable chronic COPD1 is consistent with the observation made by Keistinen et al.2 that coronary heart disease was the cause of death in 26.7% of male patients with COPD. When establishing the diagnosis of COPD in patients with co-existing left ventricular failure (LVF), however, the authors of the present study should have relied not just on an FEV1/FVC ratio of <70% as their predecessors had done,3 but also on a concomitant increase in total lung capacity (TLC),4 given the fact that an FEV1/FVC ratio of <70% (which can be documented even in non-smokers with LVF), on its own, does not distinguish the obstructive lung defect of COPD from the obstructive lung defect of LVF.5 The distinction between the two can only be made on the basis that the obstructive lung defect of COPD is accompanied by an increase in TLC,4 whereas in LVF, airflow obstruction is accompanied by a fall in TLC due to lung stiffness attributable to alveolar oedema.5 Where the two conditions co-exist, the index of suspicion may be raised by the fact that ‘the TLC is not as high as expected for this level of airflow obstruction’,6 but to establish the presence of the COPD component beyond all doubt requires documentation of a high TLC either before the onset of LVF7 or after the resolution of pulmonary oedema.8
The identification of the co-existence of COPD and LVF also carries the responsibility to document the arterial blood gas tensions so that long-term oxygen therapy (LTOT) can be administered where appropriate,9,10 thereby avoiding the glaring errors of omission identified in a previous study where 50% of significantly hypoxaemic patients (with arterial oxygen tensions <7.3 kPa) characterized by the association of left ventricular ejection fraction (LVEF) <45% and stable COPD were not availed of what is now the British Thoracic Society Guidance on LTOT.10 Concomitant awareness of arterial carbon dioxide status also alerts frontline emergency medical staff about the potential dangers of uncontrolled oxygen therapy during exacerbations of COPD,11 and this is of even greater relevance when the co-existence of LVF and COPD is characterized by carbon dioxide retention (Table 2),3 given the widely prevalent practice of administering uncontrolled oxygen for exacerbations of LVF.
References
- Rutten FH, Cramer M-J, Grobbee DE, Sachs APE, Kirkels JH, Lammers J-WJ, Hoes AW. Unrecognised heart failure in elderly patients with stable chronic obstructive pulmonary disease. Eur Heart J 2005;26:1887–1894.
[Abstract/Free Full Text] - Keinstinen T, Tuuponen T, Kivela S-L. Survival experience of the population needing hospital treatment for asthma or COPD at age 50–54 years. Respir Med 1998;92:568–572.[CrossRef][Web of Science][Medline]
- Steele P, van Dyke D, Sutton F, Creagh E, Davies H. Left ventricular ejection fraction in severe chronic obstructive airways disease. Am J Med 1975;59:21–28.[CrossRef][Web of Science][Medline]
- Gibson J. Lung volumes and elasticity. In: Hughes JMB, Pride B, eds. Lung Function Tests Physiological and Clinical Applications. London/Edinburgh/New York: W.B. Saunders; 1999.
- Light B, George RB. Serial pulmonary function in patients with acute heart failure. Arch Int Med 1983;143:429–433.
[Abstract/Free Full Text] - Gibson GJ. Obstructive and restrictive ventilatory defects. In: Gibson GJ, ed. Clinical Tests of Respiratory Function. 2nd ed. London/Glasgow/Weinheim: Chapman & Hall Medical; 1996.
- Jolobe OMP. Survival experience of the population needing hospital treatment for asthma or chronic obstructive pulmonary disease at the age of 50–54 years. (Letter). Respir Med 1998;92:1256.[Medline]
- Jolobe OMP. The yield of a diagnostic hospital dyspnoea clinic for the primary care section. (Letter). J Int Med 2002;251:366–367.[Medline]
- Medical Research Council Working Party. Long term domiciliary oxygen therapy in chronic hypoxic cor pulmonale complicating chronic bronchitis and emphysema. Lancet 1981;1:681–686.[CrossRef][Medline]
- The COPD Guidelines Group of the Standards of Care Committee of the BTS. Diagnosis and management of stable COPD. Thorax 1997;52(Suppl. 5):S7–S15.
- Durington HJ, Flubacher M, Ramsay CF, Howard LSGE, Harrison BDW. Initial oxygen management in patients with an exacerbation of chronic obstructive pulmonary disease. Q J Med 2005;98:499–504.
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