COPD & CAD :

CO-EXISTING COMMON PROBLEM

Anudya Kartika Ratri
Agus Subagjo
 INTRODUCTION

OVERLAPPING
PATHOMECHANISM

Lung Health Study25% of deaths were due to cardiovascular disease;

COPD patients 5x more likely to have a CVD
Maclay, et al. Respirology (2007)
Murray C, Lopez A. N Engl J Med 2013)
 COPD-CAD INTERPLAY

Systemic dissemination of local lung inflammation

Hypoxia induced production of inflammatory mediators
Effects of lung hyperinflation.

Maclay, et al. Respirology (2007) 12, 634641

 DYSPNEA ON EXERTION
Classical symptom of COPD and is also the clinical manifestation of
due to LV dysfunction.

Am Fam Physician. 2012 Jul 15;86(2):173-180.

 DDx of CAD and COPD
HF ec CORONARY OBSTRUCTIVE PULMONARY

Dyspnea on exertion, PND, Tobacco use, cough, relief

orthopnea, chest pain or with bronchodilator,
tightness, prior CAD or AF increased sputum
production, hemoptysis

Edema, JVD, displaced Wheezing, barrel chest,

cardiac apical impulse, decreased breath sounds,
murmur ec papillary accessory muscle use,
muscle rupture, crackles, clubbing
wheezing, tachycardia

ECG, Echocardiography, Peak flow, spirometry, chest

stress testing, coronary radiography (hyperinflation)
angiography

Am Fam Physician. 2012 Jul 15;86(2):173-180.

 MARKERS OF SYST. INFLAMMATION

Inflammatory process in airways spillover into systemic circulation generalised

inflammatory reaction a process of reverse causation

Laratta et al.2014.
 MARKERS: COPD & CAD
CRP

Circulating CRP levels are associated with increased mortality in both COPD patients
& in the general population.

Maclay JD, Mcallister DA, Macnee W. Respirology 2007;12:634-41

 hsTroponinT
Stable COPD is associated with elevated cardiac troponin T
levels
hs-cTnT levels increase with the severity of airflow limitation

Syseth V, et al. Heart 2013;99:122126. d

Neukamm AMC, et al. Heart 2013;99:382387
Syseth V, et al. Heart 2013;99:122126.
Underlying mechanisms for the association between
COPD and TropT

Systemic inflammation

Hyperinflation

Shared risk factors and genetics

Neukamm AMC, et al. Heart 2013;99:382387 Syseth V, et al. Heart 2013;99:122126.

 NT-proBNP
Elevated NT-proBNP and troponin T were strongly associated
early mortality with exacerbations of COPD >>

15-fold higher mortality at 30 days VS with normal values for both markers.

Chang C, et al. Thorax 2011;66:764e768

 ERGOSPIROMETRY
Ergometer increased stepwise (25 W each 2mins)
A transducer for measurement of ventilation
Gas analyzers for O2 and CO2
A computer measured data
A multichannel ECG

Kramme R, Hoffman KP, Pozos R, et al. http://www.springer.com/978-3-540-74657-7

ERGOSPIROMETRY PARAMETERS

Kramme R, Hoffman KP, Pozos R, et al.

http://www.springer.com/978-3-540-74657-7
 BETA BLOCKER USE
CAD coexists in up to 27% of COPD
require the use of BBs

Albouaini K, Andron M, Alahmar A, et al. International Journal of COPD 2007:2(4) 535540

 BETA BLOCKER

General reluctance to use them in COPD px fear of inducing adverse reactions/

bronchspasm
Albouaini K, Andron M, Alahmar A, Egred M.International Journal of COPD
2007:2(4) 535540
 FEAR OF BRONCHOSPASM
Only 54% ACS px were discharged on BBs.

COPD was the most common cause for withholding

BBs only 62% of patients with COPD have been
reviewed by a chest physician or had a previous
pulmonary fx test

Only 31% of patients (93/298) with COPD and CHF or

MI received B blockers.

Dransfield MT, Rowe SM, Johnson JE, Bailey W, Gerald L. Thorax 2008;63:3015.

Egred M, Shaw S, Mohammad B, et al. 2005. Q J Med, 98:4937.

 METANALYSIS

no significant change in FEV1 or respiratory symptoms compared to placebo

did not effect the FEV1 treatment response to beta2-agonists.

Subgroup analyses of patients with severe COPD (FEV1<1.4 L or < 50 % normal

predicted values) or for those with a reversible obstructive component (FEV1
increase of > 15% to 2-agonists) same result
Salpeter SR, Ormiston TM, Salpeter EE. Cardioselective beta-blockers for chronic obstructive pulmonary disease. Cochrane
Database Syst Rev 2002;(4):CD003566.
 ACE-I vs ARB in COPD
The reninangiotensin/kallikrein-kinin system
is important in maintaining BP regulation

Packard KA, Wurdeman RL, and Arouni AJ. Ann Pharmacother 2002;36:1058-67
 ACE-I INDUCED COUGH
20% or more of px who receive ACE-I dry cough

Kathleen A Packard, Richard L Wurdeman, and Amy J Arouni Ann Pharmacother 2002;36:1058-67.
 ARB IN COPD
ARBs confer many of the same hemodynamic
benefits as ACE-I, but act more distally

Not directly inhibit ACE activity or inhibit the

breakdown of bradykinin.

The accumulation of bronchial irritants such

as the bradykinins and substance P doesnt
occur

Kathleen A Packard, Richard L Wurdeman, and Amy J Arouni Ann Pharmacother 2002;36:1058-67.
 ARB in COPD

The incidence of cough in losartan-treated patients significantly less

than in lisinopril-treated patients (97%; p < 0.001).

Kathleen A Packard, Richard L Wurdeman, and Amy J Arouni Ann Pharmacother 2002;36:1058-67.
 RATE CONTROL AGENTS FOR COPD
Resting heart rate was associated with both cardiovascular and
all-cause mortality across all stages of COPD (p<0.001)

Jensen FT, et al. Eur Respir J 2013; 42: 341349

 IVABRADINE (If blocker)

inhibiting the pacemaker current, If (an the sino-atrial node) without affecting cardiac
contractility, repolarization, or atrioventricular conduction

Majewski S, Slomka S, Wyderkiewicz EW, Ciebiada M et al. 2012. Am J Cardiovasc Drugs 2012
In patients with asthma and COPD, Ivabradine produced an effective reduction in HR and did
not alter respiratory function and symptoms over the short term.
Majewski S, Slomka S, Wyderkiewicz EW, Ciebiada M et al. 2012. Am J Cardiovasc Drugs 2012
 SUMMARY
COPD is a complex lung and systemic disease that has
a critical influence on severity and prognosis &
associated with a variety of CV diseases including
CAD

Both COPD and CAD are global epidemics that are

frequently found in combination, and they can also
be found independent of the common causal factors
(smoking)

COPD patients should be treated in a more

comprehensive manner, including the treatment of
cardiac comorbidities, particularly CAD
THANK YOU