Cardiovascular disease and COPD: dangerous liaisons?

Abstract

Chronic obstructive pulmonary disease (COPD) and cardiovascular disease (CVD) frequently occur together and their coexistence is associated with worse outcomes than either condition alone. Pathophysiological links between COPD and CVD include lung hyperinflation, systemic inflammation and COPD exacerbations. COPD treatments may produce beneficial cardiovascular (CV) effects, such as long-acting bronchodilators, which are associated with improvements in arterial stiffness, pulmonary vasoconstriction, and cardiac function. However, data are limited regarding whether these translate into benefits in CV outcomes. Some studies have suggested that treatment with long-acting β₂-agonists and long-acting muscarinic antagonists leads to an increase in the risk of CV events, particularly at treatment initiation, although the safety profile of these agents with prolonged use appears reassuring. Some CV medications may have a beneficial impact on COPD outcomes, but there have been concerns about β-blocker use leading to bronchospasm in COPD, which may result in patients not receiving guideline-recommended treatment. However, there are few data suggesting harm with these agents and patients should not be denied β-blockers if required. Clearer recommendations are necessary regarding the identification and management of comorbid CVD in patients with COPD in order to facilitate early intervention and appropriate treatment.

FIGURE 1

Prevalence of comorbidities in pooled studies of patients with chronic obstructive pulmonary disease (COPD). Cardiovascular (CV) conditions and comorbidities are highlighted as orange bars and other comorbidities as yellow bars. Data are pooled from numerous studies and comorbidities with a prevalence (calculated as a weighted average based on study sample size) >5% are shown. IHD: ischaemic heart disease; HF: heart failure; AF: atrial fibrillation; CVA: cerebrovascular accident; AAA: abdominal aortic aneurysm; DVT: deep vein thrombosis; BPH: benign prostatic hypertrophy; PH: pulmonary hypertension; GERD: gastro-oesophageal reflux disease. ^#: comorbidities with a significant increase in mortality risk compared to patients with COPD without the comorbidity; ^¶: comorbidities with a significantly increased prevalence in patients with COPD compared with the general population. Reproduced and modified with permission from [3].

FIGURE 2

Association between cardiovascular disease, cardiovascular risk factors and chronic obstructive pulmonary disease (COPD) on mortality. Arrows and associated values indicate the impact of each comorbidity on the mortality risk of patients with COPD versus those patients with COPD alone. Where available, the reverse is also shown (the impact of COPD on the mortality risk of patients with each comorbidity versus those with the comorbidity alone). AF: atrial fibrillation; HF: heart failure; HR: hazard ratio; IHD: ischaemic heart disease; PH: pulmonary hypertension. ^#: HR was not significant after adjustment for confounding risk factors. Reproduced and modified with permission from [3].

FIGURE 3

Potential interactions between chronic obstructive pulmonary disease (COPD), cardiovascular (CV) risk and cardiovascular disease.