What should pneumologists think about when looking at the heart of their COPD patients? We summarize such options in the form of a compact multiple-choice questionnaire.
Today I provide my readers with a short quiz on a topic of highest relevance: cardiovascular diseases as the most important and frequent comorbidity of COPD. We often come across the statement: "The COPD patient does not die of COPD, but of a heart attack". We are aware that given the severity of COPD, the probability of a pulmonary cause of death increases. However, it is clear that we must keep an eye on the heart and blood vessels as well as on the underlying pulmonary disease itself.
A German-language article on COPD (see source 1) served as a reference point. Unfortunately, there are no CME points after taking the quiz, but in any case, the answers are at the end of the article. Hopefully, this short quiz approach can expand or refresh your knowledge!
Question 1: How often do cardiovascular diseases occur in COPD patients? Systemic inflammation with endothelial dysfunction as a consequence of COPD is regarded as a pathogenetic link. The percentage of cardiovascular COPD patients (according to a French cohort study from 2016) is around:
a. 35%
b. 52%
c. 69%
Question 2: Regarding “Cor pulmonale” or pulmonary hypertension (PH) in COPD, which statements are correct?
a. Pulmonary hypertension (PH) is also prognostically relevant in a mild form. A further evaluation, including an examination of the pressure conditions in the pulmonary circulation, is useful if there is a considerable discrepancy between the severity of the symptoms and the severity of respiratory obstruction.
b. In COPD patients with type 2 diabetes, the PH incidence appears to be significantly increased. A complete pneumological machine-aided diagnosis should be performed including body plethysmography, blood gas analysis, diffusion capacitance and if possible spiroergometry.
c. If possible, every patient with severe COPD should be echocardiographically examined in order to obtain early indications of left ventricular dysfunction (LVD) or right-side ventricular stress. The right-heart catheter remains the gold standard for the detection of PH.
d. The principle of treating comorbidities in COPD as in patients without COPD and vice versa does not apply to PH. Specific pharmacotherapy is also indicated for mild forms, which are usually present in COPD patients. There is plenty of evidence supporting this benefit.
e. Patients with accompanying chronic heart failure should be treated according to guidelines.
Question 3: Adenosine Stress Cardiovascular MRI in COPD: In the detection of hemodynamically relevant coronary artery stenosis, adenosine stress MRI has the highest diagnostic accuracy among non-invasive imaging procedures. What should be considered?
a. In severe COPD with hypoxemia at rest, as in asthma and bronchospasm, the administration of adenosine is contraindicated. Radiologists also frequently advise against stress MRIs with adenosine in less severely ill COPD patients.
b. MRI with regadenoson, which selectively binds to A2A receptors, is not an alternative. In COPD patients, cardio-CT should always be preferred as a diagnostic procedure.
c. Nothing.
Question 4: Regarding cardiac biomarkers in COPD patients: Which statements are correct?
a. The measurement of troponin T and BNP/NT-proBNP, the two most important biomarkers in cardiology, is recommended for COPD patients in acute exacerbation because of their prognostic relevance and possible therapeutic consequences.
b. In acute exacerbation, about 50% of COPD patients show an increase in troponin, often without further signs of a heart attack. According to a prospective study, troponin T elevation in exacerbation as well as in stable COPD is associated with a 3-fold increase in mortality risk, regardless of the severity of COPD, existing hypoxemia or cardiovascular risk factors.
c. The risk of myocardial infarction is significantly increased in COPD patients, especially in the first 3 months after an acute exacerbation. The reasons for the increased mortality are a delayed diagnosis, a greater severity than in healthy lungs and poorer secondary prevention.
d. The importance of natriuretic peptides as prognostic markers of COPD per se is obviously lower compared to troponin. However, they offer relevant help in identifying chronic heart failure, which affects up to 20% of COPD patients.
Source:
1. Neurohr C et al. Essential practical questions: COPD a matter of the heart. Dtsch Arztebl 2019;116(7):[10]. doi:10.3238/PersPneumo.2019.02.15.002
Acronyms:
CT = computed tomography
MRI = magnetic resonance imaging
Quiz Answers:
1: c; 2: a, b, c & e; 3: a; 4: a, b, c, & d.