Impact of Chronic Obstructive Pulmonary Disease in Patients With Heart Failure With Preserved Ejection Fraction: Insights From PARAGON‐HF

Abstract

Background Little is known about the impact of chronic obstructive pulmonary disease (COPD) in patients with heart failure with preserved ejection fraction (HFpEF). Methods and Results We examined outcomes in patients with heart failure with preserved ejection fraction, according to COPD status, in the PARAGON‐HF (Prospective Comparison of Angiotensin Receptor Neprilysin Inhibitor With Angiotensin Receptor Blocker Global Outcomes in Heart Failure With Preserved Ejection Fraction) trial. The primary outcome was a composite of first and recurrent hospitalizations for heart failure and cardiovascular death. Of 4791 patients, 670 (14%) had COPD. Patients with COPD were more likely to be men (58% versus 47%; P <0.001) and had worse New York Heart Association functional class (class III/IV 24% versus 19%), worse Kansas City Cardiomyopathy Questionnaire Clinical Summary Scores (69 versus 76; P <0.001) and more frequent history of heart failure hospitalization (54% versus 47%; P <0.001). The decrement in Kansas City Cardiomyopathy Questionnaire Clinical Summary Scores with COPD was greater than for other common comorbidities. Patients with COPD had echocardiographic right ventricular enlargement, higher serum creatinine (100 μmol/L versus 96 μmol/L) and neutrophil‐to‐lymphocyte ratio (2.7 versus 2.5), than those without COPD. After multivariable adjustment, COPD was associated with worse outcomes: adjusted rate ratio for the primary outcome 1.51 (95% CI, 1.25–1.83), total heart failure hospitalization 1.54 (95% CI, 1.24–1.90), cardiovascular death (adjusted hazard ratio [HR], 1.42; 95% CI, 1.10–1.82), and all‐cause death (adjusted HR, 1.52; 95% CI, 1.25–1.84). COPD was associated with worse outcomes than other comorbidities and Kansas City Cardiomyopathy Questionnaire Clinical Summary Scores declined more in patients with COPD than in those without. Conclusions Approximately 1 in 7 patients with heart failure with preserved ejection fraction had concomitant COPD, which was associated with greater functional limitation and a higher risk of heart failure hospitalization and death. Registration URL: https://www.clinicaltrials.gov ; Unique identifier: NCT01920711 .

Biomarker‐driven prognostic models in chronic heart failure with preserved ejection fraction: the EMPEROR–Preserved trial

“…peripheral oedema and breathlessness) and elevated natriuretic peptides. The presence of both conditions confers a worse prognosis than either disease alone 16,17 . Diabetes mellitus is a frequent comorbidity among HFpEF patients which is associated with a poor prognosis, particularly when requiring insulin for lowering glycaemia which occurs more often in long‐standing diabetes with difficult glycaemic control and concomitant cardiovascular complications 18 .…”

“…The presence of both conditions confers a worse prognosis than either disease alone. 16 , 17 Diabetes mellitus is a frequent comorbidity among HFpEF patients which is associated with a poor prognosis, particularly when requiring insulin for lowering glycaemia which occurs more often in long‐standing diabetes with difficult glycaemic control and concomitant cardiovascular complications. 18 Low haemoglobin levels and anaemia are also frequent among patients with HFpEF and associated with worse symptoms and a poor prognosis.…”

Exercise testing in heart failure with preserved ejection fraction: an appraisal through diagnosis, pathophysiology and therapy – A clinical consensus statement of the Heart Failure Association and European Association of Preventive Cardiology of the European Society of Cardiology

“…This phenogroup exhibited a COPD pattern as the main driver of dyspnoea, raising the question that HFpEF was not the true cause of symptoms in at least some of these patients 8 . Even more in the PARAGON‐HF trial, one in seven patients was diagnosed with COPD and this subset presented with worse outcome 10 …”

“…8 Even more in the PARAGON-HF trial, one in seven patients was diagnosed with COPD and this subset presented with worse outcome. 10 Furthermore, community-based cohort studies demonstrated a high prevalence of transthyretin amyloid cardiomyopathy in HFpEF patients with ventricular wall thickening, particularly in older men. 11 Patients with transthyretin amyloid cardiomyopathy often present with a severely reduced ventilatory efficiency and peak VO 2 compared to HFpEF.…”

The Importance of Controlling Comorbidities in HFpEF and How They Influence Disease Evolution

“…Patients with COPD have worse symptoms and a greater number of fatal and nonfatal outcomes independently. 3 Approximately 20% of patients with HF also have COPD and vice-versa. Importantly, the adequate treatment of one disease reduces the morbidity and mortality of the other.…”