Structured cardiac assessment and treatment following exacerbations of Chronic Obstructive Pulmonary Disease

Abstract

Introduction: Heart disease is common in COPD, yet is inadequately managed due to systemic deficiencies in both diagnosis and treatment. Through a systematic review and meta-analysis of published studies, it is estimated that 10-20% of patients have undiagnosed left ventricular systolic dysfunction. During exacerbations of COPD (ECOPD), cardiac risk is temporally elevated. In view of these problems, a pilot randomised controlled trial, examining the feasibility and effect of inpatient structured cardiac assessment (SCA) to diagnose and prompt guideline recommended treatment of heart disease, was conducted. Methods: 115 inpatients with ECOPD were randomised 1:1 to receive usual care (UC, n=58) or SCA (n=57), comprising transthoracic echocardiography, CT coronary artery calcium scoring, 24-hour ECG, blood pressure and diabetes assessment. Follow-up was for 12 months. The prevalence of underdiagnosis and undertreatment of heart disease were captured, and potential outcome measures for future trials assessed. An economic analysis was also rehearsed. Results: Among patients undergoing SCA, 42/57 (73.7%) received a new cardiac diagnosis compared with 11/58 (19.0%; p<0.001) in UC. When heart disease was diagnosed, the proportion receiving optimal treatment at discharge was significantly higher in SCA (35/47 (74%) vs 4/11 (34%); p=0.029). There was no difference in days alive outside hospital between the arms. Survival curves for both adverse cardiovascular and cardiopulmonary events separated throughout follow-up, with ACE occurring in 17.2% in usual care vs. 10.5% in SCA in one year. The economic analysis suggested a low probability of cost-effectiveness, but estimates were very broad. Conclusions: A structured cardiac assessment during ECOPD significantly improved diagnosis and treatment of heart disease. Further research is needed in order to establish how to deliver SCA with the greatest clinical and economic effectiveness. Future interventional trials should use time to first adverse cardiovascular or cardiopulmonary event as the primary outcome.