Impact of heart failure and other comorbidities on mortality in patients with chronic obstructive pulmonary disease: a register-based, prospective cohort study.

BACKGROUND: Multimorbidity has already become common in primary care and will be a challenge in the future. Primary care in Sweden participates to a great extent in the care of patients with two severe, chronic conditions: chronic obstructive pulmonary disease (COPD) and heart failure. Both conditions are characterized by high mortality and often coexist. Age, sex, heart failure and other comorbidities are considered to be the major predictors of mortality in patients with COPD. We aimed to study the impact of heart failure, other comorbidities, age and sex on mortality in patients with COPD. METHODS: A register-based, prospective cohort study conducted in Blekinge County in Sweden with about 150,000 inhabitants. The study population was comprised of people aged ≥35 years. The data about diagnoses of COPD and heart failure came from the 2007 health care register, in which we found 984 individuals with a diagnosis of COPD. Date of death was collected from January 1st, 2008 -August 31st, 2015. The diagnosis-based Adjusted Clinical Groups (ACG) Case-Mix System 7.1 was used to describe comorbidity. Each individual was assigned one of six comorbidity levels called resource utilization bands (RUB) graded from 0 to 5. RESULTS: Estimated eight year mortality in patients with COPD and coexisting heart failure was seven times higher than in patients with COPD alone - odds ratio 7.06 (95% CI 3.88-12.84). Adjusting for age and male sex resulted in odds ratio 3.75 (95% CI 1.97-7.15). Further adjusting for other comorbidities resulted in odds ratio 3.26 (95% CI 1.70-6.25). The mortality was strongly associated with the highest comorbidity level - RUB 5 where the odds ratio was 5.19 (95% CI 2.59-10.38). CONCLUSION: Heart failure has an important impact on mortality in patients with COPD. The mortality in patients with COPD and coexisting heart failure was strongly associated with age, male sex and other comorbidities. Of those three predictors, only other comorbidities can be influenced. Heart failure and other comorbidities should be recognized early and properly treated in order to improve survival in patients with coexisting COPD and heart failure.

Heart failure and levels of other comorbidities in patients with chronic obstructive pulmonary disease in a Swedish population: a register-based study.

BACKGROUND: Despite the fact that heart failure and chronic obstructive pulmonary disease (COPD) often exist together and have serious clinical and economic implications, they have mostly been studied separately. Our aim was to study prevalence of coexisting heart failure and COPD in a Swedish population. A further goal was to describe levels of other comorbidity and investigate where the patients received care: primary, secondary care or both. METHODS: We conducted a register-based, cross-sectional study. The population included all people older than 19 years, living in Östergötland County in Sweden. The data were obtained from the Care Data Warehouse register from the year 2006. The diagnosis-based Adjusted Clinical Groups Case-Mix System 7.1 was used to describe the comorbidity level. RESULTS: The prevalence of the diagnosis of heart failure in patients with COPD was 18.8% while it was 1.6% in patients without COPD. Age standardized prevalence was 9.9 and 1.5%, respectively. Standardized relative risk for the diagnosis of heart failure in patients with COPD was 6.6. The levels of other comorbidity were significantly higher in patients with coexisting heart failure and COPD compared to patients with either heart failure or COPD alone. Primary care was the only care provider for 36.2% of patients with the diagnosis of heart failure and 20.7% of patients with coexisting diagnoses of heart failure and COPD. Primary care participated furthermore in shared care of 21.5% of patients with the diagnosis of heart failure and 21.7% of patients with coexisting diagnoses of heart failure and COPD. The share of care between primary and secondary care varied depending on levels of comorbidity both in patients with coexisting heart failure and COPD and patients with heart failure alone. CONCLUSION: Patients with coexisting diagnoses of heart failure and COPD are common in the Swedish population. Patients with coexisting heart failure and COPD have higher levels of other comorbidity than patients with heart failure or COPD alone. Primary care in Sweden participates to a great extent in care of patients with diagnoses of heart failure alone and coexisting heart failure and COPD.

Comparing impedance cardiography and echocardiography in the assessment of reduced left ventricular systolic function.

BACKGROUND: An early and accurate diagnosis of chronic heart failure is a big challenge for a general practitioner. Assessment of left ventricular function is essential for the diagnosis of heart failure and the prognosis. A gold standard for identifying left ventricular function is echocardiography. Echocardiography requires input from specialized care and has a limited access in Swedish primary health care. Impedance cardiography (ICG) is a noninvasive and low-cost method of examination. The survey technique is simple and ICG measurement can be performed by a general practitioner. ICG has been suggested for assessment of left ventricular function in patients with heart failure. We aimed to study the association between hemodynamic parameters measured by ICG and the value of ejection fraction as a determinant of reduced left ventricular systolic function in echocardiography. METHODS: A non-interventional, observational study conducted in the outpatients heart failure unit. Thirty-six patients with the diagnosis of chronic heart failure were simultaneously examined by echocardiography and ICG. Distribution of categorical variables was presented as numbers. Distribution of continuous variables was presented as a mean and 95% Confidence Interval. Kruskal-Wallis test was used to compare variables and show differences between the groups. A p-value of <0.05 was considered significant. RESULTS: We found that three ICG parameters: pre-ejection fraction, left ventricular ejection time and systolic time ratio were significantly associated with ejection fraction measured by echocardiography. CONCLUSIONS: The association which we found between EF and ICG parameters was not reported in previous studies. We found no association between EF and ICG parameters which were suggested previously as the determinants of reduced left ventricular systolic function.The knowledge concerning explanation of hemodynamic parameters measured by ICG that is available nowadays is not sufficient to adopt the method in practice and use it to describe left ventricular systolic dysfunction.

Using NT-proBNP to Detect Chronic Heart Failure in Elderly Patients with Chronic Obstructive Pulmonary Disease.

Objective. To detect chronic heart failure in elderly patients with a registered diagnosis of chronic obstructive pulmonary disease (COPD) treated in Swedish primary health care using natriuretic peptide NT-proBNP. Design. A cross-sectional study. Setting. Two primary health care centres in southeastern Sweden each with about 9000 listed patients. Subjects. Patients aged 65 years and older with a registered diagnosis of COPD. Main Outcome Measures. Percentage of patients with elevated NT-proBNP, percentage of patients with abnormal left ventricular function assessed by echocardiography, and association between elevated NT-proBNP and symptoms, signs, and electrocardiography. Results. Using NT-proBNP threshold of 1200 pg/mL, we could detect and confirm chronic heart failure in 5.6% of the study population with concurrent COPD. An elevated level of NT-proBNP was only associated with nocturia and abnormal electrocardiography. Conclusions. We found considerably fewer cases of heart failure in patients with COPD than could be expected from the results of previous studies. Our study shows the need for developing improved strategies to enhance the validity of a suspected heart failure diagnosis in patients with COPD.