The impact of heart failure and chronic obstructive pulmonary disease on mortality in patients presenting with breathlessness.

BACKGROUND: Differentiating heart failure from chronic obstructive pulmonary disease (COPD) in a patient presenting with breathlessness is difficult but may have implications for outcome. We investigated the prognostic impact of diagnoses of COPD and/or heart failure in consecutive patients presenting to a secondary care clinic with breathlessness. METHODS: In patients with left ventricular systolic dysfunction (LVSD) by visual estimation, N-terminal pro B-type natriuretic peptide (NTproBNP) levels and spirometry were evaluated (N = 4986). Heart failure was defined as either LVSD worse than mild (heart failure with reduced ejection fraction) or LVSD mild or better and raised NTproBNP levels (> 400 ng/L) (heart failure with normal ejection fraction). COPD was defined as forced expiratory volume in 1 s (FEV1) to forced vital capacity (FVC) ratio < 0.7. The primary outcome was all-cause mortality. RESULTS: 1764 (35%) patients had heart failure alone, 585 (12%) had COPD alone, 1751 (35%) had heart failure and COPD, and 886 (18%) had neither. Compared to patients with neither diagnosis, those with COPD alone [hazard ratio (HR) = 1.84 95% confidence interval (CI) 1.40-2.43], heart failure alone [HR = 4.40 (95% CI 3.54-5.46)] or heart failure and COPD [HR = 5.44 (95% CI 4.39-6.75)] had a greater risk of death. COPD was not associated with increased risk of death in patients with heart failure on a multivariable analysis. CONCLUSION: While COPD is associated with increased risk of death compared to patients with neither heart failure nor COPD, it has a negligible impact on prognosis amongst patients with heart failure.

Effect of increased inspired oxygen on exercise performance in patients with heart failure and normal ejection fraction.

INTRODUCTION: We investigated whether increased concentrations of inspired oxygen (Fio2) affects exercise tolerance in patients with heart failure and normal ejection fraction (HeFNEF). METHODS: 46 patients (mean age 75 years (63% male) and median NTproBNP 1432 (interquartile range: 543-2378 ng/l)) with HeFNEF (defined as signs or symptoms of heart failure requiring treatment with diuretics, with a left ventricular ejection fraction of >45% by echocardiography and amino terminal pro brain natriuretic peptide (NTproBNP) >220 ng/l) completed three maximal incremental exercise tests with different Fio2 (21%, 28% and 40%) in random order. Fio2 was controlled by investigator but blinded to patients. The primary outcome was exercise time (ET). RESULTS: Increasing Fio2 significantly increased exercise time (522 ±â€¯180 seconds for 21% to 543 ±â€¯176 seconds, and 542 ±â€¯177 seconds, for 28% and 40%, respectively, P = 0.04) with no difference in peak workload (57 ±â€¯25 W, 58 ±â€¯25 W and 57 ±â€¯25 W, for 21%, 28% and 40%, respectively, P = 0.50). There was an increase in oxygen saturation but no change in peak heart rate with increasing Fio2. Compared to patients with LVEF ≥50%, patients with LVEF between 45 and 49% had a significantly greater exercise time and peak workload. There was a correlation between the difference in exercise time between Fio2 21% and 40% and age; but not with BMI, haemoglobin, creatinine or NTproBNP. CONCLUSION: Increasing Fio2 during exertion leads to a small increase in exercise time in patients with HeFNEF.