1. Grazie per aver scelto di utilizzare a scopo didattico questo materiale delle Guidelines 2011 libra. Le ricordiamo che questo materiale è di proprietà dell’autore e fornito come supporto didattico per uso personale.

2. Cardiology & Respiratory Medicine, Hvidovre Hospital COPD in patients with chronic diseases Jørgen Vestbo Respiratory Section, Hvidovre Hospital / University of Copenhagen, DK. Manchester Academic Health Sciences Centre, University of Manchester, UK.

3. Modena March 2011 Cardiology & Respiratory Medicine, Hvidovre Hospital  I have received honoraria for presenting and advising from several pharmaceutical companies  I hold research grants from GSK  My wife has worked for several pharmaceutical companies Disclosure of Interest

4. Modena March 2011 Cardiology & Respiratory Medicine, Hvidovre Hospital

5. Modena March 2011 Cardiology & Respiratory Medicine, Hvidovre Hospital Fjellanger et al, Tidsskr Nor Lægeforen 2003 Effect of comorbidities on COPD prognosis 100 80 60 40 0 6 12 18 24 30 Follow-up (months) 1+ comorbidities No comorbidities Women Survival (%) 100 80 60 40 0 6 12 18 24 30 Follow-up (months) 1+ comorbidities No comorbidities Men Survival (%)

6. Modena March 2011 Cardiology & Respiratory Medicine, Hvidovre Hospital  Cardiovascular disease  Osteoporosis  Depression  … Comorbidities of particular interest in COPD

7. Modena March 2011 Cardiology & Respiratory Medicine, Hvidovre Hospital  In cardiovascular disease  In depression  In all patients eligible for rehabilitation including physical exercise  In the elderly When is COPD of particular interest ?

8. Modena March 2011 Cardiology & Respiratory Medicine, Hvidovre Hospital 400 350 300 250 200 150 100 50 0 0 1 23 4 RR in COPD versus non-COPD Rate per 10,000 Angina, 1.67 Myocardial Infarction, 1.75 Osteoporosis, 3.14 Respiratory Infection, 2.24 Fractures, 1.58 Glaucoma, 1.29 Cataracts, 0.90 COPD and comorbidities UK General Practice Research Database Soriano et al, Chest 2005.

9. Modena March 2011 COPD + HF, Scotland Cardiology & Respiratory Medicine, Hvidovre Hospital Hawkins et al, Eur J Heart Fail 2010.

10. Modena March 2011 COPD + HF, Scotland Cardiology & Respiratory Medicine, Hvidovre Hospital Hawkins et al, Eur J Heart Fail 2010.

11. Modena March 2011 COPD + HF, UK Cardiology & Respiratory Medicine, Hvidovre Hospital NICE Guidelines on Heart Failure 2010 Five papers were identified comparing beta-blockers with placebo in older adults with chronic heart failure 55,56,57,58,59.

12. Modena March 2011 COPD + HF, UK Cardiology & Respiratory Medicine, Hvidovre Hospital NICE Guidelines on Heart Failure 2010 Five papers were identified comparing beta-blockers with placebo in older adults with chronic heart failure 55,56,57,58,59.... Patients with COPD were excluded in all studies except one study 58.

13. Modena March 2011 COPD + HF, UK Cardiology & Respiratory Medicine, Hvidovre Hospital NICE Guidelines on Heart Failure 2010

14. Modena March 2011 COPD + HF, UK Orthopnoea Cardiology & Respiratory Medicine, Hvidovre Hospital NICE Guidelines on Heart Failure 2010

15. Modena March 2011 COPD + HF, UK Natriuretic peptides Non-HF causes of high NP. LVH, ischaemia, tachycardia, RV overload, hypoxaemia (including pulmonary embolism), renal dysfunction (eGFR 70 years), cirrhosis of the liver. Factors causing low NP. Obesity and treatment with diuretics, ACEI, BB, ARB and AA. Cardiology & Respiratory Medicine, Hvidovre Hospital NICE Guidelines on Heart Failure 2010

16. Modena March 2011 Cardiology & Respiratory Medicine, Hvidovre Hospital Consecutive patients (n = 532) with symptomer of heart failure NYHA class III-IV admitted with Heart failure and treated with diuretics. Iversen et al, J Intern Med 2008. COPD and acute HF

17. Modena March 2011 Cardiology & Respiratory Medicine, Hvidovre Hospital Consecutive patients (n = 532) with symptomer of heart failure NYHA class III-IV admitted with Heart failure and treated with diuretics. COPD was only known in 43% of patients with COPD according to spirometry; 33% af patients claiming to have COPD did not have airflow limitation. Iversen et al, J Intern Med 2008. COPD and acute HF

18. Modena March 2011 Cardiology & Respiratory Medicine, Hvidovre Hospital COPD and prognosis in HF ECHOS study, 532 patients Iversen et al, Eur J Heart Fail 2010

19. Modena March 2011 Cardiology & Respiratory Medicine, Hvidovre Hospital COPD and Atrial Fibrillation Buch et al, ERJ 2003.

20. www.escardio.org/guidelines

21. Modena March 2011 Cardiology & Respiratory Medicine, Hvidovre Hospital Clinical consequenses of osteoporosis Loss of Quality of Life (All)  Loss of mobility (1/2)  Loss of independence (1/3)

22. Modena March 2011 Cardiology & Respiratory Medicine, Hvidovre Hospital COPD and depression nChanges in mood often under-diagnosed nHigh prevalence of anxiety and depression in COPD patents (Kunick, 2005) nRelated to the rate of the emergency treatment for COPD exacerbation (Dahlen, 2002) nAfter discharge, patients with higher SGRQ score showed in the follow-up a higher risk of exacerbation (Gudsmusson, 2005)

23. Modena March 2011 Cardiology & Respiratory Medicine, Hvidovre Hospital Dahlen et al, Chest 2005. Anxiety/depression are associated with poor prognosis in COPD patients p<0.05 No anxiety/depression Probable anxiety and/or depression 0 5 10 152025 Time, days 100 80 60 40 20 0 % of patients without treatment failure

24. Modena March 2011 Cardiology & Respiratory Medicine, Hvidovre Hospital Exercise Capacity Limitation and Depression in COPD 6 MWD COPD [N=106, FEV 1 =52 %] K Al-Shair et al. Respir Med 2009. Depression scales [CES-D, BASDEC] 6MWD  350m < 350mp CES-D6120.001 BASDEC24.30.002

25. Modena March 2011 Depression in adults with a chronic physical health problem Implementing NICE guidance 2009 NICE clinical guideline 91

26. Modena March 2011 Cardiology & Respiratory Medicine, Hvidovre Hospital COPD and depression NICE Guidelines on Depression in Adults with a Chronic Health Problem 2010

27. Modena March 2011 Cardiology & Respiratory Medicine, Hvidovre Hospital COPD and depression NICE Guidelines on Depression in Adults with a Chronic Health Problem 2010

28. Modena March 2011 Cardiology & Respiratory Medicine, Hvidovre Hospital COPD, depression and rehabilitation Clinical observation

29. Modena March 2011 Cardiology & Respiratory Medicine, Hvidovre Hospital Mobilisation and Rehabilitation

30. Modena March 2011 Cardiology & Respiratory Medicine, Hvidovre Hospital Mobilisation and Rehabilitation Cataract (37%), deafness (31%) and osteoarthritis of the knee (29%) were the most frequent non-CV comorbidities. COPD was No 4 (24.5%) van der Wel et al. Eur J Heart Fail 2007.

31. Modena March 2011 Cardiology & Respiratory Medicine, Hvidovre Hospital Mobilisation and Rehabilitation Cataract (37%), deafness (31%) and osteoarthritis of the knee (29%) were the most frequent non-CV comorbidities. COPD was No 4 (24.5%) – no spirometry ! van der Wel et al. Eur J Heart Fail 2007.

32. Modena March 2011 Cardiology & Respiratory Medicine, Hvidovre Hospital COPD and the elderly

33. Modena March 2011 Polypharmacy Polypharmacy can be  Necessary  Un-necessary ”Good polypharmacy”  Type 2 diabetes  Heart failure Cardiology & Respiratory Medicine, Hvidovre Hospital

34. Modena March 2011 Polypharmacy The general rules  Think NNT critically  Primary ASA prophylaxis, NNT for MI (5yrs) 200, NNH for severe bleeding 150  Consider if new symptoms could be side effects to existing therapy  Follow-up crucial Cardiology & Respiratory Medicine, Hvidovre Hospital

35. Modena March 2011 Polypharmacy The general rules  Think NNT critically  Primary ASA prophylaxis, NNT for MI (5yrs) 200, NNH for severe bleeding 150  Consider if new symptoms could be side effects to existing therapy  Follow-up crucial  Problems with adherence increase exponentially from 4+ drugs Cardiology & Respiratory Medicine, Hvidovre Hospital

36. Modena March 2011 Cardiology & Respiratory Medicine, Hvidovre Hospital COPD and adherence

37. Modena March 2011 Conclusions  COPD is a frequent comorbidity in many chronic diseases  COPD will have an impact on treatment and outcomes in many chronic disease  Expect COPD to be overlooked  ”Thing polypharmacy and adherence” Cardiology & Respiratory Medicine, Hvidovre Hospital

38. Modena March 2011 Cardiology & Respiratory Medicine, Hvidovre Hospital