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COPD in patients with chronic diseases

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. COPD in patients with chronic diseases. Jørgen Vestbo

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COPD in patients with chronic diseases

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  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. Cardiology & Respiratory Medicine, Hvidovre Hospital Disclosure of Interest • 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

  4. Cardiology & Respiratory Medicine, Hvidovre Hospital

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

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

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

  8. Cardiology & Respiratory Medicine, Hvidovre Hospital COPD and comorbiditiesUK General Practice Research Database 400 Angina, 1.67 350 Respiratory Infection, 2.24 300 250 Cataracts, 0.90 Fractures, 1.58 Rate per 10,000 200 Osteoporosis, 3.14 150 Glaucoma, 1.29 100 Myocardial Infarction, 1.75 50 0 0 2 3 1 4 RR in COPD versus non-COPD Soriano et al, Chest 2005.

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

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

  11. Cardiology & Respiratory Medicine, Hvidovre Hospital COPD + HF, UK Fivepaperswereidentifiedcomparing beta-blockers with placebo in older adults with chronicheartfailure 55,56,57,58,59. NICE Guidelines on Heart Failure 2010

  12. Cardiology & Respiratory Medicine, Hvidovre Hospital COPD + HF, UK Fivepaperswereidentifiedcomparing beta-blockers with placebo in older adults with chronicheartfailure 55,56,57,58,59. ... Patients with COPD wereexcluded in all studies exceptone study58. NICE Guidelines on Heart Failure 2010

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

  14. Cardiology & Respiratory Medicine, Hvidovre Hospital COPD + HF, UKOrthopnoea NICE Guidelines on Heart Failure 2010

  15. Cardiology & Respiratory Medicine, Hvidovre Hospital COPD + HF, UKNatriuretic peptides • Non-HF causes of high NP. LVH, ischaemia, tachycardia, RV overload, hypoxaemia (including pulmonary embolism), renal dysfunction (eGFR < 60ml/min), sepsis, COPD, diabetes, age (>70 years), cirrhosis of the liver. • Factors causing low NP. Obesity and treatment with diuretics, ACEI, BB, ARB and AA. NICE Guidelines on Heart Failure 2010

  16. Cardiology & Respiratory Medicine, Hvidovre Hospital COPD and acute HF 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.

  17. Cardiology & Respiratory Medicine, Hvidovre Hospital COPD and acute HF 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.

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

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

  20. Cardiology & Respiratory Medicine, Hvidovre Hospital Clinical consequenses of osteoporosis • Loss of mobility (1/2) • Loss of independence (1/3) Loss of Quality of Life (All)

  21. Cardiology & Respiratory Medicine, Hvidovre Hospital COPD and depression • Changes in mood often under-diagnosed • High prevalence of anxiety and depression in COPD patents (Kunick, 2005) • Related to the rate of the emergency treatment for COPD exacerbation (Dahlen, 2002) • After discharge, patients with higher SGRQ score showed in the follow-up a higher risk of exacerbation (Gudsmusson, 2005)

  22. Cardiology & Respiratory Medicine, Hvidovre Hospital Anxiety/depression are associated with poor prognosis in COPD patients No anxiety/depression Probable anxiety and/or depression 100 80 p<0.05 60 % of patients without treatment failure 40 20 0 0 10 5 15 20 25 Time, days Dahlen et al, Chest 2005.

  23. Cardiology & Respiratory Medicine, Hvidovre Hospital 6 MWD Exercise Capacity Limitation and Depression in COPD COPD [N=106, FEV1=52 %] Depression scales [CES-D, BASDEC] K Al-Shair et al. Respir Med 2009.

  24. Depression in adults with a chronic physicalhealth problem Implementing NICE guidance 2009 NICE clinical guideline 91

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

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

  27. Cardiology & Respiratory Medicine, Hvidovre Hospital COPD, depression and rehabilitation Clinical observation

  28. Cardiology & Respiratory Medicine, Hvidovre Hospital Mobilisation and Rehabilitation

  29. 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.

  30. 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.

  31. Cardiology & Respiratory Medicine, Hvidovre Hospital COPD and the elderly

  32. Cardiology & Respiratory Medicine, Hvidovre Hospital Polypharmacy Polypharmacy can be • Necessary • Un-necessary ”Good polypharmacy” • Type 2 diabetes • Heart failure

  33. Cardiology & Respiratory Medicine, Hvidovre Hospital PolypharmacyThe general rules • ThinkNNT critically • Primary ASA prophylaxis, NNT for MI (5yrs) 200, NNH for severebleeding 150 • Considerif new symptoms couldbe side effects to existingtherapy • Follow-upcrucial

  34. Cardiology & Respiratory Medicine, Hvidovre Hospital PolypharmacyThe 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

  35. Cardiology & Respiratory Medicine, Hvidovre Hospital COPD and adherence

  36. Cardiology & Respiratory Medicine, Hvidovre Hospital 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”

  37. Cardiology & Respiratory Medicine, Hvidovre Hospital

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