Dr Sanjay Sethi on the Economic Burdens of Chronic Obstructive Pulmonary Disease

In this interview with The American Journal of Managed Care® (AJMC®) Sanjay Sethi, MD, professor and chief, Pulmonary, Critical Care and Sleep Medicine; assistant vice president for Health Sciences, Department of Medicine, Jacobs School of Medicine & Biomedical Sciences, Buffalo, New York, discussed the economic impact chronic obstructive pulmonary disease (COPD) can have on both patients and the health care system.

Because of the increased risk of cardiovascular disease in patients with COPD, they are often on multiple medications, misdiagnosed, and are at increased risk for relapse. Sethi emphasized the need for continuous education for patients and providers in order to better diagnose and manage the disease. By intervening early in a COPD diagnosis, exacerbations can be prevented, and cardiovascular disease can be reduced.

AJMC: What is the link between COPD and cardiovascular conditions?

Sethi: What we know is that there is an increased risk or increased prevalence of cardiovascular conditions in patients with COPD. There is an estimate that there may be as much as about 20% incidence of cardiac conditions. If you think in terms of congestive heart failure, ischemic heart disease and arrhythmia, those are more common in the context of patients who have COPD.

AJMC: Are individuals with COPD more likely to have concurrent cardiovascular disease? Are they more susceptible to developing cardiovascular conditions?

Sethi: There is an element of both. There are individuals who will. As we follow these individuals, yes, they are more likely to develop cardiovascular disease. COPD is an inflammatory condition and we know that systemic inflammatory conditions can precipitate cardiovascular disease, but I think it goes beyond that. COPD puts a lot of stress on the body especially during exacerbations. There is a very clear link between exacerbations of COPD and then following that development, the discovery of cardiac conditions. Even acute cardiac events and cardiac arrhythmias are very common in the context of COPD exacerbations. There is clearly an increased risk of developing cardiovascular or manifesting cardiovascular disease. Concurrent cardiovascular disease is more common and I think that is also related to the fact that things that lead to susceptibility factors or the path of physiological factors are common between the two diseases.

AJMC: From a pathophysiological perspective, is there any overlap between COPD and CBD?

Sethi: I think the biggest one is tobacco smoking. Most COPD in the country is tobacco-smoking related. Tobacco smoking is a major risk factor for ischemic heart disease. I think that is a strong link to start with. If we look at COPD comorbidities today, many of them are like metabolic syndrome. There is an increased risk of diabetes and increased risk of metabolic syndrome. There was a time when COPD patients used to be really skinny because they were working so hard breathing, but they've changed now. The average BMI is higher and it's in the overweight range very commonly. There is a higher prevalence of metabolic syndrome in COPD. We know that metabolic syndrome leads to cardiovascular disease. I think that is another common pathophysiological factor. The third interesting one is inflammation. We know that there is an element of inflammation in cardiovascular disease, and inflammation is a big factor in COPD. Are those linked? I don't think we totally understand whether that is, but that's another potential link between the two diseases.

AJMC: COPD and cardiovascular disease both play a great deal of burden on the health care system from a clinical and economic perspective. Could you please describe the clinical and economic impact of these burdens on patients with COPD and cardiovascular disease, as well as the health care system?

Sethi: Let’s start from the patient point of view. Both conditions have overlapping symptoms. Shortness of breath is the one that overlaps. If you have congestive heart failure, you have ischemic heart disease, you have COPD, and you are going to get short of breath. Clearly that is a major clinical manifestation. Patients who have bad COPD and also have congestive heart failure are going to be even more limited and even more symptomatic. That's one aspect of it. A lot of these patients end up with multiple medications. You have these medications to treat COPD and you have these multiple medications to treat the cardiac conditions. It causes a major economic impact. Patients tend to be elderly, so this is almost essential polypharmacy that they get subjected to. That is another issue with these patients. The other clinical impact is in the context of COPD exacerbations. That has a clinical impact because the COPD exacerbations have been linked to subsequent cardiovascular events. So, that's one aspect of it. The second aspect is actually some extent of diagnostic confusion which can be a problem. Patients come in and they are short of breath. Is it the lungs? Is it the heart? There is confusion. Some of the medications we use to treat one affects the other condition in a negative way. That also creates a major clinical impact. From the health care system, these are the second and third most common causes of death. These are huge impacts. A lot of hospitalizations are driven by COPD and cardiovascular disease. There is good data showing that people with cardiovascular disease who have COPD have worse outcomes and vice versa. So, having both diseases together is clearly worse for the patient, and because of that also for the health care system because they're more expensive to treat.

AJMC: How does the development of cardiovascular disease with COPD impact mortality?

Sethi: They have worse outcomes and we know that. There is data showing that if you have COPD and you have a concomitant cardiovascular disease. What is interesting is that it is not only in the context of chronic disease, but even with acute exacerbations. When we look at exacerbations of COPD and outcomes if they have concomitant cardiac disease, those people will tend to have more relapses, or non-resolution, or die from the exacerbations. In that context, I think that is another overlap, which creates a problem for these individuals.

AJMC: Proper diagnosis and treatment are paramount to the management of individuals with COPD and cardiovascular disease. How can we best promote prompt and accurate diagnosis for these individuals?

Sethi: That is a clinical challenge. We need to do more. And I think the most common scenario is people with cardiovascular disease or people suspected to have cardiovascular disease not getting diagnosed with COPD. Clinically we see that a lot. When patients come in short of breath, have some chest discomfort, or have an arrhythmia there is always this focus on cardiac work-up; let's get the echo, let's get the stress test, let's get the cardiac cath. Many times, just an assessment of the lung function is completely not done. I have had patients come in with multiple cardiac tests, which cost a lot of money, and they haven't had a spirometry which is such a simple diagnostic test. Then, when you do the spirometry you find that they have COPD, and that's what's driving the dyspnea, that's what's causing them palpitations and chest discomfort. That clearly is a problem. It also makes a diagnosis difficult. We joke between us that the cardiologist blamed the lung and the pulmonologist blamed the heart. We always have this in a patient who has dyspnea. It does cause diagnostic difficulties for us. That is another clinical barrier or clinical difficulty. What we need to do, I think, is education for patients and providers. In general providers in the U. S. are very attuned to cardiac workups, but are not that attuned to doing respiratory testing. There is data showing that spirometry is way under utilized. People are given the label of COPD just on the basis of smoking history rather than getting the proper diagnostic testing. I think we need to promote accurate diagnosis. They can coexist. We need to look at both of those situations. The other scenario which is of interest is people with COPD. Should we be screening them for cardiovascular disease? It has been suggested in the literature, but there is no real data to show that it is cost effective. I know for your audience, that's going to be an interesting question. I think we have to be careful about that, because I have my COPD patients who are very limited, and maybe they never get to the point of stressing the heart enough to manifest their ischemic heart disease. I have seen that happen. For example, they get a CAT scan because they're short of breath and they have coronary artery calcifications. Next thing, they can't do a stress test and they are doing a nuclear stress, or they're getting a cardiac cath. All of that disease may actually have never become an issue for them because their lung disease is so bad. We want prompt and accurate diagnosis, but I think we should be utilizing our clinical judgment and at least doing the basic diagnostic testing in all our patients. For example, when I get a patient where I think he has COPD, I do get an echo to see what the heart is doing, and I think it should be the other way around which is not always the case.

AJMC: Do you think if we manage COPD better, from an earlier standpoint, that they would have a less chance or less reduced risk of developing cardiovascular disease or because it's not causation, does that matter?

Sethi: It does matter, and I'll tell you why it matters. It is not so much that we don't really modify the course of COPD except by smoking cessation. Yes, if we diagnose COPD and we practice smoking cessation that is one way to change the course of COPD, as well as change the chances of getting cardiovascular disease. So, that's one way. The other very strong link is between COPD exacerbations and consequent cardiac events. There are several studies now that have documented this link. If you step back and ask, if I had diagnosed COPD earlier, managed COPD appropriately with bronchodilators inhaled steroids, maybe we would have reduced exacerbations. If you reduce exacerbations you could reduce consequent cardiovascular events. I think by intervening early with COPD with both smoking cessation and adequate medication to prevent exacerbations you could actually reduce cardiovascular disease.