Are My Symptoms From COPD, Heart Failure, or Both?

Many patients with COPD also have congestive heart failure and vice versa

Doctor showing patient results on tablet
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Shortness of breath is a primary symptom of chronic obstructive pulmonary disease (COPD). It is very commonly the reason patients with COPD go to the emergency room or visit a physician. Most exacerbations of COPD manifest with significant shortness of breath, wheezing, and cough  If you are a patient with COPD, you probably know these symptoms all too well, and perhaps you or your doctors  might assume that your symptoms are all related to COPD.

  However, it’s important to keep in mind that 30 percent of patients with chronic obstructive pulmonary disease (COPD) have some degree of congestive heart failure (CHF).  In other words, patients with COPD who have poorly controlled symptoms such as shortness of breath or wheezing should also be evaluated for congestive heart failure (CHF).

Similarities Between COPD and CHF

  1. Symptoms: Both COPD and CHF is a disease have virtually identical symptoms: shortness of breath, cough, and/or wheezing.  In addition, CHF may cause leg swelling, which is not a symptom of COPD, but not all patients with CHF have leg swelling.  
  2. Exacerbations:  Both COPD and CHF are diseases that frequently get worse, then better, then worse. These worsenings are called ‘exacerbations’ and are a hallmark of these two disease courses. COPD exacerbations may be triggered by infections, colds (viruses), smoke and fumes. CHF exacerbations are usually triggered by changes in diet (eating excess salt or water), forgetting to take medications, and changes in health status (for example, a heart attack or kidney problems).  In both cases, if you are suffering from either a COPD or CHF exacerbation, you may notice that your symptoms are getting worse. Simple chores may make you more breathless, you may cough more or hear yourself wheezing. It is sometimes very hard to tell the difference between a COPD exacerbation and a CHF exacerbation, especially for patients who suffer from both diseases.
  1. Decreases in pulmonary function: If you have COPD, you are no stranger to breathing tests, or pulmonary function tests. This test involves blowing into a machine that measures your respiratory function, with the primary number of interest being the FEV-1 (forced expiratory volume). When patients with COPD or CHF have exacerbations, this number drops, which signifies a decrease in lung function.  Once exacerbations improve, this number should improve as well.  The worse the drop in the lung function, the more severe the exacerbation– and this is true for both COPD and CHF exacerbations.

    How Do Doctors Tell COPD and CHF Apart?

    1. Physical Exam: Anytime you have a worsening of symptoms, it is important to visit a doctor so they can do a full physical exam. In particular, clinicians will look for signs that tell COPD and CHF apart.  For the lung exam,  doctors may detect wheezing (which occurs during both COPD and CHF exacerbations).  However, if the problem is primarily CHF, then a noise called a “crackle” (which signifies fluid buildup) may be a predominant sound.  Doctors will also likely examine your legs to assess for swelling, which is a common problem in CHF but less so for COPD exacerbations.  The cardiac exam may reveal new murmurs, which more often occur when CHF is the problem and neck veins may be distended which can signify fluid backup.  All of these findings are clues, however, and none of them confirm that one disease is responsible for your symptoms versus the other.
    2. Chest-xrays:  The chest x-ray is another way physicians might look to determine the difference between a COPD exacerbation and a CHF exacerbation in patients who may have both diseases.  When a patient has a CHF exacerbation, fluid buildsup in or around the lungs, and this can be seen on a chest x-ray.  However, if the symptoms are purely because of COPD, then this fluid will not be seen.
    1. Echocardiograms:  An echocardiogram is an ultrasound of the heart. It allows clinicians to take a look at the structure of the heart, the flow of the blood, and the pumping function of the heart muscle itself. If the heart function is reduced (sometimes called a low ejection fraction), this may prompt suspicion from the doctor that CHF is the main problem. If the heart is functioning normally, this may make the physician suspect that COPD is the main problem, instead. Remember, however, patients may have BOTH problems, and so all of these results must be taken in context.
    2. Blood tests.  Finally, a blood test called the BNP, or basic natriuretic peptide may be very elevated during a CHF exacerbation.  This test can be very helpful when it is low, because that suggests that the heart is not overworked.

    What Are the Differences in Treatment?

    For COPD exacerbations, the treatment involves bronchodilators or inhaled steroids plus oral steroids (such as prednisone) or sometimes IV steroids.  Patients with COPD exacerbations should also receive nebulizers or albuterol inhalers.  Often, antibiotics are prescribed as well.

    For CHF exacerbations, the primary treatment involves diuretics (such as Lasix or Bumex).  A new CHF exacerbation should prompt a visit to your cardiologist in order to make sure that no new heart problems have arisen that may have caused your worsening symptoms.  Other medications may be adjusted or prescribed during a CHF exacerbation as well, and so it’s always a good idea to talk to your doctor if you are having new symptoms.

    When patients have both COPD and CHF it is often difficult to tell them apart—and many times, patients may have both diseases which often flare around the same time. Doctors will often treat both COPD symptoms and CHF symptoms simultaneously if its not entirely clear which disease is contributing to the symptoms the most and guidelines recommend continuing patients with heart failure on their current medication regimen (including beta blockers) and also recommend continuing COPD medications if both diseases are contributing to symptoms.

    The Bottom Line

    COPD and CHF are very similar in terms of symptoms and other findings, and many patients suffer from both diseases.  Therefore, it is not uncommon for doctors to treat you for both COPD and CHF at the same time if it is not clear which disease is the culprit.

    Source
    Global Initiative for Chronic Obstructive Lung Disease (GOLD Guidelines) 2016

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