Ci a ion: Méndez-Bailón, M.;
Lo enzo-Villalba, N.; Rome o-Co ea,
M.; Josa-Lao den, C.;
Inglada-Galiana, L.; Meno -Campos,
E.; Gómez-Agui e, N.;
Clemen e-Sa asa, C.; Salas-Campos,
R.; Ga cía-Redecillas, C.; e al.
Ch onic Obs uc i e Pulmona y
Disease in Elde ly Pa ien s wi h
Acu e and Ad anced Hea Failu e:
Pallia i e Ca e Needs—Analysis o
he EPICTER S udy. J. Clin. Med.
2022,11, 3709. h ps://doi.o g/
10.3390/jcm11133709
Academic Edi o : Luigino Calze a
Recei ed: 4 Ap il 2022
Accep ed: 24 June 2022
Published: 27 June 2022
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A ibu ion (CC BY) license (h ps://
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Jou nal o
Clinical Medicine
A icle
Ch onic Obs uc i e Pulmona y Disease in Elde ly Pa ien s
wi h Acu e and Ad anced Hea Failu e: Pallia i e Ca e
Needs—Analysis o he EPICTER S udy
Manuel Méndez-Bailón1, Noel Lo enzo-Villalba 2,*, Mi iam Rome o-Co ea 3, Claudia Josa-Lao den 4,
Luis Inglada-Galiana 5, E a Meno -Campos 6, Noelia Gómez-Agui e 7, Ca olina Clemen e-Sa asa 8,
Rosa io Salas-Campos 9, Ca men Ga cía-Redecillas 10, Ma ía Asenjo-Ma ínez 11, Joan Ca les T ullàs12 ,
Begoña Co és-Rod íguez 13, Ca la de la Gue a-Acebal 14, Ana Se ado Iglesias 15, Reyes Apa icio-San os 16,
F ancesc Fo miga 17 , Emmanuel And ès3, Osca A ambu u-Bodas 18,19, P ado Salamanca-Bau is a 18,19
and on behal o EPICTER S udy G oup †
1Se icio de Medicina In e na, Hospi al Clínico Uni e si a io San Ca los, Uni e sidad Complu ense de
Mad id Ins i u o de In es igación Sani a ia (IdISSC), 28040 Mad id, Spain; [email p o ec ed]
2Se ice de Médecine In e ne, Diabè e e Maladies Mé aboliques, Hôpi aux Uni e si ai es de S asbou g,
67000 S asbou g, F ance
3Se icio de Medicina In e na, Hospi al Gene al de Rio in o, 21660 Huel a, Spain;
[email p o ec ed] (M.R.-C.); emmanuel.and es@ch u-s asbou g. (E.A.)
4Se icio de Medicina In e na, Hospi al Clínico Uni e si a io Lozano Blesa, 50009 Za agoza, Spain;
[email p o ec ed]
5Se icio de Medicina In e na, Hospi al Uni e si a io Río Ho ega, 47012 Valladolid, Spain;
[email p o ec ed]
6
Se icio de Medicina In e na, Hospi al Uni e si a io de Je ez de la F on e a, 11407 Je ez de la F on e a, Spain;
[email p o ec ed]
7Se icio de Medicina In e na, Hospi al E nes Lluch Ma ín, 50299 Cala ayud, Spain; [email p o ec ed]
8Se icio de Medicina In e na, Hospi al Royo Villano a, 50015 Za agoza, Spain;
[email p o ec ed]
9Se icio de Medicina In e na, Hospi al Uni e si a io Sag a Co , 08029 Ba celona, Spain;
[email p o ec ed]
10
Se icio de Medicina In e na, Complejo Hospi ala io de Jaén, 23007 Jaén, Spain; ga cia [email p o ec ed]
11 Se icio de Medicina In e na, Hospi al Uni e si a io Rey Juan Ca los, 28933 Mós oles, Spain;
[email p o ec ed]
12
Se icio de Medicina In e na, Hospi al d’Olo i Coma cal de la Ga o xa, 17800 Olo , Spain; [email p o ec ed]
13 Se icio de Medicina In e na, Hospi al Al o Guadalqui i , 23740 Andúja , Spain; [email p o ec ed]
14 Se icio de Medicina In e na, Hospi al de Menda o, 20850 Menda o, Spain; [email p o ec ed]
15 Se icio de Medicina In e na, Hospi al Municipal de Badalona, 08911 Badalona, Spain; [email p o ec ed]
16 Se icio de Medicina In e na, Hospi al San Juan de Dios del Alja a e, 41930 Bo mujos, Spain;
[email p o ec ed]
17 Se icio de Medicina In e na, Hospi al Uni e si a io de Bell i ge, 08907 Ba celona, Spain;
[email p o ec ed]
18 Se icio de Medicina In e na, Hospi al Uni e si a io Vi gen Maca ena, 41009 Se illa, Spain;
[email p o ec ed] (O.A.-B.); [email p o ec ed] (P.S.-B.)
19 Depa men o Medecine, Uni e sidad de Se illa, San Fe nando, 4, 41004 Se illa, Spain
*Co espondence: noello [email p o ec ed]
† Membe s o he s udy g oup a e lis ed in Acknowledgmen s.
Abs ac : In oduc ion:
The e a e s udies ha e alua e he associa ion be ween ch onic obs uc i e
pulmona y disease (COPD) and hea ailu e (HF) bu he e is li le e idence ega ding he p ognosis
o his como bidi y in olde pa ien s admi ed o acu e HF. In addi ion, li le a en ion has been gi en
o he ex aca diac and ex apulmona y symp oms p esen ed by pa ien s wi h HF and COPD in mo e
ad anced s ages. The aim o his s udy was o e alua e he p ognos ic impac o COPD on mo ali y
in elde ly pa ien s wi h acu e and ad anced HF and he clinical mani es a ions and managemen
om a pallia i e poin o iew.
Me hods:
The EPICTER s udy (“Epidemiological su ey o ad anced
hea ailu e”) is a c oss-sec ional, mul icen e p ojec ha consecu i ely collec ed pa ien s admi ed
o HF in 74 Spanish hospi als. Demog aphic, clinical, ea men , o gan-dependen e minal c i e ia
J. Clin. Med. 2022,11, 3709. h ps://doi.o g/10.3390/jcm11133709 h ps://www.mdpi.com/jou nal/jcm
J. Clin. Med. 2022,11, 3709 2 o 9
(NYHA III-IV, LVEF <20%, in ac able angina, HF despi e op imal ea men ), and gene al e minal
c i e ia (es ima ed su i al <6 mon hs, pa ien / amily accep ance o pallia i e app oach, and one o
he ollowing: e idence o HF p og ession, mul iple Eme gency Room isi s o admissions in he
las six mon hs, 10% weigh loss in he las six mon hs, and unc ional impai men ) we e collec ed.
Te minal HF was conside ed i he pa ien me a leas one o gan-dependen c i e ion and all he
gene al c i e ia. Bo h g oups (HF wi h COPD and wi hou COPD) we e compa ed. A Kaplan–Meie
su i al analysis was pe o med o e alua e he p esence o COPD on he i al p ognosis o pa ien s
wi h HF.
Resul s:
A o al o 3100 pa ien s we e included o which 812 had COPD. In he COPD
g oup, dyspnea and anxie y we e mo e equen ly obse ed (86.2% s. 75.3%, p= 0.001 and 35.4%
s. 31.2%, p= 0.043, espec i ely). In pa ien s wi h a his o y o COPD, p esen a ion o HF was in
he o m o acu e pulmona y edema (21% s. 14.4% in pa ien s wi hou COPD, p= 0.0001). Pa ien s
wi h COPD mo e equen ly su e ed om ad anced HF (28.9% s. 19.4%; p< 0.001). Consul a ion
wi h he hospi al pallia i e ca e se ice du ing admission was mo e equen when pa ien s wi h
HF p esen ed wi h associa ed COPD (94% s. 6.8%; p= 0.036). In-hospi al and six-mon h ollow-up
mo ali y was 36.5% in pa ien s wi h COPD s. 30.7% in pa ien s wi hou COPD, p= 0.005. The mean
numbe o hospi al admissions du ing ollow-up was highe in pa ien s wi h HF and COPD han in
hose wi h isola ed HF (0.63
±
0.98 s. 0.51
±
0.84; p< 0.002). Su i al analysis showed ha pa ien s
wi h a his o y o COPD had ewe su i al days du ing ollow-up han hose wi hou COPD (log
Rank chi-squa ed 4.895 and p= 0.027).
Conclusions:
pa ien s wi h HF and COPD had mo e se e e
symp oms (dyspnea and anxie y) and also a wo se p ognosis han pa ien s wi hou COPD. Howe e ,
he p ognosis o pa ien s admi ed o ou se ing is poo and many pa ien s wi h HF and COPD
may no ecei e he assessmen and pallia i e ca e suppo hey need. Pallia i e ca e is necessa y in
ch onic non-oncologic diseases, especially in mul ipa hologic and symp om-in ensi e pa ien s. This
is a clinical ca e aspec o be imp o ed and e alua ed in u u e esea ch s udies.
Keywo ds: h onic obs uc i e pulmona y disease; ad ance hea ailu e; pallia i e ca e
1. In oduc ion
The incidence and p e alence o hea ailu e (HF) and ch onic obs uc i e pulmona y
disease (COPD) is con inuously inc easing. HF p e alence has been epo ed o be highe
in pa ien s wi h COPD compa ed o he gene al popula ion (10–30% e sus 1–2%) [
1
,
2
]. HF
is a common condi ion in pa ien s hospi alized o exace ba ion o COPD: in hese pa ien s,
20% ha e been desc ibed o ha e p e-exis ing HF while 40% ha e new HF [
3
]. Pa ien s
p esen ing bo h como bid condi ions (HF and COPD) a e likely o be smoke s and olde
wi h an impo an bu den o como bid condi ions compa ed o pa ien s wi h HF wi hou
COPD [1,3,4].
Clinically, he associa ion o hese wo condi ions is pa icula ly challenging as hey
can p esen wi h simila clinical mani es a ions, which can signi ican ly delay he diagnosis
o HF [
5
,
6
]. In addi ion, HF emains unde diagnosed and unde ea ed in pa ien s wi h
COPD, wi h a one yea mo ali y a e eaching 50% [
3
,
7
]. Thus, COPD is associa ed
wi h inc eased ca dio ascula mo bidi y and mo ali y independen o he le en icula
ejec ion ac ion (LVEF) [8].
HF wi h p ese ed o educed LVEF should no be ea ed di e en ly i COPD coexis s
(1) and HF guidelines should be ollowed. Howe e , be a-blocke s a e unde p esc ibed in
hese pa ien s due o conce ns ega ding hei side e ec s on pulmona y unc ion [
1
,
9
]. In a
la ge e ospec i e analysis om an HF egis y, be a-blocke selec i i y was no associa ed
wi h a di e ence in ou comes o pa ien s wi h HF wi h COPD as compa ed wi h hose
wi h HF wi hou COPD [
10
]. In addi ion, bene i s om be a-blocke s ou weigh po en ial
isks e en in pa ien s wi h se e e COPD [
1
,
10
]. Rega ding he impac o ea men wi h
sacubi il/ alsa an on pulmona y unc ion, no da a a e a ailable.
J. Clin. Med. 2022,11, 3709 3 o 9
The e a e s udies ha e alua e he associa ion be ween COPD and HF bu he e is
li le e idence ega ding he p ognosis o his como bidi y in olde pa ien s admi ed o
acu e HF. In addi ion, li le a en ion has been gi en o he ex aca diac and ex apulmona y
symp oms p esen ed by pa ien s wi h HF and COPD in mo e ad anced s ages.
The aim o his s udy was o e alua e he p ognos ic associa ion o COPD on mo -
ali y in elde ly pa ien s wi h acu e HF and o e alua e he clinical mani es a ions and
managemen om a pallia i e poin o iew.
2. Ma e ial and Me hods
2.1. S udy Popula ion
The EPICTER s udy (“Epidemiological su ey o ad anced hea ailu e”) is a c oss-
sec ional and p ospec i e, mul icen e p ojec ha consecu i ely collec ed da a on pa ien s
admi ed o HF in 74 Spanish public o p i a e hospi als, ega dless o hospi al size. Pa ien s
we e ec ui ed in wo pe iods (summe and win e ). To a oid bias, hospi als began collec ing
da a on he same day (1 June and 30 No embe 2016) in which all pa ien s admi ed o
Ca diology o In e nal Medicine depa men s, In ensi e Ca e Uni s, o any o he se ice
we e included. Resea che s a each cen e checked pa ien s who me he inclusion c i e ia
daily and each hospi al con inued o ec ui pa ien s on subsequen days un il he equi ed
numbe was eached. The minimum numbe o pa ien s o be included o each hospi al
was p e-de e mined acco ding o he numbe o hospi al beds. Inclusion c i e ia we e (1) age
olde han 18 yea s, (2) admission o he hospi al oom be o e 8:00 o’clock on he day o da a
collec ion, (3) HF as he main cause o admission: acu e HF, acu e pulmona y edema, acu e
co ona y synd ome Killip III-IV, o ca diogenic shock. Exclusion c i e ia we e (1) pa ien s
a ended in he Eme gency Depa men , bu no ye admi ed, and (2) pa ien s who did no
sign he in o med consen . All pa ien s ecei ed he usual ea men s and medical ca e and
we e classi ied in o wo g oups acco ding o whe he o no hey had no COPD.
2.2. S udy Va iables
Demog aphic, clinical, ea men , o gan-dependen e minal c i e ia (NYHA III-IV,
LVEF < 20%, in ac able angina, HF despi e op imal ea men ), and gene al e minal
c i e ia (es ima ed su i al <6 mon hs, pa ien / amily accep ance o pallia i e app oach,
and one o hese: e idence o HF p og ession, mul iple ER isi s o admissions in he las
6 mon hs, 10% weigh loss in he las 6 mon hs, unc ional impai men ) we e collec ed.
Te minal HF was conside ed i he pa ien me a leas one o gan-dependen c i e ion and
all he gene al c i e ia. Vi al s a us o pa ien s a 6 mon hs ollow-up was e i ied by he
esea che s o each hospi al. Fo his pu pose, local heal h da abases we e used o ela i es
we e con ac ed (Supplemen a y File S1).
2.3. S a is ical Analysis
Con inuous a iables we e exp essed as mean (s anda d de ia ion) o median (wi h
25 h o 75 h in e qua ile ange), and ca ego ical a iables as equencies and pe cen ages.
Con inuous a iables we e compa ed using S uden ’s - es o non-pa ame ic K uskal–
Wallis es . Ca ego ical a iables we e compa ed using he Chi-squa e es .
Bo h g oups (HF wi h and wi hou COPD) we e compa ed. A Kaplan–Meie su i al
analysis was pe o med o e alua e he impac o he p esence o COPD on he i al
p ognosis o pa ien s wi h HF. A p- alue o less han 0.05 was conside ed s a is ically
signi ican . All analyses we e pe o med wi h he S a is ical Package o he Social Sciences
(SPSS) p og am ( e sion 26.0, SPSS Inc., Chicago, IL, USA).
2.4. E hical Aspec s
The s udy was ca ied ou in acco dance wi h he Decla a ion o Helsinki. E hical
app o al (E hics Commi ee o he Hospi al Vi gen Maca ena, In e nal code 0942-N-15;
24 No embe 2015
) was ob ained be o e ec ui men . All pa ien s signed he in o med
consen a inclusion.
J. Clin. Med. 2022,11, 3709 4 o 9
2.5. Resul s
A o al o 3100 pa ien s we e included o which 812 had COPD. The mean age in he
COPD g oup was 79.29
±
10.2 yea s wi h a p edominance o male sex (63%). Mean LVEF
was 53.28%
±
15.78 and mean NT-p oBNP was 8936.2 pg/mL
±
1047.51. O he pa ien s,
21.4% we e in NYHA unc ional class III-IV. Pa ien s wi h COPD had a mo e ad anced
NYHA unc ional class han pa ien s wi hou COPD. No signi ican s a is ical di e ences
we e obse ed be ween g oups in ela ion o LVEF and NT-p oBNP le els (Table 1).
Table 1. Clinical cha ac e is ics o pa ien s wi h HF wi h/wi hou his o y o COPD.
Va iable HF wi h COPD
(n = 812)
HF wi hou COPD
(n = 2288) p
Age (yea s) mean ±SD 77.5 ±10.1 79.4 ±11.1 0.001
Sex (male), N (%) 575 (70.8%) 955 (41.7%) 0.001
NYHA III-IV, N (%) 233/802 (29.1%) 486/2241 (21.7%) 0.001
LVEF, mean ±SD 50.08 ±16.5 51.26 ±15.9 0.65
NTp o-BNP pg/mL, mean 7910.4 8550.2 0.4
Como bidi ies
Cha lson como bidi y index mean
±
SD
4.49 ±1.76 3.24 ±1.8 0.0001
Hype ension N (%) 694/809 (85.8%) 1936/2283 (84.8%) 0.528
Diabe es N (%) 397/810 (49%) 1010/2279 (44.3%) 0.022
Ischemic hea disease N (%) 271/804 (33.7%) 713/2257 (31.6%) 0.271
A ial ib illa ion N (%) 470/809 (58.1%) 1286/2281 (56.4%) 0.409
Val e disease N (%) 176/377 (37.8%) 1012/2194 (46.1%) 0.001
Ch onic kidney disease N (%) 410/807 (50.8%) 1041/2270 (45.9%) 0.017
Ce eb o ascula disease N (%) 164/797 (20.6%) 498/2269 (21.9%) 0.453
Anemia N (%) 382/806 (47.4%) 1118/2274 (48.7%) 0.390
Legend: NYHA: New Yo k Hea Associa ion unc ional class, LVEF: le en icula ejec ion ac ion, COPD:
ch onic obs uc i e pulmona y disease. The diagnosis o acu e HF was based on 2016 ESC clinical p ac ice
guidelines. COPD was conside ed i he pa ien p esen ed he diagnosis o he disease acco ding o hei medical
his o y. The diagnosis o anemia was es ablished acco ding o he de ini ion o he Wo ld Heal h O ganiza ion
(<13 g/L hemoglobin o men and <12 g/L hemoglobin o women). Ch onic enal ailu e was de ined as a
pe sis en glome ula il a ion a e below 60 mL/min/acco ding o MDRD a leas h ee mon hs.
Pa ien s wi h a his o y o COPD had a highe equency o diabe es and ch onic kidney
disease a admission as well as a highe Cha lson como bidi y index wi h s a is ically
signi ican di e ences (4.49 ±1.76 s. 3.24 ±1.8; p< 0.001) (Table 1).
In ela ion o he collec ed symp oms o ad anced and e minal disease, in he COPD
g oup, dyspnea and anxie y we e mo e equen ly obse ed (86.2% s. 75.3%, p= 0.001 and
35.4% s. 31.2%, p= 0.043, espec i ely). No signi ican s a is ical di e ences we e obse ed
be ween g oups in ela ion o ches pain, nausea, insomnia, deli ium, and gene alized pain
(Table 2). In pa ien s wi h COPD, p esen a ion in he o m o acu e pulmona y edema was
mo e equen han in pa ien s wi hou COPD (21% s. 14%, p= 0.0001). Pa ien s wi h
COPD mo e equen ly expe ience ad anced HF (28.9% s. 19.4%; p< 0.001).
Table 2.
Clinical mani es a ions o ad anced disease e alua ed among elde ly acu e HF pa ien s wi h
and wi hou COPD.
Va iable HF wi h COPD
n = 528
HF wi hou COPD
n = 1480 p-Value
Dyspnea N (%) 455/528 (86.2%) 1114/1480 (75.3%) 0.0001
>10% Weigh loss N (%) 48/356 (13.5%) 121/900 (11.9%) 0.236
Func ional impai men N (%) 146/379 (38.5%) 390/715 (35.3%) 0.265
Anxie y N (%) 187/528 (35.4%) 462/1480 (31.2%) 0.043
Nausea N (%) 52/528 (9.8%) 176/1480 (11.9%) 0.231
Ches pain N (%) 99/528 (18.8%) 281/1478 (19%) 0.948
Gene alized pain N (%) 157/528 (29.7%) 394/1477 (26.7%) 0.098
Deli ium N (%) 83/528 (15.7%) 217/1480 (14.7%) 0.570
Insomnia N (%) 197/528 (37.3%) 507/1478 (35%) 0.222
J. Clin. Med. 2022,11, 3709 5 o 9
Table 3shows he ea men ecei ed du ing admission in bo h g oups o pa ien s.
Subjec s wi h a his o y o COPD we e mo e equen ly ea ed wi h nonin asi e mechanical
en ila ion (7.6 s. 4.6; p= 0.004) and high low oxygen (14% s. 11.4%; p= 0.018). No
s a is ically signi ican di e ences we e ound be ween g oups in he adminis a ion o
u osemide doses, use o amines, and o al and subcu aneous mo phine. Consul a ion wi h
he hospi al pallia i e ca e se ice du ing admission was mo e equen when pa ien s wi h
HF p esen ed wi h associa ed COPD (49/520; 94% s. 99/1450; 6.8%; p= 0.036).
Table 3.
T ea men ecei ed du ing admission in g oups o hea ailu e pa ien s wi h and wi hou COPD.
Va iable HF wi h COPD
(n = 812)
HF wi hou COPD
(n = 2288) p
Non-in asi e mechanical en ila ion n (%) 62 (7.6%) 105 (4.6%) 0.004
High Flow oxygen n (%) 74/529 (14%) 229/2014 (11.4%) 0.018
Ni oglice ine i 69/805(86%) 237/2281(20.4%) 0.222
Hype onic saline + u osemide n (%) 15/536 (2.8%) 34/1495 (2.3%) 0.297
Fu osemide pe usion n (%) 138/812 (17%) 364/2288 (15.9%) 0.770
Use o amines n (%) 50/812 (6.2%) 110/2288 (4.8%) 0.326
Le osimendan n (%) 11/812 (1.4%) 23/2288 (1%)
Dialysis n (%) 6/536 (1.1%) 17/1493 (1.1%) 1.000
O al mo phine n (%) 151/536 (28.2%) 379/1497 (25.3%) 0.109
Subcu aneous mo phine n (%) 74/472 (15.7%) 223/1304 (17.1%) 0.263
Benzodiazepines n (%) 185/535 (34.6%) 496/1496 (33.2%) 0.292
In-hospi al and 6-mon h ollow-up mo ali y was 36.5% (270/740) in pa ien s wi h
COPD s. 30.7% (639/2080) wi hou COPD (p= 0.005). The mean numbe o hospi al
admissions du ing ollow-up was highe in pa ien s wi h HF and COPD han in hose wi h
isola ed HF (0.63 ±0.98 s. 0.51 ±0.84; p< 0.002).
Su i al analysis showed ha pa ien s wi h a his o y o COPD had ewe su i al
days du ing ollow-up han hose wi hou COPD (log Rank chi-squa ed 4.895 and
p= 0.027
).
(Figu e 1). The causes among pa ien s wi h acu e HF wi h and wi hou COPD a e shown in
Supplemen a y Table S1.
J. Clin. Med. 2022, 11, x FOR PEER REVIEW 6 o 10
Figu e 1. Kaplan–Meie su i al cu e be ween HF pa ien s wi h and wi hou COPD.
3. Discussion
The esul s o ou esea ch demons a e ha six mon h mo ali y a e hospi al ad-
mission in elde ly acu e HF pa ien s was highe in hose subjec s wi h a medical an eced-
en o COPD. This en i y con e s an e en g ea e isk o dying ollowing hospi aliza ion
o acu e HF as epo ed in p e ious s udies [9]. Measu es o he se e i y o COPD (FEV1
and GOLD [Global Ini ia i e o Ch onic Obs uc i e Lung Disease] s age) ha e been
shown o be independen p edic o s o mo ali y and e en - ee su i al, espec i ely, in
pa ien s wi h COPD and concomi an HF [11]. In addi ion, he impac o COPD on mo -
ali y in acu e HF seems o be mo e impo an o e he long e m [9]. In he OPTIMIZE-
HF egis y o pa ien s hospi alized wi h acu e HF he e we e no di e ences in in-hospi al
Figu e 1. Kaplan–Meie su i al cu e be ween HF pa ien s wi h and wi hou COPD.

J. Clin. Med. 2022,11, 3709 6 o 9
3. Discussion
The esul s o ou esea ch demons a e ha six mon h mo ali y a e hospi al admis-
sion in elde ly acu e HF pa ien s was highe in hose subjec s wi h a medical an eceden o
COPD. This en i y con e s an e en g ea e isk o dying ollowing hospi aliza ion o acu e
HF as epo ed in p e ious s udies [
9
]. Measu es o he se e i y o COPD (FEV
1
and GOLD
[Global Ini ia i e o Ch onic Obs uc i e Lung Disease] s age) ha e been shown o be
independen p edic o s o mo ali y and e en - ee su i al, espec i ely, in pa ien s wi h
COPD and concomi an HF [
11
]. In addi ion, he impac o COPD on mo ali y in acu e HF
seems o be mo e impo an o e he long e m [
9
]. In he OPTIMIZE-HF egis y o pa ien s
hospi alized wi h acu e HF he e we e no di e ences in in-hospi al o 60-day mo ali y
a es be ween pa ien s wi h and wi hou COPD [
12
]. Howe e , in ou s udy, we obse ed a
high mo ali y a e o mo e han 30% a six mon hs o ollow-up, which was e en highe o
pa ien s wi h COPD. The di e ences in he sho - e m p ognosis obse ed in he di e en
published s udies show ha ou sample o pa ien s included in he EPICTER egis y wi h
HF and COPD we e in a mo e ad anced and e minal phase o he disease [12].
The p esence o COPD was mo e equen in he men in ou sample. This inding
may be due o a highe equency o smoking in elde ly pa ien s admi ed o HF in ou
en i onmen [13].
The p esence o COPD was also accompanied by a g ea e numbe o como bidi ies
associa ed wi h HF such as diabe es and he p esence o p e ious ch onic kidney disease.
These indings may be because COPD is also associa ed wi h an inc eased isk o diabe es,
among which he use o s e oids o con ol la e-ups may con ibu e o wo sened glycemic
con ol in his ype o pa ien . I is well known ha diabe es, p e ious smoking, and
ad anced age con ibu e o he de elopmen o ch onic kidney disease [1–3].
Pa ien s wi h HF and COPD in he EPICTER s udy p esen ed mo e symp oms o
ad anced HF epo ing mo e dyspnea, anxie y, and need o mo e use o high oxygen
mask supply and nonin asi e mechanical en ila ion han pa ien s wi h isola ed HF. These
indings may be explained by he p esence o bo h condi ions in he same pa ien s which
impa s a nega i e impac upon hem.
I is e y common ha HF p oduces diso de s in pulmona y en ila ion and pe u-
sion ha agg a a e COPD and, con e sely, ha COPD i sel , h ough hypoxemia and/o
hype capnia, inc eases he isk o ca diac a hy hmias and wo sens pulmona y conges ion.
These indings could explain why COPD pa ien s p esen ed mo e equen ly in acu e
pulmona y edema as he HF p esen a ion in his s udy. The indings o ou in es iga ion
show ha he pallia i e ca e eam e alua ed pa ien s wi h HF and COPD mo e equen ly.
The e was no di e ence in he pallia i e ea men ecei ed. In e es ingly, al hough HF is
gene ally conside ed as a se ious condi ion and equi alen o malignan disease in e ms o
symp om bu den and mo ali y, only a ew pa ien s ecei e specialis pallia i e ca e [
14
–
16
].
Howe e , e idence indica es ha a pallia i e app oach in HF signi ican ly imp o es pa ien
ou comes, including symp om con ol and men al heal h, dec eased hospi al admissions
and mo ali y, and educed heal hca e cos s [17,18].
In e es ingly, he e we e no di e ences in he use o le osimendan in bo h g oups.
Le osimendan augmen s he calcium sensi i i y o he oponin complex subsequen ly
imp o ing ca diac muscle con ac ili y [
19
,
20
]. Besides, i has also been shown o imp o e
con ac ili y o he diaph agm [
19
]. In ad anced HF pa ien s, le osimendan has showed
posi i e e ec s in educing mo ali y and h ee mon hs hospi aliza ion [21,22]. Rega ding
quali y o li e and symp oms imp o emen le osimendan showed con as ing e ec among
he s udies on ad anced HF pa ien s [21,23].
The s udy has some limi a ions. Fi s , we mus conside ha he COPD a iable was
es ablished as an an eceden in he EPICTER s udy da a collec ion. In his ega d, we do
no know i he diagnosis o COPD was based on spi ome ic c i e ia o on concomi an
ea men ecei ed o COPD. Second, in-hospi al mo ali y was no di e en ia ed om
ha o pa ien s su i ing admission. Since his was an acu e HF egis y, only d ugs o he
con ol and ea men o acu e HF we e collec ed. We do no ha e speci ic ea men s o
J. Clin. Med. 2022,11, 3709 7 o 9
ch onic HF o COPD. We did no e alua e da a ega ding conges ion such as he p esence
o pleu al e usion as i has ela ed o mo e ca dio- espi a o y complica ions wi h highe
mo ali y [
22
]. Finally, no all cen e s had he same access o specialized pallia i e ca e.
These aspec s a e impo an when in e p e ing ou esul s. A s eng h o he s udy is ha
he la ge coho is p ospec i e and unselec ed, so i is ep esen a i e o he eal wo ld.
4. Conclusions
Pa ien s wi h HF and COPD had mo e se e e symp oms (dyspnea and anxie y) and
also a wo se p ognosis han pa ien s wi hou COPD. Howe e , he p ognosis o pa ien s
admi ed o ou se ing is poo and many pa ien s wi h HF and COPD may no ecei e he
assessmen and pallia i e ca e suppo hey need. Pallia i e ca e is necessa y in ch onic
non-oncologic diseases, especially in mul ipa hologic and symp om-in ensi e pa ien s.
This is a clinical ca e aspec o be imp o ed and e alua ed in u u e esea ch s udies.
Supplemen a y Ma e ials:
The ollowing suppo ing in o ma ion can be downloaded a : h ps:
//www.mdpi.com/a icle/10.3390/jcm11133709/s1, Supplemen a y File S1. End s age disease
c i e ia. Table S1. Causes o dea h in pa ien s wi h HF wi h and wi hou COPD in he EPICTER
egis y. Table S2. Logis ic eg ession analysis o mo ali y e alua ing he COPD a iable.
Au ho Con ibu ions:
Concep ualiza ion, M.M.-B., N.L.-V., M.R.-C., C.J.-L., L.I.-G., E.M.-C., N.G.-A.,
C.C.-S., R.S.-C., C.G.-R., M.A.-M., J.C.T., B.C.-R., C.d.l.G.-A., A.S.I., R.A.-S., F.F., E.A., O.A.-B., P.S.-B.;
me hodology, M.R.-C., C.J.-L., L.I.-G., E.M.-C., N.G.-A., C.C.-S., R.S.-C., C.G.-R., M.A.-M., J.C.T.,
B.C.-R., C.d.l.G.-A., A.S.I., R.A.-S., F.F., E.A., O.A.-B., P.S.-B.; so wa e, M.M.-B.; alida ion, M.M.-B.,
N.L.-V., E.A., O.A.-B., P.S.-B.; o mal analysis, M.M.-B., N.L.-V., O.A.-B., P.S.-B.; in es iga ion, M.M.-B.,
N.L.-V., M.R.-C., C.J.-L., L.I.-G., E.M.-C., N.G.-A., C.C.-S., R.S.-C., C.G.-R., M.A.-M., J.C.T., B.C.-R.,
C.d.l.G.-A., A.S.I., R.A.-S., F.F., E.A., O.A.-B., P.S.-B.; esou ces, M.M.-B., N.L.-V., O.A.-B., P.S.-B.; da a
cu a ion, M.M.-B., N.L.-V., O.A.-B., P.S.-B.; w i ing—o iginal d a p epa a ion, M.M.-B., E.A., N.L.-V.,
O.A.-B., P.S.-B.; w i ing— e iew and edi ing, M.M.-B., E.A., N.L.-V., O.A.-B., P.S.-B.; isualiza ion,
M.M.-B., N.L.-V.; supe ision, M.M.-B., N.L.-V., O.A.-B., P.S.-B.; p ojec adminis a ion, M.M.-B.,
O.A.-B., P.S.-B. All au ho s ha e ead and ag eed o he published e sion o he manusc ip .
Funding: This esea ch ecei ed no ex e nal unding.
Ins i u ional Re iew Boa d S a emen :
E hical app o al (E hics Commi ee o he Hospi al Vi gen
Maca ena, In e nal code 0942-N-15; 24 No embe 2015) was ob ained be o e ec ui men .
In o med Consen S a emen :
In o med consen was ob ained om all subjec s in ol ed in he s udy.
Da a A ailabili y S a emen : Da a is con ained wi hin he a icle.
Acknowledgmen s:
EPICTER S udy G oup: Pa icia Vázquez-Rod íguez, Te esa Choucino-Fe nández,
Ana B. Po o-Pé ez, Pa icia Piñei o-Pa ga, Manuel L. López-Reboi o, C is ina Ped osa-F aga, Roi
Suá ez-Gil, Juan J. González-Sole , Pablo López-aMa o, Ana La o e-Díez, Ad iana Gómez-Gigi ey,
Lucía Fe ei a-González, Me cedes Sánchez-Cembellin, Ma ía Gallego-Villalobos, Jessica P. Rugeles-
Niño, Elisa E. Rod íguez-A ila, Al a o González-F anco, Ca la de la Gue a-Acebal, Angel Sebas ián-
Leza, Juan Mon e-A men e os, Go ka F u os-Muñoye o, Ca olina Clemen e-Sa asa, Jesús Díez-
Manglano, Claudia Josa-Lao den, Isabel To es-Cou choud, Noelia Gómez-Agui e, Rosa Jo dana-
Camajuncosa, Luis E. Cajama ca-Cal a, Isabel To en e-Jiménez, Ana Se ado-Iglesias, Luis M.
Ce esuela, Rosa io Salas-Campos, Jo di Delás-Ama , F ancesc Fo miga, A iadna B asé-A nau, I ene
Pe i -Salas, Ve ónica Romaní-Cos a, An onia Expósi o-López, Ca los E. Sabbagh-Faja do, Jesús
Recio-Iglesias, Ca men Alemán-Llansó, Josep M. Su iñach-Ca al , Joan Ca les T ullás-Vila, A ola
A mengou-A xe, Sa a Ga cía-To as, JoséLuis Mo ales-Rull, C is ina Solé-Felip, Ana Lacal-Ma ínez,
C is ina Sánchez-Sánchez, Miguel O e o-Sole , Albe o Muela-Moline o, Ma ga i a Ca e a-Izquie do,
Pa icio A ibas-A ibas, Luis Inglada-Galiana, Ángela Ruiz de Temiño de la Peña, Ál a o Sil a-
Vázquez, Lucía Fuen es-Pa do, Ma ía Ga cía-Ga cía, Es he Piniella-Ruiz, Be hania Pé ez-Al es,
Sonia Gonzalo-Pascua, Jo ge Ma e o-F ancés, Manuel Méndez-Bailón, F ancico J. Ma ín-Sánchez,
Ma a Va as-Mayo al, Ma ía Asenjo-Ma ínez, Miguel Yeb a-Yeb a, Bea iz Sánchez-Sauce, Ben-
jamín He e os-Ruiz, Angus ias Quesada-Simón, I o Vi es-Bel án, Jo ge Ál a ez-T oncoso, Luis A.
Ma ínez-Ma ín, Paloma Gil Ma ínez, Es ella Díaz de Mayo ga, Miguel A. Mo eno-Palanco, Llanos
Sole -Rangel, Ja ie Abellán-Ma ínez, Ana M. Colás-He e a, Geno e a T. López-Cas ellanos, Raúl
J. Clin. Med. 2022,11, 3709 8 o 9
Ruíz-O ega, E elyn Ruiz-Ba aza, Ma ía L. Ma ín-Jiménez, Es he Mon e o-He nández, JoséC.
A é alo-Lo ido, Juana Ca e e o-Gómez, Pa icia Calde ón-Jiménez, Almudena He e o-Domingo,
Sheyla Ma ín-Ba ba, Julio C. Blázquez-Encina , Ca los Jiménez-Gua diola, Jóse M. Cepeda-Rod igo,
Dolo es Quiles-Ga cía, Sa a Ca ascosa-Ga cía, Pau Llace -Ibo a, Ma ía C. Mo eno-Ga cía, Luis F.
Díez-Ga cía, Pu i icación Sánchez-López, Ma ía J. Ma ínez-So iano, E a Meno , Manuel Mon e o-
Pé ez-Ba que o, Manuel P. Angui a-Sánchez, Ma ía Sánchez-Mo uno, Ma ía Fuen es-Espínola, José
L. Zamb ana-Ga cía, Es he Guisado-Espa e o, Inmaculada Mejías-Real, JoséN. Alcalá-Ped ajas,
Inmaculada Páez-Rubio, F ancisco J. Ca asco-Sánchez, Ca alina Díaz-Pé ez, Ma cos Guzmán-Ga cía,
Sa a Domingo-Roa, Begoña Co és-Rod íguez, Ca men Ga cía-Redecillas, Rosa io Ma ín-Na a o,
Raúl Qui ós-López, Pa icia Macías-Á ila, Isabel An eque a-Ma ín-Po ugués, Ma ía Blanco-So o,
JoséL. A ias-Jiménez, Osca A ambu u-Bodas, P ado Salamanca-Bau is a, Mi iam Rome o-Co ea,
JoséA. Ga cía-Ga cía, F ancisco J. Flo es-Ál a ez, Reyes Apa icio-San os, M. Dolo es Nie o-Ma ín,
Rocío Ga cía-Se ano, Ca los Jiménez-de-Juan, Ja a Te ne o-Vega, Ma ía Villalonga-Comas, Manuel
Díaz-Cañes o, Ja ie Asensio-Rod íguez, Alicia Conde-Ma el, Aída Gil-Díaz, I án Ma e o-Medina,
Alicia Puen e-Fe nández, Diego Gudiño-Agui e, Meli ón F. Dá ila-Ramos, Edua do Calde ón.
Con lic s o In e es : The au ho s decla e no con lic o in e es .
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