Chronic Obstructive Pulmonary Disease and Atrial Fibrillation

An Interdisciplinary Perspective

Sami O. Simons; Adrian Elliott; Manuel Sastry; Jeroen M. Hendriks; Michael Arzt; Michiel Rienstra; Jonathan M. Kalman; Hein Heidbuchel; Stanley Nattel; Geertjan Wesseling; Ulrich Schotten; Isabelle C. van Gelder; Frits M.E. Franssen; Prashanthan Sanders; Harry J.G.M. Crijns; Dominik Linz

Disclosures

Eur Heart J. 2021;42(5):532-540. 

In This Article

Chronic Obstructive Pulmonary Disease Treatment in Atrial Fibrillation Patients

Pharmacological treatment

Bronchodilators are the mainstay of COPD treatment.[39] The recent SUMMIT trial[57] and ASCENT-COPD[58] trial have shown that bronchodilators can be safely used in COPD patients with concomitant cardiovascular disease. Both the inhaled beta2-agonists and anticholinergics have been associated with tachyarrhythmias.[59] For inhaled beta2-agonists, an increased risk was mainly seen with the new use of inhaled beta2-agonist (prescription within 30 days) and was stronger for short-acting bronchodilators than for long-acting beta2-agonists.[60,61] The risk for cardiac arrhythmias in patients treated by anticholinergics is much weaker and increased risk of tachyarrhythmias and AF were observed in some but not all studies.[59,60] Inhaled corticosteroids do not seem to increase AF risk, though in COPD fixed combinations with beta2-agonists are mostly used.[59,61] Of the oral medications used in COPD, both corticosteroids and theophylline have been associated with an increased risk of AF.[60–62] The potential effects of COPD medications on AF and potential interactions with drugs frequently used for rate and rhythm control are summarized in Table 2.

Correction of Hypoxaemia and Hypercapnia

Since hypoxaemia and hypercapnia are associated with the onset of AF, guidelines suggest correcting these abnormalities during an AECOPD.[12] In stable disease, COPD patients with AF should be screened for respiratory insufficiency. It seems prudent to correct the underlying hypoxaemia with oxygen therapy and hypercapnia with non-invasive ventilation, though the effect of these treatment modalities on the new onset of AF or progression of AF has not been studied, yet.[63]

Lifestyle Interventions

Exercise interventions, possibly guided by CPET, can be provided through physiotherapy or through specific cardiopulmonary rehabilitation programmes. Beneficial effects of risk factor modification and exercise have been shown individually in AF or in COPD populations.[64–66] In obese patients with AF, risk-factor management including weight-loss and exercise prescription within a goal-directed programme improves the long-term success of AF ablation.[64,65] Whether interventions such as weight-loss, cessation of alcohol and smoking, or other lifestyle interventions show antiarrhythmic effects in AF patients with concomitant COPD needs to be further investigated.[66]

Integrated Care Approach

The diagnosis and treatment of COPD in AF patients requires a close interdisciplinary collaboration between the electrophysiologist, cardiologist, and pulmonologist, and necessitates a structured follow-up. This may be best delivered through an integrated care model and may require multidisciplinary meetings to discuss the most optimal management, based on a combined viewpoint from both specialties. Moreover, comprehensive treatment of COPD and AF, as well as underlying conditions and risk factors should be pursued. Following the integrated approach, the COPD patients with AF should be placed in a central position and actively involved in their care process. This requires continuous patient education: it is crucial that patients understand what COPD and AF are, their treatment and lifestyle management, and how they can contribute to improving clinical outcomes through treatment and lifestyle management. A cardiopulmonary nurse as a case manager may be best positioned to provide education and work with the patient to self-manage their condition, and also co-ordinate the care to prevent fragmentation, which may be lurking given that patients will be treated by both cardiology and pulmonology departments.

Figure 2 summarizes a possible pathway for a work-up of AF patients with suspected COPD: Patients with AF and suspected COPD should be screened for COPD and exacerbating factors, like smoking and use of medications. The clinic consultation should also review all medications, address common risk factors, and consider lifestyle changes such as smoking cessation and exercise. If typical symptoms for OSA are present, targeted diagnostics should be initiated.[17] Handheld microspirometer may be a suitable method to ensure patient access and to implement screening for COPD in the standard work-up of AF patients considered for rhythm control strategies, although specific validation studies in AF populations are needed. Specific dyspnoea questionnaires, like the Modified Medical Research Council (mMRC) Dyspnoea Scale, the Dyspnoea-12 score (D-12), and the Multidimensional Dyspnoea Profile (MDP) might help to quantify and qualify the different dyspnoea sensations. However, these two latter questionnaires are more commonly used in specialized centres. Determination of natriuretic peptides and echocardiography can detect heart failure as a contributing cause of dyspnoea.

Figure 2.

Proposal of an integrated care pathway on testing for and managing chronic obstructive pulmonary disease in atrial fibrillation patients. FEV in 1 s/FEV in 6 s ratio (FEV1/FEV6). AF, atrial fibrillation; COPD, chronic obstructive pulmonary disease; FEV1, forced expiratory volume in 1 s; FVC, forced vital capacity.

processing....