Assessing and managing cardiovascular risk in COPD

This article has been funded by Aspire Pharma who had no influence on the content and reviewed for accuracy purposes only. 10103112709 v 1.0 May 2025

Primary care clinicians have a unique opportunity to provide holistic care for people living with chronic obstructive pulmonary disease (COPD), which is known to be associated with an increased likelihood of asymptomatic cardiovascular risk factors as well as active disease

Long-term conditions become more common as people get older.With an increasingly ageing population and the subsequent predicted impact on resources across health and social care, clinicians will need to work smarter to ensure that every consultation is as person-centred and effective as possible. This can be achieved by taking a holistic approach, where the person living with, or at risk of, long term conditions (LTCs) is central to the consultation, rather than the long-term condition itself.

Increasingly, clinicians are being advised to consider multi-morbidity when reviewing patients.This may mean conducting annual reviews which address all of the LTCs that the patient is known to have but which also factor in consideration of future risks at the same time.

This is not a new concept. In diabetes care, there has been a move away from glucocentric care to one which focuses on cardiorenal metabolic health is recognised to be a central to holistic care. This has been recognised in both national and international guidelines.^1,2 Someone living with type 2 diabetes will be at increased risk of cardiovascular disease, chronic kidney and liver disease, hypertension and dyslipidaemia, so it makes sense to highlight these issues with the patient and address each area within the annual review.³

In a similar vein, there is greater awareness of the increased level of cardiovascular risk in people living with chronic lung conditions such as chronic obstructive pulmonary disease (COPD).⁴ It is therefore important that clinicians are aware of the concept of cardiopulmonary health and the need to ensure that people with a diagnosis of COPD are assessed for cardiovascular risk factors and supported to reduce that risk.

By the end of this article the reader will be able to:

• Appreciate the link between COPD and cardiovascular disease
• Recognise cardiovascular risk factors, such as hypertension and dyslipidaemia, in people with COPD
• Use appropriate tools for cardiovascular risk assessment
• Establish evidence-based risk reduction strategies, including the management of hypertension and dyslipidaemia in order to optimise long-term health

COPD AND CARDIOVASCULAR RISK

The heart and the lungs work together to circulate oxygen and nutrients to the body.COPD is a chronic and largely irreversible lung condition, often caused by long-term exposure to harmful substances such as cigarette smoke.⁵ The impact of COPD on a person’s health is, therefore, far-reaching.People living with COPD can suffer from a range of symptoms, including cough, sputum production and breathlessness, which can impact on their physical and mental health.⁶They are also known to be at increased risk of cardiovascular disease, partly because of adverse health behaviours, including smoking, adopting a sedentary lifestyle and being overweight,⁷ and also because of overlapping pathophysiological changes, such as inflammation, endothelial dysfunction and vascular wall remodelling.⁸ Cardiovascular disease (CVD) is the main cause of hospital admissions in people with COPD and they have a two to fourfold increased risk of cardiovascular mortality compared with people who do not have COPD.⁹Furthermore, acute exacerbations of COPD (AECOPD) have been shown to increase the risk of a cardiovascular event in the weeks and months following an exacerbation.¹⁰It is clear, then, that clinicians are aware of this relationship and take every opportunity to pay close attention to cardiovascular health, and not just respiratory wellbeing, when consulting with people living with COPD.¹¹ 

REDUCING FUTURE RISK

Prevention of poor health is the key to improving outcomes for individuals, for the NHS and for society as a whole.Disease prevention has been identified as a priority for the government and the prevention of CVD has been incentivised through the Quality and Outcomes Framework (QOF).Although age, sex and ethnicity are non-modifiable risk factors for CVD, there are many modifiable risk factors that can be managed to reduce CVD risk.Lifestyle can play a significant role in improving health status and should be the foundation upon which long-term benefits can be achieved.Healthier lifestyles are achieved through following a balanced diet, maintaining a healthy weight, avoidance of smoking, keeping alcohol intake to no more than 14 units per week, and taking regular physical activity as described on the NHS Better Health website, https://www.nhs.uk/better-health/ (https://www.nhs.uk/better-health/).

Although primary prevention of LTCs such as CVD is the ultimate goal, if someone already has a long-term condition, healthcare workers should still be alert to the possibilities of comorbid conditions.LTCs often occur together, so the person presenting with one condition has an increased likelihood of having at least one other chronic disease.¹² In the case of COPD, the increased risk of developing cardiovascular disease should act as a reminder that any consultation offers an opportunity to consider cardiovascular risk.This is particularly so in people who have had an acute exacerbation of their COPD.Research shows that the risk of a cardiovascular event increases significantly in the days, weeks and months following an acute exacerbation and that this increased risk persists for over a year post exacerbation.¹⁰ Thus, people living with COPD need holistic assessment of their cardiopulmonary health to reduce the likelihood of future adverse events.One way to view this is to think of acute exacerbations of COPD as the lung attacks which increase the risk of heart attacks.This increased risk can be reduced for patients through appropriate management of their COPD, using interventions that are known to improve outcomes.These include pulmonary rehabilitation, smoking cessation, vaccinations and appropriate prescribing of inhalers, with both the inhaler device and medication tailored to the individual.⁶ Along with optimising lung health, it is also important to consider other known risk factors for cardiovascular disease and ensure that these are identified and managed appropriately.

CARDIOVASCULAR RISK ASSESSMENT AND MANAGEMENT

Over 20 years ago, the INTERHEART study showed that the three dominant risk factors for CVD were smoking, dyslipidaemia and hypertension.¹³ Today, these areas remain a priority as modifiable risk factors for CVD.Clinicians should be proactively assessing for these risks, especially as both hypertension and dyslipidaemia are so-called ‘silent’ conditions.In February this year, NICE published its latest guidance on smoking cessation, highlighting dual nicotine replacement therapy, cytisine and varenicline as being treatments that offer the greatest likelihood of a successful quit attempt.¹⁴ NICE has also produced guidance on the diagnosis and management of hypertension and dyslipidaemia.^15,16

In primary prevention, the advice regarding initiation of lipid lowering therapy (LLT) is that this should be offered to people with a cardiovascular risk score of 10% or more.¹⁶The recommended risk assessment tool is QRISK3 which can be accessed via www.qrisk.org (http://www.qrisk.org).In younger people, women and others where risk may be underestimated, QRISK Lifetime, which can be accessed here https://www.qrisk.org/lifetime/ (https://www.qrisk.org/lifetime/) may offer a more accurate approach to risk assessment.QRISK Lifetime also offers an opportunity to adjust risk factors in a ‘what if’ demonstration of the impact of optimising different aspects of the risk profile; for example, the effect of treating blood pressure to target can be shown on short and long-term risk of cardiovascular events.A new risk assessment tool, QRISK4, has also been developed but has not as yet been made available for general use.¹⁷ This includes more risk factors based on an increased understanding of additional risks not included in any of the previous QRISK tools.One of the additional elements included in QRISK4 is a diagnosis of COPD.¹⁷

HYPERTENSION

Diagnosis

NICE recommends measuring the clinic blood pressure (BP) and arranging home BP readings if the clinic measurement is above 140/90 mmHg.¹⁵ Stage 1 hypertension is diagnosed if the average home readings are between 135/85mmHg and 149/94mmHg.Lifestyle advice should be given for everyone with stage 1 hypertension, with medication being offered if there is pre-existing CVD, diabetes or chronic kidney disease, or if the QRisk score is 10% or higher. This is why risk assessment is important in people newly diagnosed with hypertension. Stage 2 hypertension is diagnosed if the average home BP is 150/95mmHg or more. In this case, medication is always recommended along with lifestyle changes.

Treating hypertension

Treatment options are predominantly based on the age of the person diagnosed with hypertension.The NICE guidelines state that if someone is under the age of 55, a renin angiotensin aldosterone system inhibitor (RAASi) – an ACE inhibitor or angiotensin receptor blocker – would be the drug of choice.¹⁵ This would also be the recommended option for someone with a diagnosis of diabetes.RAASi drugs reduce vasoconstriction, fluid and salt retention which in turn reduces blood pressure.^18,19

In people aged 55 and above the first line option would be a calcium channel blocker (CCB).20 CCBs act as vasodilators and are more likely to reduce BP effectively in this age group.NICE also recommends CCBs for people of African Caribbean ethnicity.

In reality, most people with hypertension will need two or more classes of medication to get to target, a fact that is recognised by the European Society of Cardiology (ESC) guidance which recommends starting patients on two drug classes from diagnosis to optimise the likelihood of BP management.²¹ ESC guidance on what constitutes a non-elevated BP (below 120/70mmHg), an elevated BP (120-139/70-89mmHg), and overt hypertension (140/90mmHg or higher) along with the targets that should be aimed for (120–129/70–79mmHg) differs from NICE guidance and is more ambitious around diagnosing, monitoring and treating BP.

CASE STUDY – THEORY INTO PRACTICE

Carlos is a 57-year-old man with a history of COPD, which was diagnosed after he presented with recurrent symptoms of breathlessness and a productive cough after a 40-year history of cigarette smoking. Carlos attended for a review of his COPD after being treated for his second exacerbation in the space of eight months. Carlos was referred for pulmonary rehabilitation and his dual bronchodilator was replaced with a triple therapy inhaler to reduce the risk of further exacerbations. Recognising the link between COPD and CVD risk, the clinician took the opportunity to carry out a more holistic health assessment. After discussing lifestyle interventions, Carlos’s height and weight was measured, questions asked about his medical and family history and his blood pressure measured.In clinic, this was 152/92mmHg. Carlos thought it was because he was nervous. He was then booked in to get blood tests done to assess for undiagnosed diabetes or kidney disease and to measure his lipid profile. He was also asked to measure BP readings at home for a week and was taught how to do this correctly. At his next appointment, his average BP was recorded as 141/86mmHg. On this basis, Carlos was diagnosed with stage 1 hypertension. With no other long-term conditions, a cardiovascular risk assessment was carried out to determine whether pharmacological management should be offered along with lifestyle advice. His QRisk 3 score was 12.6%, whereas a healthy individual of the same age, sex and ethnicity would have a score of 6.7%. This indicated that Carlos’s risk was almost double what it should be and was also above the 10% cut-off where medication should be offered. Based on the current NICE guidelines on the diagnosis and management of hypertension, the recommended drug class would be a calcium channel blocker. After advising Carlos about the mode of action and possible side effects of the medication, he was happy to start on treatment and a follow-up appointment was arranged for a month later to assess how well he was tolerating the medication and to see the impact on his blood pressure, using home and clinic BP readings. If Carlos has reached target, his BP and blood tests will continue to be monitored every 6-12 months. If he has not reached target, a second treatment from the RAAS class will be added, in line with NICE. If a third treatment is needed, that would be a thiazide-like diuretic. If someone has not achieved target with three classes of medication a review of adherence, lifestyle, including salt and alcohol intake and consideration of the need for referral will need to be carried out.

SUMMARY

Cardiovascular disease is the cause of significant morbidity and mortality in the UK.Lifestyle interventions are the foundation of improving health in general, with pharmacological interventions used where appropriate to optimise outcomes.People with COPD are at high risk of CVD and should be assessed and treated in order to reduce this risk. Communication is an important part of effective risk assessment and explanation of how risks can be reduced. Clinicians should take every opportunity to maximise the impact of their consultations in order to optimise health outcomes for people living with, or at risk of, heart disease.

Scan the QR code in the Carousel below to view a COPD-CVD assessment tool. Alternatively, you can enter this address in your browser: https://meds-ops-centricity.co.uk/copd-cvd-assessment/

REFERENCES

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