Breathless and heart broken in COPD

Photo by CDC on Unsplash (https://unsplash.com/@cdc). Shared risk factors such as tobacco smoke exposure and environmental air pollution mean that is very common for people living with COPD to have other medical problems too, notably cardiovascular disease. In fact, the risk of cardiovascular disease in COPD is elevated above that due solely to shared risk factors—having damaged and inflamed lungs is bad for heart—and cardiovascular risk is elevated further around the time of exacerbations. Living with more than one long-term condition is one definition of 'multi-morbidity' (and this is a more person-centred term than 'co-morbidity' which rather implies that the condition within our own area of expertise takes precedence). Why should we be interested in multi-morbidity in COPD? Well first up, it's person-centred. Second, our interventions are delivered with the intent of improving outcomes and when it comes to the hardest outcome of all—premature death—people living with COPD are at increased risk of cardiovascular death, and death from lung cancer, and thus to improve outcomes we need to consider and mitigate these risks too. We don't know what the best way to measure cardiovascular risk in COPD is. Recently the updated QRISK score called QR4 has included COPD as a co-variate (https://doi.org/10.1038/s41591-024-02905-y), and I've written in this column before about maximizing the value of CT imaging in COPD (https://doi.org/10.1111/resp.14407), for example, through coronary artery calcium scoring. Direct measurements of cardiovascular risk in COPD—such as aortic pulse-wave velocity—remain principally a research tool. It's easiest to look for modifiable risk-factors such as smoking, physical activity hypertension and elevated cholesterol. However you choose to do it, identifying and managing cardiovascular risk in COPD is important. Whilst there is not evidence that using cardiovascular therapies in COPD outside their licenced indications improves COPD (or other) outcomes, there remains evidence that cardiovascular risk is not routinely assessed and reduced, and effective interventions such as beta-blockers remain under-utilized in COPD. And, excitingly, secondary outcomes of large trials such as ETHOS and IMPACT suggest optimizing COPD therapy may reduce cardiovascular death. John R. Hurst has received grant support, support to attend meetings, and personal payment and payment to his institution for educational and advisory work from pharmaceutical companies that make medicines to treat COPD.