Comparative effectiveness of corticosteroid choice in hospitalized patients with concurrent COPD and heart failure exacerbations

Hospitalized patients with acute exacerbations of chronic obstructive pulmonary disease (AECOPD) frequently have concurrent acute decompensated heart failure (ADHF). Corticosteroids used to treat AECOPD that have mineralocorticoid activity may promote fluid retention, potentially worsening heart failure. To compare the effectiveness of corticosteroids with mineralocorticoid activity to corticosteroids with minimal mineralocorticoid activity in patients hospitalized with both AECOPD and ADHF. Retrospective cohort study using a target trial emulation framework. Adults aged ≥ 50 years, hospitalized between October 2022 and July 2024 with both AECOPD and ADHF present on admission who were treated on hospital day 1 with systemic corticosteroids and parenteral loop diuretics, identified from the Premier Healthcare Database. Initial treatment with corticosteroids with mineralocorticoid activity (hydrocortisone or prednisone) versus corticosteroids with minimal mineralocorticoid activity (methylprednisolone or dexamethasone). The primary outcome was hospital-free days by day 30. Secondary outcomes included hospital length of stay, in-hospital mortality or discharge to hospice, days of parenteral diuretic use, days of corticosteroid use, and 30-day readmission. Among 24,162 hospitalizations meeting inclusion criteria, 2,562 (11%) received corticosteroids with mineralocorticoid activity (median age 71 years, 51% female), whereas 21,600 (89%) received corticosteroids with minimal mineralocorticoid activity (median age 72 years, 47% female). There was no difference in hospital-free days by day 30 (22.8 vs. 23.0 days; difference 0.3 [95% CI − 0.02 to 0.5]) or in-hospital mortality/discharge to hospice (6.2% vs. 5.9%; difference − 0.3% [95% CI − 1.4 to 0.8]). Patients receiving corticosteroids with mineralocorticoid activity had slightly fewer days of parenteral diuretic use (− 0.2 days), fewer days of corticosteroids (− 0.1 days), and shorter length of stay (− 0.3 days). In this large, multicenter study of patients hospitalized with both AECOPD and ADHF, initial treatment with corticosteroids with mineralocorticoid activity was not associated with fewer hospital-free days or increased mortality relative to corticosteroids with minimal mineralocorticoid activity.