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Shortness of breath: COPD or CHF?
International Journal of Cardiology 105 (2005) 349 – 350 www.elsevier.com/locate/ijcard
Letter to the Editor
Shortness of breath: COPD or CHF? Tsung O. Cheng The George Washington University Medical Center, Dept. of Medicine, Division of Cardiology, 2150 Pennsylvania Ave. NW, Washington, D.C. 20037, United States Received 17 February 2005; accepted 12 March 2005 Available online 23 May 2005
To the Editor: I enjoyed your article on patient description of breathlessness in heart failure [1]. You mentioned that breathlessness in congestive heart failure (CHF) is different from that in cancer, just as breathlessness in chronic obstructive pulmonary disease (COPD) is different from that in cancer. But you did not comment on how breathlessness in CHF is different from that of COPD. The purpose of this communication is to address this issue. When a patient complains of shortness of breath, the differential diagnosis is usually between COPD and CHF. Although this is usually not difficult (Table 1) [2], oftentimes the differentiation may not be straightforward. Therefore, I wish to make the following points: (1) Although dependent edema is usually present in CHF but absent in COPD (Table 1), it should be pointed out that when patients with COPD develop chronic cor pulmonale, the latter will manifest as dependent edema. (2) Similarly, jugular venous distention, which is present in CHF but absent in COPD (Table 1), would be present in patients with COPD after the development of chronic cor pulmonale. Furthermore, even in the absence of chronic cor pulmonale, the jugular venous pressure may be difficult to assess in patients with COPD because of large swings in intrathoracic pressure in pulmonary emphysema. (3) Although the presence of atrial fibrillation usually suggests CHF, it may also occur in patients with COPD, especially during acute respiratory failure
E-mail address: [email protected]. 0167-5273/$ - see front matter D 2005 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijcard.2005.03.033
where atrial fibrillation or flutter has been reported to exist in one quarter of patients [3]. (4) COPD may lead to left ventricular dysfunction and CHF. Several mechanisms have been postulated: insufficient myocardial oxygen delivery due to chronic hypoxia; high-output cardiac failure due to hypoxemia, hypercapnia and increased bronchial circulation; decreased preload of the left ventricle; and distorted configuration of the left ventricle due to right ventricular hypertrophy [4,5]. The last has been Table 1 Differentiating CHF’s and COPD’s signs and symptoms
Signs Tripod or upright position Tachycardia Tachypnea Accessory muscle use Decreased oxygen saturation Jugular vein distention Auscultation of bilateral dependent crackles (rales) Weight gain Weight loss Auscultation of decreased breath sounds Chest diameter increase Pursed-lip breathing Prolonged expiratory phase Low peak flow Symptoms Dyspnea Fatigue Cough Orthopnea Paroxysmal nocturnal dyspnea (PND) Dependent edema Dependent edema From Ref. [2] with permission.
CHF
COPD
+ + + + + + + +
+ + + + +
+ + + + + +
+ + + + + + +
+ + +
350
T.O. Cheng / International Journal of Cardiology 105 (2005) 349 – 350
called the Freversed_ Bernheim’s syndrome [6]. Under the heading of Bernheim’s syndrome are included cases of right heart failure due to lesions that cause massive hypertrophy of the left ventricle including the interventricular septum, which encroaches upon the right ventricular chamber to such an extent that there is a functional obstruction to inflow into the right ventricle [7]. (5) Because COPD often exists in elderly patients who are also prone to have coronary heart disease complicated by ischemic cardiomyopathy and CHF, both COPD and CHF may coexist in the same patient. (6) Finally, although the recent introduction of B-type natriuretic peptide (BNP) measurement is helpful in CHF diagnosis with a sensitivity of 90%, the specificity of BNP is only 75% [8].
References [1] Edmonds PM, Rogers A, Addington-Hall JM, McCoy A, Coats AJS, Gibbs JSR. Patient descriptions of breathlessness in heart failure. Int J Cardiol 2005;98:61 – 6. [2] Upchurch J. COPD vs. CHF. JEMS 2002;27(9):83 – 94. [3] Sideris DA, Katsadoros DP, Valianos G, Assioura A. Type of cardiac dysrhythmias in respiratory failure. Am Heart J 1975;89:32 – 5. [4] Cheng TO. The international textbook of cardiology. New York’ Pergamon Press; 1987. p. 913 – 24. [5] Cheng TO. Left ventricular dysfunction due to chronic right ventricular pressure overload. Am J Med 1988;84:1097. [6] Dexter L. Atrial septal defect. Br Heart J 1956;18:209 – 25. [7] Bernhein PI. Venous asystole in hypertrophy of the left heart with associated stenosis of the right ventricle. Rev Med 1910;30:785 – 801. [8] Knudsen CW, Omland T, Clopton P, et al. Diagnostic value of B-type natriuretic peptide and chest radiographic findings in patients with acute dyspnea. Am J Med 2004;116:363 – 8.
Letter to the Editor
Shortness of breath: COPD or CHF? Tsung O. Cheng The George Washington University Medical Center, Dept. of Medicine, Division of Cardiology, 2150 Pennsylvania Ave. NW, Washington, D.C. 20037, United States Received 17 February 2005; accepted 12 March 2005 Available online 23 May 2005
To the Editor: I enjoyed your article on patient description of breathlessness in heart failure [1]. You mentioned that breathlessness in congestive heart failure (CHF) is different from that in cancer, just as breathlessness in chronic obstructive pulmonary disease (COPD) is different from that in cancer. But you did not comment on how breathlessness in CHF is different from that of COPD. The purpose of this communication is to address this issue. When a patient complains of shortness of breath, the differential diagnosis is usually between COPD and CHF. Although this is usually not difficult (Table 1) [2], oftentimes the differentiation may not be straightforward. Therefore, I wish to make the following points: (1) Although dependent edema is usually present in CHF but absent in COPD (Table 1), it should be pointed out that when patients with COPD develop chronic cor pulmonale, the latter will manifest as dependent edema. (2) Similarly, jugular venous distention, which is present in CHF but absent in COPD (Table 1), would be present in patients with COPD after the development of chronic cor pulmonale. Furthermore, even in the absence of chronic cor pulmonale, the jugular venous pressure may be difficult to assess in patients with COPD because of large swings in intrathoracic pressure in pulmonary emphysema. (3) Although the presence of atrial fibrillation usually suggests CHF, it may also occur in patients with COPD, especially during acute respiratory failure
E-mail address: [email protected]. 0167-5273/$ - see front matter D 2005 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijcard.2005.03.033
where atrial fibrillation or flutter has been reported to exist in one quarter of patients [3]. (4) COPD may lead to left ventricular dysfunction and CHF. Several mechanisms have been postulated: insufficient myocardial oxygen delivery due to chronic hypoxia; high-output cardiac failure due to hypoxemia, hypercapnia and increased bronchial circulation; decreased preload of the left ventricle; and distorted configuration of the left ventricle due to right ventricular hypertrophy [4,5]. The last has been Table 1 Differentiating CHF’s and COPD’s signs and symptoms
Signs Tripod or upright position Tachycardia Tachypnea Accessory muscle use Decreased oxygen saturation Jugular vein distention Auscultation of bilateral dependent crackles (rales) Weight gain Weight loss Auscultation of decreased breath sounds Chest diameter increase Pursed-lip breathing Prolonged expiratory phase Low peak flow Symptoms Dyspnea Fatigue Cough Orthopnea Paroxysmal nocturnal dyspnea (PND) Dependent edema Dependent edema From Ref. [2] with permission.
CHF
COPD
+ + + + + + + +
+ + + + +
+ + + + + +
+ + + + + + +
+ + +
350
T.O. Cheng / International Journal of Cardiology 105 (2005) 349 – 350
called the Freversed_ Bernheim’s syndrome [6]. Under the heading of Bernheim’s syndrome are included cases of right heart failure due to lesions that cause massive hypertrophy of the left ventricle including the interventricular septum, which encroaches upon the right ventricular chamber to such an extent that there is a functional obstruction to inflow into the right ventricle [7]. (5) Because COPD often exists in elderly patients who are also prone to have coronary heart disease complicated by ischemic cardiomyopathy and CHF, both COPD and CHF may coexist in the same patient. (6) Finally, although the recent introduction of B-type natriuretic peptide (BNP) measurement is helpful in CHF diagnosis with a sensitivity of 90%, the specificity of BNP is only 75% [8].
References [1] Edmonds PM, Rogers A, Addington-Hall JM, McCoy A, Coats AJS, Gibbs JSR. Patient descriptions of breathlessness in heart failure. Int J Cardiol 2005;98:61 – 6. [2] Upchurch J. COPD vs. CHF. JEMS 2002;27(9):83 – 94. [3] Sideris DA, Katsadoros DP, Valianos G, Assioura A. Type of cardiac dysrhythmias in respiratory failure. Am Heart J 1975;89:32 – 5. [4] Cheng TO. The international textbook of cardiology. New York’ Pergamon Press; 1987. p. 913 – 24. [5] Cheng TO. Left ventricular dysfunction due to chronic right ventricular pressure overload. Am J Med 1988;84:1097. [6] Dexter L. Atrial septal defect. Br Heart J 1956;18:209 – 25. [7] Bernhein PI. Venous asystole in hypertrophy of the left heart with associated stenosis of the right ventricle. Rev Med 1910;30:785 – 801. [8] Knudsen CW, Omland T, Clopton P, et al. Diagnostic value of B-type natriuretic peptide and chest radiographic findings in patients with acute dyspnea. Am J Med 2004;116:363 – 8.