Rationale: Heart failure (HF) management in chronic obstructive pulmonary disease (COPD) is often delayed or suboptimal.

Objectives: To examine the effect of HF and HF medication use on moderate-to-severe COPD exacerbations.

Methods and Measurements: Retrospective cohort studies from 2006-2016 using nationally-representative English primary care electronic healthcare records linked to national hospital and mortality data. COPD patients with diagnosed and possible HF were identified. Possible HF defined as continuous loop diuretic use in the absence of a non-cardiac indication. Incident exposure to HF medications was defined as ≥2 prescriptions within 90 days with no gaps >90 days during ≤6 months of continuous use; prevalent exposure as 6+ months continuous use. HF medications investigated were angiotensin receptor blockers, angiotensin converting enzyme inhibitors, beta-blockers, loop diuretics, and mineralocorticoid receptor antagonists. Cox regression, stratified on sex and age; further adjusted for patient characteristics, was used to determine the association of HF on exacerbation risk.

Main Results: 86,795 COPD patients were categorized as; no evidence of HF (n=60,047); possible HF (n=8,476); newly diagnosed HF (n=2,066). Newly diagnosed HF (adjusted hazard ratio (aHR): 1.45, 95% confidence interval (CI): 1.30, 1.62) and possible HF (aHR: 1.65, 95%CI: 1.58, 1.72) similarly increased exacerbation risk. Incident and prevalent use of all HF medications were associated with increased exacerbation risk. Prevalent use was associated with reduced exacerbation risk compared with incident use.

Conclusions: Earlier opportunities to improve diagnosis and management of HF in the COPD population are missed. Managing HF may reduce exacerbation risk in the longer term.