MANAGEMENT OF HEART FAILURE (T MEYER, SECTION EDITOR) Challenges in the Management of Patients with Chronic Obstructive Pulmonary Disease and Heart Failure With Reduced Ejection Fraction Abhishek Jaiswal 1 & Astha Chichra 2 & Vinh Q. Nguyen 1 & Taraka V. Gadiraju 1 & Thierry H. Le Jemtel 1 # Springer Science+Business Media New York 2016 Abstract Chronic obstructive pulmonary disease (COPD) and heart failure with reduced ejection fraction (HFrEF) com- monly coexist in clinical practice. The prevalence of COPD among HFrEF patients ranges from 20 to 32 %. On the other hand; HFrEF is prevalent in more than 20 % of COPD pa- tients. With an aging population, the number of patients with coexisting COPD and HFrEF is on rise. Coexisting COPD and HFrEF presents a unique diagnostic and therapeutic clin- ical conundrum. Common symptoms shared by both condi- tions mask the early referral and detection of the other. Beta blockers (BB), angiotensin-converting enzyme inhibitors, and aldosterone antagonists have been shown to reduce hospitali- zations, morbidity, and mortality in HFrEF while long-acting inhaled bronchodilators (beta-2-agonists and anticholinergics) and corticosteroids have been endorsed for COPD treatment. The opposing pharmacotherapy of BBs and beta-2-agonists highlight the conflict in prescribing BBs in COPD and beta- 2-agonists in HFrEF. This has resulted in underutilization of evidence-based therapy for HFrEF in COPD patients owing to fear of adverse effects. This review aims to provide an update and current perspective on diagnostic and therapeutic manage- ment of patients with coexisting COPD and HFrEF. Keywords Heart failure . HFrEF . COPD . Beta blocker therapy . Obstructive lung disease Introduction Heart failure with reduced ejection fraction (HFrEF) and chronic obstructive pulmonary disease (COPD) are common- ly encountered chronic conditions. The prevalence of COPD among HFrEF patients ranges from 20 to 32 % [1]. On the other hand, HFrEF is prevalent in more than 20 % of COPD patients [1]. Moreover; the risk of developing HFrEF among COPD patients is 4.5 times higher, after adjusting for age and traditional cardiovascular risk factors [2]. The increased prev- alence of COPD and HFrEF in recent years is likely due to improved detection and an increased disease burden with the aging population [3]. The presence of COPD in HFrEF in- creases burden of co-morbidities, longer hospitalizations, un- derutilization of evidence-based medicine, and increased mor- tality [4]. Similarly, the presence of LV dysfunction in COPD patients increases the morbidity and mortality [2]. An analysis from the ARIC (atherosclerosis risk in com- munities) study underlined a strong inverse association be- tween baseline lung function and incident HFrEF after adjusting for age, gender, race, and smoking status [5], sug- gesting that low-grade systemic inflammation leads to pro- gression of atherosclerosis and ischemic heart disease as the underlying pathobiology. Moreover, the presence of endothe- lial dysfunction, elevated inflammatory markers, and acceler- ated atherosclerosis in untreated patients with combined obstructive sleep apnea and COPD or COPD alone is Abhishek Jaiswal and Astha Chichra contributed equally to the manuscript. This article is part of the Topical Collection on Management of Heart Failure * Thierry H. Le Jemtel lejemtel@tulane.edu 1 Tulane School of Medicine, Tulane University Heart and Vascular Institute, 1430 Tulane Avenue, SL-48, New Orleans, LA 70112, USA 2 Division of Pulmonary and critical care medicine, Tulane School of Medicine, 1430 Tulane Avenue, SL-48, New Orleans, LA 70112, USA Curr Heart Fail Rep DOI 10.1007/s11897-016-0278-8