# Assessment of cardiopulmonary risk in COPD patients: Expert opinion formalized using the Delphi method

Nicolas Roche, Maeva Zysman, Victor Aboyans, Gaëtan Deslee, Laurent Fauchier, Serge Kownator, Gilles Montalescot, Christophe Pinet, Bouchra Lamia, Alain Cohen-Solal

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## ► To cite this version:

Nicolas Roche, Maeva Zysman, Victor Aboyans, Gaëtan Deslee, Laurent Fauchier, et al.. Assessment of cardiopulmonary risk in COPD patients: Expert opinion formalized using the Delphi method. Respiratory Medicine and Research, 2025, 88, pp.101187. 10.1016/j.resmer.2025.101187. hal-05303085

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Submitted on 23 Jan 2026

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Original article

# Assessment of cardiopulmonary risk in COPD patients: Expert opinion formalized using the Delphi method

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Nicolas Roche<sup>a,*</sup>, Maeva Zysman<sup>b</sup>, Victor Aboyans<sup>c</sup>, Gaëtan Deslee<sup>d</sup>, Laurent Fauchier<sup>e</sup>, Serge Kownator<sup>f</sup>, Gilles Montalescot<sup>g</sup>, Christophe Pinet<sup>h</sup>, Bouchra Lamia<sup>i</sup>, Alain Cohen-Solal<sup>j</sup>, Responders' group<sup>l</sup>

ARTICLE INFO

Keywords:

COPD

Multimorbidity

Cardiovascular disease

Cardiopulmonary risk

Delphi method

ABSTRACT

**Background:** Cardiovascular (CV) comorbidities are frequent in patients with chronic obstructive pulmonary disease (COPD), increasing individual morbidity and mortality. This observation has given rise to the concept of cardiopulmonary risk. However, assessment and management of CV risk in COPD patients is highly variable in practice. Cardiologists' and pulmonologists' knowledge and understanding of cardiopulmonary risk and its assessment in COPD patients, along with the management of special situations, were analyzed using the Delphi consensus methodology.

**Study Design and Methods:** A Steering Committee of ten experts (five cardiologists and five pulmonologists) developed a questionnaire covering 73 clinical situations grouped into 31 statements. This Steering Committee recommended a panel of expert respondents with clinical experience. The Delphi consensus methodology was applied in two rounds, with 74 respondents in the first round and 68 in the second. Consensus was defined as agreement or disagreement by >75 % of respondents.

**Results:** The panel agreed that COPD patients face elevated CV risk independently of other risk factors. Consensus was reached on systematically assessing CV risk factors in COPD patients and the necessity for cardiovascular consultation and arterial imaging (coronary, supra-aortic trunks) if CV risk scores are high. The panel opposed routine Holter EKG use, but recommended both cardiological and pneumological investigations in cases of disproportionate dyspnea. Minor disagreements emerged between pulmonologists and cardiologists about abdominal aortic aneurysm screening, glycated hemoglobin testing, and specific CV assessments post COPD exacerbation.

**Interpretation:** This Delphi report summarizes expert cardiologist and pulmonologist perspectives on CV risk assessment in COPD patients, emphasizing the need for integrated management of respiratory and CV conditions.

**Abbreviation:** ACEI, angiotensin converting enzyme inhibitor; AECOPD, acute exacerbation of COPD; AF, atrial fibrillation; ARB, angiotensin receptor blocker; AOMI, obliterative arterial disease of the lower limbs; BGF, budesonide/glycopyrronium/formoterol; BNP, brain natriuretic peptide; CBC, platelets/blood count; COPD, chronic obstructive pulmonary disease; CRP, C-reactive protein; CV, cardiovascular; CVD, cardiovascular disease; DLCO, carbon monoxide diffusion capacity; EKG, electrocardiogram; ESC, European Society of Cardiology; GFR, glomerular filtration rate; GOLD, Global Initiative for Chronic Obstructive Lung Disease; HAS, Haute Autorité de Santé (French Health Authority); HbA1c, glycated hemoglobin; ICS, inhaled corticosteroids; LABA, long-acting β2 agonist; LAMA, long-acting muscarinic antagonist; NT-proBNP, NT-pro-brain natriuretic peptide; PA/AO, ratio of the pulmonary artery to aorta diameters; SAS, sleep apnea syndrome; SAT, supra-aortic trunks; SPI, systolic pressure index; SPLF, Société de Pneumologie de Langue Française (French Pulmonology Society); TTE, transthoracic echocardiography; uACR, urine albumin/creatinine ratio; VSEs, ventricular extrasystoles; WHO, World Health Organization

<footnote><sup>a</sup> Service de Pneumologie, Hôpital Cochin, APHP Centre and UMR 1016 Institut Cochin, Université Paris Cité, Paris, France</footnote>

<footnote><sup>b</sup> Services des Maladies Respiratoires, CHU Haut Léveque, Pessac, France / Centre de Recherche cardio-thoracique de Bordeaux, UMR 1045, Université de Bordeaux, Pessac, France</footnote>

<footnote><sup>c</sup> Service de cardiologie, CHU de Limoges / EpiMaCT, Inserm1094/IRD270, Université de Limoges, Limoges, France</footnote>

<footnote><sup>d</sup> Université de Reims Champagne-Ardenne, INSERM, UMR51250, Reims, France / CHU Reims, Hôpital Maison Blanche, Service de Pneumologie, Reims, France</footnote>

<footnote><sup>e</sup> Service de Cardiologie, Pôle Cœur Thorax Vasculaire, CHU Trousseau / Faculté de Médecine, Université François Rabelais, Tours, France</footnote>

<footnote><sup>f</sup> Centre Cardiologique et Vasculaire « cœur de Lorraine » Thionville, France</footnote>

<footnote><sup>g</sup> ACTION Study Group, Sorbonne Université, Institut de Cardiologie, Pitié-Salpetrière Hospital AP-HP, Paris, France</footnote>

<footnote><sup>h</sup> Hôpital Privé de Provence, Aix en Provence, France</footnote>

<footnote><sup>i</sup> Département de Pneumologie, Groupe Hospitalier du Havre, Le Havre, France / Université de Rouen Normandie, UNIROUEN, UR3830- GRHVN, IRIB, Rouen, France</footnote>

<footnote><sup>j</sup> Université Paris Cité. INSERM U942. Service de Cardiologie, Hôpital Lariboisière, AP-HP, Paris, France</footnote>

<footnote>*Corresponding author.</footnote>

<footnote>E-mail address: nicolas.roche@aphp.fr (N. Roche).</footnote>

<footnote n="1">¹ The complete list of the panel of experts can be found in Supplementary Table 1.</footnote>
These findings demonstrate the importance of a multidisciplinary approach and suggest that while some practical aspects of CV assessment in COPD patients are the subject of clear consensus, other areas require further research to develop precise protocols.

# 1. Introduction

Chronic obstructive pulmonary disease (COPD) is a progressive respiratory disease characterized by persistent airway obstruction. COPD is a major cause of morbidity and mortality worldwide [1], with an estimated prevalence of 10.3 % of the global population, affecting 391.9 million people aged between 30 and 79 years [2,3]. In 2019, COPD was the third leading cause of death worldwide, with 3.23 million deaths. The World Health Organization (WHO) predicts this figure will rise to 7 million by 2060 [2,4]. Comorbidities associated with COPD are frequent, with cardiovascular diseases (CVDs) identified in 28 % to 70 % of patients; this is two to five times higher than in individuals without COPD [5].

Algorithms are being developed to improve cardiovascular (CV) risk management, such as COPDCoRi and QRISK4, helping practitioners to adopt a more preventive and proactive early detection approach, which could significantly increase the number of new CVD diagnoses in COPD patients in primary care [6,7].

The link between COPD, its exacerbations and CV risk is likely multifactorial, including common risk factors (dominated by smoking); lung hyperinflation impairing cardiac function (especially left ventricular filling); systemic inflammation and oxidative stress; permanent or intermittent hypoxia; and physical inactivity. COPD patients are at significant risk of major pulmonary and CV events, which has led to the emergence of the new and increasingly recognized concept of cardiopulmonary risk [2]. The growing recognition of the intricate relationship between pulmonary and CV diseases necessitates a comprehensive patient care approach to improve outcomes [8]. This paradigm shift has driven a surge in publications exploring the cardiopulmonary nexus and potential underlying causes [9,10].

Despite increasing awareness and some integrated care pathways being piloted in specialized centers in France, there appears to be a significant gap in the implementation of guidelines on CV assessment and management in COPD patients. Literature is scarce, making it difficult to identify priorities for clinical guidance. One noteworthy exception is the Global initiative for chronic obstructive lung disease (GOLD), which added a new section to its 2024 report on cardiovascular risk in COPD and its implications for clinically stable patients and those with acute exacerbations. However, the French Health Authority's most recent guide on the pharmacological management of COPD patients dates back to 2019, and has not been updated to address the issue of cardiovascular risk and comorbidities [11]. The Spanish Medical Society of Pulmonology and Thoracic Surgery (SEPAR) and the Spanish Society of Cardiology (SEC) recently published guidelines on multidisciplinary management of patients with chronic obstructive pulmonary disease and cardiovascular disease. These publications reviewed the prevalence and impact of CVD and COPD, highlighted clinical challenges in care, and put forth recommendations to optimize management [12]. To explore this gap, a Delphi consensus process was applied to assess the current knowledge of French cardiologists and pulmonologists, and to identify areas of agreement on the risks, complications, and appropriate assessment and management methods for CV comorbidities and cardiopulmonary risk in patients with COPD. This study will focus on cardiopulmonary diseases related to left heart conditions and systemic vascular involvement. Pulmonary hypertension, although commonly considered part of the cardiopulmonary context in COPD is not addressed in this work.

# 2. Study design and methods

## 2.1. Delphi method

The Delphi technique is a structured iterative methodology used to gather and refine expert opinions on a specific topic. It systematically

and interactively assesses opinions through iterative rounds, to converge on agreement on prespecified statements.

Our study was conducted in three main stages: Firstly, the statements included in the Delphi questionnaire were drafted. These statements were developed and proposed by the four project coordinators, then discussed and validated by the Steering Committee following an online meeting to identify the main topics to address. Seventy-three clinical situations were identified and organized into 31 statements, divided into six categories: 1) CV risk factors and complications. 2) Assessment of CV risk in stable COPD patients. 3) Assessment of CV risk after COPD exacerbation. 4) Special clinical situations in patients with COPD. 5) Follow-up of a patient with COPD at increased CV risk. 6) CV medications for COPD patients.

In the second stage, an initial round was held, lasting about three weeks. The questionnaire was shared with selected experts (see below), who agreed to participate using a SurveyMonkey® online survey that adhered to General Data Protection Regulation (GDPR). For each statement, participants rated their agreement using a four-point Likert scale ("strongly disagree", "disagree", "agree", or "strongly agree"). The results were aggregated, anonymized, analyzed, and presented to the Steering Committee. In a Delphi approach, the agreement or disagreement threshold is generally set between 67 % and 80 %, depending on the level of strength needed. In this project, the threshold was set at 75 % by the Steering Committee. All statements that failed to achieve the consensus threshold (see below) in the first round were revised and reframed, based on evidence from the literature (if deemed necessary by the Steering Committee), in preparation for the second round.

The third stage was the second round itself, whereby the updated statements, along with the global first-round answers, were shared with the experts. Respondents were asked to rate the revised statements and could reconsider their previous answers in the light of the group's comments. The Steering Committee analyzed and discussed the final results, and a final report was drafted to present the consensus and divergence points.

## 2.2. Steering committee and panel of participants

The Steering Committee comprised five cardiologists and five pulmonologists, all experts in managing patients with COPD, and included four coordinators leading the project. The pulmonologists were selected based on their expertise in COPD, while the cardiologists were chosen for their expertise in managing heart failure and arterial hypertension.

There is no standard size of panel members in published studies, and a sample size of 30–50 panelists is generally considered optimal in concluding rounds for a homogenous panel in a Delphi process [13]. In this case, panelists were selected based on the same expertise as for Steering committee members. Each committee member proposed approximately ten experts to participate in the survey in order to achieve the appropriate sample size and be able to draw comparisons between pulmonologists and cardiologists.

## 2.3. Analysis

Agreement, also called "consensus", was obtained when three-fourths of respondents (75%) were in agreement ("agree" + "strongly agree"), or disagreement ("disagree" + "strongly disagree"), with a statement. The results were analyzed descriptively. A strong consensus was defined as one in which >50 % of the panel "strongly agreed" or "strongly disagreed". A universal consensus was defined as 100 % of respondents agreeing or disagreeing.
As the respondent population included cardiologists and pulmonolo-
gists, subgroup analyses were conducted to analyze the responses for
these populations separately.

3. Results

3.1. Participants

108 experts were identified and contacted, of whom 74 agreed to
participate. In the first round, carried out from January 12 to February
2, 2024, 73 statements were provided for rating clinical situations. The
response rate was 95 % (70/74; 38 pulmonologists, 32 cardiologists).
For the second round, which took place from March 15 to April 7, 2024,
68/70 participants (32 cardiologists, 36 pulmonologists) responded (i.
e., a 97 % response rate). The geographical breakdown of respondents is
given in Supplementary Table 1. The study flowchart is shown in Fig. 1.

## 3.2. Knowledge of COPD as a CV risk factor and of CV complications associated with COPD

Consensus was reached for all proposed statements about knowledge
of COPD as a CV risk factor. There was a strong consensus in favor of all
CV risk factors being systematically investigated in patients with COPD,
including obesity, high blood pressure, diabetes, family history of CVD,
obstructive sleep apnea syndrome (OSAS), and hypercholesterolemia,
with universal strong agreement (100 %) on smoking. Participants
strongly agreed that coronary artery disease and acute CV events should
be included as major CV comorbidities of COPD, and a positive consen-
sus was reached for the other CV comorbidities mentioned (see Fig. 2).

For all patients over 40 years of age with a history of smoking (>10 pack-years), the panel strongly agreed that a systematic assessment should be carried out, including both a CV assessment for respiratory patients with cardiac symptoms and a respiratory assessment in CV patients with respiratory symptoms.

Participants also strongly agreed that CVD is one of the most frequent
causes of death in COPD patients; that COPD exacerbation increases the
risk of CV events and is a major respiratory comorbidity of CVD; and
that COPD patients have an increased CV risk that is independent of
other CV risk factors. All results are presented in Fig. 2.

No differences were found in the subgroup analysis comparing the
cardiologists' responses with those of pulmonologists.

3.3. Assessment of CV risk in COPD patients

Experts agreed on the necessity of comprehensive CV examinations for COPD patients. They strongly agreed on specific components, including blood pressure measurement, auscultation of the heart, lungs and arteries, and assessment of peripheral pulses. For additional biological tests, strong consensus was reached for a complete lipid profile, creatinine and glomerular filtration rate, platelets/blood count, and NT-pro-brain natriuretic peptide. There was also agreement on glycated hemoglobin; however, there was no consensus on whether C-reactive protein and urine albumin/creatinine ratio should be measured. Results are presented in Fig. 3.

In the subgroup analysis, two differences were observed between
pulmonologists and cardiologists. Only cardiologists reached a positive
consensus on the need for a clinical examination to look for abdominal
aortic aneurysm (cardiologists 97 % agreement vs. pulmonologists
66 %). Similarly, only cardiologists reached a consensus on glycated
hemoglobin (91 % vs. 71 % for pulmonologists).

3.4. Imaging and other additional explorations

Depending on the situations detailed in Fig. 4, positive consensus
was achieved for transthoracic echocardiography, carotid ultrasounds
(Doppler of the cervical arteries), coronary calcium score, and coronary
CT scan, and a negative one for systematic Holter EKG in the absence of
palpitations. There was no consensus on the other statements.

Positive consensus was achieved on establishing the CV risk score
(the ESC's SCORE2) at the initial consultation and for considering coro-
nary artery imaging when SCORE2 >5 % in an asymptomatic COPD
patient with no previous history. Conversely, no consensus was achieved
regarding indications of functional stress/effort test, nor of screening for
obstructive sleep apnea syndrome.

Similar results were observed for pulmonologists and cardiologists,
with no differences between the consensus reached.

<figure><img src="image_4.png" /><figcaption>Fig. 1. Delphi study process and consensus results.</figcaption></figure>

*Number of panelists.

**Number of respondents.
<figure><img src="image_5.png" /><figcaption>**Fig. 2.** Results of the participants' responses to the cardiovascular risk factors and complications section, expressed as a percentage (%). Dark green represents strong agreement, light green agreement, light red disagreement and dark red strong disagreement. A consensus is achieved when at least 75 % of the responses converge (agree + strongly agree or disagree + strongly disagree) – illustrated in bold. A strong consensus is achieved when the “strongly agree”, or “strongly disagree”, exceed 50 %.</figcaption></figure>

<figure><img src="image_6.png" /><figcaption>**Fig. 3.** Results of participants' responses to assessment of cardiovascular risk in COPD patients, expressed as a percentage (%). Dark green represents strong agreement (strongly agree), light green an agreement (agree), light red a disagreement (disagree) and dark red a strong disagreement (strongly disagree). A consensus is reached when at least 75 % of the responses converge (agree + strongly agree or disagree + strongly disagree) – illustrated in bold. A strong consensus is reached when the “strongly agree”, or “strongly disagree”, exceed 50 %.</figcaption></figure>

### 3.5. Assessment of CV risk after COPD exacerbation

For the assessment of CV risk after COPD exacerbation, the results were similar to the initial assessment except for HbA1c measurement, which did not show a consensus.

The other items related to COPD exacerbations all achieved a positive consensus, including the need for a cardiology consultation within

three months of a severe (hospitalized) COPD exacerbation and one year after a moderate one. Results are presented in Fig. 5.

Two differences were observed between specialties: 1) For post-exacerbation cardiology consultation, following a moderate COPD exacerbation, 87 % of pulmonologists agreed on a cardiology consultation within one year, compared with 69 % of cardiologists. 2) For stress test indications, when the ESC SCORE2 exceeds 5 %, 83 % of
<figure><img src="image_7.png" /><figcaption>**Fig. 4.** Results of the imaging and additional explorations expressed as a percentage ( %). Dark green represents strong agreement (strongly agree), light green an agreement (agree), light red a disagreement (disagree) and dark red a strong disagreement (strongly disagree). A consensus is reached when at least 75 % of the responses converge (agree + strongly agree or disagree + strongly disagree) – illustrated in bold. A strong consensus is reached when the “strongly agree”, or “strongly disagree”, exceed 50 %.</figcaption></figure>

BNP: brain natriuretic peptide; EKG: electrocardiogram; SAS: sleep apnea syndrome, SAT: supra-aortic trunks.

<figure><img src="image_8.png" /><figcaption>**Fig. 5.** Results of the assessment of cardiovascular risk after COPD exacerbation, expressed as a percentage ( %). Dark green represents strong agreement (strongly agree), light green an agreement (agree), light red a disagreement (disagree) and dark red a strong disagreement (strongly disagree). A consensus is reached when at least 75 % of the responses converge (agree + strongly agree or disagree + strongly disagree) – illustrated in bold. A strong consensus is reached when the “strongly agree”, or “strongly disagree”, exceed 50 %.</figcaption></figure>

pulmonologists recommended a functional stress/effort test, while only 59 % of cardiologists agreed with this approach.

## 3.6. Special situations in patients with COPD and therapeutics

All special situations showed positive agreement and even strong agreement except for statements on severe hypoxemia and beta2-mimetics. Special situations are presented in Fig. 6.

CV medications, lifetime prescription of an antiaggregant for patients with coronary heart disease, as well as the lack of indication of beta-blockers for COPD in the absence of a relevant CV indication all achieved strong positive consensus. Prescribing acetylsalicylic acid in addition to a statin for an asymptomatic COPD patient with no history of coronary disease and >50 % stenosis achieved a positive consensus, but there was no consensus on starting a statin as primary prevention in asymptomatic patients with no previous history of COPD. There was a strong consensus in favor of the use of cardio-selective beta-blockers in the case of heart failure or coronary artery disease in patients with COPD, whatever the stage of severity of airflow obstruction. Results are presented in Fig. 6.

The statement on using a statin as primary prevention in the event of a SCORE2 ≥5 % garnered positive support among pulmonologists but not cardiologists (78 % vs. 54 % respectively), and the same was observed for using a cardio-selective beta-blocker for heart failure or coronary artery disease in COPD patients irrespective of the severity (97 % vs. 73 %).

For restricting the use of cardio-selective beta-blockers to patients with non-severe COPD, cardiologists did not reach a consensus, while pulmonologists reached a negative consensus (44 % vs. 11 % respectively).

## 4. Discussion

This Delphi consensus method revealed strong agreement among pulmonologists and cardiologists about increased CV risk in COPD patients and the need for tailored risk assessments. The consensus findings are consistent with the ESC's recommendations, which stress the importance of a thorough risk factor assessment, including smoking, obesity, hypertension, family history, diabetes, sleep apnea and hypercholesterolemia [9]. Furthermore, it is recognized that COPD patients have an inherently
<figure><img src="image_9.png" /><figcaption>**Fig. 6.** Results of the special situations in patients with COPD and therapeutics, expressed as a percentage (%). Dark green represents strong agreement (strongly agree), light green an agreement (agree), light red a disagreement (disagree) and dark red a strong disagreement (strongly disagree). A consensus is reached when at least 75 % of the responses converge (agree + strongly agree or disagree + strongly disagree) – illustrated in bold. A strong consensus is reached when the “strongly agree”, or “strongly disagree”, exceed 50 %.</figcaption></figure>

AF: atrial fibrillation; DLCO: carbon monoxide diffusion capacity; PA/AP: ratio of the pulmonary artery to aorta diameters; VEs: ventricular extrasystoles.

elevated cardiovascular risk, independent of other factors, emphasizing the necessity of a comprehensive evaluation. In a context where clinicians' physical examination skills have been declining due to reduced practice and increased reliance on technology [14–16], this consensus highlights the importance of regular patient examinations. Physical examination is a cost-effective tool, enabling experienced clinicians to make swift and accurate diagnoses, and it informs the need for further tests [14,16]. Essential biological assessments include a comprehensive lipid profile, glomerular filtration rate (GFR), creatinine, complete blood count and HbA1c. NT-proBNP can determine the cardiac or extracardiac origin of acute dyspnea in COPD patients [11,17].

The Systematic Coronary Risk Evaluation 2 (SCORE2) is a risk prediction model developed by the European Society of Cardiology (ESC) to estimate the 10-year risk of fatal and non-fatal cardiovascular disease (CVD) in individuals aged between 40 and 69 years with no history of CVD or diabetes. For better individualization of care, the ESC recommends that practitioners assess SCORE2 during the initial consultation, in patients in apparent good health, with no proven CVD, diabetes, CKD, genetic lipid or blood pressure abnormalities [18,19]. Nevertheless, the SCORE2 model has limitations in COPD patients as it does not account for systemic inflammation or other disease-specific factors, and it may therefore underestimate cardiovascular risk in this population [18]. The fact that cardiologists are more familiar with this assessment model may explain why they appear less inclined (59 %) to recommend a stress test than pulmonologists (83 %) when the SCORE2 exceeds 5 %. One may imagine that cardiologists are more concerned by the limits of stress/exercise tests in the setting of severe COPD and prefer go directly to coronary imaging techniques such a CT scan. Similarly, only 54 % of cardiologists recommend prescribing statins in cases of a SCORE2 greater than 5 %, versus 78 % of pulmonologists. This lack of consensus on additional assessments suggests that depending on the patient's clinical presentation, selecting either functional or imaging tests may be sufficient, and performing both is unnecessary.

When exacerbations occur, assessing CV status is crucial, as COPD patients with frequent exacerbations have a threefold increase in CV risk over five years [20]. Significant CV risks after severe exacerbations have been identified, with some risks emerging even after moderate exacerbations [10]. A study analyzing patient data (French national hospital database) from 2018 to 2019 confirmed that post-exacerbation CV

events can be severe, leading to patient death in 10 % of cases [21]. Routine post-exacerbation EKGs are thus advisable, and the panel agrees on a CV assessment after an exacerbation similar to that used in stable patients, which is in line with the SPLF (Société de Pneumologie de Langue Française) guidelines [17]. Also, panelists both agreed on the need for a cardiology consultation within three months of a severe (hospitalized) COPD exacerbation and within one year after a moderate one. This is in line with the findings that exacerbations elevated the risk for a broad range of cardiac events and all-cause mortality, persisting for 1 year or more. Strategies to manage patients who experience exacerbations should be emphasized, and risk stratification for both cardiac and pulmonology disease should be revisited and reinforced [3,22].

The higher agreement rate in favor of performing an EKG rather than a cardiology consultation may reflect challenges faced in clinical practice. For example, access to cardiology consultations may not be straightforward in all regions. A 2023 mapping of healthcare access in France revealed that the median wait time to see a cardiologist is 42 days [23]. The EKG is an easy-to-perform assessment, which can be carried out and interpreted routinely by any physician involved in the management of COPD (pulmonologists, primary care physicians, etc.). Performing it can assess cardiopulmonary risk and support cardiologists by addressing patients for an urgent cardiology consultation only if abnormalities are detected, although this test is also the first step for a patient to access a cardiology consultation in France.

This Delphi report clarifies important aspects of cardiopulmonary risk assessment in COPD patients, but some issues remain unsettled. For example, regarding the usefulness of CRP assessment during the initial evaluation, some respondents consider this assessment to be non-specific for CV risk and unlikely to impact clinical practice, whereas others argued that inflammation could be an indirect marker of the risk of stroke or acute coronary syndrome risk and may be associated with exacerbation risk. In the literature, acute and chronic pulmonary inflammation is an underrecognized risk factor for CVD [24,25], and some authors advocate that the CRP level could be an indicator of COPD severity [26]. The ESC guidelines also recommend a complete lipid profile and kidney function assessment for managing CV risk factors in COPD [18]. The uACR test, though emerging for the evaluation of comorbidities and CV risk [27] as demonstrated in diabetes [28], is rarely used as a first-line risk assessment tool, but more often as a
second-line screening tool in diabetes, hypertension, or other comorbidities [29]. This test has minimal impact on clinical practice and may be considered difficult to interpret without nephrological expertise. French guidelines recommend a uACR test in hypertension or CV risk assessment but do not specifically include COPD patients [30].

The variability of investigations according to patient symptoms, clinical assessment and practitioner preferences is notable. A coronary work-up and an imaging examination are common in current practice, but no recommendation currently ranks examinations, leaving room for individualized hierarchization [3,11]. Transthoracic echocardiography, carotid ultrasound, coronary calcium score and coronary CT scan are the most frequently recommended tests. However, the choice between functional tests and imaging remains complex and, ideally, a specialized assessment by a cardiologist should precede this decision. Conversely, the consensus against the use of systematic Holter testing reflects the use of this test depending on the clinical presentation, patient history and cardiologist's judgment, rather than routinely.

Panelists' diverging views on abdominal aortic aneurysm screening highlight the need for a multidisciplinary approach to ensure comprehensive assessment. Given the high prevalence of CV comorbidities in COPD patients, cardiac and peripheral assessments should not be neglected [25,31].

Variations between the pulmonologists and cardiologists' answers regarding therapeutics illustrate the complexity of decisions and differences in knowledge. Considering the close association between COPD and CVD, some authors of publications hypothesized that CV treatments may influence COPD outcomes. Improvements in morbidity and mortality have been suggested by observational studies of agents targeting CV risk in patients with COPD, such as angiotensin-converting enzyme inhibitors (ACEIs), angiotensin receptor blockers (ARBs), β-blockers and statins [31,32]. However, subsequent randomized controlled trials showed no benefits of statins or beta-blockers on COPD exacerbations [33,34], suggesting that CV treatments are of use in COPD only when CV indications are present. Recently, evidence has emerged from two large RCTs that fixed dose inhaled triple combinations (ICS/LABA/LAMA), reduce all-cause mortality compared to dual bronchodilation therapy [3,35,36]. Studies and meta-analyses have demonstrated CV safety of β2-agonists (LABA), muscarinic antagonists (LAMA), ICS/LABA, and LABA/LAMA in COPD treatment [37], and ongoing studies like THARROS (NCT06283966) aim to explore the impact of fixed-dose inhaled triple combinations BGF on improvement of cardiopulmonary outcomes.

The concept of cardiopulmonary risk, defined as the risk of severe respiratory and/or CV events in patients with COPD, is becoming increasingly recognized. CV events include, but are not limited to: COPD exacerbations, myocardial infarction, stroke, heart failure decompensation, arrhythmia, and death due to any of these events [2,9,10,38]. The exact mechanisms linking these events in COPD are not fully understood. Exacerbations may be a foundational risk factor for both respiratory and CV events, potentially amplifying underlying mechanisms in COPD, such as systemic inflammation, hyperinflation, and hypoxemia, as illustrated in Fig. 2 [2]. Shifting COPD management toward proactive and automatic cardiopulmonary risk reduction, with greater referrals from pulmonologists to cardiologists and vice versa, could transform care standards and improve clinical outcomes.

This consensus report is among the first to engage both pulmonologists and cardiologists in discussing the management of cardiopulmonary risk, offering a comprehensive overview of best practices in both specialties. The major study limitation is that it primarily reflects aspirational rather than real practice. The variability may be due to differences in physician awareness of CV risks, resource availability, and organizational practices.

The results of this Delphi report show that expert pulmonologists and cardiologists are well aligned on best practices, consistent with French (SPLF), European (ESC), and GOLD recommendations. While the panel agreed on many preventive measures, questions remain about their

implementation in clinical practice. Several international studies have attempted to standardize the evaluation and management of cardiopulmonary risk in COPD patients: Miravitlles et al. developed a discharge protocol based on four evidence-based care bundle items, and Wuyts et al. evaluated the feasibility of such protocol implementation in a rehabilitation hospital in Belgium [39,40]. The Spanish Medical Society guidelines on multidisciplinary management also support our conclusions, illustrating convergence in practice in several countries in Europe.

Despite these efforts, physicians still lack appropriate protocols to assess and manage cardiopulmonary risk, and more comprehensive and specific guidance for clinical practice are needed [31]. Consequently, some assessments are not consistently performed, and bias may be introduced. Scoring systems are evolving to minimize these biases, notably QRISK4, which may be more accurate than SCORE2, although they underestimate the CV risk [41]. Research needs to be carried out, multidisciplinary management protocols need to be developed and implemented in clinical practice, and awareness of the ESC SCORE2 should be promoted among both pulmonologists and cardiologists. Concrete actions including reminders and simple decision trees are essential to helping pulmonologists and cardiologists incorporate these practices into their daily routines, and need to be promoted by appropriate initial and continuing medical education. Patient information is also crucial.

In addition, it would be interesting to repeat this Delphi process among physicians not specialized in respiratory medicine or cardiology but involved in the care for patients with COPD or CV diseases, including primary care physicians, emergency medicine specialists, and intensivists of internal medicine practitioners. Further research can continue this work by stratifying COPD patients based on phenotype severity and evaluating its impact on diagnostic and therapeutic options. Finally, confronting reported opinions to indicators of real practice would provide useful information to define effective implementation strategies.

## 5. Conclusion

This study highlighted agreement and differences of opinion between cardiologists and pulmonologists on the evaluation of cardiopulmonary risk in COPD patients. COPD is an independent CV risk factor. COPD exacerbations worsen CV risk, and CV conditions worsen COPD, so both must be addressed. There is an urgent need to take these factors into account, and to apply best practices to standardize assessments and management. A multidisciplinary approach, including pulmonologists, cardiologists, and general practitioners, enabling specific prevention and management strategies, could effectively reduce cardiopulmonary risk in COPD patients. Based on these findings, guidelines should include this holistic approach for more comprehensive and effective disease management. A lack of agreement in certain areas highlights the need for further research and clarification in clinical practice.

## Funding

AstraZeneca France funded the project. The funder was given an overview of the project's development but did not intervene or influence the study at any stage.

## Declaration of competing interest

NR: Pfizer, GSK, Austral, Biosency, AstraZeneca, Chiesi, Menarini, MSD, Nuvaira, Roche, Sanofi, Zambon.

MZ: CSL Behring, Chiesi, GSK, Boeringer Ingelheim, AstraZeneca, Menarini, Sanofi.

VA: AstraZeneca, Boehringer-Ingelheim, NovoNordisk.

BL: AstraZeneca, Bayer, Chiesi, GSK, Lowenstein, MSD, Philips Ultra-sons, Sanofi, SOS Oxygène.

GD: Boehringer Ingelheim, GSK, AstraZeneca, Chiesi, Sanofi.

LF: AstraZeneca, Bayer, BMS/Pfizer, Boehringer Ingelheim, Novo, Boston Scientific, Medtronic, Zoll.
SK: Amgen, Astra Zeneca, Bayer, BMS, Boehringer Ingelheim, Lilly, NovoNordisk, Organon, Pfizer, Philips Healthcare, Sanofi, Servier.

GM: Abbott, Amgen, AstraZeneca, Bayer, BMS, Boehringer-Ingelheim, Celecor, CSL Behring, Hexacath, Idorsia, Lilly, Novo Nordisk, Pfizer, SMT, Terumo.

CP: AstraZeneca, Boeringer Ingelheim, GSK, Menarini, Novartis.

ACS: Astra Zeneca, Bayer, Boehringer Ingelheim, Sanofi, Novartis, Vifor.

## CRediT authorship contribution statement

**Nicolas Roche:** Conceptualization, Investigation, Methodology, Supervision, Validation, Writing – review & editing. **Maeva Zysman:** Investigation, Supervision, Validation, Writing – review & editing. **Victor Aboyans:** Investigation, Supervision, Validation, Writing – review & editing. **Gaëtan Deslee:** Investigation, Supervision, Validation, Writing – review & editing. **Laurent Fauchier:** Investigation, Supervision, Validation, Writing – review & editing. **Serge Kownator:** Investigation, Supervision, Validation, Writing – review & editing. **Gilles Montales-cot:** Investigation, Supervision, Validation, Writing – review & editing. **Christophe Pinet:** Investigation, Supervision, Validation, Writing – review & editing. **Bouchra Lamia:** Investigation, Supervision, Validation, Writing – review & editing. **Alain Cohen-Solal:** Investigation, Supervision, Validation, Writing – review & editing.

## Acknowledgements

The Delphi consensus project was coordinated by the medical education agency KPL Paris, with medical writing and editorial assistance provided by Alice Moreau. AstraZeneca France supported the project. The authors are especially grateful to the panel of participants who contributed to this project and whose names are listed in Supplementary Table 1.

## Supplementary materials

Supplementary material associated with this article can be found in the online version at doi:10.1016/j.resmer.2025.101187.

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