COPD-Asthma-Heart Failure Overlap: Optimizing Bronchodilators and ICS in a High-Risk Triad

Chronic obstructive pulmonary disease (COPD), asthma, and heart failure (HF) frequently coexist, forming a high-risk clinical triad characterized by overlapping symptoms and pathophysiological mechanisms. This COPD-asthma-HF overlap complicates diagnosis and treatment due to shared clinical features such as dyspnea, wheezing, and exercise intolerance. Epidemiologically, up to 30% of COPD patients have concomitant HF, while 15-20% of obstructive airway disease patients exhibit asthma-COPD overlap, many of whom also develop HF due to chronic hypoxia, systemic inflammation, or shared risk factors like smoking. The interplay between these conditions is driven by chronic inflammation, airway obstruction, and cardiac dysfunction, creating a self-perpetuating cycle of disease progression. Inflammation in COPD and asthma contributes to endothelial dysfunction and atherosclerosis, exacerbating HF, while HF-induced hypoxia and congestion worsen pulmonary inflammation. Diagnostic challenges arise from overlapping symptoms and limitations of traditional tools such as spirometry and biomarkers, necessitating a multimodal approach. Therapeutic management is complex, as treatments for one condition may worsen another (eg, beta-agonists exacerbating HF or diuretics increasing mucus viscosity in COPD). Precision medicine approaches targeting treatable traits such as eosinophilic inflammation, fluid overload, and bronchospasm offer a strategic framework for personalized care. Pharmacological strategies must balance bronchodilation, anti-inflammatory effects, and cardiac support, with careful consideration of drug safety profiles. This review highlights the need for integrated diagnostic and therapeutic strategies to optimize outcomes in this high-risk population, emphasizing the importance of recognizing shared pathophysiology and individualized management.