BARCELONA, Spain — Chronic obstructive pulmonary disease (COPD) has been treated almost exclusively as an airway disorder. Yet for millions living with the condition, the threat of the disease extends beyond the lungs.

Speaking at the European Respiratory Society (ERS) 2026 International Congress during a joint symposium with the European Society of Cardiology (ESC), experts warned that failing to look beyond spirometry is costing lives. Cardiovascular events, right heart strain, and silent vascular remodeling increase mortality. “When we look at patients with mild-to-moderate airflow obstruction, the leading cause of death is not respiratory failure; it is cardiovascular disease and cancer,” said Daiana Stolz, MD, MPH, professor and chair of pulmonology at University Hospital Freiburg, Freiburg, Germany.

Chris Gale, MBChB, PhD, professor of cardiovascular medicine at the University of Leeds, in Leeds, England, said that the two specialties can no longer operate in isolation. “Cardiologists and pulmonologists are simply not talking to each other enough, yet these patients are suffering from a shared, highly lethal continuum.” 

Standardizing Heart and Lung Care

Gale outlined key guidance from the ESC consensus document on managing heart disease in people with COPD.

• Heart medications and Troponin blood tests: Although clinicians previously worried that heart drugs might trigger breathing problems, cardio-selective beta-blockers are safe, effective, and preferred for treating heart failure and controlling irregular heart rhythms in patients with COPD. In addition, blood tests frequently show raised troponin levels during sudden COPD flare-ups. Gale explained that elevated troponin levels do not always indicate a heart attack, so doctors must interpret these results in the context of the patient’s full clinical picture. However, when a true acute cardiac event occurs, full standard care, including antiplatelet drugs, statins, and stent procedures (percutaneous coronary intervention), must be delivered without hesitation. “COPD is not a reason to deliver less intensive coronary care,” he said.
• Heart failure, CT imaging, and early prevention: Heart failure affects 10%-50% of patients with COPD, and standard heart failure medications remain safe and highly effective. When hyperinflated lungs make echocardiograms hard to read, cardiac MRI should be used instead. Additionally, standard lung CT scans can be reviewed for evidence of hardened heart arteries and enlarged pulmonary blood vessels to detect heart strain early. Finally, even the earliest stages of lung impairment, such as pre-COPD and PRISm, carry increased cardiometabolic risk, requiring early heart evaluations and standard preventive care.

Managing High Lung Blood Pressure in COPD

Understanding high blood pressure in the lungs due to blood vessel changes in COPD, known as group 3 pulmonary hypertension (PH-COPD), makes managing the condition exceptionally delicate. Carrying one of the worst survival rates among all types of lung-related high blood pressure, group 3 pulmonary hypertension is defined under 2022 ESC/ERS guidelines as severe when pulmonary vascular resistance exceeds 5 Wood units.

Gabor Kovacs, MD, a professor of pulmonology at the Medical University of Graz, in Graz, Austria, explained why widening blood vessels in lung disease is fraught with risk. Standard drugs used for primary pulmonary arterial hypertension (PAH), such as PDE-5 inhibitors, are not recommended for nonsevere high lung pressure. Opening blood vessels indiscriminately risks directing blood flow to damaged, nonventilated areas of the lung, which worsens blood oxygen levels. Kovacs said the phase 3 PERFECT trial, which tested inhaled treprostinil in PH-COPD, was stopped early because it failed to show benefits and was associated with higher rates of adverse events.

Patients with severe emphysema and very low lung diffusion capacity suffered frequent clinical decline. As Kovacs said, “severe emphysema might just not be a treatable trait” for inhaled blood-vessel dilators as destroyed lung tissue cannot respond to these medications.

For patients with severe high lung blood pressure, guidelines recommend individualized care at specialized medical centers. Analysis from the GoDeep registry suggests that carefully targeted PDE-5 inhibitor treatment in severe cases may offer survival benefits. Additionally, about 7% of patients with primary PAH also have coexisting mild COPD. “If we have a PAH patient with coexisting COPD, we should treat the PAH according to guidelines,” said Kovacs, adding that clinicians should anticipate more frequent side effects and potentially reduced treatment effectiveness.

To protect blood oxygen levels, researchers are developing inhaled medications that act only within the ventilated regions of the lungs. Kovacs mentioned two key ongoing clinical trials: the INSIGNIA-PH-COPD trial, evaluating an inhaled drug called frespasiguat (MK-5475), and the ERASE PH-COPD trial, studying tadalafil in patients with severe lung-related high blood pressure.

Stolz reported receiving consulting fees from Boehringer Ingelheim, Almirall, GSK, AstraZeneca, Vifor, MSD, Bayer, Sanofi, CLS, Behring, Grifols, Roche, Chiesi, Berlin Chemie, and Pfizer. Gale reported being founder and director of FIND-Health Ltd; he reported receiving consulting fees from AstraZeneca, Amgen, Bayer, Boston Scientific, Bristol Myers Squibb, Berlin-Chemie, Boehringer Ingelheim, Chiesi, Daiichi Sankyo, Eli Lilly, GPRI Research BV, GSK, Menarini, Novartis, iRhythm. Kovacs reported receiving research support from Boehringer-Ingelheim, Johnson & Johnson, MSD, European Respiratory Society; he reported receiving consultation fees from AOP Orphan, Boehringer-Ingelheim, Chiesi, Ferrer, Gebro Pharma, Gossamer, Inhibikase Therapeutics, Johnson & Johnson, Liquidia, MSD, Pulmovant, United Therapeutics.

Manuela Callari is a freelance science journalist specializing in human and planetary health. Her work has been published in The Medical Republic, Rare Disease Advisor, New Scientist, The Guardian, MIT Technology Review, and others.