What differential diagnoses must be considered and how should other diagnoses be excluded

• Heart failure

• Bronchiectasis

The diagnostic overlap with asthma has already been described. Table 3.2 compares the symptoms, signs and test results typical in COPD, ischaemic heart disease and bronchiectasis.

In early to moderate disease, the symptomatic overlap between COPD and ischaemic heart disease (IHD) is almost complete and there are no reliable distinguishing features. The radiographic features are a guide, but are not absolute. COPD patients may have no evidence of hyperinflation and may have a large heart (without failure) on a radiograph, whereas cardiac patients do not necessarily exhibit cardiac enlargement. It is the FEV1 that is most helpful, although even then chronic cardiac failure is often associated with mild reductions of FEV1. However, a clue to a cardiac problem is that the level of dyspnoea is disproportionately more severe than the reduction in FEV1. COPD patients with symptoms will always have a significant FEV1 reduction.

Table 3.2 A comparison of clinical features in three overlapping conditions.

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