Cardiovascular disease in asthma and COPD: a population-based retrospective cross-sectional study

Burden of cardiovascular disease in chronic obstructive pulmonary disease

BACKGROUND

Chronic obstructive pulmonary disease (COPD) and atherosclerotic vascular disease share several etiopathogenic factors.

PURPOSE

To compare the prevalence of self-reported cardiovascular and cerebrovascular disease (CCVD) between COPD and non-COPD subjects using the National Health and Nutrition Examination Survey (NHANES) database. Among subjects without pre-existent CCVD, the short-term and lifetime risks of future CCVD were also compared between the two groups.

METHODS

Pooled NHANES 2007-2010 data were analyzed in May 2012 and April 2013. Based on predicted Framingham risk, subjects without self-reported CCVD were classified as follows: high short-term risk, low short-term/high lifetime risk, and low short-term/low lifetime risk for future CCVD.

RESULTS

Estimated self-reported CCVD prevalence was 20.0% and 7.4% in COPD and non-COPD groups, respectively (p<0.001). On multivariable analysis, COPD was an independent risk factor for prevalent self-reported CCVD (prevalence ratio=1.4, 95% CI=1.1, 1.8). Among subjects without CCVD, there were significant differences in predicted future CCVD risk between the two groups. In the non-COPD group, prevalence of high short-term risk, low short-term/high lifetime risk, and low short-term/low lifetime risk was 18.9%, 62.7%, and 18.4%, respectively. In the COPD group, corresponding prevalence estimates were 35.8%, 53.2%, and 11.1%, respectively. Men and women had significantly different risk factor profiles for future CCVD.

CONCLUSIONS

The prevalence of self-reported CCVD was significantly higher in subjects with COPD than in those without COPD. Among subjects without pre-existent CCVD, the risk of future CCVD was significantly higher in the COPD group than in the non-COPD group.

COPD management according to old and new GOLD guidelines: an observational study with Italian general practitioners

BACKGROUND

Guideline recommendations for COPD management are only partially applied within primary care clinical practice.

OBJECTIVE

To compare the COPD management by Italian general practitioners (GPs) according to either the old GOLD (oGOLD) or the new GOLD (nGOLD) guidelines.

RESEARCH DESIGN AND METHODS

Observational study in different Italian areas. A total of 176 GPs enrolled their patients with a COPD diagnosis. Questionnaires were used to collect data on: COPD symptoms, disease severity, exacerbations, prescribed pharmacological and non-pharmacological treatments. COPD severity was estimated according to oGOLD and nGOLD guidelines.

RESULTS

A total of 526 subjects had complete information to assess COPD severity level according to guidelines (symptoms level, spirometry, history of exacerbations). The investigated subjects were more frequently males (71.2%) with a mean age of 72.5 years, and ex-smokers (44.4%). GPs reported sufficient control of the disease in 47.2% of the subjects with over two exacerbations in the last 12 months. Most patients have moderate COPD (51.5%), according to oGOLD, and belong to D groups (high risk, more symptoms) (45.6%), according to nGOLD. Overall, a low use of post-bronchodilator spirometry (65.1%) and of pulmonary rehabilitation (13.4%) was shown. The results highlighted a low prescriptive appropriateness but with higher value according to nGOLD than oGOLD: 61.4% vs 35.6%.

STUDY LIMITATIONS

Prescription data only provide limited information to judge prescribing quality, thus the results have to be evaluated with caution; moreover, this study was not designed to assess the difference between oGOLD and nGOLD.

CONCLUSIONS

Guideline recommendations are applied only partially within clinical practice. A higher prescriptive appropriateness is shown by GPs using nGOLD classification. This might be due to the fact that nGOLD, with respect to oGOLD, takes into account anamnestic usual features considered by GPs in their clinical practice.

Coronary artery disease concomitant with chronic obstructive pulmonary disease

BACKGROUND

Numerous epidemiologic studies have linked the presence of chronic obstructive pulmonary disease (COPD) to coronary artery disease (CAD). However, prevalence, pathological processes, clinical manifestations and therapy are still debated, as progress towards uncovering the link between these two disorders has been hindered by the complex nature of multimorbidity.

METHODS

Articles targeting CAD in patients with COPD were identified from the searches of MEDLINE and EMBASE databases in July 2013. Three authors reviewed available evidence, focusing on the latest development on disease prevalence, pathogenesis, clinical manifestations and therapeutic strategies. Both clinical trial and previous reviews have been included in this work.

RESULTS

The most accredited hypothesis asserts that the main common risk factors, that is, cigarette smoke and ageing, elicit a chronic low-grade systemic inflammatory response, which affects both cardiovascular endothelial cells and airways/lung parenchyma. The development of CAD in patients with COPD potentiates the morbidity of COPD, leading to increased hospitalizations, mortality and health costs. Moreover, correct diagnosis is challenging and therapies are not clearly defined.

CONCLUSIONS

Evidence from recently published articles highlights the importance of multimorbidity in patient management and future research. Moreover, many authors emphasize the importance of low-grade systemic inflammation as a common pathological mechanism and a possible future therapeutic target.

Validity of the COPD assessment test translated into local languages for Asian patients

OBJECTIVE

Our objective was to evaluate the validity of the COPD Assessment Test (CAT), translated locally, for measuring the health status of patients in Asian countries.

METHODS

A pooled analysis of cross-sectional studies from Indonesia, Korea, Vietnam, and Hong Kong was performed. Smokers or ex-smokers, aged ≥ 40 years, with a smoking history of ≥ 10 pack-years and a COPD diagnosis in the past 6 months or more were recruited. Demographic, smoking, and COPD history and spirometry data were collected from patients who completed the CAT or St. George's Respiratory Questionnaire (SGRQ) and had their dyspnea assessed.

RESULTS

The study included 333 patients with mean age of 69 ± 9 years and smoking history of 38 ± 25 pack-years; 82% had ceased smoking. One-third suffered from cardiovascular comorbidities, 72% reported at least one exacerbation in the past year, and 82% recorded at least moderate health impairment (CAT scores ≥ 10 units). The CAT score was positively correlated with the SGRQ score (r = 0.72, P &lt; .001) and Medical Research Council (MRC) dyspnea score (r = 0.50, P &lt; .001) and poorly correlated with the FEV1 (r = -0.23, P &lt; .001) and number of exacerbations in the past year (r = 0.11, P = .04). The relationships between the CAT score and SGRQ score, MRC dyspnea score, or FEV1 did not differ between countries (P value for interaction term = 0.76, 0.75, and 0.06, respectively).

CONCLUSIONS

The CAT correlated well with the SGRQ and MRC dyspnea score in all countries, and the relationship did not differ between countries despite varying patient characteristics. This suggests that a CAT score in one of these countries has the same clinical significance as the same score in another.

Comorbidities of asthma: current knowledge and future research needs

PURPOSE OF REVIEW

Asthma is often associated with different comorbidities, mainly gastro-oesophageal reflux disease and allergic rhinitis, but also obesity, depression, diabetes mellitus and cardiovascular disease, which may affect its clinical intensity and severity. The prevalence of these comorbidities varies tremendously between studies. Nevertheless, it imposes a significant reflection on the need to explore the phenomenon in depth.

RECENT FINDINGS

Both clinical and basic studies have established that inflammation plays a vital role in the initiation and progression of several comorbidities. However, the role of systemic inflammation in asthma is still unclear. Understanding mechanism(s) that link(s) asthma and its comorbid diseases is essential to design an effective therapeutic approach.

SUMMARY

In the future, researchers must identify the weight of any comorbidity in patients with asthma, find the true mechanism(s) that link(s) it to asthma and act on these mechanisms that probably create a vicious circle. Conversely, we do not think it reasonable that the generalization of treatment with a holistic approach might affect the link(s) between asthma and its comorbidities.

Asthma and COPD in an Italian adult population: role of BMI considering the smoking habit

Smoking and body mass index (BMI) are well-documented risk factors that contribute substantially to chronic obstructive pulmonary disease (COPD) and asthma. However, the relations among smoking, obesity, and COPD or asthma remain to be clarified. We conducted a population-based cross-sectional epidemiologic study to explore the association between BMI and COPD or asthma among non-smokers, smokers and ex-smokers using information obtained from the Health Search database (HSD) owned by the Italian College of General Practitioners (SIMG), which stores information on about 1.5% of the total Italian population served by general practitioners (GPs). Our study confirms the importance of smoking status in patients with COPD, but not in those with asthma. Moreover, it demonstrates that the increase in BMI is frequently associated with the diagnosis of COPD or asthma, suggesting that the probability of suffering from COPD or asthma increases with the increase in body weight regardless of the smoking status. The association between an increase in BMI appears to be greater in women than in men. Our data also show that underweight is significantly associated with COPD, but only in men, while being underweight apparently protects from the possibility of suffering from asthma.

Systemic inflammatory biomarkers and co-morbidities of chronic obstructive pulmonary disease

Chronic obstructive pulmonary disease (COPD) can no longer be considered as a disease affecting only the lungs. Increasing evidence supports the presence of a systemic inflammatory component which is thought to provide the link between COPD and the co-morbidities commonly associated with this disease. These include cardiovascular disorders, skeletal muscle dysfunction, diabetes, and osteoporosis. The majority of current therapies for COPD have been developed to improve airway obstruction or to target airway inflammation, leaving an unmet medical need with respect to the systemic inflammatory component of COPD and its extra-pulmonary manifestations. This review describes systemic biomarkers in COPD and their relationship with both the local lung and systemic manifestations of the disease. A summary is provided of the most promising biomarkers that have been investigated in COPD and its co-morbidities. Such biomarkers may be used to assess and manage the systemic effects of COPD, and may guide future development of novel therapeutic interventions to provide a more holistic approach to treating this multi-faceted disease.

Aclidinium bromide for the treatment of chronic obstructive pulmonary disease

INTRODUCTION

Although there are some challenges with current therapies, the growing evidence that tiotropium bromide is important in the maintenance treatment of chronic obstructive pulmonary disease (COPD) has led to enthusiastic investigation in search of novel muscarinic antagonists which share some of the beneficial characteristics of tiotropium and perhaps improve upon less desirable ones.

AREAS COVERED

Aclidinium bromide is a new muscarinic antagonist that has been developed to relieve symptoms in patients with COPD. Preclinical data showed that it has an intriguing pharmacodynamic and pharmacokinetic profile. Aclidinium bromide was initially assessed as a once-daily bronchodilator. Subsequently, it has been evaluated as a twice-daily agent to increase the size of the clinical effect. Pivotal Phase III trials have documented that aclidinium bromide 400 μg twice-daily shows clinically meaningful effects in lung function and other important supportive outcomes, such as health-related quality of life, dyspnea and night-time/early morning symptoms, and is safe.

EXPERT OPINION

Aclidinium bromide can to be used as an alternative to tiotropium or a long-acting β₂-agonist. It is likely that the device used to deliver aclidinium, Genuair inhaler, a novel, multidose and a breath-actuated dry powder inhaler (DPI), will be important for the possible success of this drug. However, additional Phase III trials to assess advantages over tiotropium bromide and long-acting β₂-agonists are required to allow the place of aclidinium bromide to be fully elucidated.

Cardiorespiratory coupling in health and disease

Cardiac and respiratory activities are intricately linked both functionally as well as anatomically through highly overlapping brainstem networks controlling these autonomic physiologies that are essential for survival. Cardiorespiratory coupling (CRC) has many potential benefits creating synergies that promote healthy physiology. However, when such coupling deteriorates autonomic dysautonomia may ensue. Unfortunately there is still an incomplete mechanistic understanding of both normal and pathophysiological interactions that respectively give rise to CRC and cardiorespiratory dysautonomia. Moreover, there is also a need for better quantitative methods to assess CRC. This review addresses the current understanding of CRC by discussing: (1) the neurobiological basis of respiratory sinus arrhythmia (RSA); (2) various disease states involving cardiorespiratory dysautonomia; and (3) methodologies measuring heart rate variability and RSA.

High-sensitivity cardiac troponin T levels are increased in stable COPD

Objective

To assess the distribution of high-sensitivity cardiac troponin T (hs-cTnT) concentrations in stable chronic obstructive pulmonary disease (COPD), and whether hs-cTnT is associated with pulmonary function.

Design

Prospectively designed, cross-sectional study.

Setting

Outpatient clinic of Norwegian teaching hospital and community-based setting.

Participants

Sample of 101 stable COPD patients from the hospital's outpatient clinic and 120 individuals derived from a random general population sample.

Main outcomes

Ratio of hs-cTnT in stable COPD patients compared with references from the general population. Change in ratio of hs-cTnT per unit increase of relevant covariables.

Results

The crude geometric means of circulating hs-cTnT in the cases and the references were 7.75 and 3.01 ng/l, respectively (p <0.001); that is, a relative ratio of 2.57 (95% CI 2.05 to 3.23). After adjustment for relevant confounders, this ratio was moderately attenuated to 1.65 (1.31–2.08). In the total study cohort, as well as among stable COPD patients, we found a significant positive association between hs-cTnT and interleukin-6 concentrations (p <0.001) and the presence of pathologic Q waves (p=0.023). Among stable COPD patients, one quartile increase in forced expiratory volume 1 was associated with a 39% decrease in hs-cTnT and patient category (Global Initiative of Obstructive Lung Disease  classification 2011) was positively associated with hs-cTnT (p trend <0.001) after multivariate adjustment.

Conclusions

Stable COPD is independently associated with higher hs-cTnT compared with randomly drawn subjects from the general population. In patients with stable COPD, higher hs-cTnT seems to be associated with immune activation and the severity of the disease.

Treatment of COPD: moving beyond the lungs

We still do not know whether the successful treatment of the comorbid diseases associated with COPD, mainly cardiovascular disease, also positively influences the course of the lung disease because so far there are few definite data documenting that treatment of COPD comorbidities will reduce morbidity and mortality rates in these patients. Observational studies suggest that COPD patients treated with statins, angiotensin-converting enzyme inhibitors and angiotensin II type 1 receptor blockers, and β-adrenoceptor blockers may have improved survival and reduced hospitalisation from exacerbations. Progress in basic and translational research has led to a better understanding of pharmacological mechanisms that may explain the effects of these drugs on COPD and some small clinical trial activity is beginning to generate promising results.