Chronic obstructive pulmonary disease as an independent risk factor for cardiovascular morbidity

Impact of chronic inflammatory airway disease on stroke severity and long-term survival after ischemic stroke--a retrospective analysis

Background

Chronic inflammatory airway disease (CIAD) has emerged as independent risk factor for cardiovascular mortality and ischemic stroke but the impact of co-existing CIAD in patients with ischemic stroke is less clear.

Methods

We retrospectively analyzed 1013 patients with acute ischemic stroke who were consecutively admitted to the Department of Neurology, Charité - Universitätsmedizin Berlin, Germany within one year. Mean follow-up was 80 months (IQR 32–85 months). Using multivariable regression models we analyzed the impact of CIAD (defined as chronic obstructive pulmonary disease or asthma bronchiale) on stroke severity and outcome.

Results

Co-existing CIAD was evident in 7.1 % (n = 72) of all patients with acute ischemic stroke. Baseline characteristics of stroke patients with CIAD did not differ significantly from ischemic stroke patients without CIAD. Age (OR 1.17 [95 % CI 1.03-1.37] per decade), atrial fibrillation (OR 3.43 [95 % CI 2.47-4.78]) and coronary artery disease (OR 1.51 [95 % CI 1.07–2.14]) but not a history of CIAD (p = 0.30) were associated with severe stroke (NIHSS≥11) on hospital admission. Age (HR 1.70 [95 % CI 1.53-1.87] per decade), peripheral artery disease (HR 1.91 [95 % CI 1.35-2.7]), stroke severity at hospital admission (NIHSS per point HR 1.08 [95 % CI 1.06-1.10]), and history of CIAD (HR 1.43 [95 % CI 1.02-2.00]) were independently associated with mortality during long-term follow-up. However, CIAD was not significantly associated with short-term mortality after stroke.

Conclusion

Co-existing CIAD showed no significant association with stroke severity at hospital admission and early mortality after ischemic stroke. CIAD was negatively associated with long-term survival after ischemic stroke.

Inflammation in chronic obstructive pulmonary disease and its role in cardiovascular disease and lung cancer

Chronic obstructive pulmonary disease (COPD) is characterized by lung inflammation that persists after smoking cessation. This inflammation is heterogeneous but the key inflammatory cell types involved are macrophages, neutrophils and T cells. Other lung cells may also produce inflammatory mediators, particularly the epithelial cells. The main inflammatory mediators include tumor necrosis factor alpha, interleukin-1, interleukin-6, reactive oxygen species and proteases. COPD is also associated with systemic inflammation and there is a markedly increased risk of cardiovascular disease (particularly coronary artery disease) and lung cancer in patients with COPD. There is strong associative evidence that the inflammatory cells/mediators in COPD are also relevant to the development of cardiovascular disease and lung cancer. There are a large number of potential inhibitors of inflammation in COPD that may well have beneficial effects for these comorbidities. This is a not well-understood area and there is a requirement for more definitive clinical and mechanistic studies to define the relationship between the inflammatory process of COPD and cardiovascular disease and lung cancer.

Chronic obstructive pulmonary disease and cerebrovascular disease: A comprehensive review

Along with the aging population, the public health burden of cerebrovascular disease is increasing. Cerebral small vessel disease and accumulation of brain pathology associate with cognitive decline and can lead to clinical outcomes, such as stroke and dementia. Chronic Obstructive Pulmonary Disease (COPD) is a common respiratory disease among elderly. The quality of life and prognosis of patients with COPD is greatly determined by the presence of comorbidities including stroke and cognitive impairment. Despite the clinical relevance of cerebral small vessel disease, stroke and (vascular) cognitive impairment in patients with COPD, literature is scarce and underlying mechanisms are unknown. The aim of the present review is therefore to summarize current scientific knowledge, to provide a better understanding of the interplay between COPD and the aging brain and to define remaining knowledge gaps. This narrative review article 1) overviews the epidemiology of cerebral small vessel disease, stroke and cognitive impairment in patients with COPD; 2) discusses potential underlying mechanisms including aging, smoking, systemic inflammation, vasculopathy, hypoxia and genetic susceptibility; and 3) highlights areas requiring further research.

Risk of cardiovascular comorbidity in patients with chronic obstructive pulmonary disease: a systematic review and meta-analysis

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is a systemic inflammatory disorder associated with increased comorbid prevalence of cardiovascular diseases. We aimed to quantify the magnitudes of association between overall and specific types of cardiovascular disease, major cardiovascular risk factors, and COPD.

METHODS

We searched Cochrane, Medline, and Embase databases for studies published between Jan 1, 1980, and April 30, 2015, on the prevalence of cardiovascular disease and its risk factors in patients with COPD versus matched controls or random samples from the general public. We assessed associations with random-effects meta-analyses. We studied heterogeneity and biases with random-effects meta-regressions, jackknife sensitivity analyses, assessment of funnel plots, and Egger tests.

FINDINGS

We identified 18,176 unique references and included 29 datasets in the meta-analyses. Compared with the non-COPD population, patients with COPD were more likely to be diagnosed with cardiovascular disease (odds ratio [OR] 2·46; 95% CI 2·02-3·00; p<0·0001), including a two to five times higher risk of ischaemic heart disease, cardiac dysrhythmia, heart failure, diseases of the pulmonary circulation, and diseases of the arteries. Additionally, patients with COPD reported hypertension more often (OR 1·33, 95% CI 1·13-1·56; p=0·0007), diabetes (1·36, 1·21-1·53; p<0·0001], and ever smoking (4·25, 3·23-5·60; p<0·0001). The associations between COPD and these cardiovascular disease types and cardiovascular disease risk factors were consistent and valid across studies. Enrolment period, age, quality of data, and COPD diagnosis partly explained the heterogeneity.

INTERPRETATION

The coexistence of COPD, cardiovascular disease, and major risk factors for cardiovascular disease highlights the crucial need for the development of strategies to screen for and reduce cardiovascular risks associated with COPD.

FUNDING

Canadian Institutes of Health Research.

Underdiagnosis and prognosis of chronic obstructive pulmonary disease after percutaneous coronary intervention: a prospective study

BACKGROUND

Retrospective studies based on clinical data and without spirometric confirmation suggest a poorer prognosis of patients with ischemic heart disease (IHD) and chronic obstructive pulmonary disease (COPD) following percutaneous coronary intervention (PCI). The impact of undiagnosed COPD in these patients is unknown. We aimed to evaluate the prognostic impact of COPD - previously or newly diagnosed - in patients with IHD treated with PCI.

METHODS

Patients with IHD confirmed by PCI were consecutively included. After PCI they underwent forced spirometry and evaluation for cardiovascular risk factors. All-cause mortality, new cardiovascular events, and their combined endpoint were analyzed.

RESULTS

A total of 133 patients (78%) male, with a mean (SD) age of 63 (10.12) years were included. Of these, 33 (24.8%) met the spirometric criteria for COPD, of whom 81.8% were undiagnosed. IHD patients with COPD were older, had more coronary vessels affected, and a greater history of previous myocardial infarction. Median follow-up was 934 days (interquartile range [25%-75%]: 546-1,160). COPD patients had greater mortality (P=0.008; hazard ratio [HR]: 8.85; 95% confidence interval [CI]: 1.76-44.47) and number of cardiovascular events (P=0.024; HR: 1.87; 95% CI: 1.04-3.33), even those without a previous diagnosis of COPD (P=0.01; HR: 1.78; 95% CI: 1.12-2.83). These differences remained after adjustment for sex, age, number of coronary vessels affected, and previous myocardial infarction (P=0.025; HR: 1.83; 95% CI: 1.08-3.1).

CONCLUSION

Prevalence and underdiagnosis of COPD in patients with IHD who undergo PCI are both high. These patients have an independent greater mortality and a higher number of cardiovascular events during follow-up.

Underrecognized comorbidities of chronic obstructive pulmonary disease

COPD is associated with different comorbid diseases, and their frequency increases with age. Comorbidities severely impact costs of health care, intensity of symptoms, quality of life and, most importantly, may contribute to life span shortening. Some comorbidities are well acknowledged and established in doctors’ awareness. However, both everyday practice and literature searches provide evidence of other, less recognized diseases, which are frequently associated with COPD. We call them underrecognized comorbidities, and the reason why this is so may be related to their relatively low clinical significance, inefficient literature data, or data ambiguity. In this review, we describe rhinosinusitis, skin abnormalities, eye diseases, different endocrinological disorders, and gastroesophageal reflux disease. Possible links to COPD pathogenesis have been discussed, if the data were available.

Chronic obstructive pulmonary disease and coronary disease: COPDCoRi, a simple and effective algorithm for predicting the risk of coronary artery disease in COPD patients

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is often associated with cardiovascular artery disease (CAD), representing a potential and independent risk factor for cardiovascular morbidity. Therefore, the aim of this study was to identify an algorithm for predicting the risk of CAD in COPD patients.

METHODS

We analyzed data of patients afferent to the Cardiology ward and the Respiratory Diseases outpatient clinic of Tor Vergata University (2010-2012, 1596 records). The study population was clustered as training population (COPD patients undergoing coronary arteriography), control population (non-COPD patients undergoing coronary arteriography), test population (COPD patients whose records reported information on the coronary status). The predicting model was built via causal relationship between variables, stepwise binary logistic regression and Hosmer-Lemeshow analysis. The algorithm was validated via split-sample validation method and receiver operating characteristics (ROC) curve analysis. The diagnostic accuracy was assessed.

RESULTS

In training population the variables gender (men/women OR: 1.7, 95%CI: 1.237-2.5, P < 0.05), dyslipidemia (OR: 1.8, 95%CI: 1.2-2.5, P < 0.01) and smoking habit (OR: 1.5, 95%CI: 1.2-1.9, P < 0.001) were significantly associated with CAD in COPD patients, whereas in control population also age and diabetes were correlated. The stepwise binary logistic regressions permitted to build a well fitting predictive model for training population but not for control population. The predictive algorithm shown a diagnostic accuracy of 81.5% (95%CI: 77.78-84.71) and an AUC of 0.81 (95%CI: 0.78-0.85) for the validation set.

CONCLUSIONS

The proposed algorithm is effective for predicting the risk of CAD in COPD patients via a rapid, inexpensive and non-invasive approach.

Impact of airflow limitation on carotid atherosclerosis in coronary artery disease patients

BACKGROUND

Both airflow limitation and smoking are established cardiovascular risk factors. However, their interaction as risk factors for the development of atherosclerosis in coronary artery disease patients remains unclear.

OBJECTIVES

To evaluate the effect of the interaction between airflow limitation and smoking status on the severity of carotid atherosclerosis.

METHODS

We categorized the 234 enrolled patients with coronary artery disease into four groups: never-smokers with normal pulmonary function (group A), never-smokers with airflow limitation (group B), ever-smokers with normal pulmonary function (group C), and ever-smokers with airflow limitation (group D).

RESULTS

The prevalence of airflow limitation in the enrolled patients was 23.1% (ever-smokers: 15.8%, never-smokers: 7.3%). The prevalence of severe carotid atherosclerosis was 28.2, 29.4, 41.3, and 45.9%, respectively, in the four groups (group D vs. group A, p = 0.035). Even after multivariate adjusting for confounding factors, ever-smokers with airflow limitation were independently associated with severe carotid atherosclerosis (odds ratio 2.89, 95% confidence interval, 1.19-7.00, p = 0.019).

CONCLUSIONS

Ever-smokers with airflow limitation were significantly associated with severe carotid atherosclerosis among patients with coronary artery disease. These findings also provide additional insight into the correlation between airflow limitation and poor cardiovascular clinical outcomes.

Comorbidities of patients in tiotropium clinical trials: comparison with observational studies of patients with chronic obstructive pulmonary disease

BACKGROUND

There is an ongoing debate on whether patients with chronic obstructive pulmonary disease (COPD) seen in real-life clinical settings are represented in randomized controlled trials (RCTs) of COPD. It is thought that the stringent inclusion and exclusion criteria of RCTs may prevent the participation of patients with specific characteristics or risk factors.

METHODS

We surveyed a database of patients recruited into 35 placebo-controlled tiotropium RCTs and also conducted a systematic literature review of large-scale observational studies conducted in patients with a documented diagnosis of COPD between 1990 and 2013. Patient demographics and comorbidities with a high prevalence in patients with COPD were compared between the two patient populations at baseline. Using the Medical Dictionary for Regulatory Activities (MedDRA; v 14.0), patient comorbidities in the pooled tiotropium RCTs were classified according to system organ class, pharmacovigilance (PV) endpoints, and Standardised MedDRA Queries to enable comparison with the observational studies.

RESULTS

We identified 24,555 patients in the pooled tiotropium RCTs and 61,361 patients among the 13 observational studies that met our search criteria. The Global initiative for chronic Obstructive Lung Disease (GOLD) staging of patients in the RCTs differed from that in observational studies: the proportion of patients with GOLD stages I+II disease ranged from 40.0% to 51.5% in the RCTs but 24.5% to 44.1% in the observational studies; for GOLD stage III or IV disease these ranges were 7.2%-45.8% (RCTs) and 13.7-42.1% (observational studies). The comorbidities with the highest prevalence reported in the RCTs and observational studies were: hypertension (39.4%-40.0% vs 40.1%-60.6%), other ischemic heart disease (12.3%-14.2% vs 12.5%-41.0%), diabetes (10.3%-10.9% vs 4.0%-38.9%), depression (8.5%-9.5% vs 17.0%-20.6%), and cardiac arrhythmia (7.8%-11.4% vs 11.3%-15.8%).

CONCLUSION

The clinical profile of COPD patients treated in the tiotropium trial program appears to be largely in the range of clinical characteristics, including cardiovascular comorbidities, reported for "real-life patients." The tiotropium RCTs tended to include patients with more severe disease than the observational studies.

Factors associated with prolonged hospitalization, readmission, and death in elderly heart failure patients in western Romania

PURPOSE

The purpose of this prospective study was to identify factors associated with prolonged hospitalization, readmission, and death in elderly patients presenting heart failure with reduced ejection fraction.

PATIENTS AND METHODS

All consecutive patients aged ≥65 years discharged with a diagnosis of acute new-onset heart failure and a left ventricular ejection fraction (LVEF) ≤45% were included and followed up for 1 year. The variables associated with outcomes were analyzed in univariate and multivariate logistic regression. For the independent predictors identified by multivariate analysis, receiver operating characteristic (ROC) analysis was performed.

RESULTS

A total of 71 patients were included in the study. The patient mean age was 72.5 years, 50% were female, and the mean LVEF was 31.25%±5.76%. In all, 34 (48%) patients experienced prolonged hospitalization, and this was independently associated with patients who were living in a rural area (P=0.005), those with a New York Heart Association functional class of 4 (P<0.001), the presence of comorbidities (P=0.023), chronic obstructive pulmonary disease (COPD) infectious exacerbation (P<0.001), and chronic kidney disease (P=0.025). In the multivariate analysis, only COPD infectious exacerbation was independently associated with prolonged hospitalization (P=0.003). A total 19 patients (27%) experienced readmissions during the 1-year follow up, of which 12 (17%) had cardiovascular causes and seven (10%) had noncardiovascular causes. The following independent variables associated with rehospitalizations were outlined in the univariate analysis: infections (P<0.020); COPD infectious exacerbation (P=0.015); one or more comorbidity (P<0.0001); and prolonged baseline hospitalization (P<0.0001). During the multivariate analysis, it was found that the independent predictors of readmissions were the presence of comorbidities (P<0.001) and prolonged baseline hospitalization (P<0.01). The 1-year mortality rate was 9.8%, with no significant difference between cardiovascular (5.6%) and noncardiovascular (4.2%) deaths. The only independent predictive variable for mortality was a New York Heart Association NYHA functional class 4 at baseline hospitalization (P=0.001).

CONCLUSION

Elderly patients are at high risk for prolonged hospitalization, readmission, and death following a first hospitalization for heart failure with reduced ejection fraction. The most powerful predictors for outcomes are the severity of heart failure, the presence of comorbidities, and prolonged hospitalization at baseline.

Impact of COPD on the mortality and treatment of patients hospitalized with acute decompensated heart failure: the Worcester Heart Failure Study

BACKGROUND

COPD is a common comorbidity in patients with heart failure, yet little is known about the impact of this condition in patients with acute decompensated heart failure (ADHF), especially from a more generalizable, community-based perspective. The primary objective of this study was to describe the in-hospital and postdischarge mortality and treatment of patients hospitalized with ADHF according to COPD status.

METHODS

The study population consisted of patients hospitalized with ADHF at all 11 medical centers in central Massachusetts during four study years: 1995, 2000, 2002, and 2004. Patients were followed through 2010 for determination of their vital status.

RESULTS

Of the 9,748 patients hospitalized with ADHF during the years under study, 35.9% had a history of COPD. The average age of this population was 76.1 years, 43.9% were men, and 93.3% were white. At the time of hospital discharge, patients with COPD were less likely to have received evidence-based heart failure medications, including β-blockers and angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, than patients without COPD. Multivariable, adjusted in-hospital death rates were similar for patients with and without COPD. However, among patients who survived to hospital discharge, patients with COPD had a significantly higher risk of dying at 1 year (adjusted relative risk [RR], 1.10; 95% CI, 1.06-1.14) and 5 years (adjusted RR, 1.40; 95% CI, 1.28-1.52) after hospital discharge than patients who were not previously diagnosed with COPD.

CONCLUSIONS

COPD is a common comorbidity in patients hospitalized with ADHF and is associated with a worse long-term prognosis. Further research is required to understand the complex interactions of these diseases and ensure that patients with ADHF and COPD receive optimal treatment modalities.

Managing comorbidities in COPD

Chronic obstructive pulmonary disease (COPD) is a leading cause of morbidity and mortality worldwide. Age and smoking are common risk factors for COPD and other illnesses, often leading COPD patients to demonstrate multiple coexisting comorbidities. COPD exacerbations and comorbidities contribute to the overall severity in individual patients. Clinical trials investigating the treatment of COPD routinely exclude patients with multiple comorbidities or advanced age. Clinical practice guidelines for a specific disease do not usually address comorbidities in their recommendations. However, the management and the medical intervention in COPD patients with comorbidities need a holistic approach that is not clearly established worldwide. This holistic approach should include the specific burden of each comorbidity in the COPD severity classification scale. Further, the pharmacological and nonpharmacological management should also include optimal interventions and risk factor modifications simultaneously for all diseases. All health care specialists in COPD management need to work together with professionals specialized in the management of the other major chronic diseases in order to provide a multidisciplinary approach to COPD patients with multiple diseases. In this review, we focus on the major comorbidities that affect COPD patients. We present an overview of the problems faced, the reasons and risk factors for the most commonly encountered comorbidities, and the burden on health care costs. We also provide a rationale for approaching the therapeutic options of the COPD patient afflicted by comorbidity.

A perspective on point-of-care tests to detect eosinophilic bronchitis

Approximately 50% of asthma exacerbations and a third of COPD exacerbations are associated with an eosinophilic bronchitis. Quantitative cell counts reliably identify the number of eosinophils in sputum and treatment strategies that are guided by sputum eosinophil counts lead to significantly better outcomes than strategies guided by conventional assessments of symptoms and airflow. However, cell counts are not widely available and the results are not available in real time. Similarly, more sophisticated detection methods using immunoassays or genetic analysis via polymerase chain reaction are too costly and thus not amenable to rapid point-of-care diagnosis. Blood eosinophil counts and fraction of exhaled nitric oxide correlate poorly with airway eosinophilia, particularly in patients with severe airway diseases who are on corticosteroid therapy. Point of care assessments of eosinophil-specific activity may be provided by breathomics that employ metabolomics profiling of volatile compounds in breath. However, it is too early to decide if this would provide quantitative data to monitor therapy and disease activities longitudinally. Herein we provide a perspective on the potential for developing simple point-of-care tests with special emphasis on the potential for a bio-active paper diagnostic test to quantitatively assay the amount of eosinophil peroxidase in sputum samples by employing different types of detection systems.

Prevalence and risk factors of aortic aneurysm in patients with chronic obstructive pulmonary disease

BACKGROUND

Patients with chronic obstructive pulmonary disease (COPD) manifest an excess of chronic co-morbidities and present a high prevalence of cardiovascular disease such as congestive heart failure and ischemic heart disease. Aortic aneurysm (AA) also shared the risks of those diseases and its rupture is an important cause of death. However, since AA progresses almost silently, the prevalence of AA in patients with COPD remains unclear. The aim of this study was to determine AA prevalence and risk factors in patients with COPD.

METHODS

With computed tomography (CT) screening, we tested for AA in 231 COPD patients, and assessed emphysema by Goddard classification and aortic wall calcification in abdominal artery, respectively. We also evaluated that of thoracic artery using our original methods, which we assessed the extent of calcification in the thoracic artery as well as which defined as "aortic calcification index (ACI) in thoracic artery".

RESULTS

In 231 patients with COPD, 27 (11.7%) had AA determined by CT imaging and another 6 patients with previously diagnosed AA and a history of repaired operation (2.6%). In this total of 33 patients (AA group), the age of 95% confidence interval (CI) was 75.8 to 80.1 years and the prevalence of AA in patients aged 76 to 80 years was 26.8%. A low attenuation area and aortic wall calcification were more severe in the AA group than in the non-AA group, but forced expiratory volume in 1 second (FEV1) was not significantly different in those patients. The Goddard score of nine and ACI in the thoracic artery of 25.0% were determined to identify the most appropriate cut-off levels for discriminating between AA and non-AA groups.

CONCLUSIONS

Our analysis indicated that sizeable under-recognition of AA seems likely in COPD. Especially for patients with severe lung destruction and aortic calcification verifiable by chest CT, abdominal CT would be beneficial for detecting AA.

Serial pulmonary function tests to diagnose COPD in chronic heart failure

Background

It is unknown whether serial pulmonary function tests are necessary for the correct diagnosis of chronic obstructive pulmonary disease (COPD) in patients with stable non-congested chronic heart failure (CHF). The aim of this study was to determine the prevalence of COPD in outpatients with stable CHF without pulmonary congestion using initial as well as confirmatory spirometry three months after treatment for COPD.

Methods

Spirometry was performed in 187 outpatients with stable CHF without pulmonary congestion on chest radiograph who had a left ventricular ejection fraction < 40% (mean age 69 ± 10 years, 78% men). COPD was defined according to the Global Initiative for Chronic Obstructive Lung Disease guidelines. The diagnosis of COPD was confirmed three months after treatment with tiotropium in newly diagnosed COPD patients.

Results

Using a three month follow-up spirometry to confirm initial diagnosis of de novo COPD did not change COPD prevalence significantly: 32.6% initially versus 32.1% after three months of follow-up. Only 1 of 25 (4%) patients with newly diagnosed COPD was not reproducibly obstructed at follow-up. COPD was greatly under- (19%) and overdiagnosed (32%).

Conclusions

Spirometry should be used under stable and euvolemic conditions to decrease the burden of undiagnosed or overdiagnosed COPD in patients with CHF. Under these conditions, a confirmatory spirometry is unnecessary, as it does not change a newly established diagnosis of COPD in the vast majority of patients with CHF.

Trial registration

ClinicalTrials.gov Identifier NCT01429376.

Electronic supplementary material

The online version of this article (doi:10.1186/s40247-014-0012-5) contains supplementary material, which is available to authorized users.

Epidemiology and clinical impact of major comorbidities in patients with COPD

Comorbidities are frequent in chronic obstructive pulmonary disease (COPD) and significantly impact on patients’ quality of life, exacerbation frequency, and survival. There is increasing evidence that certain diseases occur in greater frequency amongst patients with COPD than in the general population, and that these comorbidities significantly impact on patient outcomes. Although the mechanisms are yet to be defined, many comorbidities likely result from the chronic inflammatory state that is present in COPD. Common problems in the clinical management of COPD include recognizing new comorbidities, determining the impact of comorbidities on patient symptoms, the concurrent treatment of COPD and comorbidities, and accurate prognostication. The majority of comorbidities in COPD should be treated according to usual practice, and specific COPD management is infrequently altered by the presence of comorbidities. Unfortunately, comorbidities are often under-recognized and under-treated. This review focuses on the epidemiology of ten major comorbidities in patients with COPD. Further, we emphasize the clinical impact upon prognosis and management considerations. This review will highlight the importance of comorbidity identification and management in the practice of caring for patients with COPD.

Temporal disease trajectories condensed from population-wide registry data covering 6.2 million patients

A key prerequisite for precision medicine is the estimation of disease progression from the current patient state. Disease correlations and temporal disease progression (trajectories) have mainly been analysed with focus on a small number of diseases or using large-scale approaches without time consideration, exceeding a few years. So far, no large-scale studies have focused on defining a comprehensive set of disease trajectories. Here we present a discovery-driven analysis of temporal disease progression patterns using data from an electronic health registry covering the whole population of Denmark. We use the entire spectrum of diseases and convert 14.9 years of registry data on 6.2 million patients into 1,171 significant trajectories. We group these into patterns centred on a small number of key diagnoses such as chronic obstructive pulmonary disease (COPD) and gout, which are central to disease progression and hence important to diagnose early to mitigate the risk of adverse outcomes. We suggest such trajectory analyses may be useful for predicting and preventing future diseases of individual patients.

Clinical characteristics and prognostic significance of chronic obstructive pulmonary disease in patients with atrial fibrillation: results from a multicenter atrial fibrillation registry study

OBJECTIVES

Atrial fibrillation (AF) and chronic obstructive pulmonary disease (COPD) are 2 common morbidities and often coexist. Studies have shown that COPD is a risk factor for cardiovascular disease, but the characteristics in patients with COPD and AF, as well as the impact of COPD on the outcomes of AF were lacking. The aim of present study was to analyze the clinical characteristics and to evaluate the association of COPD with 1-year outcomes in patients with AF.

DESIGN

Longitudinal observational study.

PARTICIPANTS

A total of 1975 consecutive patients with AF were registered. Patients were divided into COPD group and non-COPD group according to whether AF coexisted with COPD.

MEASUREMENTS

Outcome measures included all-cause mortality, stroke, and major adverse events (MAE) during 1-year follow-up.

RESULTS

A group of 227 (11.5%) patients had concomitant COPD. Compared with non-COPD patients, patients with COPD were older and tended to have other coexisting cardiovascular morbidities, and had a significantly higher percentage of smoking history. Anticoagulation with warfarin was adopted by only a few patients both with and without COPD. During 1-year follow-up, the all-cause mortality and major adverse event rate in the COPD group were significantly higher than that of non-COPD group (26.9% vs 12.3%, P < .001 and 25.6% vs 19.1%, P = .027, respectively), whereas the incidence of stroke in the 2 groups was comparable (7.9% vs 7.4%, P = .788). Moreover, the cause-specific mortality between the 2 groups was comparable. After multivariate adjustments, COPD was still an independent risk factor for both 1-year all-cause mortality [hazard rate (HR) = 1.491, 95% confidence interval (CI) 1.110-2.002, P = .008] and cardiovascular mortality (HR = 1.595, 95% CI 1.071-2.376, P = .022), but not a risk factor for stroke (HR = 0.879, 95% CI 0.527-1.464, P = .620).

CONCLUSIONS

Anticoagulation treatment is inadequate in patients with AF and COPD. The presence of COPD in patients with AF is an independent risk factor for 1-year all-cause mortality and cardiovascular mortality but not a risk factor for stroke.

COPD patients with and without metabolic syndrome: clinical and functional differences

Chronic obstructive pulmonary disease (COPD) and the metabolic syndrome (MetS) are considered public health challenges of the 21st century. The coexistence of MetS in COPD patients and any clinical differences between COPD patients with and without MetS have not been extensively studied. We aimed to describe the clinical characteristics of patients with MetS and COPD. An observational, multicenter study of 375 patients hospitalized for a COPD exacerbation with spirometric confirmation was performed. We measured the components of the MetS and collected comorbidity information using the Charlson index and other conditions. Dyspnea, use of steroids, exacerbations, and hospitalizations were also investigated. The overall prevalence of MetS in COPD patients was 42.9 %, was more frequent in women (59.5 %) than men (40.8 %), p = 0.02, but with no differences in age and smoking history. COPD patients with MetS had greater % predicted FEV1, more dyspnea, and more comorbidity and used more inhaled steroids (all p < 0.05). Diabetes, osteoporosis, coronary artery disease, and heart failure were more frequent in patients with MetS. They had been hospitalized more frequently for any cause but not for COPD. In multivariate analysis, the presence of MetS was independently associated with greater FEV1, inhaled steroids use, osteoporosis, diabetes, and heart failure. MetS is a frequent condition in COPD patients, and it is associated with greater FEV1, more dyspnea, and more comorbidities.

Prevalence of airflow limitation in outpatients with cardiovascular diseases in Japan

BACKGROUND AND OBJECTIVES

Cardiovascular disease (CVD) and chronic obstructive pulmonary disease (COPD) commonly coexist and share common risk factors. The prevalence of COPD in outpatients with a smoking history and CVD in Japan is unknown. The aim of this study was to determine the proportion of Japanese patients with a smoking history being treated for CVD who have concurrent airflow limitation compatible with COPD. A secondary objective was to test whether the usage of lung function tests performed in the clinic influenced the diagnosis rate of COPD in the patients identified with airflow limitation.

METHODS

In a multicenter observational prospective study conducted at 17 centers across Japan, the prevalence of airflow limitation compatible with COPD (defined as forced expiratory volume (FEV)1/FEV6 <0.73, by handheld spirometry) was investigated in cardiac outpatients ≥40 years old with a smoking history who routinely visited the clinic for their CVD. Each patient completed the COPD Assessment Test prior to spirometry testing.

RESULTS

Data were available for 995 patients with a mean age of 66.6±10.0 years, of whom 95.5% were male. The prevalence of airflow limitation compatible with COPD was 27.0% (n=269), and 87.7% of those patients (n=236) did not have a prior diagnosis of COPD. The prevalence of previously diagnosed airflow limitation was higher in sites with higher usage of lung function testing (14.0%, 15.2% respectively) compared against sites where it is performed seldom (11.1%), but was still low.

CONCLUSION

The prevalence of airflow limitation in this study indicates that a quarter of outpatients with CVD have COPD, almost all of whom are undiagnosed. This suggests that it is important to look routinely for COPD in CVD outpatients.

Acute exacerbation of chronic obstructive pulmonary disease: cardiovascular links

Chronic obstructive pulmonary disease (COPD) is a chronic, progressive lung disease resulting from exposure to cigarette smoke, noxious gases, particulate matter, and air pollutants. COPD is exacerbated by acute inflammatory insults such as lung infections (viral and bacterial) and air pollutants which further accelerate the steady decline in lung function. The chronic inflammatory process in the lung contributes to the extrapulmonary manifestations of COPD which are predominantly cardiovascular in nature. Here we review the significant burden of cardiovascular disease in COPD and discuss the clinical and pathological links between acute exacerbations of COPD and cardiovascular disease.

Cardiovascular comorbidity in COPD: systematic literature review

BACKGROUND

Cardiovascular disease (CVD) is common among patients with COPD. However, it is not clear whether this is due to shared risk factors or if COPD increases the risk for CVD independently. This study aimed to provide a systematic review of studies that investigated the association between COPD and CVD outcomes, assessing any effect of confounding by common risk factors.

METHODS

A search was conducted in MEDLINE (via PubMed) for observational studies published between January 1990 and March 2012 reporting cardiovascular comorbidity in patients with COPD (or vice versa).

RESULTS

Of the 7,322 citations identified, 25 studies were relevant for this systematic review. Twenty-two studies provided an estimate for CVD risk in COPD, whereas four studies provided estimates of COPD risk in CVD. The crude prevalence for the aggregate CVD category ranged from 28% to 70%, likely due to differences in populations studied and CVD definitions; unadjusted rate ratio (RR) estimates of unspecified CVD among patients with COPD compared with patients without COPD ranged from 2.1 to 5.0. The association between COPD and CVD persisted after adjustment for shared risk factors in the majority of the studies. Two studies found a relationship between the severity of airflow limitation and CVD risk. Increased RRs were observed for individual CVD types, but their estimates varied considerably for congestive heart failure, coronary heart disease, arrhythmias, stroke, arterial hypertension, and peripheral arterial disease.

CONCLUSIONS

Available observational data support the hypothesis that COPD is associated with an increased risk of CVD.

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.

Chronic obstructive pulmonary disease and cardiovascular disease

Chronic obstructive pulmonary disease (COPD) is an inflammatory disease of the lung associated with progressive airflow limitation and punctuated by episodes of acute exacerbation. There is growing recognition that the inflammatory state associated with COPD is not confined to the lungs but also involves the systemic circulation and can impact nonpulmonary organs. Epidemiologic and mechanistic studies indicate that COPD is associated with a high frequency of coronary artery disease, congestive heart failure and cardiac arrhythmias, independent of shared risk factors. Possible pathways include complex interrelationships between chronic low-grade systemic inflammation and oxidative stress as well as shared risk factors such as age, cigarette smoking, and environmental pollutants. In this review, we provide an overview of the epidemiologic data linking COPD with cardiovascular disease, comment on the interrelationships among COPD, inflammation, and cardiovascular disease, and highlight diagnostic and therapeutic challenges.

Helping COPD patients change health behavior in order to improve their quality of life

Chronic obstructive pulmonary disease (COPD) is one of the most prevalent and debilitating diseases in adults worldwide and is associated with a deleterious effect on the quality of life of affected patients. Although it remains one of the leading causes of global mortality, the prognosis seems to have improved in recent years. Even so, the number of patients with COPD and multiple comorbidities has risen, hindering their management and highlighting the need for futures changes in the model of care. Together with standard medical treatment and therapy adherence--essential to optimizing disease control--several nonpharmacological therapies have proven useful in the management of these patients, improving their health-related quality of life (HRQoL) regardless of lung function parameters. Among these are improved diagnosis and treatment of comorbidities, prevention of COPD exacerbations, and greater attention to physical disability related to hospitalization. Pulmonary rehabilitation reduces symptoms, optimizes functional status, improves activity and daily function, and restores the highest level of independent physical function in these patients, thereby improving HRQoL even more than pharmacological treatment. Greater physical activity is significantly correlated with improvement of dyspnea, HRQoL, and mobility, along with a decrease in the loss of lung function. Nutritional support in malnourished COPD patients improves exercise capacity, while smoking cessation slows disease progression and increases HRQoL. Other treatments such as psychological and behavioral therapies have proven useful in the treatment of depression and anxiety, both of which are frequent in these patients. More recently, telehealthcare has been associated with improved quality of life and a reduction in exacerbations in some patients. A more multidisciplinary approach and individualization of interventions will be essential in the near future.

Inhaled corticosteroid use in patients with chronic obstructive pulmonary disease and the risk of pneumonia: a retrospective claims data analysis

BACKGROUND

The use of inhaled corticosteroids in patients with chronic obstructive pulmonary disease (COPD) has been associated with an increased risk of pneumonia in controlled clinical trials and case-control analyses.

OBJECTIVE

Using claims databases as a research model of real-world diagnosis and treatment, to determine if the use and dose of inhaled corticosteroids (ICS) among patients with newly diagnosed COPD are associated with increased risk of pneumonia.

PATIENTS AND METHODS

This was a retrospective cohort analysis of patients diagnosed with COPD between January 01, 2006 and September 30, 2010, drawn from databases (years 2006-2010). Patients (aged ≥45 years) were followed until first pneumonia diagnosis, end of benefit enrollment, or December 31, 2010, whichever was earliest. A Cox proportional hazard model was used to assess the association of ICS use and risk of pneumonia, controlling for baseline characteristics. Daily ICS use was classified into low, medium, and high doses (1 μg-499 μg, 500 μg-999 μg, and ≥1000 μg fluticasone equivalents daily) and was modeled as a time-dependent variable.

RESULTS

Among 135,445 qualifying patients with a total of 243,097 person-years, there were 1020 pneumonia incidences out of 5677 person-years on ICS (crude incidence rate, 0.180 per person-year), and 27,730 pneumonia incidences out of 237,420 person-years not on ICS (crude incidence rate, 0.117 per person-year). ICS use was associated with a dose-related increase in risk of pneumonia, with adjusted hazard ratios (versus no use; (95% confidence interval) of 1.38 (1.27-1.49) for low-dose users, 1.69 (1.52-1.88) for medium-dose users, and 2.57 (1.98-3.33) for high-dose users (P < 0.01 versus no use and between doses).

CONCLUSION

The use of ICS in newly diagnosed patients with COPD is potentially associated with a dose-related increase in the risk of pneumonia.

Increased prevalence of obstructive lung disease in patients with obstructive sleep apnea

STUDY PURPOSES

This study aims to determine whether there is an increased prevalence of obstructive lung diseases (OLDs) in patients with obstructive sleep apnea (OSA). We also determined whether among the OLD patients there is a difference in the prevalences of specific chronic disease co-morbidities between patients with and without OSA.

METHODS

The prevalences of COPD, asthma, and COPD combined with asthma (ICD-9 coding) were compared between 1,497 adult OSA patients and 1,489 control patients, who were matched for age, gender, geographic location, and primary care physician. The prevalences of specific co-morbidities were measured in the OLD groups between patients with OSA and the matched control group.

RESULTS

COPD, asthma, and COPD combined with asthma were found to be more prevalent among OSA patients compared to the matched controls. Prevalences among patients with and without OSA, respectively, were COPD-7.6 and 3.7 % (P<0.0001), asthma-10.4 and 5.1 % (P<0.0001), COPD plus asthma-3.3 and 0.9 % (P<0.0001). The Charlson Comorbidity Index was greater for OSA patients (2.3 ± 0.2) than for controls (1.9 ± 1.8; P<0.0001). These trends held for all severity ranges of OSA. Patients with OSA and COPD were characterized by more severe hypoxia at night compared with the OSA patients without OLD.

CONCLUSION

OSA was associated with an increased prevalence of OLDs.

The role of the β2 adrenergic receptor on endothelial progenitor cells dysfunction of proliferation and migration in chronic obstructive pulmonary disease patients

BACKGROUND

Cardiovascular disease (CVD) is the leading cause of morbidity and mortality in patients with moderate-to-severe chronic obstructive pulmonary disease (COPD), with > 44% of these patients presenting with generalized atherosclerosis at autopsy. It is accepted that endothelial progenitor cells (EPCs) participate in the repair of dysfunctional endothelium, thereby, protecting against atherosclerosis. The β2 adrenergic receptor (β2AR) expressed on mononuclear cells in peripheral blood and CD34(+) cells in bone has been shown to regulate T-cell traffic and proliferation. At present, there have been few systematic studies evaluating β2AR expression on EPCs in the peripheral blood of COPD patients and its role in EPCs migration and proliferation. Therefore, the objective of this study was to determine the role of β2ARs in EPCs function and, if this role is altered, in the COPD population.

METHODS

EPCs from 25 COPD and 16 control patients were isolated by Ficoll density-gradient centrifugation and identified using fluorescence-activated cell sorting. β2AR expression on EPCs was determined by western blotting and real-time PCR. The transwell migration assay was performed to determine the migration capacity of EPCs treated with a β2AR agonist, antagonist and β2AR monoclonal antibody. EPCs proliferation was assayed throughout the cell cycle. Following arterial damage in NOD/SCID mice, the number of EPCs treated with siRNA-β2AR incorporated at the injured vascular site was determined by fluorescence microscopy.

RESULTS

Data showed a significant increase in the total number of β2ARs in addition to an increased expression on early EPCs in COPD patients. COPD EPCs treated with β2AR antagonist (ICI 118551) increased migration to SDF-1α when compared to treatment with the β2AR agonist, norepinephrine. These changes were directly correlated to increase CXCR4 on EPCs. The proliferation of early EPCs treated with β2AR antagonist was improved and was correlated to an intercellular decrease in reactive oxygen species.

CONCLUSION

Changes in β2AR in COPD patients alter EPCs migration and proliferation, contributing to altered EPC repair capacity in this patient population.

Gender-related differences in hospitalized heart failure patients

AIMS

The burden of heart failure (HF)-related hospitalization and mortality of female patients with HF is substantial. Currently, several gender-specific distinctions have been recognized amongst HF patients, but their relationships to outcomes have not been fully elucidated. Accordingly, in the current work, we aimed to explore gender-specific clinical and echocardiographic measures and to assess their potential impact on outcome.

METHODS AND RESULTS

We studied all consecutive HF patients, aged 50 or older, who had been hospitalized between January 2000 and December 2009, and had undergone at least one echocardiography study. A comparative analysis of clinical and echocardiographic findings was performed between 5228 males and 4107 females. Patients were followed for a mean of 2.8 ± 2.6 years. Females compared with males had less ischaemic heart disease, prior stroke, chronic renal failure, and COPD, and higher rates of hypertension, AF, obesity, valvular abnormalities, and pulmonary hypertension. Unadjusted 30-day and 1-year mortality rates were higher among women, while age-adjusted rates were similar. Predictors of outcomes varied between genders. Female-specific predictors of mortality included aortic stenosis, pulmonary hypertension, and malignancy, whereas diastolic dysfunction and chronic renal failure were found to be male-specific predictors.

CONCLUSIONS

Age-adjusted mortality rates of male and female hospitalized HF patients are similarly high. Predictors of mortality, however, are gender distinctive, and these measures may allow a better identification of high-risk HF patients.

Exercise and COPD: therapeutic responses, disease-related outcomes, and activity-promotion strategies

Chronic obstructive pulmonary disease (COPD) reduces patients' exercise capacities and their abilities to perform daily physical activities, thereby increasing morbidity and mortality rates. The cycle of dyspnea, deconditioning, and declining physical activity not only accelerates the progression of COPD but also increases the risk for developing or aggravating metabolic and cardiovascular diseases. Cardiovascular and metabolic comorbidities also limit physical function, and their disabling effects in combination with COPD may be greater than the effects of each disease alone. The impact of COPD and its treatment on the ability to exercise, and the degree of physical activity in daily life, can be measured by field-based tests (eg, the 6-minute walk test or incremental and endurance shuttle-walk test), laboratory-based tests (eg, incremental or constant work-rate treadmill and cycle-ergometer tests), and physical activity assessments (eg, questionnaires and accelerometers). Walking tests increase oxygen consumption and desaturation in patients with COPD more than cycling tests with similar work-rate profiles and may more closely resemble patients' normal activities. Despite the questionable relevance of exercise testing to patients' daily functionality, exercise parameters remain important predictors of survival in patients with COPD. Treatment of COPD (pharmacotherapy, pulmonary rehabilitation, or both) can increase exercise capacity and physical activity in daily life, which potentially slows the decline of lung function, reduces the frequencies of exacerbations and hospitalizations, decreases mortality, slows the progression of comorbidities, improves health-related quality of life, and increases the activity reserve for routine function. This article examines the interactions of reduced physical activity and decreased exercise capacity with the progression of COPD, comorbidities, and mortality. The article also describes the available exercise tests for patients with COPD and reviews the evidence indicating that treating COPD improves exercise capacity. Notably, it appears that even mild COPD reduces exercise capacity and daily physical activity, indicating the need for early intervention.

Chronic obstructive pulmonary disease: an update of treatment related to frequently associated comorbidities

Chronic obstructive pulmonary disease (COPD) is associated with a pulmonary inflammatory response to inhaled substances, and individuals with COPD often have raised levels of several circulating inflammatory markers indicating the presence of systemic inflammation. Recently, there has been increasing interest in comorbidities associated with COPD such as skeletal muscle dysfunction, cardiovascular disease, osteoporosis, diabetes and lung cancer. These conditions are associated with a similar inflammation-based patho-physiology to COPD, and may represent a lung inflammatory 'overspill' to distant organs. Cardiovascular disease is a significant cause of mortality in COPD, and the concepts of an inflammatory link raise the possibility that treatment for one organ may show benefits to comorbidities in other organs. When considering treatment of COPD and its comorbidities, one approach is to target the pulmonary inflammation and hence reduce any 'overspill' effect of inflammatory mediators systemically as suggested by response to inhaled corticosteroids. Alternatively, treatment targeted towards comorbid organs may alter features of pulmonary disease as statins, angiotensin-converting enzyme (ACE) inhibitors and peroxisome proliferator-activated receptor (PPAR) agonists may have beneficial effects on COPD by reducing exacerbations and mortality. Newer anti-inflammatory treatments, such as phosphodiesterase 4 (PDE4), nuclear factor(NF)-kB, and p38 mitogen-activated protein kinase (MAPK) inhibitors, are given systemically and may confer benefits to both COPD and its comorbidities. With common inflammatory pathways it might be expected that successful anti-inflammatory therapy in one organ may also influence others. In this review we explore the concepts of systemic inflammation in COPD and current evidence for treatment of its related comorbidities.

Coronary artery disease is under-diagnosed and under-treated in advanced lung disease

BACKGROUND

Coronary artery disease is a potentially treatable comorbidity observed frequently in both chronic obstructive pulmonary disease and interstitial lung disease. The prevalence of angiographically proven coronary artery disease in advanced lung disease is not well described. We sought to characterize the treatment patterns of coronary artery disease complicating advanced lung disease and to describe the frequency of occult coronary artery disease in this population.

METHODS

We performed a 2-center, retrospective cross-sectional study of patients with either chronic obstructive pulmonary disease or interstitial lung disease evaluated for lung transplantation. Medications and diagnoses before the transplant evaluation were recorded in conjunction with left heart catheterization results.

RESULTS

Of 473 subjects, 351 had chronic obstructive pulmonary disease, and 122 had interstitial lung disease. In subjects diagnosed clinically with coronary artery disease, medical regimens included a statin in 78%, antiplatelet therapy in 62%, angiotensin-converting enzyme inhibitor or angiotensin receptor blocker in 42%, and a beta-blocker in 37%. Ten percent were on no medication from these 4 classes. Fifty-seven percent of these subjects were on an antiplatelet agent as well as a statin, and 13% were on neither. Beta-blockers were less frequently prescribed in chronic obstructive pulmonary disease than interstitial lung disease (23% vs 58%, P=.007). Coronary angiography was available in 322 subjects. It demonstrated coronary artery disease in 60% of subjects, and severe coronary artery disease in 16%. Occult coronary artery disease and severe occult coronary artery disease were found in 53% and 9%, respectively. There were no significant differences in angiographic results between chronic obstructive pulmonary disease and interstitial lung disease, despite imbalanced risk factors.

CONCLUSIONS

Coronary artery disease is common in patients with advanced lung disease attributable to chronic obstructive pulmonary disease or interstitial lung disease and is under-diagnosed. Guideline-recommended cardioprotective medications are suboptimally utilized in this population.

Chronic obstructive pulmonary disease as a cardiovascular risk factor. Results of a case-control study (CONSISTE study)

Introduction

Chronic obstructive pulmonary disease (COPD) patients present a high prevalence of cardiovascular disease. This excess of comorbidity could be related to a common pathogenic mechanism, but it could also be explained by the existence of common risk factors. The objective of this study was to determine whether COPD patients present greater cardiovascular comorbidity than control subjects and whether COPD can be considered a risk factor per se.

Methods

1200 COPD patients and 300 control subjects were recruited for this multicenter, cross-sectional, case–control study.

Results

Compared with the control group, the COPD group showed a significantly higher prevalence of ischemic heart disease (12.5% versus 4.7%; P < 0.0001), cerebrovascular disease (10% versus 2%; P < 0.0001), and peripheral vascular disease (16.4% versus 4.1%; P < 0.001). In the univariate risk analysis, COPD, hypertension, diabetes, obesity, and dyslipidemia were risk factors for ischemic heart disease. In the multivariate analysis adjusted for the remaining factors, COPD was still an independent risk factor (odds ratio: 2.23; 95% confidence interval: 1.18–4.24; P = 0.014).

Conclusion

COPD patients show a high prevalence of cardiovascular disease, higher than expected given their age and the coexistence of classic cardiovascular risk factors.

[Alveolar epithelial cell injury as an etiopathogenic factor in pulmonary fibrosis]

Idiopathic pulmonary fibrosis (IPF) is characterized by a progressive accumulation of extracellular matrix and an imbalance between profibrotic and antifibrotic mediators. In the last few years, understanding of the mechanisms of the biology of IPF has increased. One of the most significant discoveries is the finding that alveolar epithelial cell injury plays an important role in the pathogenesis of this disease. In this review, we describe some of the mechanisms involved in alveolar cell injury and their contribution to the development of IPF.

The association of metabolic syndrome with adipose tissue hormones and insulin resistance in patients with COPD without co-morbidities

Chronic obstructive pulmonary disease (COPD) and metabolic syndrome represent common causes of morbidity and mortality in ageing populations. The effect of the co-existence of COPD and metabolic syndrome on adipose tissue hormones and insulin resistance as well as the differences between COPD patients with and without metabolic syndrome have not been adequately studied. The prevalence of metabolic syndrome, based on Adult Treatment Panel III (ATP III) criteria, was evaluated in 114 male patients with COPD without significant co-morbidities. Pulmonary functions tests (PFTs), arterial blood gases, quality of life and BODE index were assessed. Blood samples were obtained for the assessment of adipose tissue hormones and insulin resistance. The overall prevalence of metabolic syndrome was 21%, being more prevalent in earlier stages of COPD. Patients with COPD and metabolic syndrome were younger with higher body-mass index (BMI), had better pulmonary function, less static hyperinflation and air-trapping, better diffusing capacity for carbon monoxide and BODE index. These patients had higher levels of leptin, lower levels of adiponectin and increased insulin resistance, as expressed by HOMA index, compared with patients without metabolic syndrome. Metabolic syndrome was more prevalent in younger patients with less severe COPD. These patients may constitute a specific COPD phenotype with greater leptin to adiponectin imbalance and insulin resistance, despite smaller impairment in PFTs. The prognosis and differences of these patients compared with other COPD phenotypes needs to be determined in prospective studies.

[Comorbidities in patients hospitalized due to chronic obstructive pulmonary disease. A comparative analysis of the ECCO and ESMI studies]

BACKGROUNDS AND OBJECTIVES

The presence of associated diseases is very frequent in patients hospitalized due to exacerbation of COPD. We have studied the comorbidities of patients admitted due to the disease in the Spanish Internal Medicine Services and we have evaluated the variations in regards to a previous study (ECCO study) performed two years earlier.

PATIENTS AND METHODS

A cross-sectional, multicenter and cohort study was performed. Patients hospitalized due to exacerbation of COPD in Spanish Internal Medicine Services were enrolled. All the patients were studied for the presence of comorbidity using the Charlson index and a questionnaire with relevant conditions not included in this index. Furthermore, spirometric data were collected on the duration of the disease or home treatment, among other variables.

RESULTS

A total of 1004 patients (398 in the ECCO study and 606 in the ESMI study) were studied. Of these, 89.4% were males, with mean age of 73 years (SD: 9.5 years). The patients of the ESMI study obtain higher scores on the Charlson index (3.04 vs. 2.71; P<0.01), and had a greater prevalence of ischemic heart disease (17 vs. 22.0%; P<0.05), heart failure (26.9 vs. 35.5%; P<.002), peripheral vascular disease (12.6 vs. 17.4%; P<.02), arterial hypertension (54.8 vs. 65.6%; P<.001), diabetes mellitus (29.4 vs. 37%; P<.02) and renal failure (6.5 vs. 16.8%; P<.0001).

CONCLUSIONS

This study confirms the elevated prevalence of associated diseases in patients with COPD who are admitted to the Spanish Internal Medicine Services and the increase of comorbidities.

Impact of chronic obstructive pulmonary disease severity on symptoms and prognosis in patients with systolic heart failure

BACKGROUND

Systolic heart failure (SHF) and chronic obstructive pulmonary disease (COPD) are frequently associated. The purpose of our study was to explore the impact of COPD severity on symptoms and prognosis in patients with SHF.

METHODS AND RESULTS

Chronic obstructive pulmonary disease was systematically screened by spirometry in 348 patients admitted for SHF from April 2002 to December 2006. Severity of COPD was defined according to the GOLD classification. Prevalence of COPD was 37.9 %. Patients' distribution according to GOLD stages I, II, II and IV were, respectively, 51.5, 37.9, 7.6 and 3.0 %. Severity of dyspnoea increases with GOLD stage. There was a significant correlation between NYHA stage and left ventricular ejection fraction in patients without COPD (R (2) = 0.03; P = 0.01) but not in patients with COPD. Mean follow-up was of 54.9 ± 27.4 months. Mortality was 46.6 % and was highest in the COPD group (53.8 vs. 42.3 %; P = 0.049). Kaplan-Meier survival curves showed that patients with GOLD stage I had the same prognosis than patients without COPD and mortality increased from GOLD stage II to stage IV. After multivariate analysis, GOLD stage and diuretics' dose were independently associated with mortality.

CONCLUSIONS

Chronic obstructive pulmonary disease is frequent in patients with SHF and increases mortality. Since dyspnoea is poorly specific of COPD in chronic heart failure patients, COPD remains underdiagnosed thus leading to inappropriate increase of diuretics' dose. COPD should be systematically screened in patients with SHF to adapt prescription of selective β1-blockers, and diuretics' dose and reduce the exposition to risk factors.