Relation of Chronic Obstructive Pulmonary Disease to Cardiovascular Disease in the General Population

Cost-effectiveness of rhythm control strategy: Ablation versus antiarrhythmic drugs for treating atrial fibrillation in Korea based on real-world data

Background

Ablation-based treatment has emerged as an alternative rhythm control strategy for symptomatic atrial fibrillation (AF). Recent studies have demonstrated the cost-effectiveness of ablation compared with medical therapy in various circumstances. We assessed the economic comparison between ablation and medical therapy based on a nationwide real-world population.

Methods and findings

For 192,345 patients with new-onset AF (age ≥ 18 years) identified between August 2015 and July 2018 from the Korean Health Insurance Review and Assessment Service (HIRA) database, medical resource use data were collected to compare AF patients that underwent ablation (N = 2,131) and those administered antiarrhythmic drugs (N = 8,048). Subsequently, a Markov chain Monte Carlo model was built. The patients had at least one risk factor for stroke, and the base-case used a 20-year time horizon, discounting at 4.5% annually. Transition probabilities and costs were estimated using the present data, and utilities were derived from literature review. The costs were converted to US $ (2019). Sensitivity analyses were performed using probabilistic and deterministic methods. The net costs and quality-adjusted life years (QALY) for antiarrhythmic drugs and ablation treatments were $37,421 and 8.8 QALYs and $39,820 and 9.3 QALYs, respectively. Compared with antiarrhythmic drugs, incremental cost-effectiveness ratio of ablation was $4,739/QALY, which is lower than the willingness-to-pay (WTP) threshold of $32,000/QALY.

Conclusion

In symptomatic AF patients with a stroke risk under the age of 75 years, ablation-based rhythm control is potentially a more economically attractive option compared with antiarrhythmic drug-based rhythm control in Korea.

Cardiovascular disease in chronic obstructive pulmonary disease: a narrative review

Patients with chronic obstructive pulmonary disease (COPD) are at increased risk of cardiovascular disease (CVD) and concomitant disease leads to reduced quality of life, increased hospitalisations and worse survival. Acute pulmonary exacerbations are an important contributor to COPD burden and are associated with increased cardiovascular (CV) events. Both COPD and CVD represent a significant global disease impact and understanding the relationship between the two could potentially reduce this burden. The association between CVD and COPD could be a consequence of (1) shared risk factors (environmental and/or genetic) (2) shared pathophysiological pathways (3) coassociation from a high prevalence of both diseases (4) adverse effects (including pulmonary exacerbations) of COPD contributing to CVD and (5) CVD medications potentially worsening COPD and vice versa. CV risk in COPD has traditionally been associated with increasing disease severity, but there are other relevant COPD subtype associations including radiological subtypes, those with frequent pulmonary exacerbations and novel disease clusters. While the prevalence of CVD is high in COPD populations, it may be underdiagnosed, and improved risk prediction, diagnosis and treatment optimisation could lead to improved outcomes. This state-of-the-art review will explore the incidence/prevalence, COPD subtype associations, shared pathophysiology and genetics, risk prediction, and treatment of CVD in COPD.

Comparison of risk profiles for new-onset atrial fibrillation between patients aged <60 and ≥60 years

BACKGROUND

Atrial fibrillation (AF) has a heterogeneous pathophysiology according to individual patient characteristics. This study aimed to identify the effects of widely known risk factors on AF incidence according to age and to elucidate the clinical implications of these effects.

METHODS AND RESULTS

We analyzed data from 501,668 subjects (≥18years old) without AF and valvular heart disease from the Korean National Health Insurance Service-National Sample Cohort. The total population was divided into two groups according to age, <60years and ≥60years. AF occurred in 0.7% of the overall population (3,416 of 501,668) during the follow-up period (mean 47.6 months). In Cox regression analysis, age, male sex, previous ischemic stroke, heart failure, and hypertension were related to increased risk of new-onset AF in both age groups. Especially in the <60years age group, risk of new-onset AF was increased by relatively modifiable risk factors: obesity (body mass index ≥25kg/m2; hazard ratio[HR] 1.37 [1.22-1.55], p<0.001, interaction p<0.001), and hypertension (HR 1.93[1.69-2.22], p<0.001, interaction p<0.001). Although interactions were not significant, chronic obstructive pulmonary disease (HR 1.41[1.24-1.60], p<0.001) and chronic kidney disease (HR 1.28[1.15-1.41], p<0.001) showed increased trends of the risk of new-onset AF in the ≥60years age group.

CONCLUSION

The risk profile for new-onset AF was somewhat different between the <60years and the ≥60years age groups. Compared to the ≥60years group, relatively modifiable risk factors (such as obesity and hypertension) had a greater impact on AF incidence in the <60years age group. Different management strategies to prevent AF development according to age may be needed.

Changes in Cardiovascular Risk Factors and Cardiovascular Events in the Elderly Population

Background

This study examines changes in the ideal cardiovascular health (CVH) status and whether these changes are associated with incident cardiovascular disease (CVD) and mortality in the elderly Asian population.

Methods and Results

In the Korea National Health Insurance Service–Senior cohort aged ≥60 years, 208 673 participants without prior CVD, including 109 431 who showed changes in CVH status, were assessed. The association of the changes in cardiovascular risk factors with incident CVD was assessed from 2004 to 2014 in the elderly (aged 60–74 years) and very elderly (≥75 years) groups. During the follow‐up period (7.1 years for CVD and 7.2 years for mortality), 19 429 incident CVD events and 24 225 deaths occurred. In both the elderly and very elderly participants, higher CVH status resulted in a lower risk of CVD and mortality. In the very elderly participants, compared with consistently low CVH, consistently high CVH (subhazard ratio, 0.41; 95% CI, 0.23–0.73) was associated with a lower risk of CVD. This trend was consistently observed in the elderly population. In the very elderly participants, total cholesterol level was not informative enough for the prediction of CVD events. In both the elderly and very elderly groups, body mass index and total cholesterol were not informative enough for the prediction of all‐cause mortality.

Conclusions

In both the elderly and very elderly Asian populations without CVD, a consistent relationship was observed between the improvement of a composite metric of CVH and the reduced risk of CVD. Body mass index and total cholesterol were not informative enough for the prediction of all‐cause mortality in both the elderly and very elderly groups.

What Is the Ideal Blood Pressure Threshold for the Prevention of Atrial Fibrillation in Elderly General Population?

Intensive blood pressure (BP) lowering in patients with hypertension at increased risk of cardiovascular disease has been associated with a lowered risk of incident atrial fibrillation (AF). It is uncertain whether maintaining the optimal BP levels can prevent AF in the general elderly population. We included 115,866 participants without AF in the Korea National Health Insurance Service-Senior (≥60 years) cohort from 2002 to 2013. We compared the influence of BP on the occurrence of new-onset AF between octogenarians (≥80 years) and non-octogenarians (<80 years) subjects. With up to 6.7 ± 1.7 years of follow-up, 4393 incident AF cases occurred. After multivariable adjustment for potentially confounding clinical covariates, the risk of AF in non-octogenarians was significantly higher in subjects with BP levels of <120/<80 and ≥140/90 mm Hg, with hazard ratios of 1.15 (95% confidence interval (CI), 1.03-1.28; p < 0.001) and 1.14 (95% CI, 1.04-1.26; p < 0.001), compared to the optimal BP levels (120-129/<80 mm Hg). In octogenarians, the optimal BP range was 130-139/80-89 mm Hg, higher than in non-octogenarians. A U-shaped relationship for the development of incident AF was evident in non-octogenarians, and BP levels of 120-129/<80 mm Hg were associated the lowest risk of incident AF. Compared to non-octogenarians, the lowest risk of AF was associated with higher BP levels of 130-139/80-89 mm Hg amongst octogenarians.

Effect of hypertension duration and blood pressure level on ischaemic stroke risk in atrial fibrillation: nationwide data covering the entire Korean population

AIMS

There are a paucity of data on the association of duration of hypertension and blood pressure (BP) level with risk of ischaemic stroke in patients with atrial fibrillation (AF). Our objective was to investigate the association between duration of hypertension and secondly, BP levels with risk of ischaemic stroke among patients with AF.

METHODS AND RESULTS

A total of 246 459 oral anticoagulant-naïve non-valvular AF patients were enrolled from Korea National Health Insurance Service (NHIS) database (2005-2015). The risk of ischaemic stroke according to the duration of hypertension and systolic BP (SBP) levels were assessed. One-year increase of hypertension duration continuously increased the adjusted risk of ischaemic stroke (95% confidence interval 1.07-1.09) until 7 years, and reached a plateau with adjusted hazard ratio of 1.6. Risk of ischaemic stroke increased linearly with the increase of hypertension duration in patients younger than 65 years of age, whereas the risk reached a plateau in patients aged 65 years or older. In all baseline and pre-AF average SBP subgroups, longer duration of hypertension before AF was associated with higher ischaemic stroke risk than shorter duration of hypertension (all P-values for trends <0.01). However, the effect of long-term hypertension was not observed in patients with strictly well-controlled pre-AF average SBP of less than 120 mmHg.

CONCLUSION

The increase of hypertension duration was associated with the increased risk of ischaemic stroke. However, this long-term effect of hypertension duration can be attenuated by long-term strict SBP control throughout the entire duration of hypertension.

The Summit Score Stratifies Mortality and Morbidity in Chronic Obstructive Pulmonary Disease

Introduction

Tobacco use and other cardiovascular risk factors often accompany chronic obstructive pulmonary disease (COPD). This study derived and validated the Summit Score to predict mortality in people with COPD and cardiovascular risks.

Methods

SUMMIT trial subjects (N=16,485) ages 40–80 years with COPD were randomly assigned 50%/50% to derivation (N=8181) and internal validation (N=8304). Three external COPD validations from Intermountain Healthcare included outpatients with cardiovascular risks (N=9251), outpatients without cardiovascular risks (N=8551), and inpatients (N=26,170). Cox regression evaluated 40 predictors of all-cause mortality. SUMMIT treatments including combined fluticasone furoate (FF) 100μg/vilanterol 25μg (VI) were not included in the score.

Results

Mortality predictors were FEV₁, heart rate, systolic blood pressure, body mass index, age, smoking pack-years, prior COPD hospitalizations, myocardial infarction, heart failure, diabetes, anti-thrombotics, anti-arrhythmics, and xanthines. Combined in the Summit Score (derivation: c=0.668), quartile 4 vs 1 had HR=4.43 in SUMMIT validation (p<0.001, 95% CI=3.27, 6.01, c=0.662) and HR=8.15 in Intermountain cardiovascular risk COPD outpatients (p<0.001, 95% CI=5.86, 11.34, c=0.736), and strongly predicted mortality in the other Intermountain COPD populations. Among all SUMMIT subjects with scores 14–19, FF 100μg/VI 25μg vs placebo had HR=0.76 (p=0.0158, 95% CI=0.61, 0.95), but FF 100μg/VI 25μg was not different from placebo for scores <14 or >19.

Conclusion

In this post hoc analysis of SUMMIT trial data, the Summit Score was derived and validated in multiple Intermountain COPD populations. The score was used to identify a subpopulation in which mortality risk was lower for FF 100μg/VI 25μg treatment.

Trial Registration

The SUMMIT trial is registered at ClinicalTrials.gov as number NCT01313676.

Age Threshold for Ischemic Stroke Risk in Atrial Fibrillation

Background and Purpose- Although older age is one of the most important risk factor for stroke in atrial fibrillation (AF), the appropriate age threshold (eg, CHA₂DS₂-VASc score [congestive heart failure, hypertension, age ≥75 years (doubled), diabetes mellitus, prior stroke or transient ischemic attack (doubled), vascular disease, age 65-74 years, female], 1 point for age 65-74 years, 2 points for age ≥75 years) for increased risk is controversial because actual age thresholds may differ between countries and ethnic groups. We investigated the age threshold for ischemic stroke risk among Asian AF patients. Methods- Using National Health Insurance Service database, including 426 650 oral anticoagulant-naive nonvalvular AF patients from 2005 to 2015, with ≤2 nongender-related CHA₂DS₂-VASc risk scores (CHA₂DS₂-VASc score 0-2 in males, 1-3 in females), we assessed the risk of ischemic stroke in AF patients according to the age. Results- Patients who fulfill the age risk criterion (age, 65-74 years) without other risk factors showed a significantly higher risk of stroke (4.76 per 100 person-years [100PY]; adjusted hazard ratio, 2.25; 95% confidence interval [CI], 2.17-2.36) compared with patients with 1 risk score other than age (1.87/100PY). Patients aged 55 to 59 years with no risk factors showed similar risk of stroke (1.94/100PY; adjusted hazard ratio, 0.95; 95% confidence interval, 0.90-1.00) than patients with 1 risk score (2.06/100PY). Patients aged 65 to 69 years and no other risk factors had similar stroke risk (4.08/100PY; adjusted hazard ratio, 0.93; 95% confidence interval, 0.90-0.97) than patients with 2 nongender-related risk scores (4.42/100PY). Conclusions- Older age is the most important predictor of ischemic stroke in AF, particularly for patients with low to intermediate risk of stroke. These nationwide data suggest lowering the current age threshold (age, ≥65 years) in the CHA₂DS₂-VASc score to age ≥55 years might be appropriate among Asian patients with AF.

Impact of chronic obstructive pulmonary disease on mortality: A large national cohort study

BACKGROUND AND OBJECTIVE

The global burden of chronic obstructive pulmonary disease (COPD) is increasing and COPD patients are at higher risk for all-cause mortality. We aimed to evaluate the impact of COPD on specific-cause mortality using national data.

METHODS

This was nationwide retrospective cohort study of 340, 767 adults aged 40-84 years who lacked COPD diagnosis at baseline between 1 January 2003 and 31 December 2013. Incident COPD was defined by reference to COPD claim codes and prescription of COPD medication at least twice annually. Cox proportional hazard ratio (HR) for each cause of death in the COPD group was compared to that of the non-COPD group, with other causes of death accounted as the competing risk.

RESULTS

All-cause mortality was higher in the COPD (2,978 per 100, 000 person-years) than the non-COPD group (629 per 100, 000 person-years) and adjusted HR was 1.41 (95% CI = 1.32, 1.50). The association was particularly strong for chronic lower airway disease (adjusted sub-HR = 9.67; 95% CI = 7.21, 12.96) and lung cancer (adjusted sub-HR = 3.16; 95% CI = 2.68, 3.71), and the association was stronger in those aged <60 years.

CONCLUSION

In this large national cohort, COPD patients were at a statistically significant higher risk for all-cause mortality than those without COPD. They were more likely to die from chronic lower airway disease, lung cancer and pneumonia than subjects without COPD. The impact of COPD on specific mortalities was stronger in younger subjects.

Effectiveness of pulmonary rehabilitation in elderly patients with COPD: A systematic review and meta-analysis of randomized controlled trials

AIM

The review aimed to evaluate the effects of pulmonary rehabilitation in elderly patients with chronic obstructive pulmonary disease (COPD).

BACKGROUND

With an increase in published reports on pulmonary rehabilitation, there is a need for a meta-analysis to measure the effects of pulmonary rehabilitation in elderly COPD patients.

DESIGN

A systematic review and meta-analysis.

DATA SOURCES

The Cochrane library (Issue 4, 2018), Web of Science (1975 to April 2018), Embase (1974 to April 2018), Pubmed (1966 to April 2018), CINAHL (1982 to April 2018), JBI (The Joanna Briggs Institute) (1996 to April 2018), CNKI (China National Knowledge Infrastructure) (1979 to April 2018), CBM (SinoMed) (1982 to April 2018), and Wanfang Data (1900 to April 2018) were searched.

REVIEW METHODS

Six outcome indicators were utilized for the effects of pulmonary rehabilitation. Two reviewers selected trials, evaluated the quality, and extracted data. Meta-analysis was performed by using the RevMan 5.3 software.

RESULTS

Eight studies recruited 414 elderly patients. Pulmonary rehabilitation resulted in significantly improved exercise capacity and quality of life in elderly people but with no influence on oxygen saturation compared with the control group.

CONCLUSION

There is a need to provide more detailed pulmonary rehabilitation programs for elderly patients with COPD.

Interaction between blood lead level and chronic obstructive pulmonary disease (COPD) on risk of heart attack or stroke: USA NHANES, 2013-2014

BACKGROUND

Among all risk factors of cardiovascular disease (CVD), lead is associated with cardiovascular mortality. Besides CVD, blood lead level is also related to the chronic obstructive pulmonary disease (COPD). The inter-relationship of CVD, blood lead level and COPD are not yet studied.

OBJECTIVE

The aim of this study is to examine the interaction of COPD and blood lead level on the occurrence of heart attack.

METHODS

This analyzed data is from the 2013-2014 NHANES. The final analysis included 5736 adults. Survey logistic regression models were built to control confounders. We computed adjusted odds ratios (ORs) and 95% confidence intervals (95% CIs).

RESULTS

A significant interaction (OR = 0.26, CI = 0.12, 0.56) between COPD and blood lead level on the occurrence of heart attack was observed. Those who had COPD were 4.05 times more likely to have heart attack than those who did not have COPD for 1 μg/dL increase in blood lead level. Similarly, a significant interaction between COPD and lead was found for the occurrence of stroke (OR = 0.44, CI = 0.19,1.00), leading to 1.15 times likely to have stroke than those who did not have COPD for 1 μg/dL increase in blood lead level. For the combined outcome, OR = 0.28 with CI=(0.14, 0.57).

CONCLUSIONS

The low lead level today means more effect of COPD on the occurrence of heart attack and stroke. More studies required to understand the pathways of the association of COPD, CVD and lead due to their shared risk factors.

Long-Term Impact of Newly Diagnosed Atrial Fibrillation During Critical Care: A South Korean Nationwide Cohort Study

BACKGROUND

The long-term risks of thromboembolism and mortality are unknown in patients who survived following atrial fibrillation (AF) newly diagnosed during critical care.

METHODS

Using the Korean National Health Insurance Service database, we identified 30,869 adults who survived for > 6 months following AF newly diagnosed during critical care (ICU-AF), 269,751 control subjects with non-ICU AF (AF-control), and 439,868 control subjects without AF (No-AF) from 2005 to 2013. We performed propensity score matching and compared the risks of stroke/systemic embolism and all-cause mortality.

RESULTS

The adjusted hazard ratios (HRs) for long-term stroke/systemic embolism in the patients with ICU-AF were 0.93 (95% CI, 0.88-0.98) compared with the AF-control group and 1.50 (95% CI, 1.42-1.60) compared with the No-AF group. The adjusted HRs of the ICU-AF group for long-term mortality were 1.73 (95% CI, 1.70-1.83) and 3.20 (95% CI, 3.08-3.33) compared with the AF-control and No-AF groups, respectively. The risks of stroke/systemic embolism and mortality were significantly higher in the ICU-AF group than in the No-AF group after excluding patients with AF recurrence (adjusted HR, 1.08; 95% CI, 1.01-1.17), regardless of the causes of critical care and cardiovascular or noncardiovascular surgery.

CONCLUSIONS

The patients who survived following AF newly diagnosed during critical care remained at a higher risk of long-term stroke/systemic embolism and mortality than the patients without AF regardless of AF recurrence and the causes of critical care. Close follow-up and continuous anticoagulation might be needed for these patients.

Effects of airway obstruction and hyperinflation on electrocardiographic axes in COPD

Background

COPD influences cardiac function and morphology. Changes of the electrical heart axes have been largely attributed to a supposed increased right heart load in the past, whereas a potential involvement of the left heart has not been sufficiently addressed. It is not known to which extent these alterations are due to changes in lung function parameters. We therefore quantified the relationship between airway obstruction, lung hyperinflation, several echo- and electrocardiographic parameters on the orientation of the electrocardiographic (ECG) P, QRS and T wave axis in COPD.

Methods

Data from the COPD cohort COSYCONET were analyzed, using forced expiratory volume in 1 s (FEV₁), functional residual capacity (FRC), left ventricular (LV) mass, and ECG data.

Results

One thousand, one hundred and ninety-five patients fulfilled the inclusion criteria (mean ± SD age: 63.9 ± 8.4 years; GOLD 0–4: 175/107/468/363/82). Left ventricular (LV) mass decreased from GOLD grades 1–4 (p = 0.002), whereas no differences in right ventricular wall thickness were observed. All three ECG axes were significantly associated with FEV₁ and FRC. The QRS axes according to GOLD grades 0–4 were (mean ± SD): 26.2° ± 37.5°, 27.0° ± 37.7°, 31.7° ± 42.5°, 46.6° ± 42.2°, 47.4° ± 49.4°. Effects of lung function resulted in a clockwise rotation of the axes by 25°-30° in COPD with severe airway disease. There were additional associations with BMI, diastolic blood pressure, RR interval, QT duration and LV mass.

Conclusion

Significant clockwise rotations of the electrical axes as a function of airway obstruction and lung hyperinflation were shown. The changes are likely to result from both a change of the anatomical orientation of the heart within the thoracic cavity and a reduced LV mass in COPD. The influences on the electrical axes reach an extent that could bias the ECG interpretation. The magnitude of lung function impairment should be taken into account to uncover other cardiac disease and to prevent misdiagnosis.

Electronic supplementary material

The online version of this article (10.1186/s12931-019-1025-y) contains supplementary material, which is available to authorized users.

Antithrombotic Medication and the Risk of Vitreous Hemorrhage in Atrial Fibrillation: Korean National Health Insurance Service National Cohort

PURPOSE

Antithrombotic therapy could be related with nuisance bleeding. This study investigated whether vitreous hemorrhage (VH) is associated with specific types of antithrombotic medication in patients with atrial fibrillation (AF).

MATERIALS AND METHODS

In the Korean National Health Insurance Service National Sample Cohort, we identified 9352 antiplatelet/anticoagulant-treated AF patients. The occurrence of VH was compared between warfarin (n=1493) and a propensity score (PS)-matched antiplatelet group (n=1493) and between warfarin (n=1493) and a PS-matched warfarin+antiplatelet group (n=1493).

RESULTS

The outcomes of VH were lower in the warfarin than in the matched antiplatelet (1.45 vs. 3.72 events/1000 patient-years) and matched warfarin+antiplatelet groups (1.45 vs. 6.87 events/1000 patient-years). Compared with warfarin, the risk of VH increased with antiplatelet [adjusted hazard ratio (aHR) 3.90; 95% confidence interval (CI) 1.22-12.4, p=0.022] and warfarin+antiplatelet agents (aHR 4.39, 95% CI 1.74-11.2, p=0.002). Compared with warfarin only, warfarin+antiplatelet agents increased the risk of VH in patients ≥65 years, regardless of gender and hypertension. The risk of VH was significantly higher with dual antiplatelet therapy (aHR: 5.02, 95% CI: 1.56-16.2, p=0.007) or in dual (aHR: 5.02, 95% CI: 1.74-14.5, p=0.003) or triple therapy using warfarin and antiplatelet agents than with warfarin monotherapy (aHR: 6.12, 95% CI: 1.76-21.3, p=0.004).

CONCLUSION

Dual antiplatelet or triple therapy increased the risk of VH significantly, compared to warfarin monotherapy. Considering the low efficacy of preventing ischemic stroke and high risk of bleeding, dual or triple therapy using warfarin and antiplatelet agents should be avoided to prevent VH in AF patients.

Impact of Renal Function on Outcomes With Edoxaban in Real-World Patients With Atrial Fibrillation

Background and Purpose—

Edoxaban is a direct oral factor Xa inhibitor with proven efficacy and safety among patients with atrial fibrillation. Concerns have been raised about an excess of stroke among patients with creatinine clearance (CrCl) >95 mg/mL treated with edoxaban. We assessed the real-world effectiveness and safety of edoxaban in atrial fibrillation patients in relation to CrCl.

Methods—

In the Korean National Health Insurance Service data during the period from January to December 2016, we identified 9537 edoxaban-treated patients. Effectiveness and safety outcomes were compared between high-dose edoxaban regimen (HDER, 60 mg daily, n=2840) and a propensity score–matched warfarin group (n=2840) and between low-dose edoxaban regimen (LDER, 30 mg daily, n=3016) and matched warfarin group (n=3016).

Results—

The median follow-up period was 5.0 months (interquartile range, 2–7 months). The mean age was 68 years, and 63% were men in HDER group, and the mean age was 73 years, and 52% were men in LDER group. Compared with warfarin, both HDER and LDER significantly decreased the risk for ischemic stroke or systemic embolism (S/SE; HDER: adjusted hazard ratio [aHR], 0.44; 95% CI, 0.31–0.64; LDER: aHR, 0.57; 95% CI, 0.42–0.78), major bleeding (HDER: aHR, 0.40; 95% CI, 0.26–0.61; LDER: aHR, 0.61; 95% CI, 0.43–0.85), and mortality (HDER: aHR, 0.34; 95% CI, 0.22–0.53; LDER: aHR, 0.55; 95% CI, 0.41–0.73). In patients with CrCl >95 mL/min, the incidence of S/SE was higher with LDER than warfarin and comparable between HDER and warfarin group. There was lower effectiveness for the prevention of S/SE with LDER compared with warfarin at higher CrCl levels ( P for interaction=0.023).

Conclusions—

In real-world practice, both doses of edoxaban were associated with reduced risks for S/SE, major bleeding, and mortality compared with warfarin. LDER had lower effectiveness for the prevention of S/SE compared with warfarin at higher levels of CrCl (>95 mL/min).

Analysis of curative effect of adjuvant therapy with bronchoalveolar lavage on COPD patients complicated with pneumonia

Clinical effect of adjuvant therapy with bronchoalveolar lavage on chronic obstructive pulmonary disease (COPD) patients complicated with pneumonia and its influence on the expression levels of inflammatory factors were studied. One hundred and twenty mild-moderate COPD patients complicated with pneumonia treated in the Department of Respiratory Medicine, The Sixth People's Hospital of Nantong from February 2016 to February 2017 were selected and randomly divided into three groups: One-time lavage group (n=40), two-time lavage group (n=40) and control group (n=40). Fasting peripheral blood was collected from all the patients in the morning. The lung function and blood gas analyses, and the detection of peripheral white blood cells (WBC), procalcitonin (PCT) and C-reactive protein (CRP) were performed. Moreover, the messenger RNA (mRNA) levels of interleukin-6 (IL-6), IL-8, tumor necrosis factor-α (TNF-α) and leukotriene B4 (LTB4) in lavage fluid were detected via reverse transcription-quantitative polymerase chain reaction. The lung functions of patients in the two-time lavage group were significantly improved compared with that in the one-time lavage group (p<0.01). pH and PaO₂ in two-time lavage group were higher than those in the one-time lavage group (p<0.01). Peripheral WBC, PCT and CRP levels in the two-time lavage group were lower than those in the one-time lavage group (p<0.05). The mRNA levels of IL-6, IL-8, TNF-α and LTB4 in lavage fluid in two-time lavage group were lower than those in one-time lavage group (p<0.01). IL-6, IL-8, TNF-α and LTB4 expression levels in lavage fluid in two-time lavage group were lower than those in one-time lavage group (p<0.01). In conclusion, the adjuvant therapy with bronchoalveolar lavage improves the therapeutic effect on COPD patients complicated with pneumonia, which can significantly reduce the expression levels of inflammatory factors, and facilitate the control of pulmonary infection and recovery of lung function.

Relative lymphocyte count as an indicator of 3-year mortality in elderly people with severe COPD

BACKGROUND

Prognostic stratification of elderly patients with chronic obstructive pulmonary disease (COPD) is difficult due to the wide inter-individual variability in the course of the disease. No marker can exactly stratify the evolution and natural history of COPD patients. Studies have shown that leukocyte count is associated with increased risk of mortality in COPD patients. The aim of this study was to evaluate the possible role of relative lymphocyte count as a risk marker for mortality in elderly patients with COPD.

METHODS AND RESULTS

This is a3-year prospective study. A total of 218patients, mean age 75.2±7 years, with moderate to severe COPD and free from conditions affecting lymphocyte count were enrolled. The population was divided into two groups according to the relative lymphocyte count, with a cut-off of 20%. Eighty-five patients (39%) had a relative lymphocyte count ≤20%. Three-year mortality rates from any cause in patients with relative lymphocyte count ≤ or > 20% were 68 and 51%, respectively (p = 0.0012). Survival curve analysis showed higher mortality in patients with relative lymphocyte count ≤20% (p = 0.0005). After adjustment for age and sex, the hazard ratio for mortality risk according to lymphocyte count was 1.79 (95% confidence interval [CI]: 1.26-2.57, p = 0.0013), even in the analysis limited to the 171 patients without congestive heart failure (1.63; 95% CI: 1.03-2.58, p = 0.038).

CONCLUSIONS

Low relative lymphocyte count was associated with higher mortality in elderly patients with severe COPD.

Variations of Prevalence and Incidence of Atrial Fibrillation and Oral Anticoagulation Rate According to Different Analysis Approaches

The reported incidence and prevalence of atrial fibrillation (AF) has been inconsistent across published studies. Using the National Health Insurance Service database of Korea, the prevalence and incidence of AF, and oral anticoagulation (OAC) use of AF patients were explored according to three different approaches; ‘formal approach’, considering individual AF diagnosis and mortality; ‘limited diagnosis approach’, using upper 5 main diagnosis; and ‘medical use approach’, using the number of medical use AF population by year without considering individual AF history and mortality. The AF prevalence progressively increased by 2.46-fold from 0.50% in 2004 to 1.54% in 2015 when using a ‘formal approach’ (p for trend <0.001). The overall prevalence was 1.09% and 0.97% when using a ‘formal approach’ and ‘limited diagnosis approaches’, respectively. Overall prevalence decreased to 0.52% with a ‘medical use approach’. The trend of annual AF incidence was stable when using a ‘formal approach’, but increased by 15% when using a ‘medical use approach’. OAC rate in 2015 was 2.1 times higher when using a ‘medical use approach’ compared to using a ‘formal approach’ (40.3% vs. 19.1%, p < 0.001). Given the wide variability in prevalence and incidence figures with different analysis approaches, careful attention to the analysis methodology is needed.