Chronic obstructive pulmonary disease as a risk factor for ventricular arrhythmias independent of left ventricular function

Comorbidity of patients with noncommunicable diseases in general practice. Eurasian guidelines

Создание руководства поддержано Советом по терапевтическим наукам отделения клинической медицины Российской академии наук.

Effects of COPD on Left Ventricular and Left Atrial Deformation in Patients with Acute Myocardial Infarction: Strain Analysis Using Speckle-Tracking Echocardiography

Myocardial strain analysis, which describes myocardial deformation (shortening or lengthening), provides more detailed information about left ventricular (LV) and atrial (LA) functions than conventional echocardiography and delivers prognostic information. To analyze the effects of COPD on left heart function upon acute myocardial infarction (AMI), consecutive AMI patients were retrospectively screened, and patients were included if a post-AMI echocardiography and results of recent pulmonary function tests (PFTs) were available. Strain analysis was performed by a cardiologist who was blinded to clinical information. Overall, 109 AMI patients were included (STEMI: 38%, non-STEMI: 62%). COPD patients (41%) had significantly more impaired LV “global-longitudinal-strain” (LV-GLS) compared to non-COPD patients (−15 ± 4% vs. −18 ± 4%; p < 0.001, respectively), even after adjusting for LV-ejection-fraction (LVEF) and age (mean estimated difference: 1.7%, p = 0.009). Furthermore, COPD patients had more impaired LA strain (LAS) than non-COPD patients in all cardiac cycle phases (estimated mean differences after adjusting for LVEF and age: during reservoir phase: −7.5% (p < 0.001); conduit phase: 5.5% (p < 0.001); contraction phase: 1.9% (p = 0.034)). There were no correlations between PFT variables and strain values. In conclusion, the presence of COPD was associated with more impaired LV and LA functions after AMI, as detected by strain analysis, which was independent of age, LVEF, and PFT variables.

Electrocardiographic Abnormalities in Patients With Acute Exacerbation of Chronic Obstructive Pulmonary Disease

Objective: The objective of this article was to determine the frequency of different electrocardiographic (ECG) abnormalities in patients with acute exacerbation of chronic obstructive pulmonary disease (COPD).

Design: This is a cross-sectional study.

Place and duration: The study was conducted at the medicine department at Civil Hospital Karachi, Pakistan, between November 2018 and May 2019.

Method: Both female and male participants aged 18-60 years with acute exacerbation of COPD (as per the operational definition) for more than three days who did not receive any treatment for exacerbation were included in the study. Twelve-lead ECG was recorded (Schiller AG, Baar, Switzerland) for 10 minutes after the supine rest, with a 50 mm/s of paper speed, 10 mm/mV of gain, and filter default settings.

Results: In total, 140 participants (male: n = 124 [88.6%] and female: n = 16 [11.4%]) were included the research. The mean age of the participants was 40.43 ± 11.51 years. In terms of severity, 46 (32.95) patients presented with mild, 46 (32.9%) with moderate, and 48 (34.4%) with severe exacerbation. Moreover, 33 (23.65%) participants had ECG abnormalities, i.e., 13 (9.3%) patients presented with right atrial enlargement, and eight (5.7%) with right ventricular hypertrophy. Patients with a longer smoking duration (years) were likely to present with ECG abnormalities.

Conclusion: Patients with COPD who had severe acute exacerbation and a long smoking duration have a high prevalence of ECG abnormalities. Hence, ECG may be a valuable tool for detecting ischemic abnormalities among patients with COPD, independent of previously known heart disease, in clinical settings.

Influenza Vaccination and the Risk of Ventricular Arrhythmias in Patients With Chronic Obstructive Pulmonary Disease: A Population-Based Longitudinal Study

Backgrounds: Influenza vaccination could decrease the risk of major cardiac events in patients with chronic obstructive pulmonary disease (COPD). However, the effects of the vaccine on decreasing the risk of ventricular arrhythmia (VA) development in such patients remain unclear. Methods: We retrospectively analyzed the data of 18,658 patients with COPD (≥55 years old) from the National Health Insurance Research Database from January 1, 2001, to December 31, 2012. After a 1:1 propensity score matching by the year of diagnosis, we divided the patients into vaccinated and unvaccinated groups. Time-varying Cox proportional hazards regression was applied to assess the time to event hazards of influenza vaccination exposure. Results: The risk of VA occurrence was significantly lower in the vaccinated group during influenza season and all seasons [adjusted hazard ratio (aHR): 0.62, 95% CI: 0.41-0.95; aHR: 0.69, 95% CI: 0.44-1.08; and aHR: 0.65, 95% CI: 0.48-0.89, in the influenza season, non-influenza season, and all seasons, respectively]. Among patients with CHA₂DS₂-VASc scores (conditions and characteristics included congestive heart failure, hypertension, diabetes, stroke, vascular disease, age, and sex) of 2-3, receiving one time and two to three times of influenza vaccination were associated with lower risk of VA occurrence in all seasons (aHR: 0.28, 95% CI: 0.10-0.80; aHR: 0.27, 95% CI: 0.10-0.68, respectively). Among patients without stroke, peripheral vascular disease, and diabetes, a lower risk of VA occurrence after receiving one and two to three times vaccination was observed in all seasons. Among patients with a history of asthma and patients without a history of heart failure, ischemic heart disease, angina hypertension, or renal failure, a significantly lower risk of VA occurrence was observed after the first time of vaccination in all seasons. Conclusions: Influenza vaccination may be associated with lower risks of VA among patients with COPD aged 55-74. Further investigation is still needed to resolve this clinical question.

Association of Chronic Obstructive Pulmonary Disease With Arrhythmia Risks: A Systematic Review and Meta-Analysis

Background: A large number of studies have shown that the arrhythmia risks may be the potential causes of death among chronic obstructive pulmonary disease (COPD) patients. However, the association of COPD with risks of arrhythmias has never been systematically reviewed. Therefore, we performed a meta-analysis to assess the relationship between COPD and arrhythmia risks.

Methods: An updated systematic retrieval was carried out within the databases of Embase and PubMed until June 27, 2021.The random-effects model was used to pool studies due to the potential heterogeneity across the included studies. The risk ratios (RRs) with 95% confidence intervals (CIs) were regarded as effect estimates.

Results: A total of 21 studies were included in our meta-analysis. In the pooled analysis by the random-effects model, the results showed that COPD was significantly related to the risk of atrial fibrillation (AF) (RR = 1.99, 95% CI: 1.46–2.70), ventricular arrhythmias (VA) (RR = 2.01, 95% CI: 1.42–2.85), and sudden cardiac death (SCD) (RR = 1.68, 95% CI: 1.28–2.21). The corresponding results were not changed after exclusion one study at a time. The pooled results were also stable when we re-performed the analysis using the fixed-effects model.

Conclusions: Our current data suggested that COPD was associated with increased risks of AF, VA, and SCD.

Low lung function, sudden cardiac death and non-fatal coronary events in the general population

BACKGROUND

Many of those who suffer from a first acute coronary event (CE) die suddenly during the day of the event, most of them die outside hospital. Poor lung function is a strong predictor of future cardiac events; however, it is unknown whether the pattern of lung function impairment differs for the prediction of sudden cardiac death (SCD) versus non-fatal CEs. We examined measures of lung function in relation to future SCD and non-fatal CE in a population-based study.

METHODS

Baseline spirometry was assessed in 28 584 middle-aged subjects, without previous history of CE, from the Malmö Preventive Project. The cohort was followed prospectively for incidence of SCD (death on the day of a first CE, inside or outside hospital) or non-fatal CE (survived the first day). A modified version of the Lunn McNeil's competing risk method for Cox regression was used to run models for both SCD and non-fatal CE simultaneously.

RESULTS

A 1-SD reduction in forced expiratory volume in 1 s (FEV₁) was more strongly associated with SCD than non-fatal CE even after full adjustment (FEV₁: HR for SCD: 1.23 (1.15 to 1.31), HR for non-fatal CE 1.08 (1.04 to 1.13), p value for equal associations=0.002). Similar associations were found for forced vital capacity (FVC) but not FEV₁/FVC. The results remained significant even in life-long never smokers (FEV₁: HR for SCD: 1.34 (1.15 to 1.55), HR for non-fatal CE: 1.11 (1.02 to 1.21), p value for equal associations=0.038). Similar associations were seen when % predicted values of lung function measures were used.

CONCLUSIONS

Low FEV₁ is associated with both SCD and non-fatal CE, but consistently more strongly associated with future SCD. Measurement with spirometry in early life could aid in the risk stratification of future SCD. The results support the use of spirometry for a global assessment of cardiovascular risk.

Association between chronic obstructive pulmonary disease and ventricular arrhythmia: a nationwide population-based cohort study

The ventricular arrhythmia (VA)-chronic obstructive pulmonary disease (COPD) association and related risk factors remain unclear. Using 2001-2012 data from National Health Insurance Research Database, we retrospectively reviewed 71,838 patients diagnosed as having COPD and 71,838 age- and sex-matched controls. After adjustments for comorbidities, medication, urbanization level, and monthly income, patients with COPD had higher incidence rates of VA than did the controls (adjusted hazard ratio [aHR] [95% confidence interval (CI)]: 1.45 [1.25-1.68]). More hospitalization or emergency visits because of acute COPD exacerbation (aHRs [95% CIs] for first, second, and third visits: 1.28 [1.08-1.50], 1.75 [1.32-2.32], and 1.88 [1.46-2.41], respectively) and asthma-COPD overlap (aHR [95% CI]: 1.49 [1.25-1.79]) were associated with high VA risk in patients with COPD. In the multivariate analysis, heart failure (aHR [95% CI]: 2.37 [1.79-3.14]), diabetes (aHR [95% CI]:1.64 [1.29-2.08]), age ≥75 (aHR [95% CI]: 2.48 [1.68-3.67]), male (aHR [95% CI]: 1.69[1.34-2.12]), and class III antiarrhythmic drug use (aHR [95% CI]: 2.49 [1.88-3.28]) are the most significant risk factors of new onset of VA in patients with COPD.

Burden and impact of arrhythmias in asthma-related hospitalizations: Insight from the national inpatient sample

BACKGROUND

This study aimed to analyze the burden and impact of cardiac arrhythmias in adult patients hospitalized with asthma exacerbation using the nationwide inpatient database.

METHODS

We used the National Inpatient Sample (NIS) database (2010-2014) to identify arrhythmias in asthma-related hospitalization and its impact on inpatient mortality, hospital length of stay (LOS), and hospitalization charges. We also used multivariable analysis to identify predictors of in-hospital arrhythmia and mortality.

RESULTS

We identified 12,988,129 patients hospitalized with primary diagnosis of asthma; among them, 2,014,459(16%) patients had cardiac arrhythmia. The most frequent arrhythmia identified is atrial fibrillation (AFib) (8.95%). The AFib and non-AFib arrhythmia group had higher mortality (3.40% & 2.22% vs 0.74%), mean length of stay (LOS) (5.9 & 5.4 vs 4.2 days), and hospital charges ($53,172 & $51,105 vs $34,585) as compared to the non-arrhythmia group (P < .005). Predictors of arrhythmia in asthma-related hospitalization were history of PCI or CABG, valvular heart disease, congestive heart failure (CHF), and acute respiratory failure. Predictors of higher mortality in arrhythmia group were acute respiratory failure, sepsis, and acute myocardial infarction.

CONCLUSIONS

Around 16% of adult patients hospitalized with asthma exacerbation experience arrythmia (mostly AFib 8.95%). The presence of arrhythmias was associated with higher in-hospital mortality, LOS, and hospital charges in hospitalized asthmatics.

Sudden cardiac death during nighttime hours

BACKGROUND

In the absence of apparent triggers, sudden cardiac death (SCD) during nighttime hours is a perplexing and devastating phenomenon. There are few published reports in the general population, with insufficient numbers to perform sex-specific analyses. Smaller studies of rare nocturnal SCD syndromes suggest a male predominance and implicate sleep-disordered breathing.

OBJECTIVE

The purpose of this study was to identify mechanisms of nighttime SCD in the general population.

METHODS

From the population-based Oregon Sudden Unexpected Death Study, we evaluated SCD cases that occurred in the community between 10 PM and 6 AM (nighttime) and compared them with daytime cases. Univariate comparisons were evaluated using Pearson χ² tests and independent samples t tests. Logistic regression was used to further assess independent SCD risk.

RESULTS

A total of 4126 SCD cases (66.2% male, 33.8% female) met criteria for analysis and 22.3% (n = 918) occurred during nighttime hours. Women were more likely to present with nighttime SCD than men (25.4% vs 20.6%; P < .001). In a multivariate regression model, female sex (odds ratio [OR] 1.3 [confidence interval (CI) 1.1-1.5]; P = .001), medications associated with somnolence/respiratory depression (OR 1.2 [CI 1.1-1.4]; P = .008) and chronic obstructive pulmonary disease/asthma (OR 1.4 [CI 1.1-1.6]; P < .001) were independently associated with nighttime SCD. Women were taking more central nervous system-affecting medications than men (1.9 ± 1.7 vs 1.4 ± 1.4; P = .001).

CONCLUSION

In the general population, women were more likely than men to suffer SCD during nighttime hours and female sex was an independent predictor of nighttime events. Respiratory suppression is a concern, and caution is advisable when prescribing central nervous system-affecting medications to patients at an increased risk of SCD, especially women.

ECG changes at rest and during exercise in lowlanders with COPD travelling to 3100 m

BACKGROUND

The incidence and magnitude of cardiac ischemia and arrhythmias in patients with chronic obstructive pulmonary disease (COPD) during exposure to hypobaric hypoxia is insufficiently studied. We investigated electrocardiogram (ECG) markers of ischemia at rest and during incremental exercise testing (IET) in COPD-patients travelling to 3100 m.

STUDY DESIGN AND METHODS

Lowlanders (residence <800 m) with COPD (forced volume in the first second of expiration (FEV₁) 40-80% predicted, oxygen saturation (SpO₂) ≥92%, arterial partial pressure of carbon dioxide (PaCO₂) <6 kPa at 760 m) aged 18 to 75 years, without history of cardiovascular disease underwent 12‑lead ECG recordings at rest and during cycle IET to exhaustion at 760 m and after acute exposure of 3 h to 3100 m. Mean ST-changes in ECGs averaged over 10s were analyzed for signs of ischemia (≥1 mm horizontal or downsloping ST-segment depression) at rest, peak exercise and 2-min recovery.

RESULTS

80 COPD-patients (51% women, mean ± SD, 56.2 ± 9.6 years, body mass index (BMI) 27.0 ± 4.5 kg/m², SpO₂ 94 ± 2%, FEV₁ 63 ± 10% prEd.) were included. At 3100 m, 2 of 53 (3.8%) patients revealed ≥1 mm horizontal ST-depression during IET vs 0 of 64 at 760 m (p = 0.203). Multivariable mixed regression revealed minor but significant ST-depressions associated with altitude, peak exercise or recovery and rate pressure product (RPP) in multiple leads.

CONCLUSION

In this study, ECG recordings at rest and during IET in COPD-patients do not suggest an increased incidence of signs of ischemia with ascent to 3100 m. Whether statistically significant ST changes below the standard threshold of clinical relevance detected in multiple leads reflect a risk of ischemia during prolonged exposure remains to be elucidated.

COPD and acute myocardial infarction

COPD is strongly associated with cardiovascular disease, in particular acute myocardial infarction (AMI). Besides shared risk factors, COPD-related factors, such as systemic inflammation and hypoxia, underlie the pathophysiological interaction between COPD and AMI. The prevalence of COPD amongst AMI populations ranges from 7% to 30%, which is possibly even an underestimation due to underdiagnoses of COPD in general. Following the acute event, patients with COPD have an increased risk of mortality, heart failure and arrhythmias during follow-up. Adequate risk stratification can be performed using various imaging techniques, evaluating cardiac size and function after AMI. Conventional imaging techniques such as echocardiography and cardiac magnetic resonance imaging have already indicated impaired cardiac function in patients with COPD without known cardiovascular disease. Advanced imaging techniques such as speckle-tracking echocardiography and T1 mapping could provide more insight into cardiac structure and function after AMI and have proven to be of prognostic value. Future research is required to better understand the impact of AMI on patients with COPD in order to provide effective secondary prevention. The present article summarises the current knowledge on the pathophysiologic factors involved in the interaction between COPD and AMI, the prevalence and outcomes of AMI in patients with COPD and the role of imaging in the acute phase and risk stratification after AMI in patients with COPD.

Outcomes, Costs, and 30-Day Readmissions After Catheter Ablation of Myocardial Infarct-Associated Ventricular Tachycardia in the Real World: Nationwide Readmissions Database 2010 to 2015

BACKGROUND

Patients undergoing catheter ablation of myocardial infarction-associated ventricular tachycardia (VT) have significant comorbidities that can increase the risks of adverse outcomes. The rates of readmissions after VT ablation are unknown. We sought to examine in-hospital outcomes, costs, and 30-day readmissions after catheter ablation of myocardial infarction-associated VT.

METHODS

Using the Nationwide Readmissions Database, we evaluated 4109 admissions for catheter ablation of myocardial infarction-associated VT occurring between 2010 and 2015. On the basis of International Classification of Diseases, Ninth Revision, Clinical Modification and Clinical Classification Software codes, we identified comorbidities, procedural complications, 30-day readmissions, and costs associated with VT ablation.

RESULTS

The index admission in-hospital mortality rate and procedural complication rate after VT ablation were 2.7% and 11.5%, respectively. Independent predictors of mortality included pulmonary hypertension, lung disease, obesity, and coagulopathy. Following discharge after VT ablation, the 30-day readmission rate was 19.2% with a median time to readmission of 10.0 days (IQR, 3.8-17.6 days) and an in-hospital mortality rate of 2.9%. Cardiac causes accounted for 74% of readmissions, with VT and congestive heart failure constituting 41% and 14% of all readmissions, respectively. Pulmonary hypertension, congestive heart failure, smoking, chronic pulmonary disease, and prolonged index hospitalization were significant independent predictors of 30-day readmission. After adjustment, 30-day readmissions were associated with a 38.9% increase in cumulative hospitalization costs.

CONCLUSIONS

Thirty-day readmissions after catheter ablation of VT occur in nearly 1 out of 5 cases, with the majority of readmissions being caused by recurrent VT or congestive heart failure. Baseline comorbidities are significant predictors of procedural mortality, complications, and readmissions. Strategies to reduce recurrent VT postablation by improving procedural success, optimizing postablation heart failure treatment, and ensuring close postdischarge follow-up may help reduce readmissions and healthcare costs.

[Arrhythmias in patients with pulmonary hypertension and chronic lung disease]

Pulmonary arterial hypertension (PAH) occurs in 1% of the global population and can be divided in different disease groups. Pathophysiological aspects leading to supraventricular arrhythmias in these patients are due to increased pulmonary and right atrial pressure, increased activity of the sympathetic nervous system leading to right atrial electrical remodeling and ischemia in the right atrium. In the clinical setting these patients present with atrial flutter, atrial fibrillation or with ectopic atrial tachycardia. Regarding ventricular tachycardia there is a lack of data. Occurrence of arrhythmia in these patients leads to a deterioration of PAH, so rhythm control should be the aim. This can be achieved by right atrial ablation, especially in patients presenting with atrial flutter; electric cardioversion or antiarrhythmic drug therapy are without definite guideline recommendations since there are too few clinical trials. Ablation with a transseptal approach in the left atrium is considered rather dangerous and should be avoided. Regarding arrhythmias in patients with chronic lung disease, few data are available. For patients with chronic obstructive pulmonary disease (COPD), there are good data available. These patients often suffer from coronary heart disease, atrial fibrillation, and ventricular tachycardia. Beta-blockers play an important role in COPD patients, even during exacerbation. Interventional therapies are safe but the arrhythmogenic foci often located outside of the pulmonary veins (in the right atrium).

[Predictors for development of major cardiovascular events in elderly patients with severe and extremely severe chronic obstructive pulmonary disease in combination with early stages of chronic kidney disease]

AIM

To study the structure of major cardiovascular events (MCVE) and to identify their independent predictors in elderly patients with severe and extremely severe chronic obstructive pulmonary disease (COPD) in combination with early stages of chronic kidney disease (CKD).

MATERIALS AND METHODS

The study included 172 elderly patients with stage 3-4 COPD associated with stage 1-2 CKD. Initially, risk factors for MCVE were identified and levels of vitamin D (25 (ОН) D) were measured for all patients. In 12 months, MCVE anamnesis was collected, and patients were divided into two groups with and without MCVE during the observation period. The risk factors for MCVE, which were significantly different between the two groups according to results of a one-way analysis, were successively included into a logistic regression for identifying independent predictors of MCVE. A ROC analysis was performed for the identified variables to identify a predictive cut-off point.

RESULTS

21 MCVEs were observed in 8.7% (15) patients. Heart rhythm disorders (HRD) not reversed at the prehospital stage were observed in 38.1% patients; acute cerebrovascular disease and transient ischemic attack - in 23.8%, acute coronary syndrome - in 23.8%, and pulmonary thromboembolism (PTE) - in 14.3%. Two MCVEs, namely, a combination of HRD not reversed at the prehospital stage and PTE, were observed in 3 (20%) patients. The ROC analysis showed that the incidence of COPD exacerbation for the previous 12 months &gt;3 had the highest predictive value for the 12-month risk of MCVE in patients with COPD associated with early CKD (95% CI, 0.823-0.925, р=0.001). A total PROCAM score &lt;50 (95% CI, 0.882-0.964, р=0.001); GFR ≥80 ml/min/1.73 m2 (95% CI, 0.750-0.870, р=0.001); and a level of vitamin D ≥33 ng/ml (95% CI, 0.730-0.855, р=0.001) reduced the risk for MCVE.

CONCLUSIONS

In elderly patients with grade 3-4 COPD associated with stage 1-2 CKD, the development of MCVE within 12 months was determined by the incidence of COPD exacerbations for the previous 12 months &gt;3 while a total PROCAM score &lt;50, GFR &gt;80 ml/min/1.73 m3 , and levels of vitamin D &gt;33 ng/ml reduced the risk of MCVE in these patients.