The revised GOLD 2017 COPD categorization in relation to comorbidities

Bibliometric and visual assessment of research trends in the management of hyperuricemia (HUA)

OBJECTIVE

To analyze the development status and trend of related research in the health management of hyperuricemia and provide a theoretical basis for clinical treatment.

METHODS

A bibliometric analysis was conducted on hyperuricemia health management research data from 2000 to 2024 using the Web Science Core Collection database, PubMed, and SINOMED. A total of 789 articles were evaluated for specific characteristics, such as year of publication, journal, author, institution, country/region, reference, and keyword. The VOSviewer was used for co-author, co-occurrence, co-citation, and network visualization. Important sub-topics identified by bibliometric characteristics were discussed and reviewed.

RESULTS

The number of articles published in the last 24 years has generally followed a year-on-year trend, and the total number of papers published is increasing. Over 200 affiliations from 70 countries and regions contributed papers, and PLOS ONE has the highest number of linked publications. Dalbeth N, is the author with the most publications, with an H-index of 17. Hyperuricemia, gout, management, prevalence, allopurinol, risk, and other keywords were often used. Researchers formed mature teams, and the teams' study directions intersect and are comparable. However, these teams demonstrated a lack of communication and coordination.

CONCLUSIONS

This study highlights research hotspots, global cooperation models, and emerging frontiers in hyperuricemia, focusing on uric acid control, disease screening, health education, and epidemiological investigation in hyperuricemia-associated complications over the past two decades. However, there is still a lack of standardized management processes and systems, and the communication between research teams needs to be enhanced. Key Points • The study analyzed hyperuricemia health management research data from 2000 to 2024 using the Web Science Core Collection database, PubMed, and SINOMED, evaluating 789 articles and discussing key sub-topics using VOSviewer. • Over 200 articles from 70 countries, including PLOS ONE, have been published over the past 24 years, focusing on hyperuricemia, gout, management, prevalence, allopurinol risk, etc. • Our study outlines research hotspots, global cooperation models, and emerging hyperuricemia frontiers, emphasizing the need for standardized management processes and improved communication between research teams.

Expiratory Venous Volume and Arterial Tortuosity are Associated with Disease Severity and Mortality Risk in Patients with COPD: Results from COSYCONET

Purpose

The aim of this study was to evaluate the association between computed tomography (CT) quantitative pulmonary vessel morphology and lung function, disease severity, and mortality risk in patients with chronic obstructive pulmonary disease (COPD).

Patients and Methods

Participants of the prospective nationwide COSYCONET cohort study with paired inspiratory-expiratory CT were included. Fully automatic software, developed in-house, segmented arterial and venous pulmonary vessels and quantified volume and tortuosity on inspiratory and expiratory scans. The association between vessel volume normalised to lung volume and tortuosity versus lung function (forced expiratory volume in 1 sec [FEV1]), air trapping (residual volume to total lung capacity ratio [RV/TLC]), transfer factor for carbon monoxide (TLCO), disease severity in terms of Global Initiative for Chronic Obstructive Lung Disease (GOLD) group D, and mortality were analysed by linear, logistic or Cox proportional hazard regression.

Results

Complete data were available from 138 patients (39% female, mean age 65 years). FEV1, RV/TLC and TLCO, all as % predicted, were significantly (p < 0.05 each) associated with expiratory vessel characteristics, predominantly venous volume and arterial tortuosity. Associations with inspiratory vessel characteristics were absent or negligible. The patterns were similar for relationships between GOLD D and mortality with vessel characteristics. Expiratory venous volume was an independent predictor of mortality, in addition to FEV1.

Conclusion

By using automated software in patients with COPD, clinically relevant information on pulmonary vasculature can be extracted from expiratory CT scans (although not inspiratory scans); in particular, expiratory pulmonary venous volume predicted mortality.

Trial Registration

NCT01245933.

Statins did not reduce the frequency of exacerbations in individuals with COPD and cardiovascular comorbidities in the COSYCONET cohort

BACKGROUND

The evidence regarding effects of statins on exacerbation risk in COPD remains controversial. Previous studies often excluded patients with cardiovascular comorbidities despite their high prevalence in COPD and role for exacerbations. Based on the cardioprotective properties of statins, we hypothesised that statins may reduce the risk of exacerbations especially in patients with cardiovascular comorbidities.

METHODS

One thousand eight hundred eighty seven patients of the German COPD cohort COSYCONET (COPD and Systemic Consequences Comorbidities Network) of GOLD grades 1-4 (37.8% female, mean age 64.78 ± 8.3) were examined at baseline and over a period of 4.5 years for the occurrence of at least one exacerbation or severe exacerbation per year in cross-sectional and longitudinal analyses adjusted for age, gender, BMI, GOLD grade and pack-years. Due to their collinearity, various cardiovascular diseases were tested in separate analyses, whereby the potential effect of statins in the presence of a specific comorbidity was tested as interaction between statins and comorbidity. We also identified patients who never took statins, always took statins, or initiated statin intake during the follow-up.

RESULTS

One thousand three hundred six patients never took statins, 31.6% were statin user, and 12.9% initiated statins during the follow-up. Most cardiovascular diseases were significantly (p < 0.05)may associated with an increased risk of COPD exacerbations, but in none of them the intake of statins was a significant attenuating factor, neither overall nor in modulating the increased risk linked to the specific comorbidities. The results of the cross-sectional and longitudinal analyses were consistent with each other, also those regarding at least 1 exacerbation or at least 1 severe exacerbation per year.

CONCLUSION

These findings complement the existing literature and may suggest that even in patients with COPD, cardiovascular comorbidities and a statin therapy that targets these comorbidities, the effects of statins on exacerbation risk are either negligible or more subtle than a reduction in exacerbation frequency.

TRIAL REGISTRATION

Trial registration ClinicalTrials.gov, Identifier: NCT01245933. Other Study ID (BMBF grant): 01GI0881, registered 18 November 2010, study start 2010-11, primary completion 2013-12, study completion 2023-09. https://clinicaltrials.gov/study/NCT01245933?cond=COPD&term=COSYCONET&rank=3.

Differences in nutritional status of patients with chronic obstructive pulmonary disease between Mediterranean and non-Mediterranean regions in Croatia

The nutritional status of patients with chronic obstructive pulmonary disease (COPD) is a significant factor that influences the prognosis of the disease. This observational study aimed to analyze the nutritional status of COPD patients and assess the associations between nutritional status, disease severity, and exercise capacity in four different regions of Croatia. In this multicenter study, 534 COPD patients were recruited and evaluated concerning fat-free mass (FFM), FFM index (FFMI), skeletal muscle mass index (SMMI), phase angle (PhA), pulmonary function tests, and the 6-minute walk test (6MWT). There were 325 (60.9%) male and 209 (39.1%) female patients with a mean age of 66.7±8.4 years. Most patients (73.2%) exhibited a moderate to severely abnormal obstructive pattern and had a reduced 6MWT distance (396.5±110.8 m). Among the participants, 32.8% were overweight and 22.3% were obese, and they had satisfactory values for nutritional status variables (FFM, FFMI, SMMI, PhA). There were no statistical differences between the centers in terms of nutritional status variables. There was a significantly positive correlation of forced expiratory volume in one second with body mass index (BMI) (r=0.148, p=0.001), PhA (r=0.256, p=0.00), FFM (r=0.365, p=0.00), and SMMI (r=0.238, p=0.00). However, there was no significant correlation of the 6MWT with BMI (r=-0.049, p=0.254), FFM (r=0.065, p=0.133), and SMMI (r=-0.007, p=0.867). The data analysis demonstrated that our patients were not underweight and that there was no significant difference between the centers in terms of BMI, FFM, FFMI, SMMI, and PhA. This lack of significant difference was observed even though one of the regions studied was Mediterranean.

Classification of chronic obstructive pulmonary disease as ABCD according to the GOLD 2011 and 2017 versions in patients at the University Medical Center in Ho Chi Minh City, Vietnam

In 2017, the Global Initiative for Chronic Obstructive Lung Disease (GOLD) substantially changed its ABCD group categorization. Although several studies had been conducted to assess the impact of the new GOLD category, there was no research on the change in the GOLD classification in Vietnam. This retrospective analysis was conducted at the Asthma and Chronic Obstructive Pulmonary Disease (COPD) Clinic at the University Medical Center in Ho Chi Minh City, Vietnam. Our study population comprised patients visiting the medical center from January 2018 to January 2020. We categorized patients' demographics, clinical characteristics, and pharmacotherapy based on GOLD 2011 and 2017 guidelines. A comparison between the two versions was also determined. A total of 457 patients were included in this study. The percentage of groups A, B, C, and D according to GOLD 2011 was 5%, 20.8%, 13.1%, and 61.1%, respectively, and according to GOLD 2017, it was 6.1%, 34.1%, 12%, and 47.8%, respectively. In terms of gender, male patients constituted nearly 95% of the study's population (433/457 patients). Regarding pharmacotherapy, approximately 20% of the low-risk group (groups A and B) was overtreated with inhaled corticosteroid (ICS) components: long-acting β-agonists (LABA) + ICS (15.8%) and long-acting muscarinic antagonist + LABA + ICS (3.8%). There were 13.3% and 1.1% of patients transferred from D to B and from C to A, respectively. All of them had a lower predicted percentage of forced vital capacity (FVC), forced expiratory volume in the first second (FEV1), and FEV1/FVC than the patients who remained in groups B or A (p<0.005). This is the first research in Vietnam to show the distribution of COPD patients using both the GOLD 2011 and GOLD 2017 criteria. 14% of patients were reclassified from high-risk to low-risk groups when changing from the 2011 version to the 2017 one, and there was discordance of medications between guidelines and real-life practice. Therefore, clinicians should use their clinical competence to consider patients' conditions before deciding on the appropriate therapeutic approach. Consequently, further studies were required to evaluate the effect of the change in the GOLD classification.

The serum creatinine to cystatin C ratio predicts the risk of acute exacerbation of chronic obstructive pulmonary disease

The purpose of acute exacerbation of chronic obstructive pulmonary disease (AECOPD) treatment is to minimize the negative impact of the current exacerbation and to prevent the development of subsequent events. Therefore, it is important to identify readily available serological indicators during hospital admission to assess the prognosis of patients with AECOPD. All patients hospitalized in a Department of Respiratory and Critical Care Medicine of tertiary care hospital between January 2021 and December 2021 for AECOPD were analyzed using univariate correlations and binary logistic regression analysis with 2 models for associations between demographic, clinical, and laboratory features and AECOPD risk. The ratio of creatinine to cystatin C (Cre/Cys C) ratio was significantly associated with age (r = -0.206, P = .000), weight (R = 0.331, P = .000), body mass index (BMI) (R = 0.133, P = .007), and forced vital capacity (FVC)% predicted (R = 0.130, P = .009). Multiple regression was performed to predict the Cre/Cys C ratio from age, weight, BMI, forced expiratory volume during 1 second/FVC ratio, and FVC% predicted FABP-4, with F (5, 405) = 24.571, P = .000, R2 = 0.233. The results showed that the most significant predictors of the Cre/Cys C ratio were age (P = .007), weight (P = .000), BMI (P = .000), and predicted forced expiratory volume during 1 second (P = .000). Multivariate analysis was performed to determine whether the Cre/Cys C ratio was a predictor of AECOPD risk. Model 1 showed that a low Cre/Cys C ratio was associated with an increased hospital length of stay (odds ratio: -0.114, 95% confidence interval: -0.061 to -0.005) and admission to the intensive care unit (odds ratio: 0.951, 95% confidence interval: 0.907-0.996). After adjustment for potential confounding factors, model 2 showed that a low Cre/Cys C ratio was not independently associated with AECOPD risk. The present study indicated that the Cre/Cys C ratio is an easy, cheap, repeatable, and promising tool that allows us to evaluate the risk of AECOPD using serum markers. A low Cre/Cys C ratio was associated with a prolonged hospital length of stay and admission to the intensive care unit in AECOPD patients. However, the associations were not independent.

Clinical-functional characteristics and risk of exacerbation and mortality among more symptomatic patients with chronic obstructive pulmonary disease: a retrospective cohort study

OBJECTIVES

The Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2017 classified chronic obstructive pulmonary disease (COPD) patients into more and less symptomatic groups. This study aimed to analyze the clinical characteristics, risk of future exacerbation and mortality among patients in more symptomatic group.

DESIGN

A retrospective cohort study.

SETTING

Data were obtained from patients enrolled in a database setup by Second Xiangya Hospital of Central South University.

PARTICIPANTS

1729 stable COPD patients listed from September 2017 to December 2019 in the database. The patients were classified into more and less symptomatic groups based on GOLD 2017 report.

OUTCOMES

All patients were followed up for 18 months. We collected baseline data and recorded the number of exacerbations and mortality during follow-up.

RESULTS

The more symptomatic patients were older, had higher Clinical COPD Questionnaire (CCQ) scores, more severe airflow limitation and higher number of exacerbations and hospitalizations in the past year (P < 0.05). Logistic regression showed that having more symptoms correlated with the CCQ scores and exacerbations in the past year (P < 0.05). After patients were followed up, there were higher numbers of exacerbations, hospitalizations and mortality rates in more symptomatic patients (P < 0.05). The multivariate model showed that age more than 65 years (OR = 2.047, 95% CI = 1.020-4.107) and COPD assessment test scores more than 30 (OR = 2.609, 95% CI = 1.339-5.085) were independent risk factors for mortality, whereas current smoker (OR = 1.565, 95% CI = 1.052-2.328), modified Medical Research Council scores (OR = 1.274, 95% CI = 1.073-1.512) and exacerbations in the past year (OR = 1.061, 95% CI = 1.013-1.112) were independent risk factors for exacerbation in more symptomatic patients (P < 0.05).

CONCLUSIONS

More symptomatic COPD patients have worse outcomes. In addition, several independent risk factors for exacerbation and mortality were identified. Therefore, clinicians should be aware of these risk factors and take them into account during interventions.

[What have we learned from the German COPD cohort COSYCONET and where do we go from here?]

COSYCONET 1 is the only German COPD cohort which is large enough to be internationally comparable. The recruitment, which started in 2010 and ended in December 2013, comprised 2741 patients with the diagnosis of COPD who were subsequently investigated in regular follow-up visits. All visits included a comprehensive functional and clinical characterisation. On the basis of this detailed data set, it was possible to address a large number of clinical questions. These questions ranged from the prescription of medication, the detailed analysis of comorbidities, in particular cardiovascular disease, and biomarker assessment to radiological and health-economic aspects. Currently, more than 60 publications of COSYCONET data are internationally available. The present overview provides a description of all the results that were obtained, focussing on the relationship between different clinical and functional aspects as well as their potential practical consequences. In addition, information on the follow-up study COSYCONET 2 is given.

Association Between Blood Urea Nitrogen Levels and Length of Stay in Patients with Pneumonic Chronic Obstructive Pulmonary Disease Exacerbation: A Secondary Analysis Based on a Multicentre, Retrospective Cohort Study

Purpose

High blood urea nitrogen (BUN) is associated with an elevated risk of mortality in various diseases, such as heart failure and pneumonia. Heart failure and pneumonia are common comorbidities of chronic obstructive pulmonary disease (COPD) exacerbation. However, data on the relationship of BUN levels with length of stay (LOS) in patients with pneumonic COPD exacerbation are sparse. The purpose of this study was to evaluate the correlation between BUN levels and LOS in a cohort of patients with pneumonic COPD exacerbation.

Patients and Methods

The present study was a multicentre, retrospective cohort study. A total of 1226 patients with pneumonic COPD exacerbation were included through a validated algorithm derived from the 10th revision of the International Classification of Diseases and Related Health Problems (ICD-10). It should be noted that the entire study was completed by Shiroshita et al, who uploaded the data to the DATADRYAD website. The author only used these data for secondary analysis.

Results

After adjusting for potential confounders (age, gender), a nonlinear relationship was detected between BUN levels less than 40 mg/dl and LOS. The effect sizes and the confidence intervals on the left and right sides of the inflection point were 0.27 (0.16, 0.39) and −0.17 (−0.34, 0.01), respectively.

Conclusion

High levels of BUN in the hospital may be associated with increased LOS. BUN was positively related to LOS when BUN was less than 40 mg/dl.

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.

IgE is associated with exacerbations and lung function decline in COPD

Background

Both allergen-specific IgE and total IgE in serum play a major role in asthma. However, the role of IgE in chronic obstructive pulmonary disease (COPD) is poorly understood. It was the aim of this study to systematically analyze the relationship between serum IgE levels and disease characteristics in large COPD cohorts.

Methods

COSYCONET is a comprehensively characterized cohort of patients with COPD: total IgE and IgE specific to common aeroallergens were measured in serum of 2280 patients, and related to clinical characteristics of the patients. WISDOM is another large COPD population (2477 patients): this database contains the information whether total IgE in serum was elevated (≥ 100 IU/l) or normal in patients with COPD.

Results

Both in COSYCONET and WISDOM, total IgE was elevated (≥ 100 IU/l) in > 30% of the patients, higher in men than in women, and higher in currently than in not currently smoking men. In COSYCONET, total IgE was elevated in patients with a history of asthma and/or allergies. Men with at least one exacerbation in the last 12 months (50.6% of all men in COSYCONET) had higher median total IgE (71.3 IU/l) than men without exacerbations (48.3 IU/l): this difference was also observed in the subgroups of not currently smoking men and of men without a history of asthma. Surprisingly, a history of exacerbations did not impact on total IgE in women with COPD. Patients in the highest tertiles of total IgE (> 91.5 IU/ml, adjusted OR: 1.62, 95% CI 1.12–2.34) or allergen-specific IgE (> 0.19 IU/ml, adjusted OR: 2.15, 95% CI 1.32–3.51) were at risk of lung function decline (adjusted by: age, gender, body mass index, initial lung function, smoking status, history of asthma, history of allergy).

Conclusion

These data suggest that IgE may play a role in specific COPD subgroups. Clinical trials using antibodies targeting the IgE pathway (such as omalizumab), especially in men with recurrent exacerbations and elevated serum IgE, could elucidate potential therapeutic implications of our observations.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12931-021-01847-0.

The association of blood urea nitrogen levels upon emergency admission with mortality in acute exacerbation of chronic obstructive pulmonary disease

Background and purpose

High blood urea nitrogen (BUN) is associated with an elevated risk of mortality in various diseases, such as heart failure and pneumonia. Heart failure and pneumonia are common comorbidities of acute exacerbation of chronic obstructive pulmonary disease (AECOPD). However, data on the relationship of BUN levels with mortality in patients with AECOPD are sparse. The purpose of this study was to evaluate the correlation between BUN level and in-hospital mortality in a cohort of patients with AECOPD who presented at the emergency department (ED).

Methods

A total of 842 patients with AECOPD were enrolled in the retrospective observational study from January 2018 to September 2020. The outcome was all-cause in-hospital mortality. Receiver operating characteristic (ROC) curve analysis and logistic regression models were performed to evaluate the association of BUN levels with in-hospital mortality in patients with AECOPD. Propensity score matching was used to assemble a cohort of patients with similar baseline characteristics, and logistic regression models were also performed in the propensity score matching cohort.

Results

During hospitalization, 26 patients (3.09%) died from all causes, 142 patients (16.86%) needed invasive ventilation, and 190 patients (22.57%) were admitted to the ICU. The mean level of blood urea nitrogen was 7.5 ± 4.5 mmol/L. Patients in the hospital non-survivor group had higher BUN levels (13.48 ± 9.62 mmol/L vs. 7.35 ± 4.14 mmol/L, p < 0.001) than those in the survivor group. The area under the curve (AUC) was 0.76 (95% CI 0.73–0.79, p < 0.001), and the optimal BUN level cutoff was 7.63 mmol/L for hospital mortality. As a continuous variable, BUN level was associated with hospital mortality after adjusting respiratory rate, level of consciousness, pH, PCO_2, lactic acid, albumin, glucose, CRP, hemoglobin, platelet distribution width, D-dimer, and pro-B-type natriuretic peptide (OR 1.10, 95% CI 1.03–1.17, p=0.005). The OR of hospital mortality was significantly higher in the BUN level ≥7.63 mmol/L group than in the BUN level <7.63 mmol/L group in adjusted model (OR 3.29, 95% CI 1.05–10.29, p=0.041). Similar results were found after multiple imputation and in the propensity score matching cohort.

Conclusions

Increased BUN level at ED admission is associated with hospital mortality in patients with AECOPD who present at the ED. The level of 7.63 mmol/L can be used as a cutoff value for critical stratification.

Treatment of COPD Groups GOLD A and B with Inhaled Corticosteroids in the COSYCONET Cohort - Determinants and Consequences

Background

In COPD patients of GOLD groups A and B, a high degree of treatment with inhaled corticosteroids (ICS) has been reported, which is regarded as overtreatment according to GOLD recommendations. We investigated which factors predict ICS use and which relationship it has to clinical and functional outcomes, or healthcare costs.

Methods

We used pooled data from visits 1 and 3 of the COSYCONET cohort (n=2741, n=2053, interval 1.5 years) including patients categorized as GOLD grades 1-4 and GOLD group A or B at both visits (n=1080). Comparisons were performed using ANOVA, and regression analyses using propensity matching and inverse probability weighting to adjust for differences between ICS groups. These were defined as having ICS at both visits (always) vs no ICS at both visits (never). Measures were divided into predictors of ICS treatment and outcomes.

Results

Among 1080 patients, 608 patients were eligible for ICS groups (n=297 never, n=311 always). Prior to matching, patients with ICS showed significantly (p<0.05 each) impaired lung function, symptoms and exacerbation history. After matching, the outcomes generic quality of life and CO diffusing capacity were increased in ICS patients (p<0.05 each). Moreover, costs for respiratory medication, but not total health care costs, were significantly elevated in the ICS group by 780€ per year.

Conclusion

ICS therapy in COPD GOLD A/B patients can have small positive and negative effects on clinical outcomes and health care costs, indicating that the clinical evaluation of ICS over-therapy in COPD requires a multi-dimensional approach.

Impact of insomnia and obstructive sleep apnea on the risk of acute exacerbation of chronic obstructive pulmonary disease

Chronic obstructive pulmonary disease (COPD) is a major health burden worldwide. Acute exacerbation of chronic obstructive pulmonary disease (AECOPD) is characterized by worsening of patients' respiratory symptoms that requires a modification in medication. This event could accelerate disease progression and increase the risk of hospital admissions and mortality. Both insomnia and obstructive sleep apnea (OSA) are prevalent in patients with COPD, and are linked to increased susceptibility to AECOPD. Improper treatment of insomnia may increase the risk of adverse respiratory outcomes for patients with COPD, while effective continuous positive airway pressure (CPAP) treatment may reduce the risk of AECOPD and mortality in patients with overlap syndrome. Sleep disorders should be considered in clinical management for COPD.

Advances in understanding of mechanisms related to increased cardiovascular risk in COPD

INTRODUCTION

Chronic obstructive pulmonary disease (COPD) represents a serious global health issue that is commonly associated with cardiovascular (CV) disease (CVD). The close relationship between COPD and CVD could be explained by different factors, first and foremost a chronic low-grade systemic inflammation implicated in the pathogenesis of both diseases and several stimuli enhancing the inflammatory processes and causing a mixed condition with worse outcomes than either disorder alone.

AREAS COVERED

The present narrative review considers the mechanisms underlying the increased CV risk in COPD, and it provides insights on biomarkers and predictive models to predict CVD in COPD patients.

EXPERT OPINION

COPD patients often remain asymptomatic of CVD, with respiratory symptoms generally attributed to the preexisting pulmonary disease. It is fundamental to understand the mechanistic pathways that underpin the intimate relationship between the two disorders. However, it is still not clear what is the origin of the common background of low-grade systemic inflammation, it could be a 'spillover' or a general inflammatory state. Primary prevention, cross-collaboration between specialists and early detection via predictive biomarkers and validated models are fundamental to stratify COPD patients according to CV risk.

Adherence to inhalers and comorbidities in COPD patients. A cross-sectional primary care study from Greece

Background

Comorbidities and adherence to inhaled therapy appears to have a major impact on treatment goals, health status and disease control in chronic obstructive pulmonary disease (COPD). Aim of the study was to assess levels of adherence to inhalers, comorbidities and associations with COPD outcomes in patients residing in rural and semi-urban areas of Greece.

Methods

Two hundred fifty-seven COPD patients were enrolled from primary health care in 2015–2016. Physicians used structured interviews and questionnaires to assess quality of life and disease status. Patients were classified into groups according to GOLD 2019 guidelines (based on CAT and mMRC). Adherence to inhalers was measured with the Test of Adherence to Inhalers (TAI). Multivariate linear and logistics regression models were used to assess associations between comorbidities and adherence to inhalers with COPD outcomes, including CAT and mMRC scores, exacerbations and GOLD A-D status.

Results

74.1% of COPD patients reported poor adherence, while most of them were characterized as deliberate non-compliers (69.5%). 77.1% had ≥2 comorbidities, with overweight/obese (82.2%), hypertension (72.9%) and diabetes mellitus (58%) being the most prevalent. In multivariate analysis, COPD outcomes having significant associations with poor adherence included worse health status [OR (95% CI) 4.86 (1.61–14.69) and 2.93 (1.51–5.71) based on CAT and mMRC, respectively], having ≥2 exacerbations in the past year [4.68 (1.51–4.44)], and disease status e.g., be in groups C or D [3.13 (1.49–8.53) and 3.35 (1.24–9.09) based on CAT and mMRC, respectively). Subjects with gastroesophageal reflux showed better inhaler adherence [OR (95% CI) 0.17 (0.6–0.45)], but none of the comorbid conditions was associated with COPD outcomes after adjustments.

Conclusions

Poor adherence to inhalers and comorbidities are both prevalent in COPD patients of primary care residing in rural/semi-urban areas of Greece, with adherence influencing COPD outcomes. Raising awareness of patients and physicians on the importance of comorbidities control and inhaler adherence may lead to interventions and improve outcomes.

Relationship between clinical and radiological signs of bronchiectasis in COPD patients: Results from COSYCONET

Bronchiectasis (BE) might be frequently present in COPD but masked by COPD symptoms. We studied the relationship of clinical signs of bronchiectasis to the presence and extent of its radiological signs in patients of different COPD severity. Visit 4 data (GOLD grades 1-4) of the COSYCONET cohort was used. Chest CT scans were evaluated for bronchiectasis in 6 lobes using a 3-point scale (0: absence, 1: ≤50%, 2: >50% BE-involvement for each lobe). 1176 patients were included (61%male, age 67.3y), among them 38 (3.2%) with reported physicians' diagnosis of bronchiectasis and 76 (6.5%) with alpha1-antitrypsin deficiency (AA1D). CT scans were obtained in 429 patients. Within this group, any signs of bronchiectasis were found in 46.6% of patients, whereby ≤50% BE occurred in 18.6% in ≤2 lobes, in 10.0% in 3-4 lobes, in 15.9% in 5-6 lobes; >50% bronchiectasis in at least 1 lobe was observed in 2.1%. Scores ≥4 correlated with an elevated ratio FRC/RV. The clinical diagnosis of bronchiectasis correlated with phlegm and cough and with radiological scores of at least 3, optimally ≥5. In COPD patients, clinical diagnosis and radiological signs of BE showed only weak correlations. Correlations became significant with increasing BE-severity implying radiological alterations in several lobes. This indicates the importance of reporting both presence and extent of bronchiectasis on CT. Further research is warranted to refine the criteria for CT scoring of bronchiectasis and to determine the relevance of radiologically but not clinically detectible bronchiectasis and their possible implications for therapy in COPD patients.

Prediction of air trapping or pulmonary hyperinflation by forced spirometry in COPD patients: results from COSYCONET

Background

Air trapping and lung hyperinflation are major determinants of prognosis and response to therapy in chronic obstructive pulmonary disease (COPD). They are often determined by body plethysmography, which has limited availability, and so the question arises as to what extent they can be estimated via spirometry.

Methods

We used data from visits 1–5 of the COPD cohort COSYCONET. Predictive parameters were derived from visit 1 data, while visit 2–5 data was used to assess reproducibility. Pooled data then yielded prediction models including sex, age, height, and body mass index as covariates. Hyperinflation was defined as ratio of residual volume (RV) to total lung capacity (TLC) above the upper limit of normal. (ClinicalTrials.gov identifier: NCT01245933).

Results

Visit 1 data from 1988 patients (Global Initiative for Chronic Obstructive Lung Disease grades 1–4, n=187, 847, 766, 188, respectively) were available for analysis (n=1231 males, 757 females; mean±sd age 65.1±8.4 years; forced expiratory volume in 1 s (FEV₁) 53.1±18.4 % predicted (% pred); forced vital capacity (FVC) 78.8±18.8 % pred; RV/TLC 0.547±0.107). In total, 7157 datasets were analysed. Among measures of hyperinflation, RV/TLC showed the closest relationship to FEV₁ % pred and FVC % pred, which were sufficient for prediction. Their relationship to RV/TLC could be depicted in nomograms. Even when neglecting covariates, hyperinflation was predicted by FEV₁ % pred, FVC % pred or their combination with an area under the curve of 0.870, 0.864 and 0.889, respectively.

Conclusions

The degree of air trapping/hyperinflation in terms of RV/TLC can be estimated in a simple manner from forced spirometry, with an accuracy sufficient for inferring the presence of hyperinflation. This may be useful for clinical settings, where body plethysmography is not available.

This proposed method allows estimation of hyperinflation in COPD by spirometry, obviating the need for body plethysmography or further techniques. Results are depicted in easily applicable nomograms that can be used in clinical practice.https://bit.ly/3c0tUNL

Associations of oxygenated hemoglobin with disease burden and prognosis in stable COPD: Results from COSYCONET

We studied whether in patients with stable COPD blood gases (BG), especially oxygenated hemoglobin (OxyHem) as a novel biomarker confer information on disease burden and prognosis and how this adds to the information provided by the comorbidity pattern and systemic inflammation. Data from 2137 patients (GOLD grades 1–4) of the baseline dataset of the COSYCONET COPD cohort were used. The associations with dyspnea, exacerbation history, BODE-Index (cut-off ≤2) and all-cause mortality over 3 years of follow-up were determined by logistic and Cox regression analyses, with sex, age, BMI and pack years as covariates. Predictive values were evaluated by ROC curves. Capillary blood gases included SaO₂, PaO₂, PaCO₂, pH, BE and the concentration of OxyHem [haemoglobin (Hb) x fractional SaO₂, g/dL] as a simple-to-measure correlate of oxygen content. Inflammatory markers were WBC, CRP, IL-6 and -8, TNF-alpha and fibrinogen, and comorbidities comprised a broad panel including cardiac and metabolic disorders. Among BG, OxyHem was associated with dyspnoea, exacerbation history, BODE-Index and mortality. Among inflammatory markers and comorbidities, only WBC and heart failure were consistently related to all outcomes. ROC analyses indicated that OxyHem provided information of a magnitude comparable to that of WBC, with optimal cut-off values of 12.5 g/dL and 8000/µL, respectively. Regarding mortality, OxyHem also carried independent, additional information, showing a hazard ratio of 2.77 (95% CI: 1.85–4.15, p < 0.0001) for values <12.5 g/dL. For comparison, the hazard ratio for WBC > 8000/µL was 2.33 (95% CI: 1.60–3.39, p < 0.0001). In stable COPD, the concentration of oxygenated hemoglobin provided additional information on disease state, especially mortality risk. OxyHem can be calculated from hemoglobin concentration and oxygen saturation without the need for the measurement of PaO₂. It thus appears well suited for clinical use with minimal equipment, especially for GPs.

How to Stage Airflow Limitation in Stable Chronic Obstructive Pulmonary Disease Male Patients?

No study has evaluated the utility of different classifications of chronic obstructive pulmonary disease (COPD) airflow limitation (AFL) in terms of the refined “ABCD” classification of the Global Initiative for Chronic Obstructive Lung Disease (GOLD) or in terms of the impacts on quality of life. This study aimed to compare some relevant health outcomes (i.e., GOLD classification and quality-of-life scores) between COPD patients having “light” and “severe” AFL according to five COPD AFL classifications. It was a cross-sectional prospective study including 55 stable COPD male patients. The COPD assessment test (CAT), the VQ11 quality-of-life questionnaire, a spirometry, and a bronchodilator test were performed. The patients were divided into GOLD “A/B” and “C/D.” The following five classifications of AFL severity, based on different post-bronchodilator forced expiratory volume in 1 s (FEV₁) expressions, were applied: FEV_1%pred: “light” (≥50), “severe” (<50); FEV_1z-score: “light” (≥−3), “severe” (<−3); FEV₁/height²: “light” (≥0.40), “severe” (<0.40); FEV₁/height³: “light” (≥0.29), “severe” (<0.29); and FEV_1Quotient: “light” (≥2.50), “severe” (<2.50). The percentages of the patients with “severe” AFL were significantly influenced by the applied classification of the AFL severity (89.1 [FEV_1z-score], 63.6 [FEV_1%pred], 41.8 [FEV₁/height³], 40.0 [FEV_1Quotient], and 25.4 [FEV₁/height²]; Cochrane test = 91.49, df = 4). The CAT and VQ11 scores were significantly different between the patients having “light” and “severe” AFL. In GOLD “C/D” patients, only the FEV_1Quotient was able to distinguish between the two AFL severities. To conclude, the five classifications of COPD AFL were not similar when compared with regard to some relevant health outcomes.

Time-updated resting heart rate predicts mortality in patients with COPD

High resting heart rate (RHR) is associated with higher mortality in the general population and in cardiovascular disease. Less is known about the association of RHR with outcome in chronic obstructive pulmonary disease (COPD). In particular, the time-updated RHR (most recent value before the event) appears informative. This is the first study to investigate the association of time-updated RHR with mortality in COPD. We compared the baseline and time-updated RHR related to survival in 2218 COPD patients of the German COSYCONET cohort (COPD and Systemic Consequences-Comorbidities Network). Patients with a baseline RHR > 72 beats per minute (bmp) had a significantly (p = 0.049) higher all-cause mortality risk (adjusted hazard ratio (HR) of 1.37 (1.00-1.87) compared to baseline RHR ≤ 72 bpm. The time-updated RHR > 72 bpm was markedly superior (HR 1.79, 1.30-2.46, p = 0.001). Both, increased baseline and time-updated RHR, were independently associated with low FEV1, low TLCO, a history of diabetes, and medication with short-acting beta agonists (SABAs). In conclusion, increased time-updated RHR is associated with higher mortality in COPD independent of other predictors and superior to baseline RHR. Increased RHR is linked to lung function, comorbidities and medication. Whether RHR is an effective treatment target in COPD, needs to be proven in controlled trials.

COPD and heart failure: differential diagnosis and comorbidity

Heart failure (HF) and chronic obstructive pulmonary disease (COPD) represent the most important differential diagnoses of dyspnea in elderly people. Heart failure is the inability of the heart to pump sufficient amounts of blood through the cardiovascular system. Pump failure is caused by compromised contractility and/or filling of the ventricles leading to forward and backward failure and subsequently to dyspnea. In COPD, the destruction and remodeling processes of the bronchiolar architecture inhibit proper exhalation of air, thereby leading to exhaustion of the thoracic muscles, insufficient oxygen diffusion, and dyspnea. Despite these fundamental differences in the pathophysiology of both disorders, their clinical presentation may be very similar. This renders accurate and timely diagnosis and therapy, especially in patients with coexisting disease, difficult. This clinical review summarizes typical problems in the diagnosis of COPD, HF, and coincident disease, and describes strategies that help avoid misdiagnosis and ineffective treatment.

Comorbidity and thirty-day hospital readmission odds in chronic obstructive pulmonary disease: a comparison of the Charlson and Elixhauser comorbidity indices

Background

Readmissions following exacerbations of chronic obstructive pulmonary disease (COPD) are prevalent and costly. Multimorbidity is common in COPD and understanding how comorbidity influences readmission risk will enable health systems to manage these complex patients.

Objectives

We compared two commonly used comorbidity indices published by Charlson and Elixhauser regarding their ability to estimate readmission odds in COPD and determine which one provided a superior model.

Methods

We analyzed discharge records for COPD from the Nationwide Readmissions Database spanning 2010 to 2016. Inclusion and readmission criteria from the Hospital Readmissions Reduction Program were utilized. Elixhauser and Charlson Comorbidity Index scores were calculated from published methodology. A mixed-effects logistic regression model with random intercepts for hospital clusters was fit for each comorbidity index, including year, patient-level, and hospital-level covariates to estimate odds of thirty-day readmissions. Sensitivity analyses included testing age inclusion thresholds and model stability across time.

Results

In analysis of 1.6 million COPD discharges, readmission odds increased by 9% for each half standard deviation increase of Charlson Index scores and 13% per half standard deviation increase of Elixhauser Index scores. Model fit was slightly better for the Elixhauser Index using information criteria. Model parameters were stable in our sensitivity analyses.

Conclusions

Both comorbidity indices provide meaningful information in prediction readmission odds in COPD with slightly better model fit in the Elixhauser model. Incorporation of comorbidity information into risk prediction models and hospital discharge planning may be informative to mitigate readmissions.

Medical Treatment of COPD

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is common around the world and carries a high morbidity and mortality. Symptom- and risk-oriented drug treatment is recommended, both in Germany and in other countries. It is not yet known to what extent the treatment that is actually delivered in Germany corresponds to the current recommendations in the guidelines.

METHODS

As recommended by the Global Initiative for Chronic Obstructive Lung Disease (GOLD) in 2017, 2281 patients of the national COPD cohort COSYCONET (COPD and Systemic Consequences-Comorbidities Network) were classified into Gold classes A-D on the basis of disease-specific manifestations and the frequency of exacerbations. Moreover, the regular use of medications was documented and categorized according to active substance groups. For all groups, the documented treatment that was actually given was compared to the recommended treatment.

RESULTS

67.6% of the patients received a combination of a long-acting anticholinergic drug (LAMA) and a long-acting beta-mimetic drug (LABA), while 65.8% received inhaled corticosteroids (ICS), 11.7% theophylline, and 12.6% oral corticosteroids (OCS). Despite recommendations to the contrary, 66% of the patients in Groups A and B (low exacerbation rates) were treated with ICS; some of these patients carried an additional diagnosis of bronchial asthma. There was evidence of undertreatment mainly in groups C and D (high exacerbation rate), because many of the patients in these groups were not treated with LAMA or LAMA/LABA as recommended.

CONCLUSION

The observed deviations from the recommended treatment, some of which were substantial, might lead to suboptimal treatment outcomes as well as to avoidable side effects of medication.

Combined effects of lung function, blood gases and kidney function on the exacerbation risk in stable COPD: Results from the COSYCONET cohort

RATIONALE

Alterations of acid-base metabolism are an important outcome predictor in acute exacerbations of COPD, whereas sufficient metabolic compensation and adequate renal function are associated with decreased mortality. In stable COPD there is, however, only limited information on the combined role of acid-base balance, blood gases, renal and respiratory function on exacerbation risk grading.

METHODS

We used baseline data of the COPD cohort COSYCONET, applying linear and logistic regression analyses, the results of which were implemented into a comprehensive structural equation model. As most informative parameters it comprised the estimated glomerular filtration rate (eGFR), lung function defined via forced expiratory volume in 1 s (FEV₁), intrathoracic gas volume (ITGV) and (diffusing capacity for carbon monoxide (DLCO), moreover arterial oxygen content (CaO₂), partial pressure of oxygen (PaCO₂), base exess (BE) and exacerbation risk according to GOLD criteria. All measures were adjusted for age, gender, body-mass index, the current smoking status and pack years.

RESULTS

1506 patients with stable COPD (GOLD grade 1-4; mean age 64.5 ± 8.1 y; mean FEV₁ 54 ± 18 %predicted, mean eGFR 82.3 ± 16.9 mL/min/1.73 m²) were included. BE was linked to eGFR, lung function and PaCO₂ and played a role as indirect predictor of exacerbation risk via these measures; moreover, eGFR was directly linked to exacerbation risk. These associations remained significant after taking into account medication (diuretics, oral and inhaled corticosteroids), whereby corticosteroids had effects on exacerbation risk and lung function, diuretics on eGFR, BE and lung function.

CONCLUSION

Even in stable COPD acid-base metabolism plays a key integrative role in COPD risk assessment despite rather small deviations from normality. It partially mediates the effects of impairments in kidney function, which are also directly linked to exacerbation risk.

Patients with overlapping diagnoses of asthma and COPD: is livestock exposure a risk factor for comorbidity and coexisting symptoms and infections?

BACKGROUND

Epidemiological research on health effects of livestock exposure in population subgroups with compromised respiratory health is still limited. The present study explored the association between livestock exposure and comorbid/concurrent conditions in patients with overlapping diagnoses of asthma and COPD.

METHODS

Electronic health record data from 23 general practices in the Netherlands were collected from 425 patients diagnosed with both asthma and COPD, living in rural areas with high livestock density ("study area"). Data of 341 patients with the same overlapping diagnoses, living in rural areas with lower livestock density ("control areas") were obtained from 19 general practices. First, the prevalence of comorbid disorders and symptoms/infections were compared between the study and control area. Second, the examined health outcomes were analyzed in relation to measures of individual livestock exposure.

RESULTS

Pneumonia was twice as common among patients living in areas with a high livestock density (OR 2.29, 99% CI 0.96-5.47); however, there were generally no statistically significant differences in the investigated outcomes between the study and control area. Significant associations were observed between presence of goats within 1000 m and allergic rhinitis (OR 5.71, 99% CI 1.11-29.3, p < 0.01), number of co-occurring symptoms (IRR 1.69, 99% CI 1.03-2.77, p < 0.01) and anxiety (OR 8.18, 99% 1.5-44.7, p < 0.01). Presence of cattle within 500 m was associated with pneumonia prevalence (OR 2.48, 99% CI 1.05-5.84, p < 0.01).

CONCLUSION

Livestock exposure is not associated with comorbid chronic conditions but appears to be a risk factor for symptomatic effects in patients with overlapping diagnoses of asthma and COPD.

The COPD Comorbidome in the Light of the Degree of Dyspnea and Risk of Exacerbation

The BODE group designed a bubble chart, analogous to the solar system, which depicts the prevalence of each disease and its association with mortality and called it a "comorbidome". Although this graph was used to represent mortality and, later, the risk of needing hospital admission, it was not applied to visualize the association between a set of comorbidities and the categories of the GOLD 2017 guidelines, neither according to the degree of dyspnea nor to the risk of exacerbation. For the purpose of knowing to which extent each comorbidity associates with each of the two conditions-most symptomatic group (groups B and D) and highest risk of exacerbation (groups C and D)-we performed a analysis based on the comorbidome. 439 patients were included. Cardiovascular comorbidity (especially cardiac and renal disease) is predominantly observed in patients with a higher degree of dyspnea, whereas bronchial asthma and stroke occur more frequently in subjects at higher risk of exacerbation. This is the first time that the comorbidome is presented based on the categories of the GOLD 2017 document, which we hope will serve as a stimulus for scientific debate.

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.

Effect of COPD severity and comorbidities on the result of the PHQ-9 tool for the diagnosis of depression: results from the COSYCONET cohort study

The diagnosis of depression, a frequent comorbidity of chronic obstructive pulmonary disease (COPD), is often supported by questionnaires, such as the Patient Health Questionnaire 9 (PHQ-9). It is unknown to which extent its single questions are affected by the clinical characteristics of COPD patients.

We addressed this question in 2255 GOLD grade 1–4 patients from the COSYCONET (COPD and Systemic Consequences - Comorbidities Network) COPD cohort. The dependence on COPD severity was assessed using symptoms, exacerbation risk (GOLD A-D; modified Medical Research Council dyspnoea scale (mMRC)), and frequent comorbidities as predictors of PHQ-9 results, while including age, gender, body mass index (BMI) and smoking habits as covariates.

Symptoms and exacerbation risk were associated with depression in an additive manner, with mean elevations in the PHQ-9 sum score by 2.75 and 1.44 points, respectively. Asthma, sleep apnoea, gastrointestinal disorders, osteoporosis and arthritis were linked to increases by 0.8 to 1.3 points. Overall, the COPD characteristics contributed to the mean PHQ-9 score by increases from 4.5 or 5.2 to 6.3 points, respectively, when either taking GOLD A as reference or the absence of comorbidities. This finding was independent of the diagnosis of mental disorder or the intake of antidepressants. The presence of COPD led to an increase in the proportion of scores indicating depression from 12 to 22%. Single item analysis revealed homogenous effects regarding GOLD groups, but heterogeneous effects regarding GOLD grades.

These findings indicate specific effects of COPD severity on the PHQ-9 depression score, especially symptoms and exacerbation risk, explaining the high prevalence of depression in COPD. Alternative explanations like an overlap of COPD severity and PHQ-9 items are discussed. Of note, we also found COPD treatment effects on depression scores.

Clinical characteristics and outcomes in Japanese patients with COPD according to the 2017 GOLD classification: the Ishinomaki COPD Network Registry

Purpose

The GOLD report provides a framework for classifying COPD in a way that reflects its clinical impact and allows treatment recommendations. The GOLD 2017 proposes a new classification whereby patients are grouped as A–D according to their symptoms and history of exacerbations. However, the clinical characteristics and outcomes in these patients are not well documented.

Patients and methods

In this prospective observational study, we analyzed data from the Ishinomaki COPD Network Registry. All patients with stable COPD were classified into the four groups defined by GOLD 2017. The patient demographics, clinical characteristics, number of exacerbations, and mortality rate during 1 year of follow-up were compared between the groups.

Results

Four hundred and one patients with stable COPD were identified. There were 240 patients (59.9%) in group A, 122 (30.4%) in group B, 16 (4.0%) in group C, and 23 (5.7%) in group D. Patients in groups B, C, and D had ORs of 2.95, 3.92, and 5.45, respectively, for risk of exacerbation relative to group A. Groups C and D experienced exacerbations more frequently, including exacerbations leading to hospital admission, than groups A and B (both P<0.001) during the 1-year follow-up period. Patients with a high risk of exacerbation (groups C and D) had a lower body mass index, showed more symptoms, used more respiratory medications, and had more severe airflow limitation than patients at low risk of exacerbation (groups A and B). Mortality was not different between the high-risk and low-risk groups.

Conclusion

The results of our study provide evidence that the GOLD 2017 classification identifies patients with COPD at risk of exacerbations, including those requiring hospitalization, but has a poor ability to predict mortality.

What is the impact of GOLD 2017 recommendations in primary care? - a descriptive study of patient classifications, treatment burden and costs

PURPOSE

The changes in grading of disease severity and treatment recommendations for patients with COPD in the 2017 GOLD strategy may present an opportunity for reducing treatment burden for the patients and costs to the health care system. The aim of this study was to assess the implications of the GOLD 2017 grading system in terms of change in distribution across GOLD groups A-D for existing patients in UK primary care and estimate the potential cost savings of implementing GOLD 2017 treatment recommendations in UK primary care.

PATIENTS AND METHODS

Using electronic health record data from the Clinical Practice Research Datalink (CPRD), patients aged ≥35 years with spirometry-confirmed COPD, receiving care during 2016, were included. The cohort was graded according to the GOLD 2017 groups (A-D), and treatment costs were calculated, according to corresponding recommendations, to observe the difference in actual vs predicted costs.

RESULTS

When applying GOLD 2013 criteria, less than half of the cohort (46%) was assigned to GOLD A or B, as compared to 86% when applying the GOLD 2017 grading. The actual mean annual maintenance treatment cost was £542 per patient vs a predicted £389 for treatment according to the 2017 GOLD strategy.

CONCLUSION

There is a potential to make significant cost savings by implementing the grading and treatment recommendations from the 2017 GOLD strategy.

Changes in the Burden of Comorbidities in Patients with COPD and Asthma-COPD Overlap According to the GOLD 2017 Recommendations

PURPOSE

Comorbidities associated with chronic obstructive pulmonary disease (COPD) affect quality of life and increase mortality. Asthma-COPD overlap (ACO) may express a different profile of comorbidities compared to COPD alone. It is unclear how recent changes in GOLD recommendations affect the profile of comorbidities in COPD and ACO.

METHODS

Eight hundred and thirty-four patients with COPD were recruited from 67 Hungarian secondary care outpatient clinics, 469 of them had ACO. Comorbidities were defined by respiratory specialists based on medical history, patient report, and medications. COPD grades were defined according to the old 2016 and the new 2017 GOLD document. Comorbidities were compared along COPD ABCD groups determined by the old and new GOLD.

RESULTS

66 and 72% of the COPD patients in groups C and D (GOLD 2016) were recategorized to groups A and B (GOLD 2017), respectively. There was no difference in the prevalence of disorders along the 2016 GOLD categories except for osteoporosis in ACO (p = 0.01). When the patients were categorized according to the 2017 GOLD criteria, the prevalence of osteoporosis (p = 0.01) was different among the four groups in all COPD patients. Subgroup analysis of non-ACO COPD patients revealed inter-group differences for cardiac arrhythmia (p < 0.01). No alteration was seen in the prevalence of coronary artery disease, hypertension, diabetes, or the total number of comorbidities.

CONCLUSION

A significant number of patients are recategorized according to the GOLD 2017 criteria. This change only marginally affects the profile of comorbidities; still this needs to be considered when assessing the patients in daily practice.