[Cardiovascular risk factors in chronic obstructive pulmonary disease: results of the ARCE study]

Management of the COPD Patient with Comorbidities: An Experts Recommendation Document

Background

Chronic obstructive pulmonary disease (COPD) is associated with multiple comorbidities, which impact negatively on patients and are often underdiagnosed, thus lacking a proper management due to the absence of clear guidelines.

Purpose

To elaborate expert recommendations aimed to help healthcare professionals to provide the right care for treating COPD patients with comorbidities.

Methods

A modified RAND-UCLA appropriateness method consisting of nominal groups to draw up consensus recommendations (6 Spanish experts) and 2-Delphi rounds to validate them (23 Spanish experts) was performed.

Results

A panel of Spanish internal medicine experts reached consensus on 73 recommendations and 81 conclusions on the clinical consequences of the presence of comorbidities. In general, the experts reached consensus on the issues raised with regard to cardiovascular comorbidity and metabolic disorders. Consensus was reached on the use of selective serotonin reuptake inhibitors in cases of depression and the usefulness of referring patients with anxiety to respiratory rehabilitation programmes. The results also showed consensus on the usefulness of investigating the quality of sleep, the treatment of pain with opioids and the evaluation of osteoporosis by lateral chest radiography.

Conclusion

This study provides conclusions and recommendations that are intended to improve the management of the complexity of patients with COPD and important comorbidities, usually excluded from clinical trials.

Ischemic heart disease among subjects with and without chronic obstructive pulmonary disease--ECG-findings in a population-based cohort study

Background

Cardiovascular comorbidity in COPD is common and contributes to increased mortality. A few population-based studies indicate that ischemic electrocardiogram (ECG)-changes are more prevalent in COPD, while others do not. The aim of the present study was to estimate the presence of ischemic heart disease (IHD) in a population-based COPD-cohort in comparison with subjects without COPD.

Methods

All subjects with obstructive lung function (COPD, n = 993) were identified together with age- and sex-matched controls (non-COPD, n = 993) from population-based cohorts examined in 2002–04. In 2005, data from structured interview, spirometry and ECG were collected from 1625 subjects. COPD was classified into GOLD 1–4 after post-bronchodilator spirometry. Ischemic ECG-changes, based on Minnesota-coding, were classified according to the Whitehall criteria into probable and possible IHD.

Results

Self-reported IHD was equally common in COPD and non-COPD, and so were probable and possible ischemic ECG-changes according to Whitehall. After excluding subjects with restrictive spirometric pattern from the non-COPD-group, similar comparison with regard to presence of IHD performed between those with COPD and those with normal lung-function did neither show any differences. There was a significant association between self-reported IHD (p = 0.007) as well as probable ischemic ECG-changes (p = 0.042), and increasing GOLD stage. In COPD there was a significant association between level of FEV₁ percent of predicted and self-reported as well as probable ischemic ECG-changes, and this association persisted for self-reported IHD also after adjustment for sex and age.

Conclusion

In this population-based study, self-reported IHD and probable ischemic ECG-changes were associated with COPD disease severity assessed by spirometry.

Electronic supplementary material

The online version of this article (doi:10.1186/s12890-015-0149-1) contains supplementary material, which is available to authorized users.

Coronary artery calcification, epicardial fat burden, and cardiovascular events in chronic obstructive pulmonary disease

RATIONALE

Patients with chronic obstructive pulmonary disease (COPD) suffer from significantly more cardiovascular comorbidity and mortality than would be anticipated from conventional risk factors. The aim of this study was to determine whether COPD patients have a higher coronary artery calcium score (CACS) and epicardial fat burden, compared to control subjects, and their association with cardiovascular events.

METHODS

From a registry of 1906 patients 81 patients with clinically diagnosed COPD were one-to-one matched to 81 non-COPD control subjects with a smoking history, according to their age, sex, and the number of classic cardiovascular risk factors (arterial hypertension, diabetes mellitus, dyslipidemia, family history of premature coronary artery disease). CACS, epicardial fat, and subsequent major adverse cardiovascular events (MACE) during follow-up were compared between groups.

RESULTS

Patients with COPD (Global Initiative for Chronic Obstructive Lung Disease-classification I: 5%, II: 23%, III: 16% and IV: 56%) showed no difference in CACS (median difference 68 Agatston Units [95% confidence interval -176.5 to 192.5], p=0.899) or epicardial fat volume (mean difference -0.5 cm3 [95% confidence interval -20.9 to 21.9], p=0.961) compared with controls. After a median follow-up of 42.6 months a higher incidence of MACE was observed in COPD patients (RR=2.80, p=0.016) compared with controls. Cox proportional hazard regression identified cardiac ischemias and CACS as independent predictors for MACE.

CONCLUSION

COPD patients experienced a higher MACE incidence compared to controls despite no baseline differences in coronary calcification and epicardial fat burden. Other mechanisms such as undersupply of medication seem to account for an excess cardiovascular comorbidity in COPD patients.

Coronary artery disease concomitant with chronic obstructive pulmonary disease

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Comorbidity in patients with chronic obstructive pulmonary disease in family practice: a cross sectional study

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is frequent and often coexists with other diseases. The aim of this study was to quantify the prevalence of COPD and related chronic comorbidity among patients aged over 40 years visiting family practices in an area of Madrid.

METHODS

An observational, descriptive, cross-sectional study was conducted in a health area of the Madrid Autonomous Region (Comunidad Autónoma de Madrid). The practice population totalled 198,670 persons attended by 129 Family Physicians (FPs), and the study population was made up of persons over the age of 40 years drawn from this practice population. Patients were deemed to have COPD if this diagnosis appeared on their clinical histories. Prevalence of COPD; prevalence of a further 25 chronic diseases in patients with COPD; and standardised prevalence ratios, were calculated.

RESULTS

Prevalence of COPD in family medicine was 3.2% (95% CI 3.0-3.3) overall, 5.3% among men and 1.4% among women; 90% of patients presented with comorbidity, with a mean of 4 ± 2.04 chronic diseases per patient, with the most prevalent related diseases being arterial hypertension (52%), disorders of lipid metabolism (34%), obesity (25%), diabetes (20%) and arrhythmia (15%). After controlling for age and sex, the observed prevalence of the following ten chronic diseases was higher than expected: heart failure; chronic liver disease; asthma; generalised artherosclerosis; osteoporosis; ischaemic heart disease; thyroid disease; anxiety/depression; arrhythmia; and obesity.

CONCLUSIONS

Patients with COPD, who are frequent in family practice, have a complex profile and pose a clinical and organisational challenge to FPs.

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

Introduction

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

Methods

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

Results

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

Conclusion

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

Lack of association of ischemic heart disease with COPD when taking into account classical cardiovascular risk factors

The aim of our study is to determine whether chronic obstructive pulmonary disease (COPD) is an independent risk factor for ischemic heart disease and whether this association is related with a greater prevalence of classical cardiovascular risk factors. Ours is a case-control cross-sectional study design. Cases were hospital patients with ischemic heart disease in stable phase, compared with control hospital patients. All patients underwent post-bronchodilator (PBD) spirometry, a standardized questionnaire, and blood analysis. COPD was defined as per GOLD PBD forced expiratory volume in the first second (FEV₁)/forced vital capacity (FVC) < 0.70. In our series of patient cases (n = 204) and controls (n = 100), there were 169 men in the case group (83%) and 84 in the control group (84%). Ages were 67 and 64 years, respectively (P < 0.05). There were no significant differences by weight, body mass index (BMI), packyears, leukocytes, or homocysteine. The abdominal perimeter was significantly greater in cases (mean 101 cm ± standard deviation [SD] 10 versus 96 cm ± 11; P < 0.000). Both groups also had significant differences by C-reactive protein (CRP), fibrinogen, and hemoglobin values. In univariate analysis, increased risks for cases to show with individual classical cardiovascular risk factors were seen, with odds ratio (OR) 1.86 and 95% confidence interval (CI) (1.04–3.33) for diabetes mellitus, dyslipidemia (OR 2.10, 95% CI: 1.29–3.42), arterial hypertension (OR 2.47, 95% CI: 1.51–4.05), and increased abdominal perimeter (OR 1.71, 95% CI: 1.06–2.78). Percent predicted PBD FEV₁ was 97.6% ± 23% in the patient group and 104% ± 19% in the control group (P = 0.01), but the prevalence of COPD was 24.1% in cases and 21% in controls. Therefore, COPD was not associated with ischemic heart disease: at the crude level (OR 1.19, 95% CI: 0.67–2.13) or after adjustment (OR 1.14, 95% CI:0.57–2.29). In conclusion, COPD was not associated with ischemic heart disease. The greater prevalence of classical cardiovascular risk factors in COPD patients could explain the higher occurrence of ischemic heart disease in these patients.

[Chronic obstructive pulmonary disease - a review]

COPD is a preventable and treatable disease caused by exposure to tobacco smoke and poisonous gases. It is characterised by progressive obstruction of the airflow, irreversible once lesions occur in the parenchyma. This article aims to systematically review the disease and its treatment.

DISCUSSION

Smoking is the main cause of COPD and leads to decreased oxygenation via lung hyperinflation with reduced airflow as a systemic inflammatory process. This reduces resistance to fatigue of the skeletal musculature, leading to hypoxemia, decreased peripheral blood flow and also miscarriages and premature births. Inflammatory markers such as interleukins and TNF-alpha maintain the systemic picture. While smoking cessation improves hypoxemia and exercise intolerance, it does not repair damaged tissue. COPD is a serious disease which can be avoided by a wider understanding by the population of the harm smoking causes.