Traditional and Advanced Echocardiographic Evaluation in Chronic Obstructive Pulmonary Disease: The Forgotten Relation

Chronic obstructive pulmonary disease (COPD) is a significant preventable and treatable clinical disorder defined by a persistent, typically progressive airflow obstruction. This disease has a significant negative impact on mortality and morbidity worldwide. However, the complex interaction between the heart and lungs is usually underestimated, necessitating more attention to improve clinical outcomes and prognosis. Indeed, COPD significantly impacts ventricular function, right and left chamber architecture, tricuspid valve functionality, and pulmonary blood vessels. Accordingly, more emphasis should be paid to their diagnosis since cardiac alterations may occur very early before COPD progresses and generate pulmonary hypertension (PH). Echocardiography enables a quick, noninvasive, portable, and accurate assessment of such changes. Indeed, recent advancements in imaging technology have improved the characterization of the heart chambers and made it possible to investigate the association between a few cardiac function indexes and clinical and functional aspects of COPD. This review aims to describe the intricate relation between COPD and heart changes and provide basic and advanced echocardiographic methods to detect early right ventricular and left ventricular morphologic alterations and early systolic and diastolic dysfunction. In addition, it is crucial to comprehend the clinical and prognostic significance of functional tricuspid regurgitation in COPD and PH and the currently available transcatheter therapeutic approaches for its treatment. Moreover, it is also essential to assess noninvasively PH and pulmonary resistance in patients with COPD by applying new echocardiographic parameters. In conclusion, echocardiography should be used more frequently in assessing patients with COPD because it may aid in discovering previously unrecognized heart abnormalities and selecting the most appropriate treatment to improve the patient's symptoms, quality of life, and survival.

Hepatic steatosis and respiratory diseases: a new panorama

Non-alcoholic fatty liver disease is defined as hepatic fat accumulation in more than 5% of hepatocytes, without other liver steatosis causes. It comprises a broad spectrum that can range from benign steatosis and progress to non-alcoholic steatohepatitis, fibrosis, and ultimately hepatocellular carcinoma. Non-alcoholic fatty liver is considered a multisystemic disease since it is related to multiple disorders, such as type 2 diabetes mellitus, polycystic ovary syndrome, chronic kidney disease, psoriasis, osteoporosis, hypothyroidism, cardiovascular diseases, and obstructive sleep apnea syndrome; it is becoming increasingly clear that it is also a risk factor for developing certain respiratory diseases. This article aims to understand the liver and chronic obstructive pulmonary disease mechanisms, obstructive sleep apnea syndrome, asthma, and lung cancer. Given that non-alcoholic fatty liver disease has a considerable impact on the patient's well-being and life quality, as well as on the costs they generate for the country's health services, it is essential to continue research, especially in areas such as the respiratory tract, as there is much misinformation about it.

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.

Changes in blood pressure among patients in the Ontario Telehomecare programme: An observational longitudinal cohort study

Background The objective of this study was to investigate the changes in blood pressure among patients enrolled in the Telehomecare programme in Ontario, Canada. Methods This observational study utilised a prospective longitudinal cohort design, including patients with heart failure and chronic obstructive pulmonary disease enrolled in the Ontario Telehomecare programme from July 2012 to July 2015. The outcome of interest was change in mean (biweekly) systolic and diastolic blood pressure levels over a six-month period. Patient data were extracted from the Ontario Telemedicine Network database, and analysed using generalised linear mixed model procedures. Results Overall, we analysed data for 3513 patients. Patients were on average 74.1 ± 11.4 years of age; almost half were men, 62% had heart failure, 55% chronic obstructive pulmonary disease and 29% diabetes. At baseline, the mean systolic and diastolic blood pressure levels were 130.4 ± 19.1 mmHg and 72.2 ± 12.5 mmHg for the total sample. At six months, the adjusted reduction in systolic and diastolic blood pressure values were 4.0 mmHg (95% confidence interval: -4.5 to -3.5) and 2.7 mmHg (95% confidence interval: -3.1 to -2.4), respectively. In a subgroup of 1220 patients with uncontrolled blood pressure at baseline (systolic/diastolic blood pressure of 150.7 ± 10.2 mmHg/80.2 ± 13.5 mmHg) the adjusted reduction in systolic blood pressure was 12.5 mmHg (95% confidence interval: -13.4 to -11.6) and in diastolic blood pressure was 7.1 mmHg (95% confidence interval: -7.8 to -6.5) over the six-month period. Conclusions Blood pressure levels were significantly reduced in patients enrolled in the Telehomecare programme, with changes being more pronounced in patients with uncontrolled blood pressure. The sustainability of decreased blood pressure on other clinical outcomes needs further evaluation.

Cardiovascular comorbidity in patients with chronic obstructive pulmonary disease in the Canary Islands (CCECAN study)

INTRODUCTION

Numerous studies have shown a high prevalence of cardiovascular disease in patients with chronic obstructive pulmonary disease (COPD). The aim of this study was to analyse the prevalence of cardiovascular risk factors and comorbidity in a Canary Islands population diagnosed with COPD, and compared it with data from the general population.

PATIENTS AND METHODS

A cross-sectional study was carried out in 300 patients with COPD and 524 subjects without respiratory disease (control group). The two groups were compared using standard bivariate methods. Logistic regression models were used to estimate the cardiovascular risks in COPD patients compared to control group.

RESULTS

Patients with COPD showed a high prevalence of hypertension (72%), dyslipidaemia (73%), obesity (41%), diabetes type 2 (39%), and sleep apnoea syndrome (30%) from mild stages of the disease (GOLD 2009). There was a 22% prevalence of cardiac arrhythmia, 16% of ischaemic heart disease, 16% heart failure, 12% peripheral vascular disease, and 8% cerebrovascular disease. Compared to the control group, patients with COPD had a higher risk of dyslipidaemia (OR 3.24, 95% CI; 2.21-4.75), diabetes type 2 (OR 1.52, 95% CI; 1.01-2,28), and ischaemic heart disease (OR 2.34, 95% CI; 1.22-4.49). In the case of dyslipidaemia, an increased risk was obtained when adjusted for age, gender, and consumption of tobacco (OR 5.04, 95% CI; 2.36-10.74).

CONCLUSIONS

Patients with COPD resident in the Canary Islands have a high prevalence of hypertension, dyslipidaemia, ischaemic heart disease, and cardiac arrhythmia. Compared to general population, patients with COPD have a significant increase in the risk of dyslipidaemia.

Early-life risk factors for chronic nonrespiratory diseases

We have witnessed a change in disease patterns contributing to the global burden of disease, with a shift from early childhood deaths due to the classic infectious communicable diseases to years lived with disability from chronic noncommunicable diseases. In both developing and developed countries, the years lived with disability attributable to chronic disease have increased: cardiovascular diseases by 17.7%; chronic respiratory disease by 8.5%; neurological conditions by 12.2%; diabetes by 30.0%; and mental and behavioural disorders by 5.0% over the past 20 years. Recognition of the contribution made by adverse environmental exposures in early life to noncommunicable diseases in later life is increasing. These early-life exposures appear to contribute to both chronic respiratory and chronic nonrespiratory diseases. In this State of the Art article, we aim to examine early-life environmental exposures that have an epidemiological association with chronic nonrespiratory diseases, such as obesity and type II diabetes, cardiovascular disease, and neurocognitive and behavioural problems. We will highlight the potential overlap in environmental risks with respiratory diseases, and point out knowledge gaps and research opportunities.

Cardiovascular comorbidity in COPD: systematic literature review

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

The use of the lower limit of normal as a criterion for COPD excludes patients with increased morbidity and high consumption of health-care resources

The objective of this study is to analyze the clinical characteristics of two COPD patient populations: one diagnosed using the lower limit of normal (LLN) and another diagnosed by the GOLD criteria. We also compared the population excluded by the LLN criterion with a non-COPD control population. The COPD patients determined with the LLN criterion presented significantly lower levels of FEV1/FVC at 0.55 (0.8) vs. 0.66 (0.2), P=.000; FEV1 44.9% (14) vs. 53.8% (13), P=.000, and FVC 64.7% (17) vs. 70.4% p 0.04. The two COPD groups presented more frequent ER visits in the last year (57% and 52% of the patients, respectively, compared with 11.9% of the control group), without any statistically significant differences between the two. This same pattern was observed in the number of ER visits in the last year: 1.98 (1.6), 1.84 (1.5) and 1.18 (0.7), respectively. When we analyzed the prevalence of the comorbidities that are most frequently associated COPD, there was a clear increase in the percentage of patients who presented associated disorders compared with the control group. Nevertheless, these differences were not very relevant between the two COPD groups. The differences also were not relevant between both COPD groups in the pharmacological prescription profile. In conclusion, the use of the LLN as a criterion for establishing the diagnosis of COPD, compared with the GOLD criteria, excludes a population with important clinical manifestations and with a high consumption of health-care resources. Before its implementation, the relevance of applying this criterion in clinical practice should be analyzed.

β-blockade: benefits beyond blood pressure reduction?

Hypertension is a major cardiovascular (CV) risk factor, but several other common conditions, including chronic obstructive pulmonary disease (COPD), osteoporosis, and peripheral arterial disease (PAD), have been shown to independently increase the risk of CV events and death. The physiological basis for an increased CV risk in those conditions probably lies in the augmentations of oxidative stress, endothelial dysfunction, systemic inflammation, and arterial stiffness, which all are also hallmarks of hypertension. β-Blockers have been used for the treatment of hypertension for more than 40 years, but a number of meta-analyses have demonstrated that treatment with these agents may be associated with an increased risk of CV events and mortality. However, the majority of primary prevention β-blocker trials employed atenolol, an earlier-generation β(1) -selective blocker whose mechanism of action is based on a reduction of cardiac output. Available evidence suggests that vasodilatory β-blockers may be free of the deleterious effects of atenolol. The purpose of this review is to summarize pathophysiologic mechanisms thought to be responsible for the increased CV risk associated with COPD, osteoporosis, and PAD, and examine the possible benefits of vasodilatory β-blockade in those conditions. Our examination focused on nebivolol, a β(1) -selective agent with vasodilatory effects most likely mediated via β(3) activation.

[Effect of the administration of statins in non-cardiac critical disease]

Administration of statins has been shown to be effective in reducing cardiovascular mortality. Their benefit could expand towards other areas of intensive medicine, it being possible to decrease mortality of the critically ill patient. There are several studies, although without a high level of evidence, that have detected a possible benefit when they are administered as well as clinical deterioration when they are discontinued, compared to those patients who had previously taken them. Even though most of the patients who had previously taken statins did so as primary or secondary prevention, thus having greater comorbidity, overall, a decrease is detected in the mortality of these subgroups. This benefit could be generalized to all the critical conditions, although studies with a higher level of evidence are needed for their adequate comparison.

Health, treatment and health care resources consumption profile among Spanish adults with diabetes and chronic obstructive pulmonary disease

AIMS

To describe the health, treatment and health care resources consumption profile among Spanish adults with diabetes and chronic obstructive pulmonary disease (COPD), and compare it with that of non-diabetic COPD patients.

PATIENTS AND METHODS

An observational and descriptive epidemiological study (EPIDEPOC study). The study included patients with stable COPD and aged > or =40 years, evaluated in primary care. Data were collected relating to sociodemographic variables, health profile, quality of life (SF-12), treatment and health care resources consumption. The results corresponding to diabetic and non-diabetic patients were compared.

RESULTS

A total of 10,711 patients (75.6% males) with COPD were evaluated. The prevalence of diabetes was 16.9%. The diabetic patients were significantly older, with a larger percentage of women, and a lesser educational level compared with the non-diabetic patients. In addition, the diabetics were more sedentary, smoked less, and presented a higher percentage of obesity (33.6% versus 19.7%) than the non-diabetic patients. The severity of airways obstruction was greater among the diabetics than in the non-diabetic patients (54.57+/-13.37% versus 57.92+/-13.39%, respectively, p<0.05). As to co-morbidity, the diabetics showed a greater frequency of arterial hypertension, hypercholesterolemia, heart disease, depression and anxiety. Both the physical and the mental component as measured by the SF-12 yielded significantly poorer results among the diabetics. On the other hand, the diabetic subjects showed a higher consumption of drugs for COPD. In addition, they consumed significantly more health care (and thus economical) resources than the non-diabetic patients. The results of the multivariate logistic regression analysis showed that the variables that were independently associated to COPD among diabetic patients were: higher age, higher BMI, concomitant chronic heart disease, use of inhaled corticoids, SF-12 mental component, SF-12 physical component and total cost of COPD.

CONCLUSIONS

The presence of diabetes in patients with COPD shows in the bivariate analysis a more severe lung disease, greater co-morbidity, poorer quality of life, and a greater consumption of resources, as well as a less favorable course in the previous year. However, the multivariate logistic regression shows that the variables that are independently associated to COPD among diabetic patients are higher age, higher BMI, concomitant chronic heart disease, use of inhaled corticoids, physical and mental component of quality of life questionnaire and total cost of COPD.

[Annual Review of COPD]

There have been significant advances in the knowledge in the thoracic and extrathoracic aspects of chronic obstructive pulmonary disease (COPD) in the past few years. COPD is associated with numerous comorbidities, the prevalences of which have recently been evaluated. Dyspnea has been shown to be associated with neuropsychiatric disturbances, such as anxiety. Muscular dysfunction has been associated with inflammation and oxidative stress, in which respiratory muscle satellite cells play an important role in repair. Respiratory rehabilitation and physiotherapy must form an important part of individualised patient treatment analogous to the pharmacological treatment. As regards acute exacerbations, infection is the cause of 75% of them, sputum characteristics and the suspicion of Pseudomonad being key factors in the antibiotic treatment. Questions, such as markers which can detect the origin of the infection, prognostic factors, or the role of short stay pneumology units, are of particular importance. The variability in COPD treatments and the lack of suitable international clinical guidelines, continue to be subjects of debate. To the poor use of the treatment schemes in the guidelines, can be added the irregular uses of inhaled medication, the insufficient use of medical advice or the low intervention in cigarette smoking in all age groups.

[Phenotypic heterogeneity of chronic obstructive pulmonary disease]

A functional definition of chronic obstructive pulmonary disease (COPD) based on airflow limitation has largely dominated the field. However, a view has emerged that COPD involves a complex array of cellular, organic, functional, and clinical events, with a growing interest in disentangling the phenotypic heterogeneity of COPD. The present review is based on the opinion of the authors, who have extensive research experience in several aspects of COPD. The starting assumption of the review is that current knowledge on the pathophysiology and clinical features of COPD allows us to classify phenotypic information in terms of the following dimensions: respiratory symptoms and health status, acute exacerbations, lung function, structural changes, local and systemic inflammation, and systemic effects. Twenty-six phenotypic traits were identified and assigned to one of the 6 dimensions. For each dimension, a summary is provided of the best evidence on the relationships among phenotypic traits, in particular among those corresponding to different dimensions, and on the relationship between these traits and relevant events in the natural history of COPD. The information has been organized graphically into a phenotypic matrix where each cell representing a pair of phenotypic traits is linked to relevant references. The information provided has the potential to increase our understanding of the heterogeneity of COPD phenotypes and help us plan future studies on aspects that are as yet unexplored.