Lung Function in Young Adults and Risk of Cardiovascular Events Over 29 Years: The CARDIA Study

Exploring the Impact of Inhaled Corticosteroids on Endothelial Function in Chronic Obstructive Pulmonary Disease Patients Undergoing Pulmonary Rehabilitation

Background: Chronic obstructive pulmonary disease (COPD) is associated with subclinical atherosclerosis and endothelial dysfunction, which can be assessed non-invasively through flow-mediated dilation (FMD). In this study, we evaluated the potential impact of inhaled corticosteroid (ICS) therapy on FMD of COPD patients undergoing pulmonary rehabilitation (PR). Methods: Medical records of COPD patients undergoing FMD assessment upon admission to our Pulmonary Rehabilitation Unit were reviewed in this retrospective post hoc analysis. Results: A total of 46 patients with COPD (median age 71.5 years, 28.3% postmenopausal females) were included in the final analysis. Among these, 27 participants were currently receiving ICS therapy, while 19 were not. At baseline, the two groups showed no difference in the main clinical and functional variables. Similarly, no significant difference was observed in vascular reactivity parameters, with a median FMD of 3.12% (IQR: 2.23-4.45) in ICS users and 3.39% (IQR: 2.45-4.08) in ICS nonusers (p = 0.544). After PR, a significant improvement in the main rehabilitation and patient-reported outcomes was observed in all groups, with a significant improvement in FMD documented in both patients treated with steroids (from 3.12%; IQR: 2.23-4.45 to 4.77%; IQR: 3.25-5.63, p = 0.022) and in those who were not (from 3.39%; IQR: 2.45-4.08 to 5.04%; IQR: 3.98-6.06, p = 0.005). FMD changes were of comparable magnitude among groups. Conclusions: Our preliminary findings do not indicate a significant impact of medications containing ICS on the endothelial function of COPD patients, suggesting that the potential beneficial effect of PR on this surrogate marker of cardiovascular risk is independent of inhaled therapy.

Lung function trajectories from school age to adulthood and their relationship with markers of cardiovascular disease risk

RATIONALE

Lung function in early adulthood is associated with subsequent adverse health outcomes.

OBJECTIVES

To ascertain whether stable and reproducible lung function trajectories can be derived in different populations and investigate their association with objective measures of cardiovascular structure and function.

METHODS

Using latent profile modelling, we studied three population-based birth cohorts with repeat spirometry data from childhood into early adulthood to identify trajectories of forced expiratory volume in 1 s (FEV1)/forced vital capacity (FVC). We used multinomial logistic regression models to investigate early-life predictors of the derived trajectories. We then ascertained the extent of the association between the derived FEV1/FVC trajectories and blood pressure and echocardiographic markers of increased cardiovascular risk and stroke in ~3200 participants at age 24 years in one of our cohorts.

RESULTS

We identified four FEV1/FVC trajectories with strikingly similar latent profiles across cohorts (pooled N=6377): above average (49.5%); average (38.3%); below average (10.6%); and persistently low (1.7%). Male sex, wheeze, asthma diagnosis/medication and allergic sensitisation were associated with trajectories with diminished lung function in all cohorts. We found evidence of an increase in cardiovascular risk markers ascertained by echocardiography (including left ventricular mass indexed to height and carotid intima-media thickness) with decreasing FEV1/FVC (with p values for the mean crude effects per-trajectory ranging from 0.10 to p<0.001). In this analysis, we considered trajectories as a pseudo-continuous variable; we confirmed the assumption of linearity in all the regression models.

CONCLUSIONS

Childhood lung function trajectories may serve as predictors in the development of not only future lung disease, but also the cardiovascular disease and multimorbidity in adulthood.

Determinants of lung function development from birth to age 5 years: an interrupted time series analysis of a South African birth cohort

BACKGROUND

Early life is a key period that determines long-term health. Lung development in childhood predicts lung function attained in adulthood and morbidity and mortality across the life course. We aimed to assess the effect of early-life lower respiratory tract infection (LRTI) and associated risk factors on lung development from birth to school age in a South African birth cohort.

METHODS

We prospectively followed children enrolled in a population-based cohort from birth (between March 5, 2012 and March 31, 2015) to age 5 years with annual lung function assessment. Data on multiple early-life exposures, including LRTI, were collected. The effect of early-life risk factors on lung function development from birth to age 5 years was assessed using the Generalised Additive Models for Location, Scale and Shape and Interrupted Time Series approach.

FINDINGS

966 children (475 [49·2%] female, 491 [50·8%] male) had lung function measured with oscillometry, tidal flow volume loops, and multiple breath washout. LRTI occurred in 484 (50·1%) children, with a median of 2·0 LRTI episodes (IQR 1·0-3·0) per child. LRTI was independently associated with altered lung function, as evidenced by lower compliance (0·959 [95% CI 0·941-0·978]), higher resistance (1·028 [1·016-1·041]), and higher respiratory rate (1·018 [1·063-1·029]) over 5 years. Additional impact on lung function parameters occurred with each subsequent LRTI. Respiratory syncytial virus (RSV) LRTI was associated with lower expiratory flow ratio (0·97 [0·95-0·99]) compared with non-RSV LRTI. Maternal factors including allergy, smoking, and HIV infection were also associated with altered lung development, as was preterm birth, low birthweight, female sex, and coming from a less wealthy household.

INTERPRETATION

Public health interventions targeting LRTI prevention, with RSV a priority, are vital, particularly in low-income and middle-income settings.

FUNDING

UK Medical Research Council Grant, The Wellcome Trust, The Bill & Melinda Gates Foundation, US National Institutes of Health Human Heredity and Health in Africa, South African Medical Research Council, Hungarian Scientific Research Fund, and European Respiratory Society.

FEV1 and FVC as robust risk factors for cardiovascular disease and mortality: Insights from a large population study

INTRODUCTION

Data is limited on influence of forced expiratory volume in 1 s (FEV1) and forced vital capacity (FVC) in a large adult population, including individuals with normal spirometry at baseline.

METHODS

Using the UK Biobank cohort, a multivariable Cox regression analysis was conducted on 406,424 individuals to examine the association between FEV1 and FVC, categorized into three groups based on their percentage of predicted values (%pred) (≥80, 60-80 and < 60), and overall mortality, cardiovascular mortality, myocardial infarction, stroke, and heart failure over approximately 12.5 years. Moreover, a subgroup analysis was conducted on 295,459 individuals who had normal spirometry.

RESULTS

Reduced FEV1 and FVC %pred values were associated with an elevated risk across all studied outcomes. Individuals with the lowest FEV1 and FVC %pred values (<60 %) exhibited HR of 1.83 (95 % CI 1.74-1.93) and 1.98 (95 % CI 1.76-2.22) for overall mortality, and 1.96 (95 % CI 1.83-2.1) and 2.26 (95 % CI 1.94-2.63) for cardiovascular mortality. Moreover, a graded association was observed between lower FEV1 and FVC %pred, even among never smokers and individuals with normal spirometry at baseline.

DISCUSSION

Reduced FEV1 and FVC represent robust risk factors for cardiovascular disease and mortality. The fact that the increased risk was evident also at FEV1 and FVC levels exceeding 80 %pred challenges the contemporary classification of lung function categories and the notion that the entire FEV1- and FVC-range above 80 % of predicted represents a normal lung function.

Low lung function in Bipolar Disorder and Schizophrenia: a hidden risk

Introduction: People with serious mental illness (SMI), such as schizophrenia and bipolar disorder, have a higher risk of premature morbidity and mortality. In the general population, impaired lung function is associated with increased morbidity and mortality. We compared lung function between people with and without serious mental illnesses using a cross-sectional study in 9 community mental health units. Methods: Subjects aged 40-70 years with a diagnosis of schizophrenia or bipolar disorder were recruited consecutively. The controls had no psychiatric diagnosis and were not receiving any psychotropics. Spirometry was performed by a trained nurse. We used the 2021 American Thoracic Society/European Respiratory Society standards for the interpretation of the spirometry results. Results: We studied 287 subjects. People with SMI (n = 169) had lower spirometry values than those without a psychiatric diagnosis (n = 118). An abnormal spirometry pattern (36.1% vs 16.9%, p < 0.001), possible restriction or non-specific (Preserved Ratio Impaired Spirometry [PRISm]) pattern (17.8% vs 7.6%, p = 0.014), and pattern of airflow obstruction or possible mixed disorder (18.3% vs 9.3%, p = 0.033) were more frequent in people with SMI. Multivariate analyses showed that the PRISm pattern was associated with abdominal circumference (odds ratio [OR] 1.05, 95%CI 1.03-1.08) and that the pattern of airflow obstruction or possible mixed disorder was associated with smoking behavior (OR 5.15, 95%CI 2.06-15.7). Conclusion: People with SMI have impaired lung function, with up to one-third of them showing an abnormal spirometry pattern. This suggests that regular monitoring of lung function and addressing modifiable risk factors, such as tobacco use and obesity, in this population is of paramount importance.

Household Air Pollution and Child Lung Function: The Ghana Randomized Air Pollution and Health Study

Rationale: The impact of a household air pollution (HAP) stove intervention on child lung function has been poorly described. Objectives: To assess the effect of a HAP stove intervention for infants prenatally to age 1 on, and exposure-response associations with, lung function at child age 4. Methods: The Ghana Randomized Air Pollution and Health Study randomized pregnant women to liquefied petroleum gas (LPG), improved biomass, or open-fire (control) stove conditions through child age 1. We quantified HAP exposure by repeated maternal and child personal carbon monoxide (CO) exposure measurements. Children performed oscillometry, an effort-independent lung function measurement, at age 4. We examined associations between Ghana Randomized Air Pollution and Health Study stove assignment and prenatal and infant CO measurements and oscillometry using generalized linear regression models. We used reverse distributed lag models to examine time-varying associations between prenatal CO and oscillometry. Measurements and Main Results: The primary oscillometry measure was reactance at 5 Hz, X5, a measure of elastic and inertial lung properties. Secondary measures included total, large airway, and small airway resistance at 5 Hz, 20 Hz, and the difference in resistance at 5 Hz and 20 Hz (R5, R20, and R5-20, respectively); area of reactance (AX); and resonant frequency. Of the 683 children who attended the lung function visit, 567 (83%) performed acceptable oscillometry. A total of 221, 106, and 240 children were from the LPG, improved biomass, and control arms, respectively. Compared with control, the improved biomass stove condition was associated with lower reactance at 5 Hz (X5 z-score: β = -0.25; 95% confidence interval [CI] = -0.39, -0.11), higher large airway resistance (R20 z-score: β = 0.34; 95% CI = 0.23, 0.44), and higher AX (AX z-score: β = 0.16; 95% CI = 0.06, 0.26), which is suggestive of overall worse lung function. The LPG stove condition was associated with higher X5 (X5 score: β = 0.16; 95% CI = 0.01, 0.31) and lower small airway resistance (R5-20 z-score: β = -0.15; 95% CI = -0.30, 0.0), which is suggestive of better small airway function. Higher average prenatal CO exposure was associated with higher R5 and R20, and distributed lag models identified sensitive windows of exposure between CO and X5, R5, R20, and R5-20. Conclusions: These data support the importance of prenatal HAP exposure on child lung function. Clinical trial registered with www.clinicaltrials.gov (NCT01335490).

Cause-specific mortality in COPD subpopulations: a cohort study of 339 647 people in England

BACKGROUND

Identifying correlates of cause-specific mortality in patients with chronic obstructive pulmonary disease (COPD) may aid the targeting of therapies to reduce mortality. We determined factors associated with causes of death in a primary care COPD population.

METHODS

Clinical Practice Research Datalink Aurum was linked to Hospital Episode Statistics and death certificate data. People with COPD alive between 1 January 2010 and 1 January 2020 were included. Patient characteristics were defined before the start of follow-up: (a) frequency and severity of exacerbations; (b) emphysema or chronic bronchitis; (c) Global Obstructive Lung Disease (GOLD) groups A-D; and (d) airflow limitation. We used Cox Proportional Hazards regression and competing risks to investigate the association between patient characteristics and risk of all-cause, COPD and cardiovascular (CV) mortality.

RESULTS

339 647 people with COPD were included of which 97 882 died during follow-up (25.7% COPD related and 23.3% CV related). Airflow limitation, GOLD group, exacerbation frequency and severity, and COPD phenotype were associated with all-cause mortality. Exacerbations, both increased frequency and severity, were associated with COPD-related mortality (≥2 exacerbations vs none adjusted HR: 1.64, 1.57-1.71; 1 severe vs none adjusted HR: 2.17, 2.04-2.31, respectively). Patients in GOLD groups B-D had a higher risk of COPD and CV mortality compared with GOLD group A (GOLD group D vs group A, adjusted HR for COPD mortality: 4.57, 4.23-4.93 and adjusted HR for CV mortality: 1.53, 1.41-1.65). Increasing airflow limitation was also associated with both COPD and CV mortality (GOLD 4 vs 1, adjusted HR: 12.63, 11.82-13.51 and adjusted HR: 1.75, 1.60-1.91, respectively).

CONCLUSION

Poorer airflow limitation, worse functional status and exacerbations had substantial associations with risk of all-cause mortality. Differing results for CV and COPD-related mortality suggests interventions to prevent mortality may need to target particular characteristics or time points in the disease course.

Predictive value of lung function measures for cardiovascular risk: a large prospective cohort study

INTRODUCTION

Although lung function measures are associated with cardiovascular disease (CVD), the added predictive values of these measures remain unclear.

METHODS

From the UK Biobank, 308 415 participants free of CVD with spirometry parameters were included. The CVD outcomes included were defined by QRISK3, the American College of Cardiology/American Heart Association (ACC/AHA) and the European Systematic Coronary Risk Evaluation (SCORE) prediction models, respectively. Cox proportional hazard models were used to estimate the associations of lung function measures with CVD outcomes. The predictive capability was determined by the decision curve analyses.

RESULTS

Over a median follow-up of 12.5 years, 21 885 QRISK3 events, 12 843 ACC/AHA events and 2987 SCORE events were recorded. The associations of spirometry parameters with CVD outcomes were L-shaped. Restrictive and obstructive impairments were associated with adjusted HRs of 1.84 (95% CI: 1.65 to 2.06) and 1.72 (95% CI: 1.55 to 1.90) for SCORE CVD, respectively, compared with normal spirometry. Similar associations were seen for QRISK3 CVD (restrictive vs normal, adjusted HR: 1.30, 95% CI: 1.25 to 1.36; obstructive vs normal, adjusted HR: 1.20, 95% CI: 1.15 to 1.25) and ACC/AHA CVD (restrictive vs normal, adjusted HR: 1.39, 95% CI: 1.31 to 1.47; obstructive vs normal, adjusted HR: 1.26, 95% CI: 1.19 to 1.33). Using models that integrated non-linear forced expiratory volume in 1 s led to additional 10-year net benefits per 100 000 persons of 25, 43 and 5 for QRISK3 CVD at the threshold of 10%, ACC/AHA CVD at 7.5% and SCORE CVD at 5.0%, respectively.

CONCLUSION

Clinicians could consider spirometry indicators in CVD risk assessment. Cost-effectiveness studies and clinical trials are needed to put new CVD risk assessment into practice.

Lung function and cardiovascular risk at age 45 in a cohort of the general population

BACKGROUND

Impaired lung function is associated with cardiovascular mortality, but the origins of this association are poorly understood. We investigated associations between lung function and cardiovascular risk scores in a general population cohort of men and women aged 45 years.

METHODS

Participants are members of an unselected birth cohort followed to adulthood. Lung function determined at ages 32 and 45 by spirometry, body plethysmography, gas diffusion, and airway conductance were the main predictors. Future cardiovascular risk was estimated at age 45 using a multivariable cardiovascular risk algorithm - PREDICT. Risk scores were log-transformed and used as the dependent variable in linear regression analyses. We investigated cross-sectional associations with lung function at age 45 and longitudinal associations using changes in lung function between ages 32-45 as the predictors.

RESULTS

863 of 1037 original cohort participants had data for analysis. Low lung volumes (FEV1, FVC, VA, TLC, and FRC) were associated with greater cardiovascular risk scores in the cross-sectional analyses at age 45 and the longitudinal analyses. These associations were stronger in women than in men, were independent of smoking history, and present in never smokers, even after adjusting for body mass index. Associations were not found for measures of airway function (FEV1/FVC ratio and sGaw) or gas transfer (TLco/VA).

CONCLUSIONS

Low lung volumes at age 45 and accelerated pulmonary function decline are associated with a higher estimated cardiovascular risk scores in mid-adulthood. This association is stronger in women and is not explained by smoking or obesity.

Understanding progression from pre-school wheezing to school-age asthma: Can modern data approaches help?

Preschool wheezing and childhood asthma create a heavy disease burden which is only exacerbated by the complexity of the conditions. Preschool wheezing exhibits both "curricular" and "aetiological" heterogeneity: that is, heterogeneity across patients both in the time-course of its development and in its underpinning pathological mechanisms. Since these are not fully understood, but clinical presentations across patients may nonetheless be similar, current diagnostic labels are imprecise-not mapping cleanly onto underlying disease mechanisms-and prognoses uncertain. These uncertainties also make a identifying new targets for therapeutic intervention difficult. In the past few decades, carefully designed birth cohort studies have collected "big data" on a large scale, incorporating not only a wealth of longitudinal clinical data, but also detailed information from modalities as varied as imaging, multiomics, and blood biomarkers. The profusion of big data has seen the proliferation of what we term "modern data approaches" (MDAs)-grouping together machine learning, artificial intelligence, and data science-to make sense and make use of this data. In this review, we survey applications of MDAs (with an emphasis on machine learning) in childhood wheeze and asthma, highlighting the extent of their successes in providing tools for prognosis, unpicking the curricular heterogeneity of these conditions, clarifying the limitations of current diagnostic criteria, and indicating directions of research for uncovering the etiology of the diseases underlying these conditions. Specifically, we focus on the trajectories of childhood wheeze phenotypes. Further, we provide an explainer of the nature and potential use of MDAs and emphasize the scope of what we can hope to achieve with them.

Association between spirometry pattern, left ventricular diastolic function, and mortality

BACKGROUND

Spirometric abnormalities have been related to incident heart failure in general population, who generally have preserved left ventricular ejection fraction (LVEF). We aimed to investigate the association between spirometric indices, cardiac functions and clinical outcomes.

METHODS

Subjects presenting with exertional dyspnoea and received spirometry and echocardiography were eligible for this study. Forced vital capacity (FVC) and forced expiratory volume in the first second (FEV1)/FVC ratio were measured to define the spirometry patterns: normal (FEV1/FVC ≥ 70%, FVC ≥ 80%), obstructive (FEV1/FVC < 70%, FVC ≥ 80%), restrictive pattern (FEV1/FVC ≥ 70%, FVC < 80%) and mixed (FEV1/FVC < 70%, FVC < 80%). The diastolic dysfunction index (DDi) was the counts of the indicators, including septal e' velocity <7 cm/s, septal E/e' > 15, pulmonary artery systolic pressure > 35 mmHg and left atrial dimension >40 mm.

RESULTS

Among a total of 8669 participants (65.8 ± 16.3 years, 56% men), 3739 (43.1%), 829 (9.6%), 3050 (35.2%) and 1051 (12.1%) had normal, obstructive, restrictive and mixed spirometry pattern, respectively. Subjects with restrictive or mixed spirometry pattern had higher DDi and worse long-term survival than those with obstructive or normal ventilation. FVC but not FEV1/FVC was predictive of 5-year mortality, independent of age, sex, renal function, LVEF, DDi, body mass index, and comorbidities (hazard ratio, 95% confidence intervals: .981, .977-.985). Furthermore, there was an inverse nonlinear relationship between FVC and DDi, suggesting the declined FVC may mediate 43% of the prognostic hazard of left ventricular diastolic dysfunction.

CONCLUSIONS

The restrictive spirometry pattern or the declined FVC was associated with left ventricular diastolic dysfunction, which aggravated the long-term mortality in the ambulatory dyspnoeic subjects.

Pulmonary rehabilitation and endothelial function in patients with chronic obstructive pulmonary disease: A prospective cohort study

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is associated with subclinical atherosclerosis and endothelial dysfunction, thereby leading to increased cardiovascular risk. In the present study, we evaluated the changes in endothelium-dependent flow-mediated dilation (FMD) in a cohort of severe COPD patients undergoing pulmonary rehabilitation.

METHODS

Consecutive COPD patients referred to our Pulmonary Rehabilitation Unit were screened for inclusion. All study procedures were performed at hospital admission and discharge.

RESULTS

Of 78 patients screened for eligibility, a total of 40 participants (67.5% males, median age 72.5 years) were included. After pulmonary rehabilitation, a significant improvement in functional parameters, exercise capacity, and measures of disability and quality of life were documented. FMD changed from 3.25% (IQR: 2.31-4.26) to 4.95% (IQR: 3.57-6.02), corresponding to a 52.3% increase of its median value (P < 0.001). Significantly lower changes in FMD were documented in COPD patients with hypercholesterolemia as compared to those without (+0.33% ± 1.61 vs. +1.62% ± 1.59, P = 0.037). Changes in FMD (ΔFMD) were positively associated with changes in forced expiratory volume in 1 s (FEV1), when expressed both as absolute values (ΔFEV1) (r = 0.503, P = 0.002) and as percentages of predicted values (ΔFEV1%) (r = 0.608; P < 0.001). In multiple linear regressions, after adjusting for major cardiovascular risk factors, ΔFEV1 (β=0.342; P = 0.049) and ΔFEV1% (β=0.480; P = 0.015) were both confirmed as independent predictors of ΔFMD.

CONCLUSIONS

Results of our study suggest that endothelial function may improve in COPD after pulmonary rehabilitation. The potential beneficial effect in terms of cardiovascular risk prevention should be evaluated in ad hoc designed studies.

Lung Function Decline in Young Adulthood and Coronary Artery Calcium Progression in Midlife

BACKGROUND

Reduced lung function has been linked to cardiovascular disease, but population-based evidence on the relationship between lung function decline and coronary artery calcium (CAC) progression is rare.

METHODS

A total of 2694 participants (44.7% men) with a mean ± standard deviation age of 40.4 ± 3.6 years from the Coronary Artery Risk Development in Young Adults (CARDIA) were included. The rates of decline in forced vital capacity (FVC) and forced expiratory volume in 1 second (FEV1) over a 20-year period were calculated for each participant and categorized into quartiles. The primary outcome was CAC progression.

RESULTS

During a mean follow-up of 8.9 years, 455 (16.9%) participants had CAC progression. After adjusting for traditional cardiovascular risk factors, the hazard ratios (95% confidence intervals [CIs]) for CAC progression were higher for participants in the 2nd (Q2), 3rd (Q3), and highest quartiles (Q4) of FVC decline compared with those in the lowest quartile (Q1): 1.366 (1.003-1.861), 1.412 (1.035-1.927), and 1.789 (1.318-2.428), respectively. Similar trends were observed for the association between FEV1 and CAC progression. The association remained robust across a series of sensitivity analyses and all subgroups.

CONCLUSIONS

A faster decline in FVC or FEV1 during young adulthood is independently associated with an increased risk of CAC progression in midlife. Maintaining optimal lung function during young adulthood may improve future cardiovascular health.

Association Between End-Stage Liver Disease and Incident Heart Failure in an Integrated Health System

BACKGROUND

End-stage liver disease (ESLD) and heart failure (HF) often coexist and are associated with significant morbidity and mortality. However, the true incidence of HF among patients with ESLD remains understudied.

OBJECTIVE

This study aims to evaluate the association between ESLD and incident HF in a real-world clinical cohort.

DESIGN AND PARTICIPANTS

A retrospective electronic health records database analysis of individuals with ESLD and frequency-matched controls without ESLD in a large integrated health system.

MAIN MEASURES

The primary outcome was incident HF, which was defined by the International Classification of Disease codes and manually adjudicated by physician reviewers. The Kaplan-Meier method was used to estimate the cumulative incidence of HF. Multivariate proportional hazards models adjusted for shared metabolic factors (diabetes, hypertension, chronic kidney disease, coronary heart disease, body mass index) were used to compare the risk of HF in patients with and without ESLD.

KEY RESULTS

Of 5004 patients (2502 with ESLD and 2502 without ESLD), the median (Q1-Q3) age was 57.0 (55.0-65.0) years, 59% were male, and 18% had diabetes. Over a median (Q1-Q3) follow-up of 2.3 (0.6-6.0) years, 121 incident HF cases occurred. Risk for incident HF was significantly higher for patients with ESLD compared with the non-ESLD group (adjusted HR: 4.67; 95% CI: 2.82-7.75; p < 0.001), with the majority of the ESLD group (70.7%) having HF with preserved ejection fraction (ejection fraction ≥ 50%).

CONCLUSION

ESLD was significantly associated with a higher risk of incident HF, independent of shared metabolic risk factors, with the predominant phenotype being HF with preserved ejection fraction.

Phenotype and endotype based treatment of preschool wheeze

INTRODUCTION

Preschool wheeze (PSW) is a significant public health issue, with a high presentation rate to emergency departments, recurrent symptoms, and severe exacerbations. A heterogenous condition, PSW comprises several phenotypes that may relate to a range of pathobiological mechanisms. However, treating PSW remains largely generalized to inhaled corticosteroids and a short acting beta agonist, guided by symptom-based labels that often do not reflect underlying pathways of disease.

AREAS COVERED

We review the observable features and characteristics used to ascribe phenotypes in children with PSW and available pathobiological evidence to identify possible endotypes. These are considered in the context of treatment options and future research directions. The role of machine learning (ML) and modern analytical techniques to identify patterns of disease that distinguish phenotypes is also explored.

EXPERT OPINION

Distinct clusters (phenotypes) of severe PSW are characterized by different underlying mechanisms, some shared and some unique. ML-based methodologies applied to clinical, biomarker, and environmental data can help design tools to differentiate children with PSW that continues into adulthood, from those in whom wheezing resolves, identifying mechanisms underpinning persistence and resolution. This may help identify novel therapeutic targets, inform mechanistic studies, and serve as a foundation for stratification in future interventional therapeutic trials.

The relationship between preserved ratio impaired spirometry and mortality in the myocardial infarction survivors: a population-based cohort study

INTRODUCTION

Preserved ratio impaired spirometry (PRISm) is a subtype of pulmonary function abnormality which is characterized by a proportional reduction in non-obstructive expiratory lung volume. Currently, no studies have shown a relationship between PRISm and mortality in myocardial infarction (MI) survivors.

METHODS

We used cohort data from U.S. adults who attended the National Health and Nutrition Examination Survey (NHANES) from 2007 to 2012. According to the ratio of forced expiratory volume in the first second (FEV1) to forced vital capacity (FVC), we divided lung function into normal spirometry (FEV1/ FVC) ≥ 70%, FEV1 ≥ 80%), PRISm (FEV1/FVC ≥ 70%, FEV1 < 80%) and obstructive spirometry (FEV1/FVC < 70%). Cox regression was used to estimate the correlation between lung functions and mortality among MI patients. Kaplan-Meier survival curves compared the prognosis of MI with three different lung functions. We further verify the stability of the results by sensitivity analysis.

RESULTS

411 subjects were included in our research. The mean follow-up time for the study was 105 months. Compared with normal spirometry, PRISm was significantly correlated with a greater relative risk for all-cause mortality (adjust HR 3.41, 95% confidence interval [95%CI]: 1.76-6.60, P < 0.001) and cardiovascular mortality (adjust HR 13.9, 95%CI: 2.60-74.6, P = 0.002). PRISm remains more correlated with all-cause mortality (adjust HR 2.73, 95%CI: 1.28-5.83, P = 0.009) relative to obstructive spirometry. The results are basically stable after sensitivity analysis. Kaplan-Meier survival curves showed that patients with PRISm tended to have the lowest survival during the follow-up period.

CONCLUSION

PRISm is an independent risk factor for all-cause and cardiovascular mortality in MI survivors. The presence of PRISm was associated with a significantly higher risk of all-cause mortality compared with obstructive spirometry.

[Cardiopulmonary axis and cardiovascular mortality in patients with COPD]

Chronic obstructive pulmonary disease (COPD) is the fourth leading cause of mortality in our environment and was usually considered to be confined to the lung territory. The latest studies suggest that it is a systemic disease whose most probable etiopathogenesis is a state of low-intensity chronic inflammation that worsens during exacerbations. And recent scientific evidence has highlighted that cardiovascular diseases are one of the main causes of hospitalization and mortality in these patients. This relationship must be understood considering that both systems, the pulmonary and the cardiovascular, are closely related constituting the cardiopulmonary axis. Therefore, the therapeutic approach to COPD should not only include the treatment of respiratory complications, but also the prevention and treatment of cardiovascular diseases, which are very common in these patients. In this sense, in the last years, studies have been carried out that analyze the effect of the different types of inhaled therapy on all-cause mortality and cardiovascular mortality in particular.

The interaction effect of grip strength and lung function (especially FVC) on cardiovascular diseases: a prospective cohort study in Jiangsu Province, China

OBJECTIVE

Lung function and grip strength (GS) are associated with cardiovascular disease (CVD), but whether these risk factors interact to affect CVD is unknown. This study aimed to explore the interactions between lung function and GS with major CVD (defined as fatal/non-fatal myocardial infarction, stroke, and heart failure) incidence.

METHODS

We conducted a prospective cohort study on the Chinese population in Jiangsu Province. Cox proportional hazards models were used to explore the associations between GS, lung function, and major CVD incidence.

RESULTS

A total of 5967 participants were included in our study; among them, 182 participants developed major CVD. Participants with low forced vital capacity (FVC) had a higher risk of major CVD (hazard ratio (HR) = 1.45; 95% confidence interval (CI): 1.05-2.01; P < 0.05) compared with normal FVC. The risk of major CVD incidence (HR = 0.54; 95% CI: 0.35-0.83; P < 0.01) was significantly lower in participants with high GS than in individuals with low GS. The interaction between FVC and GS for major CVD incidence (P = 0.006) was statistically significant. Compared with normal FVC participants with high GS, low FVC participants with low GS had the highest risk of major CVD incidence (HR = 2.50; 95% CI: 1.43-4.36; P < 0.01).

CONCLUSION

Among people with low FVC, the risk of major CVD is lower with high GS. Participants with low FVC and low GS have the highest risk of major CVD. Therefore, more attention should be paid to the incidence of major CVD in individuals with low FVC, especially those who have lower GS.

Towards the elimination of chronic obstructive pulmonary disease: a Lancet Commission

Despite substantial progress in reducing the global impact of many non-communicable diseases, including heart disease and cancer, morbidity and mortality due to chronic respiratory disease continues to increase. This increase is driven primarily by the growing burden of chronic obstructive pulmonary disease (COPD), and has occurred despite the identification of cigarette smoking as the major risk factor for the disease more than 50 years ago. Many factors have contributed to what must now be considered a public health emergency: failure to limit the sale and consumption of tobacco products, unchecked exposure to environmental pollutants across the life course, and the ageing of the global population (partly as a result of improved outcomes for other conditions). Additionally, despite the heterogeneity of COPD, diagnostic approaches have not changed in decades and rely almost exclusively on post-bronchodilator spirometry, which is insensitive for early pathological changes, underused, often misinterpreted, and not predictive of symptoms. Furthermore, guidelines recommend only simplistic disease classification strategies, resulting in the same therapeutic approach for patients with widely differing conditions that are almost certainly driven by variable pathophysiological mechanisms. And, compared with other diseases with similar or less morbidity and mortality, the investment of financial and intellectual resources from both the public and private sector to advance understanding of COPD, reduce exposure to known risks, and develop new therapeutics has been woefully inadequate.

Vertebral fractures at hospitalization predict impaired respiratory function during follow-up of COVID-19 survivors

PURPOSE

Morphometric vertebral fractures (VFs) have been recently reported as an important component of the endocrine phenotype of COVID-19 and emerging data show negative respiratory sequelae at long-term follow-up in COVID-19 survivors. The aim of this study was to evaluate the impact of VFs on respiratory function in COVID-19 survivors.

METHODS

We included patients referred to our Hospital Emergency Department and re-evaluated during follow-up. VFs were detected on lateral chest X-rays on admission using a qualitative and semiquantitative assessment and pulmonary function tests were obtained by Jaeger-MasterScreen-Analyzer Unit 6 months after discharge.

RESULTS

Fifty patients were included. Median age was 66 years and 66% were males. No respiratory function data were available at COVID-19 diagnosis. VFs were detected in 16 (32%) patients. No differences between fractured and non-fractured patients regarding age and sex were observed. Although no difference was observed between VF and non-VF patient groups in the severity of pneumonia as assessed by Radiological-Assessment-of-Lung-Edema score at admission, (5 vs. 6, p = 0.69), patients with VFs were characterized as compared to those without VFs by lower Forced Vital Capacity (FVC, 2.9 vs. 3.6 L, p = 0.006; 85% vs. 110% of predicted, respectively, p = 0.001), Forced Expiratory Volume 1st s (FEV1, 2.2 vs. 2.8 L, p = 0.005; 92% vs. 110% of predicted, respectively, p = 0.001) and Diffusing Capacity of the Lungs for Carbon Monoxide (DLCO 5.83 vs. 6.98 mmol/min/kPa, p = 0.036, 59% vs. 86.3% of predicted, respectively, p = 0.043) at 6-month follow up.

CONCLUSIONS

VFs, expression of the endocrine phenotype of the disease, appear to influence medium-term impaired respiratory function of COVID-19 survivors which may significantly influence their recovery. Therefore, our findings suggest that a VFs assessment at baseline may help in identifying patients needing a more intensive respiratory follow-up and patients showing persistent respiratory impairment without evidence of pulmonary disease may benefit from VFs assessment to preventing the vicious circle of further fractures and respiratory deterioration.

Association of Pulmonary Function With Late-Life Cardiac Function and Heart Failure Risk: The ARIC Study

Background Pulmonary and cardiac functions decline with age, but the associations of pulmonary dysfunction with cardiac function and heart failure (HF) risk in late life is not known. We aimed to determine the associations of percent predicted forced vital capacity (ppFVC) and the ratio of forced expired volume in 1 second (FEV₁) to forced vital capacity (FVC; FEV₁/FVC) with cardiac function and incident HF with preserved or reduced ejection fraction in late life. Methods and Results Among 3854 HF-free participants in the ARIC (Atherosclerosis Risk in Communities) cohort study who underwent echocardiography and spirometry at the fifth study visit (2011-2013), associations of FEV₁/FVC and ppFVC with echocardiographic measures, cardiac biomarkers, and risk of HF, HF with preserved ejection fraction, and HF with reduced ejection fraction were assessed. Multivariable linear and Cox regression models adjusted for demographics, body mass index, coronary disease, atrial fibrillation, hypertension, and diabetes. Mean age was 75±5 years, 40% were men, 19% were Black, and 61% were ever smokers. Mean FEV₁/FVC was 72±8%, and ppFVC was 98±17%. In adjusted analyses, lower FEV₁/FVC and ppFVC were associated with higher NT-proBNP (N-terminal pro-B-type natriuretic peptide; both P<0.001) and pulmonary artery pressure (P<0.004). Lower ppFVC was also associated with higher left ventricular mass, left ventricular filling pressure, and high-sensitivity C-reactive protein (all P<0.01). Lower FEV₁/FVC was associated with a trend toward higher risk of incident HF with preserved ejection fraction (hazard ratio [HR] per 10-point decrease, 1.31; 95% CI, 0.98-1.74; P=0.07) and HF with reduced ejection fraction (HR per 10-point decrease, 1.24; 95% CI, 0.91-1.70; P=0.18), but these associations did not reach statistical significance. Lower ppFVC was associated with incident HF with preserved ejection fraction (HR per 10-unit decrease, 1.21; 95% CI, 1.04-1.41; P=0.013) but not with HF with reduced ejection fraction (HR per 10-unit decrease, 0.90; 95% CI, 0.76-1.07; P=0.24). Conclusions Subclinical reductions in FEV₁/FVC and ppFVC differentially associate with cardiac function and HF risk in late life.

Association of 71 cardiovascular disease-related plasma proteins with pulmonary function in the community

RATIONALE

It has been speculated that shared mechanisms underlie respiratory and cardiovascular diseases (CVD) including systemic inflammation or mutual risk factors. In this context, we sought to examine the associations of CVD-related plasma proteins with lung function as measured by spirometry in a large community-based cohort of adults.

METHODS

The study included 5777 Framingham Heart Study participants who had spirometry and measurement of 71 CVD-related plasma proteins. The association of plasma proteins with lung function was assessed cross-sectionally and longitudinally using models accounting for familial correlations. Linear mixed models were used for the following measurements: FEV1%predicted, FVC%predicted, and FEV1/FVC ratio with secondary analyses examining obstructive and restrictive physiology at baseline and their new onset during follow up.

MEASUREMENTS AND MAIN RESULTS

Among the 71 CVD-related plasma proteins, 13 proteins were associated in cross-sectional analyses with FEV1%predicted, 17 proteins were associated with FVC%predicted, and 1 protein was associated with FEV1/FVC. The proteins with the greatest inverse relations to FEV1%predicted and FVC%predicted included leptin, adrenomedullin, and plasminogen activator inhibitor-1; in contrast there were three proteins with positive relations to FEV1%predicted and FVC%predicted including insulin growth factor binding protein 2, tetranectin, and soluble receptor for advanced glycation end products. In longitudinal analyses, three proteins were associated with longitudinal change in FEV1 (ΔFEV1) and four with ΔFVC; no proteins were associated with ΔFEV1/FVC.

CONCLUSION

Our findings highlight CVD-related plasma proteins that are associated with lung function including markers of inflammation, adiposity, and fibrosis, representing proteins that may contribute both to respiratory and CVD risk.

Pulmonary Function in Midlife as a Predictor of Later-Life Cognition: The Coronary Artery Risk Development in Adults (CARDIA) Study

BACKGROUND

Studies found associations between pulmonary function (PF) and cognition, but these are limited by mostly cross-sectional design and a single measure of PF (typically forced expiratory volume in 1 second [FEV1]). Our objective was to prospectively analyze the association of repeatedly measured PF with cognition.

METHODS

We studied 3 499 participants in the Coronary Artery Risk Development in Young Adults cohort with cognition measured at year 25 (Y25) and Y30, and PF (FEV1 and forced vital capacity [FVC], reflecting better PF) measured up to 6 times from Y0 to Y20. Cognition was measured via Stroop test, Rey-Auditory Verbal Learning Test [RAVLT], and digit symbol substitution test [DSST], which capture executive function, verbal learning and memory, and attention and psychomotor speed, respectively; lower Stroop, and higher RAVLT and DSST scores indicate better cognition. We modeled linear, cross-sectional associations between cognition and PF at Y30 (mean age 55), and mixed models to examine associations between cognition at Y25-Y30 and longitudinal PF (both annual rate of change, and cumulative PF from Y0 to Y20).

RESULTS

At Y30, FEV1 and FVC were cross-sectionally associated with all 3 measures of cognition (β = 0.08-0.12, p < .01-.02). Annual change from peak FEV1/FVC ratio was associated with Stroop and DSST (β = 18.06, 95% CI = 7.71-28.40; β = 10.30, 95% CI = 0.26-20.34, respectively), but not RAVLT. Cumulative FEV1 and FVC were associated with Stroop and DSST (β = 0.07-0.12, p < .01-.02), but only cumulative FEV1 was associated with RAVLT (β = 0.07, 95% CI = 0.00-0.14).

CONCLUSIONS

We identified prospective associations between measures of PF and cognition even at middle ages, adding evidence of a prospective association between reduced PF and cognitive decline.

Relação da Função Pulmonar e da Força Inspiratória com Capacidade Aeróbica e com Prognóstico na Insuficiência Cardíaca

Fundamento

A espirometria é subutilizada na insuficiência cardíaca (IC) e não está claro o grau de associação de cada defeito com a capacidade de exercício e com o prognóstico desses pacientes.

Objetivo

Determinar a relação da %CVF prevista (ppCVF) e do VEF₁/CVF contínuos com: 1) pressão inspiratória máxima (PImáx), fração de ejeção do ventrículo esquerdo (FEVE) e desempenho ao exercício; e 2) prognóstico, para o desfecho composto de morte cardiovascular, transplante cardíaco ou implante de dispositivo de assistência ventricular.

Métodos

Coorte de 111 participantes com IC (estágios AHA C/D) sem pneumopatia; foram submetidos a espirometria, manovacuometria e teste cardiopulmonar máximo. As magnitudes de associação foram verificadas por regressões lineares e de Cox (HR; IC 95%), ajustadas para idade/sexo, e p <0,05 foi considerado significativo.

Resultados

Com idade média 57±12 anos, 60% eram homens, 64% em NYHAIII. A cada aumento de 10% no VEF₁/CVF [β 7% (IC 95%: 3-10)] e no ppCVF [4% (2-6)], foi associado à reserva ventilatória (VRes); no entanto, apenas o ppCVF associado à PImáx [3,8cmH₂O (0,3-7,3)], à fração de ejeção do ventrículo esquerdo (FEVE) [2,1% (0,5-3,8)] e ao VO₂ pico [0,5mL/kg/min (0,1-1,0)], considerando idade/sexo. Em 2,2 anos (média), ocorreram 22 eventos; tanto FEV1/FVC (HR 1,44; IC 95%: 0,97-2,13) quanto ppCVF (HR 1,13; 0,89-1,43) não foram associados ao desfecho. Apenas no subgrupo FEVE ≤50% (n=87, 20 eventos), VEF₁/CVF (HR 1,50; 1,01-2,23), mas não ppCVF, foi associado a risco.

Conclusão

Na IC crônica, ppCVF reduzido associou-se a menor PImáx, FEVE, VRes e VO₂ pico, mas não distinguiu pior prognóstico em 2,2 anos de acompanhamento. Entretanto, VEF₁/CVF associou-se apenas com VRes, e, em participantes com FEVE ≤50%, o VEF₁/CVF reduzido mostrou pior prognóstico proporcional. Portanto, VEF₁/CVF e ppFVC contribuem para melhor fenotipagem de pacientes com IC.

Lung function and cardiovascular disease: a two-sample Mendelian randomisation study

BACKGROUND

Observational studies suggest an association between reduced lung function and risk of coronary artery disease and ischaemic stroke, independent of shared cardiovascular risk factors such as cigarette smoking. We use the latest genetic epidemiological methods to determine whether impaired lung function is causally associated with an increased risk of cardiovascular disease.

METHODS AND FINDINGS

Mendelian randomisation uses genetic variants as instrumental variables to investigate causation. Preliminary analysis used two-sample Mendelian randomisation with lung function single nucleotide polymorphisms. To avoid collider bias, the main analysis used single nucleotide polymorphisms for lung function identified from UKBiobank in a multivariable Mendelian randomisation model conditioning for height, body mass index and smoking.Multivariable Mendelian randomisation shows strong evidence that reduced forced vital capacity (FVC) causes increased risk of coronary artery disease (OR 1.32, 95% CI 1.19-1.46 per standard deviation). Reduced forced expiratory volume in 1 s (FEV₁) is unlikely to cause increased risk of coronary artery disease, as evidence of its effect becomes weak after conditioning for height (OR 1.08, 95% CI 0.89-1.30). There is weak evidence that reduced lung function increases risk of ischaemic stroke.

CONCLUSION

There is strong evidence that reduced FVC is independently and causally associated with coronary artery disease. Although the mechanism remains unclear, FVC could be taken into consideration when assessing cardiovascular risk and considered a potential target for reducing cardiovascular events. FEV₁ and airflow obstruction do not appear to cause increased cardiovascular events; confounding and collider bias may explain previous findings of a causal association.

The Coronary Artery Risk Development In Young Adults (CARDIA) Study: JACC Focus Seminar 8/8

The CARDIA (Coronary Artery Risk Development in Young Adults) study began in 1985 to 1986 with enrollment of 5,115 Black or White men and women ages 18 to 30 years from 4 US communities. Over 35 years, CARDIA has contributed fundamentally to our understanding of the contemporary epidemiology and life course of cardiovascular health and disease, as well as pulmonary, renal, neurological, and other manifestations of aging. CARDIA has established associations between the neighborhood environment and the evolution of lifestyle behaviors with biological risk factors, subclinical disease, and early clinical events. CARDIA has also identified the nature and major determinants of Black-White differences in the development of cardiovascular risk. CARDIA will continue to be a unique resource for understanding determinants, mechanisms, and outcomes of cardiovascular health and disease across the life course, leveraging ongoing pan-omics work from genomics to metabolomics that will define mechanistic pathways involved in cardiometabolic aging.

Evaluation of spirometry findings with severity of coronary artery disease in smoker patients undergoing angiography in military hospital during 2019-2020

BACKGROUND

Coronary heart disease is the most common cardiovascular worldwide, and some factors can affect the prognosis of this disease. So, in this study, we aimed to examine the relationship between spirometry and cardiovascular risk factors in patients undergoing coronary angiography who were referred to military hospitals.

METHODS

In this cross-sectional study, 200 smokers referred to military hospital for angiography, were enrolled in terms of the inclusion and exclusion criteria between 2019 and 2020. The severity of the coronary artery involvement was determined using Gensini score. The relationship among spirometry and the forced expiratory volume in one second (FEV1), forced vital capacity (FVC), and FEV1/FVC with other variables including lipid profile, demographic findings, blood pressure, physical activity, and severity of coronary artery involvement were also exanimated.

RESULTS

The frequency of severity of coronary involvement were reported as 3.5% with 25% involvement, 7% with 26-50% involvement, 5.5% with 51-75% involvement, 27.5% with 76-90% involvement, 47% with 91-99% involvement, and 9.5% with 100% involvement. In addition, there was no significant relationship between severity of coronary involvement and FEV1 and FVC (P>0.05). However, there was a significant difference between the groups based on FEV1/FVC (P=0.003), in which the mean of FEV1/FVC was significantly lower in higher severity of coronary involvement compared to lower severity of coronary involvement. There were significant relationships between severity of coronary involvement and body mass index, fasting blood sugar, high-density lipoprotein and low-density lipoprotein, cholesterol, triglyceride, waist circumference, systolic blood pressure, diastolic blood pressure, physical activity, and smoking (P<0.05).

CONCLUSION

There is an association between pulmonary diseases and coronary disease, in which the increased coronary involvement severity is associated with the decreased FEV1/FVC.

Association between Cardiorespiratory Fitness and Bronchiectasis at CT: A Long-term Population-based Study of Healthy Young Adults Aged 18-30 Years in the CARDIA Study

Background Protective factors against the risk of bronchiectasis are unknown. A high level of cardiorespiratory fitness is associated with a lower risk of chronic obstructive pulmonary disease. But whether fitness relates to bronchiectasis remains, to the knowledge of the authors, unknown. Purpose To examine the association between cardiorespiratory fitness and bronchiectasis. Materials and Methods This was a secondary analysis of a prospective observational study: the Coronary Artery Risk Development in Young Adults cohort (from 1985-1986 [year 0] to 2015-2016 [year 30]). During a 30-year period, healthy participants (age at enrollment 18-30 years) underwent treadmill exercise testing at year 0 and year 20 visits. Cardiorespiratory fitness was determined according to the treadmill exercise duration. The 20-year difference in cardiorespiratory fitness was used as the fitness measurement. At year 25, chest CT was performed to assess bronchiectasis and was used as the primary outcome. Multivariable logistic models were performed to determine the association between cardiorespiratory fitness changes and bronchiectasis. Results Of 2177 selected participants (at year 0: mean age, 25 years ± 4 [standard deviation]; 1224 women), 209 (9.6%) had bronchiectasis at year 25. After adjusting for age, race-sex group, study site, body mass index, pack-years smoked, history of tuberculosis, pneumonia, asthma and myocardial infarction, peak lung function, and cardiorespiratory fitness at baseline, preservation of cardiorespiratory fitness was associated with lower odds of bronchiectasis at CT at year 25 (per 1-minute-longer treadmill duration from year 0 to year 20: odds ratio [OR], 0.88; 95% CI: 0.80, 0.98; P = .02). A consistent strong association was found when cough and phlegm were included in bronchiectasis (OR, 0.72; 95% CI: 0.59, 0.87; P < .001). Conclusion In a long-term follow-up, the preservation of cardiorespiratory fitness was associated with lower odds of bronchiectasis at CT. © RSNA, 2021 Online supplemental material is available for this article. See also the editorial by Stojanovska in this issue.

Association between pulmonary function and cardiac enzymes in sickle cell disease

BACKGROUND

There is scarcity of data on association between lung function and cardiac markers in patients with sickle cell disease (SCD). Meanwhile, SCD affects multi-organs in any one population. There seem to be an association between reduced pulmonary function with cardiac dysfunction. The current study examined the association between pulomanry function with cardiac markers in patients with SCD.

METHODOLOGY

This was a cross-sectional study with cases and controls. The cases (n=117) were made up of patients with SCD. The control subjects (n=58) were voluntary blood donors without SCD. The cellulose acetate electrophoresis was used to determine the genotypes of the study subjects. Blood samples were collected from all the study subjects for full blood count and measurement of cardiac enzymes. The cardiac enzymes measured were lactate dehydrogenase (LDH) and creatine kinase-myocardial band (CK-MB). Lung function test, using the vitalograph was done on all the study subjects. The Global Lung Initiative criteria were used to categorize lung disease as obstruction, restriction, mixed obstruction/restriction and normal.

RESULTS

The prevalence of elevated CK-MB and LDH among the SCD patients was 76.92% and 9.40% respectively, higher than the non-SCD controls (51.72% and 0% for elevated CK-MB and LDH respectively). Of all the impaired lung function, lung restriction was prevalent in all the study groups (30.77% and 15.52% for SCD patients and non-SCD controls respectively). In the fully adjusted model, reduced FEV1 was associated with nearly 3.5-fold higher odds of elevated CK-MB (odds ratio 3.35, 95% CI 1.26-8.90, p-value 0.015) in individuals with SCD.

CONCLUSION

Reduced FEV₁ which reflects airflow impairments are associated with CK-MB elevations in patients with SCD, suggesting a possible damage to the cardiomyocytes.

Accelerated FEV1 decline and risk of cardiovascular disease and mortality in a primary care population of COPD patients

Accelerated lung function decline has been associated with increased risk of cardiovascular disease (CVD) in a general population, but little is known about this association in chronic obstructive pulmonary disease (COPD). We investigated the association between accelerated lung function decline and CVD outcomes and mortality in a primary care COPD population.

COPD patients without a history of CVD were identified in the Clinical Practice Research Datalink (CPRD)-GOLD primary care dataset (n=36 382). Accelerated decline in forced expiratory volume in 1 s (FEV₁) was defined using the fastest quartile of the COPD population's decline. A Cox regression was used to assess the association between baseline accelerated FEV₁ decline and a composite CVD outcome over follow-up (myocardial infarction, ischaemic stroke, heart failure, atrial fibrillation, coronary artery disease and CVD mortality). The model was adjusted for age, sex, smoking status, body mass index, history of asthma, hypertension, diabetes, statin use, Modified Medical Research Council (mMRC) dyspnoea score, exacerbation frequency and baseline FEV₁ % predicted.

6110 COPD patients (16.8%) had a CVD event during follow-up; median length of follow-up was 3.6 years (interquartile range (IQR) 1.7–6.1 years). Median rate of FEV₁ decline was –19.4 mL·year⁻¹ (IQR –40.5–1.9); 9095 patients (25%) had accelerated FEV₁ decline (> –40.5 mL·year⁻¹), 27 287 (75%) did not (≤ –40.5 mL·year⁻¹). Risk of CVD and mortality was similar between patients with and without accelerated FEV₁ decline (HR_adj 0.98, 95% CI 0.90–1.06). Corresponding risk estimates were 0.99 (95% CI 0.83–1.20) for heart failure, 0.89 (95% CI 0.70–1.12) for myocardial infarction, 1.01 (95% CI 0.82–1.23) for stroke, 0.97 (95% CI 0.81–1.15) for atrial fibrillation, 1.02 (95% CI 0.87–1.19) for coronary artery disease and 0.94 (95% CI 0.71–1.25) for CVD mortality. Rather, risk of CVD was associated with a mMRC score ≤2 and two or more exacerbations in the year prior.

CVD outcomes and mortality were associated with exacerbation frequency and severity and increased mMRC dyspnoea score but not with accelerated FEV₁ decline.

In a primary care population of COPD patients, CVD outcomes and mortality were not associated with accelerated FEV₁ decline but with frequent and severe exacerbations of COPD and increased breathlessnesshttps://bit.ly/35APXL6

Low lung function in the developing world is analogous to stunting: a review of the evidence

Background: Low vital capacity, one of the consequences of restricted lung growth, is a strong predictor of cardiovascular mortality. Vital capacity is lower in the developing world than the developed world, even after adjusting for height, weight and gender. This difference is typically dismissed as ethnic variation, adjusted for by redefining normal. Whether this is a consequence of stunted lung growth, rather than just genetically smaller lungs, has not been investigated in detail. Therefore, we sought to compare factors implicated in both stunting and lung development, particularly in the developing world.

Methods: We conducted a manual screen of articles identified through Google Scholar and assessed risk of bias. No language restrictions were applied, so long as there was an associated English abstract. We queried VizHub (Global Burden of Disease Visualization Tool) and Google Dataset search engines for disease burden and genome wide association studies.  The scope of the article and the heterogeneity of the outcome measures reported required a narrative review of available evidence. To the extent possible, the review follows PRISMA reporting guidelines.

Results: Early life influences operate in synergism with genetic, environmental and nutritional factors to influence lung growth and development in children.  Low lung function and stunting have common anthropometric, environmental and nutritional correlates originating during early development. Similar anthropometric correlates shared chronic inflammatory pathways, indicated that the two conditions were analogous.

Conclusion: The analogy between poor lung function and stunting is conspicuous in the developing world, with malnutrition at the center of non -achievement of growth potential, susceptibility to infectious diseases and intrauterine programming for metabolic syndrome. This counter the idea of redefining the normal for lung function measurements, since observed inter-ethnic variations are likely a mix of natural genetic differences as well as differences in nurture such that reduced lung function reflects early life adversities.

[Pulmonary insufficiency in acute stroke: risk factors and mechanisms of development]

Various degrees of pulmonary insufficiency (PI) (PaO₂ ≤60 mm Hg, SaO₂ ≤90%) are diagnosed in most of patients with severe acute stroke (AS). Frequency and severity of PI positively correlates with the severity of AS. PI worsens patient's condition, prolongs the hospitalization period, and increases the probability of fatal outcome. Early clinical signs of PI may be undiagnosed due to the severity of stroke and thus not treated. The initiating pathogenic mechanism of PI is stress-related activation of sympathetic nervous system (SNS) and systemic immunosuppression. In severe stroke with mass effect, the rapid and significant increase in intracranial pressure may additionally activate the SNS. Risk factors of PI include older age, previous pulmonary disease, prolonged supine position, respiratory muscle dysfunction, apnea, and concomitant somatic diseases. Decompensation of somatic diseases leads to multiple stage reactions with facilitation of functional and morphologic changes in the pulmonary system, hypoxemia and hypoxia, promotes infectious complications and multiple organ failure and worsens neurological outcome. Diagnosis and treatment of PI in AS decreases mortality and improves rehabilitation prognosis.

Low lung function in the developing world is analogous to stunting: a review of the evidence

Background: Low vital capacity, one of the consequences of restricted lung growth, is a strong predictor of cardiovascular mortality. Vital capacity is lower in the developing world than the developed world, even after adjusting for height, weight and gender. This difference is typically dismissed as ethnic variation, adjusted for by redefining normal. Whether this is a consequence of stunted lung growth, rather than genetically smaller lungs, has not been investigated in detail. Therefore, we sought to compare factors implicated in both stunting and lung development, particularly in the developing world. Methods: We conducted a manual screen of articles identified through Google Scholar and assessed risk of bias. No language restrictions were applied, so long as there was an associated English abstract. We queried VizHub (Global Burden of Disease Visualization Tool) and Google Dataset search engines for disease burden and genome wide association studies.  The scope of the article and the heterogeneity of the outcome measures reported required a narrative review of available evidence. To the extent possible, the review follows PRISMA reporting guidelines. Results: Early life influences operate in synergism with environmental and nutritional factors to influence lung growth and development in children.  Low lung function and stunting have common anthropometric, environmental and nutritional correlates originating during early development. Similar anthropometric correlates and shared chronic inflammatory pathways indicated that the two conditions were analogous. Conclusion: The analogy between poor lung function and stunting is conspicuous in the developing world, where malnutrition lies at the center of non -achievement of growth potential, susceptibility to infectious diseases and intrauterine programming for metabolic syndrome. The common pathological mechanisms governing stunting and lung function deficits counter the idea of redefining the normal for lung function measurements.

Close Association between Subclinical Atherosclerosis and Pulmonary Function in Middle-Aged Male Smokers

AIMS

Cigarette smoking provokes deleterious influences on cardiovascular and pulmonary systems, although the underlying relationship has not been sufficiently investigated especially in early-stage disease. The present study investigated possible associations between subclinical atherosclerosis and pulmonary function in middle-aged male smokers.

METHODS

Male smokers undergoing their periodic health check-up were enrolled in this study (n=3,775, 45±8 years). Pulmonary function was evaluated using spirometry by calculating forced vital capacity (FVC) as a percentage of predicted value (FVC%-predicted), forced expiratory volume in one second (FEV1) as a percentage of predicted value (FEV1%-predicted), and the ratio of FEV1 to FVC (FEV1/FVC). Subclinical atherosclerosis was assessed based on ankle-brachial pressure index (ABI), cardio-ankle vascular index (CAVI), ultrasound examination of the carotid intima-media thickness (IMT), and presence of plaque.

RESULTS

Multivariate regression analysis showed that ABI was positively associated with FVC%-predicted and FEV1%-predicted after adjustment for confounders including smoking intensity, while CAVI or carotid IMT was inversely associated with both. Participants with chronic obstructive pulmonary disease (COPD, n=256) showed reduced ABI and increased CAVI or carotid IMT compared with those without COPD, and participants with carotid plaque had lower pulmonary function than those without plaque. Reduced FEV1/FVC was an independent determinant of carotid plaque and decreased ABI was an independent determinant of COPD, as revealed by logistic regression analysis with the endpoint of carotid plaque presence or a diagnosis of COPD revealed.

CONCLUSIONS

Middle-aged male smokers showed a close association between subclinical atherosclerosis and pulmonary function, implying that smoking induced-vascular and pulmonary damage are interacting in early-stage disease.

Lung Function and Gene Expression of Pathogen Recognition Pathway Receptors: the Cardia Lung Study

Activation of toll-like receptors (TLR1, TLR5, TLR6) and downstream markers (CCR1, MAPK14, ICAM1) leads to increased systemic inflammation. Our objective was to study the association between the gene expression levels of these six genes and lung function (Forced Expiratory Volume in one second (FEV₁), Forced Vital Capacity (FVC) and FEV₁/FVC). We studied gene expression levels and lung function in the Coronary Artery Risk Development in Young Adults study. Spirometry testing was used to measure lung function and gene expression levels were measured using the Nanostring platform. Multivariate linear regression models were used to study the association between lung function measured at year 30, 10-year decline from year 20 to year 30, and gene expression levels (highest quartile divided into two levels – 75th to 95th and>95th to 100th percentile) adjusting for center, smoking and BMI, measured at year 25. Year 30 FEV₁ and FVC were lower in the highest level of TLR5 compared to the lowest quartile with difference of 4.00% (p for trend: 0.04) and 3.90% (p for trend: 0.05), respectively. The 10-year decline of FEV₁ was faster in the highest level of CCR1 as compared to the lowest quartile with a difference of 1.69% (p for trend: 0.01). There was no association between gene expression and FEV₁/FVC. Higher gene expression levels in TLR5 and CCR1 are associated with lower lung function and faster decline in FEV₁ over 10 years, in a threshold manner, providing new insights into the role of inflammation in lung function.

Field Application of Digital Technologies for Health Assessment in the 10,000 Families Study

BACKGROUND

We field tested new-to-market portable, digital applications to assess hearing, pulmonary, and cognitive function to determine the feasibility of implementing these applications across a range of age groups in the pilot phase of the 10,000 Families Study (10KFS), a new Minnesota family-based prospective cohort study.

METHODS

We followed manufacturer recommended protocols for audiometry (SHOEBOX Inc), spirometry (NuvoAir), and the digital clock drawing test (dCDT; Digital Cognition Technologies Inc).

RESULTS

These digital devices were low cost and readily implemented in a 2.5-hour health fair visit with minimal training (2-3 hours) of study staff. To date, we have performed these measurements on 197 eligible 10KFS participants during an in-person clinic visit. A total of 37 children (age 4-17 years), 107 adults (18-64 years), and 53 seniors (≥65 years) were eligible to undergo hearing and pulmonary assessments. Children were less likely to successfully complete the hearing test (76%) compared with adults (86%) and seniors (89%). However, successful completion of the pulmonary assessment was high across all groups: 100% of children and seniors and 98% of adults. The dCDT was performed among those over the age of 40, and completion rates were 92% for those aged 41-64 and 94% for those ≥65 years.

CONCLUSIONS

Our field testing indicates these digital applications are easy and cost-effective to implement in epidemiologic studies.

IMPACT

Digital applications provide exciting opportunities to collect data in population studies. Issues related to data privacy, data access, and reproducibility of measurements need to be addressed before deploying digital applications in epidemiologic studies.See all articles in this CEBP Focus section, "Modernizing Population Science."

Lung function and cardiovascular disease: A link

The relationship between lung and heart diseases has long been recognized, with necropsy studies demonstrating silent myocardial infarctions or coronary artery calcification in patients with advanced emphysema as the death cause. Improvements in non-invasive techniques and epidemiologic approaches established that lung and cardiovascular diseases frequently coexist in mid and late life. Even among those without diagnosed lung disease, lower than expected forced vital capacity, forced expiratory volume in 1 s, and their ratio each portend greater risk of developing cardiovascular risk factors including hypertension, obesity, and metabolic syndrome, and for incident cardiovascular diseases including left heart failure, atrial fibrillation and stroke. Greater longitudinal declines in these spirometric measures are further associated with cardiovascular morbidity and mortality. While obstructive ventilatory patterns are more common, restrictive ventilatory patterns seem to demonstrate an independent and more robust association with cardiovascular diseases such as heart failure. These subclinical alterations in pulmonary function also relate to subclinical abnormalities of cardiac structure and function. Although the biologic pathways linking pulmonary and cardiovascular dysfunction are not clear, chronic systemic inflammation appears to be one important underlying pathophysiologic link. Despite the growing evidence of lung dysfunction as a cardiovascular risk factor, spirometric evaluation is still underutilized in clinical practice, particularly among cardiac patients, and optimal therapeutic and preventive strategies are still unclear. In this review, we address the current knowledge and controversies regarding the links between lung function and cardiovascular disease.

Lung function as a predictor of incident type 2 diabetes in community-dwelling adults: A longitudinal finding over 12 years from the Korean Genome and Epidemiology Study

AIM

Reduced lung function is associated with type 2 diabetes (T2D), but there are limited data in East Asian populations on the relationship between them. For this reason, this study investigated the longitudinal relationship of lung function with incident T2D in Korean adults.

METHODS

The study included 7583 non-diabetic adults aged 40-69 years from the Korean Genome and Epidemiology Study. Participants were divided into four groups according to gender-specific quartiles (Q1-Q4) of %PFVC and %PFEV₁. Also, HRs with 95% CIs for incident T2D were prospectively analyzed as per American Diabetes Association criteria using multivariate Cox proportional-hazards regression models.

RESULTS

During a 12-year follow-up, 1403 (18.5%) participants presented with newly developed T2D. HRs (95% CIs) of incident T2D in Q1 vs. Q4 (reference) of %PFVC were 1.67 (1.35-2.07) for men and 1.77 (1.39-2.24) for women and, of %PFEV₁, 1.58 (1.28-1.95) for men and 1.61 (1.27-2.03) for women, after adjusting for age, waist circumference, smoking status, alcohol intake, regular exercise, education levels, monthly household income, family history of diabetes, HOMA-IR, triglycerides, HDL cholesterol and high-sensitivity C-reactive protein levels.

CONCLUSION

Reduced lung function precedes and significantly predicts the future development of T2D independently of obesity, smoking and inflammation in community-dwelling middle-aged and elderly people.

Lung Function in Young Adults and Risk of Cardiovascular Events Over 29 Years: The CARDIA Study

Background

Diminished peak lung function in young adulthood is a risk factor for future chronic obstructive pulmonary disease. The association between lung disease and cardiovascular disease later in life is well documented. Whether peak lung function measured in young adulthood is associated with risk of future cardiovascular events is unknown.

Methods and Results

CARDIA (The Coronary Artery Risk Development in Young Adults) study is a prospective, multicenter, community‐based, longitudinal cohort study including 4761 participants aged 18 to 30 years with lung function testing we investigated the association between lung health in young adulthood and risk of subsequent cardiovascular events. We performed Cox proportional hazards regression to test the association between baseline and years 10 and 20 pulmonary function with incident cardiovascular events. Linear and logistic regression was performed to explore the associations of lung function with development of risk factors for cardiovascular disease as well as carotid intima‐media thickness and coronary artery calcified plaque. At baseline, mean age (±SD) was 24.9±3.6 years. Baseline forced expiratory volume in 1 second (hazard ratio) per −10‐unit decrement in percent predicted forced expiratory volume in 1 second (hazard ratio, 1.18; 95% CI, 1.06–1.31 [P=0.002]) and FVC per −10‐unit decrement in percent predicted FVC (hazard ratio, 1.19; 95% CI, 1.06–1.33 [P=0.003]) were associated with future cardiovascular events independent of traditional cardiovascular risk factors. Baseline lung function was associated with heart failure and cerebrovascular events but not coronary artery disease events.

Conclusions

Lung function in young adulthood is independently associated with cardiovascular events into middle age. This association appears to be driven by heart failure and cerebrovascular events rather than coronary heart disease.

Clinical Trial Registration

URL: https://www.clinicaltrials.gov. Unique identifier: NCT00005130.