Hospitalisation and mortality in patients with comorbid COPD and heart failure: a systematic review and meta-analysis

Smoking cessation only partially reverses cardiac metabolic and structural remodeling in mice

AIMS

Active cigarette smoking is a major risk factor for chronic obstructive pulmonary disease that remains elevated after cessation. Skeletal muscle dysfunction has been well documented after smoking, but little is known about cardiac adaptations to cigarette smoking. The underlying cellular and molecular cardiac adaptations, independent of confounding lifestyle factors, and time course of reversibility by smoking cessation remain unclear. We hypothesized that smoking negatively affects cardiac metabolism and induces local inflammation in mice, which do not readily reverse upon 2-week smoking cessation.

METHODS

Mice were exposed to air or cigarette smoke for 14 weeks with or without 1- or 2-week smoke cessation. We measured cardiac mitochondrial respiration by high-resolution respirometry, cardiac mitochondrial density, abundance of mitochondrial supercomplexes by electrophoresis, and capillarization, fibrosis, and macrophage infiltration by immunohistology, and performed cardiac metabolome and lipidome analysis by mass spectrometry.

RESULTS

Mitochondrial protein, supercomplex content, and respiration (all p < 0.03) were lower after smoking, which were largely reversed within 2-week smoking cessation. Metabolome and lipidome analyses revealed alterations in mitochondrial metabolism, a shift from fatty acid to glucose metabolism, which did not revert to control upon smoking cessation. Capillary density was not different after smoking but increased after smoking cessation (p = 0.02). Macrophage infiltration and fibrosis (p < 0.04) were higher after smoking but did not revert to control upon smoking cessation.

CONCLUSIONS

While cigarette-impaired smoking-induced cardiac mitochondrial function was reversed by smoking cessation, the remaining fibrosis and macrophage infiltration may contribute to the increased risk of cardiovascular events after smoking cessation.

Factors associated with non-fatal heart failure and atrial fibrillation or flutter within the first 30 days post COPD exacerbation: a nested case-control study

BACKGROUND

An immediate, temporal risk of heart failure and arrhythmias after a Chronic Obstructive Pulmonary Disease (COPD) exacerbation has been demonstrated, particularly in the first month post-exacerbation. However, the clinical profile of patients who develop heart failure (HF) or atrial fibrillation/flutter (AF) following exacerbation is unclear. Therefore we examined factors associated with people being hospitalized for HF or AF, respectively, following a COPD exacerbation.

METHODS

We conducted two nested case-control studies, using primary care electronic healthcare records from the Clinical Practice Research Datalink Aurum linked to Hospital Episode Statistics, Office for National Statistics for mortality, and socioeconomic data (2014-2020). Cases had hospitalization for HF or AF within 30 days of a COPD exacerbation, with controls matched by GP practice (HF 2:1;AF 3:1). We used conditional logistic regression to explore demographic and clinical factors associated with HF and AF hospitalization.

RESULTS

Odds of HF hospitalization (1,569 cases, 3,138 controls) increased with age, type II diabetes, obesity, HF and arrhythmia history, exacerbation severity (hospitalization), most cardiovascular medications, GOLD airflow obstruction, MRC dyspnea score, and chronic kidney disease. Strongest associations were for severe exacerbations (adjusted odds ratio (aOR)=6.25, 95%CI 5.10-7.66), prior HF (aOR=2.57, 95%CI 1.73-3.83), age≥80 years (aOR=2.41, 95%CI 1.88-3.09), and prior diuretics prescription (aOR=2.81, 95%CI 2.29-3.45). Odds of AF hospitalization (841 cases, 2,523 controls) increased with age, male sex, severe exacerbation, arrhythmia and pulmonary hypertension history and most cardiovascular medications. Strongest associations were for severe exacerbations (aOR=5.78, 95%CI 4.45-7.50), age≥80 years (aOR=3.15, 95%CI 2.26-4.40), arrhythmia (aOR=3.55, 95%CI 2.53-4.98), pulmonary hypertension (aOR=3.05, 95%CI 1.21-7.68), and prescription of anticoagulants (aOR=3.81, 95%CI 2.57-5.64), positive inotropes (aOR=2.29, 95%CI 1.41-3.74) and anti-arrhythmic drugs (aOR=2.14, 95%CI 1.10-4.15).

CONCLUSIONS

Cardiopulmonary factors were associated with hospitalization for HF in the 30 days following a COPD exacerbation, while only cardiovascular-related factors and exacerbation severity were associated with AF hospitalization. Understanding factors will help target people for prevention.

Cardiovascular disease and risk in COPD: a state of the art review

INTRODUCTION

Chronic Obstructive Pulmonary Disease (COPD) and cardiovascular diseases (CVD) commonly co-exist. Outcomes of people living with both conditions are poor in terms of symptom burden, receiving evidence-based treatment and mortality. Increased understanding of the underlying mechanisms may help to identify treatments to relieve this disease burden. This narrative review covers the overlap of COPD and CVD with a focus on clinical presentation, mechanisms, and interventions. Literature up to December 2023 are cited.

AREAS COVERED

1. What is COPD 2. The co-existence of COPD and cardiovascular disease 3. Mechanisms of cardiovascular disease in COPD. 4. Populations with COPD are at risk of CVD 5. Complexity in the co-diagnosis of COPD in those with cardiovascular disease. 6. Therapy for COPD and implications for cardiovascular events and risk. 7. Cardiovascular risk and exacerbations of COPD. 8. Pro-active identification and management of CV risk in COPD.

EXPERT OPINION

The prospective identification of co-morbid COPD in CVD patients and of CVD and CV risk in people with COPD is crucial for optimizing clinical outcomes. This includes the identification of novel treatment targets and the design of clinical trials specifically designed to reduce the cardiovascular burden and mortality associated with COPD. Databases searched: Pubmed, 2006-2023.

Lung fluid content during 6MWT in patients with COPD with and without comorbid heart failure

BACKGROUND

Impact of lung fluid content changing during exercise has not been investigated in chronic obstructive pulmonary disease (COPD). Using a novel point-of-care measurement system (remote dielectric sensing (ReDS) system), we aimed to investigate changes in lung fluid content before and after 6-minute walk test (6MWT); especially, differences between patients with and without comorbid heart failure (HF) were evaluated.

METHODS

From June 2021 to July 2022, patients with COPD referred for 6MWT were prospectively enrolled. Measurements of lung fluid content by ReDS were conducted before and after 6MWT. Data on demographics, exacerbation history, spirometry and 6MWT were collected. Patients were also assessed for comorbid HF by cardiovascular evaluation. The main variables of interest were pre-6MWT ReDS, post-6MWT ReDS and post-pre ∆ReDS.

RESULTS

In total, 133 patients with COPD were included. Comparisons between patients with COPD with and without HF indicated similar pre-6MWT ReDS (26.9%±5.9% vs 26.5%±4.7%; p=0.751), but a significant difference in post-6MWT ReDS (29.7%±6.3% vs 25.7%±5.3%; p=0.002). Patients with COPD without HF exhibited a significant decrease in post-6MWT ReDS (from 26.5% to 25.7%; paired t-test p=0.001); conversely, those with HF displayed a remarkable increase in post-6MWT ReDS (from 26.9% to 29.7%; paired t-test p<0.001). Receiver operating characteristic curve analysis showed an area under the curve of 0.82 (95% CI 0.71 to 0.93) for post-pre ∆ReDS in differentiating between patients with COPD with and without HF.

CONCLUSIONS

Dynamic changes in lung fluid content prior to and following 6MWT significantly differed between patients with COPD with and without HF. Measurements of lung fluid content by ReDS during exercise testing may be of merit to identify patients with COPD with unrecognised HF.

Addressing Barriers to Chronic Obstructive Pulmonary Disease (COPD) Care: Three Innovative Evidence-Based Approaches: A Review

Chronic obstructive pulmonary disease (COPD) is a preventable yet widespread and profoundly debilitating respiratory condition, exerting substantial personal and global health ramifications alongside significant economic implications. The first objective of this literature review was to identify reviews the barriers to optimal COPD care, categorizing them into personal patient factors, professional awareness and knowledge, patient-professional relationships, and healthcare service models, including access to care that significantly impacts the quality of COPD management. The second objective was to introduce three approaches for enhancing COPD care outcomes: Self-Management Educational Programs, Health Qigong, and Telehealth service provision, each demonstrating positive effects on COPD patients' health status. These evidence-based interventions offer promising avenues for enhancing COPD care and patient outcomes. Integrating these approaches into comprehensive COPD management strategies holds potential for improving the well-being and quality of life of individuals living with this chronic condition.

Analysis and prediction of readmissions for heart failure in the first year after discharge with INCA score

To determine the readmissions trends and the comorbidities of patients with heart failure that most influence hospital readmission rates. Heart failure (HF) is one of the most prevalent health problems as it causes loss of quality of life and increased health-care costs. Its prevalence increases with age and is a major cause of re-hospitalisation within 30 days after discharge. INCA study had observational and ambispective design, including 4,959 patients from 2000 to 2019, with main diagnosis of HF in Extremadura (Spain). The variables examined were collected from discharge reports. To develop the readmission index, capable of discriminating the population with higher probability of re-hospitalisation, a Competing-risk model was generated. Readmission rate have increased over the period under investigation. The main predictors of readmission were: age, diabetes mellitus, presence of neoplasia, HF without previous hospitalisation, atrial fibrillation, anaemia, previous myocardial infarction, obstructive pulmonary disease (COPD) and chronic kidney disease (CKD). These variables were assigned values with balanced weights, our INCA index showed that the population with values greater than 2 for men and women were more likely to be re-admitted. Previous HF without hospital admission, CKD, and COPD appear to have the greatest effect on readmission. Our index allowed us to identify patients with different risks of readmission.

The rate of ward to intensive care transfer and its predictors among hospitalized COPD patients, a retrospective study in a local tertiary center in Saudi Arabia

OBJECTIVE

To investigate the prevalence of intensive care unit (ICU) admission and its predictors among hospitalized chronic obstructive pulmonary disease (COPD) patients.

METHODS

An observational retrospective study was conducted. All patients with a confirmed diagnosis of COPD according to the GOLD guidelines between 28 and 2020 and 1 March 2023 at Al-Noor Specialist Hospital were included in this study. Patients were excluded if a preemptive diagnosis of COPD was made clinically without spirometry evidence of fixed airflow limitation. Descriptive results were presented as frequency (percentage) for categorical variables and mean (SD) for continuous variables and to estimate prevalence of ICU admission. Predictors of ICU admission among hospitalized COPD patients were determined using logistic regression analysis. A SPSS (Statistical Package for the Social Sciences) version 25 was used to perform all statistical analysis.

RESULTS

A total of 705 patients with COPD were included in this study. The mean age was 65.4 (25.3) years. Around 12.4% of the hospitalized patients were admitted to the ICD. Logistic regression analysis identified that older age (OR; 1.92, (1.41-2.62)), smoking (OR; 1.60 (1.17-2.19)), and having specific comorbidities (Hypertension (OR; 1.98 (1.45-2.71)), Diabetes mellitus (OR; 1.42 (1.04-1.93)), GERD (OR; 2.81 (1.99-3.96)), Ischemic heart disease (OR; 3.22 (2.19-4.75)), Obstructive sleep apnea syndrome (OR; 2.14 (1.38-3.33)), stroke (OR; 4.51 (2.20-9.26))) were predictors of ICU admissions among patients with COPD.

CONCLUSIONS

Our study found that a step-up approach to inpatient COPD management requires admission to the ICU in 12.4%, for which age, smoking status, cardiovascular, and stroke were important predictors. Further clinical research is needed to provide a validated model that can be incorporated into clinical practice to monitor this patient population during their admission and identify at-risk individuals for early transfer to higher acuity settings and intensive care units.

Global Comparison of Readmission Rates for Patients With Heart Failure

BACKGROUND

Heart failure (HF) readmission rates are low in some jurisdictions. However, international comparisons are lacking and could serve as a foundation for identifying regional patient management strategies that could be shared to improve outcomes.

OBJECTIVES

This study sought to summarize 30-day and 1-year all-cause readmission and mortality rates of hospitalized HF patients across countries and to explore potential differences in rates globally.

METHODS

We performed a systematic review and meta-analysis using MEDLINE, Embase, and CENTRAL for observational reports on hospitalized adult HF patients at risk for readmission or mortality published between January 2010 and March 2021. We conducted a meta-analysis of proportions using a random-effects model, and sources of heterogeneity were evaluated with meta-regression.

RESULTS

In total, 24 papers reporting on 30-day and 23 papers on 1-year readmission were included. Of the 1.5 million individuals at risk, 13.2% (95% CI: 10.5%-16.1%) were readmitted within 30 days and 35.7% (95% CI: 27.1%-44.9%) within 1 year. A total of 33 papers reported on 30-day and 45 papers on 1-year mortality. Of the 1.5 million individuals hospitalized for HF, 7.6% (95% CI: 6.1%-9.3%) died within 30 days and 23.3% (95% CI: 20.8%-25.9%) died within 1 year. Substantial variation in risk across countries was unexplained by countries' gross domestic product, proportion of gross domestic product spent on health care, and Gini coefficient.

CONCLUSIONS

Globally, hospitalized HF patients exhibit high rates of readmission and mortality, and the variability in readmission rates was not explained by health care expenditure, risk of mortality, or comorbidities.

Jörres R, Behr J, Welte T. The Diagnosis and Treatment of COPD and Its Comorbidities

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is the third most common cause of death around the world. The affected patients suffer not only from impaired lung function, but also from a wide variety of comorbidities. Their cardiac comorbidities, in particular, lead to increased mortality.

METHODS

This review is based on pertinent publications retrieved by a selective search in PubMed, including guidelines from Germany and abroad.

RESULTS

The usual diagnostic criteria for COPD are a post-bronchodilator FEV1/FVC quotient below the fixed threshold of 0.7, or, preferably, below the lower limit of normal (LLN) according to the GLI reference values for the avoidance of over- and underdiagnosis. The overall prognosis is markedly affected by comorbidities of the lung itself and those that involve other organs; in particular, many persons with COPD die of heart disease. The potential presence of heart disease must be borne in mind in the evaluation of patients with COPD, as lung disease can impair the detection of heart disease.

CONCLUSION

As patients with COPD are often multimorbid, the early diagnosis and adequate treatment not only of their lung disease, but also of their extrapulmonary comorbidities are very important. Well-established diagnostic instruments and well-tested treatments are available and are described in detail in the guidelines concerning the comorbidities. Preliminary observations suggest that more attention should be paid to the potential positive effects of treating comorbidities on the lung disease itself, and vice versa.

The Role of Oxidative Stress and Antioxidants in Cardiovascular Comorbidities in COPD

Oxidative stress driven by several environmental and local airway factors associated with chronic obstructive bronchiolitis, a hallmark feature of COPD, plays a crucial role in disease pathomechanisms. Unbalance between oxidants and antioxidant defense mechanisms amplifies the local inflammatory processes, worsens cardiovascular health, and contributes to COPD-related cardiovascular dysfunctions and mortality. The current review summarizes recent developments in our understanding of different mechanisms contributing to oxidative stress and its countermeasures, with special attention to those that link local and systemic processes. Major regulatory mechanisms orchestrating these pathways are also introduced, with some suggestions for further research in the field.

Cardiovascular Diseases in COPD: From Diagnosis and Prevalence to Therapy

Chronic obstructive pulmonary disease (COPD) is considered one of the leading causes of mortality. Cardiovascular comorbidities are diagnosed often in COPD patients, not only because of the common risk factors these two diseases share, but also because of the systemic inflammation which characterizes COPD and has deleterious effects in the cardiovascular system. The comorbid cardiovascular diseases in COPD result in several difficulties in the holistic treatment of these patients and affect outcomes such as morbidity and mortality. Several studies have reported that mortality from cardiovascular causes is common among COPD patients, while the risk for acute cardiovascular events increases during COPD exacerbations and remains high for a long time even after recovery. In this review, we focus on the prevalence of cardiovascular comorbidities in COPD patients, presenting the evidence regarding the interaction of the pathophysiological pathways which characterize each disease. Furthermore, we summarize information regarding the effects of cardiovascular treatment on COPD outcomes and vice versa. Finally, we present the current evidence regarding the impact of cardiovascular comorbidities on exacerbations, quality of life and survival of COPD patients.

Day-night patterns in heart rate variability and complexity: differences with age and cardiopulmonary disease

STUDY OBJECTIVES

Heart rate variability (HRV) measures provide valuable insights into physiology; however, gaps remain in understanding circadian patterns in heart rate dynamics. We aimed to explore day-night differences in heart rate dynamics in patients with chronic cardiopulmonary disease compared with healthy controls.

METHODS

Using 24-hour heart rate data from patients with chronic obstructive pulmonary disease (COPD) and/or heart failure (n = 16) and healthy adult controls (older group: ≥50 years, n = 42; younger group: 20-49 years, n = 136), we compared day-night differences in conventional time and frequency domain HRV indices and a multiscale-entropy-based complexity index (CI1-20) of HRV among the 3 groups.

RESULTS

Twenty-four-hour HRV showed significant day-night differences (marked with "△") among younger healthy (mean age: 34.5 years), older healthy (mean age: 61.6 years), and cardiopulmonary patients (mean age: 68.4 years), including change in percentage of adjacent intervals that differ > 50 ms (△pNN50), high frequency (△HF), normalized low frequency (△nLF), ratio (△LF/HF), and △CI1-20. Among these, △LF/HF (2.13 ± 2.35 vs 1.1 ± 2.47 vs -0.35 ± 1.25; P < .001) and △CI1-20 (0.15 ± 0.24 vs 0.02 ± 0.28 vs -0.21 ± 0.27; P < .001) were significant in each pairwise comparison following analysis of variance tests. Average CI1-20 was highest in younger healthy individuals and lowest in cardiopulmonary patients (1.37 ± 0.12 vs 1.01 ± 0.27; P < .001). Younger healthy patients showed a heart rate complexity dipping pattern (night < day), older healthy patients showed nondipping, and cardiopulmonary patients showed reverse dipping (night > day).

CONCLUSIONS

As measures of 24-hour variability, traditional and complexity-based metrics of HRV exhibit large day-night differences in healthy individuals; these differences are blunted, or even reversed, in individuals with cardiopulmonary pathology. Measures of diurnal dynamics may be useful indices of reduced adaptive capacity in patients with cardiopulmonary conditions.

CITATION

Ma Y, Chang M-C, Litrownik D, Wayne PM, Yeh GY. Day-night patterns in heart rate variability and complexity: differences with age and cardiopulmonary disease. J Clin Sleep Med. 2023;19(5):873-882.

Multidimensional Interventions on Supporting Disease Management for Hospitalized Patients with Heart Failure: The Role of Clinical and Community Pharmacists

BACKGROUND

existing trials on the role of clinical pharmacists in managing chronic disease patients have focused on variety of interventions, including preparing patients for the transition from hospital to home. However, little quantitative evidence is available regarding the effect of multidimensional interventions on supporting disease management for hospitalized patients with heart failure (HF). The present paper reviews the effects of inpatient, discharge and/or after-discharge interventions performed on hospitalized HF patients by multidisciplinary teams, including pharmacists.

METHODS

articles were identified through search engines in three electronic databases following the PRISMA Protocol. Randomized controlled trials (RCTs) or non-randomized intervention studies conducted in the period 1992-2022 were included. In all studies, baseline characteristics of patients as well as study end-points were described in relation to a control group i.e., usual care and a group of subjects that received care from a clinical and/or community pharmacist, as well as other health professionals (Intervention). Study outcomes included all-cause hospital 30-day re-admission or emergency room (ER) visits, all-cause hospitalization within >30 days after discharge, specific-cause hospitalization rates, medication adherence and mortality. The secondary outcomes included adverse events and quality of life. Quality assessment was carried out using RoB 2 Risk of Bias Tool. Publication bias across studies was determined using the funnel plot and Egger's regression test.

RESULTS

a total of 34 protocols were included in the review, while the data from 33 trials were included in further quantitative analyses. The heterogeneity between studies was high. Pharmacist-led interventions, usually performed within interprofessional care teams, reduced the rates of 30-day all-cause hospital re-admission (odds ratio, OR = 0.78; 95% CI 0.62-0.98; p = 0.03) and all-cause hospitalization >30 days after discharge (OR = 0.73; 95% CI 0.63-0.86; p = 0.0001). Subjects hospitalized primarily due to heart failure demonstrated reduced risk of hospital admission within longer periods, i.e., from 60 to 365 days after discharge (OR = 0.64; 95% CI 0.51-0.81; p = 0.0002). The rate of all-cause hospitalization was reduced by multidimensional interventions taken by pharmacists: reviews of medicine lists and/or their reconciliation at discharge (OR = 0.63; 95% CI 0.43-0.91; p = 0.014), as well as interventions that were based mainly on patient education and counseling (OR = 0.65; 95% CI 0.49-0.88; p = 0.0047). In conclusion, given that HF patients often have complex treatment regimens and multiple comorbid conditions, our findings highlight the need for greater involvement from skilled clinical and community pharmacists in disease management.

Obstructive sleep apnea reduces functional capacity and impairs cardiac autonomic modulation during submaximal exercise in patients with chronic obstructive pulmonary disease: A follow-up study

BACKGROUND

Functional capacity and heart rate variability (HRV) are important prognostic markers in chronic obstructive pulmonary disease (COPD) and obstructive sleep apnea syndrome (OSA). However, the impact of the overlap of these diseases and the one-year clinical follow-up has not yet been evaluated.

OBJECTIVES

To assess whether the presence of OSA can impair functional performance and cardiac autonomic control during exercise in patients with COPD; and to verify whether the overlap of these diseases could lead to worse clinical outcomes during the one-year follow-up.

METHODS

Thirty-four patients underwent pulmonary function tests, echocardiography and polysomnography for diagnostic confirmation, disease staging, exclusion of any cardiac changes, and allocation between groups. The patients underwent the six-minute walk test (6MWT) to assess functional capacity and HRV during exercise. Subsequently, patients were followed up for 12 months to record outcomes such as exacerbation, hospitalization, and deaths. At the end of this period, the patients were revaluated to verify the hypotheses of the study.

RESULTS

The OSA-COPD group showed greater functional impairment when compared to the COPD group (p=0.003) and showed worse cardiac autonomic responses during the 6MWT with greater parasympathetic activation (p=0.03) and less complexity of the autonomic nervous system, in addition to being more likely to exacerbate (p=0.03) during one year of follow-up.

CONCLUSION

OSA-COPD produces deleterious effects on functional performance and a greater autonomic imbalance that impairs clinical outcomes.

Comprehensive care for people living with heart failure and chronic obstructive pulmonary disease—Integration of palliative care with disease-specific care: From guidelines to practice

Heart failure (HF) and chronic obstructive pulmonary disease (COPD) are the leading global epidemiological, clinical, social, and economic burden. Due to similar risk factors and overlapping pathophysiological pathways, the coexistence of these two diseases is common. People with severe COPD and advanced chronic HF (CHF) develop similar symptoms that aggravate if evoking mechanisms overlap. The coexistence of COPD and CHF limits the quality of life (QoL) and worsens symptom burden and mortality, more than if only one of them is present. Both conditions progress despite optimal, guidelines directed treatment, frequently exacerbate, and have a similar or worse prognosis in comparison with many malignant diseases. Palliative care (PC) is effective in QoL improvement of people with CHF and COPD and may be a valuable addition to standard treatment. The current guidelines for the management of HF and COPD emphasize the importance of early integration of PC parallel to disease-modifying therapies in people with advanced forms of both conditions. The number of patients with HF and COPD requiring PC is high and will grow in future decades necessitating further attention to research and knowledge translation in this field of practice. Care pathways for people living with concomitant HF and COPD have not been published so far. It can be hypothesized that overlapping of symptoms and similarity in disease trajectories allow to draw a model of care which will address symptoms and problems caused by either condition.

Association Between Asthma and All-Cause Mortality and Cardiovascular Disease Morbidity and Mortality: A Meta-Analysis of Cohort Studies

Background

Asthma and cardiovascular disease (CVD) share many risk factors. Previous meta-analyses indicated that asthma is associated with an increased risk of CVD and all-cause mortality, but these studies were limited by unstandardized search strategies and the number of articles included.

Objective

We sought to systematically synthesize evidence investigating the impact of asthma on all-cause mortality and CVD morbidity and mortality.

Methods

We searched in PubMed and EMBASE for observational cohort studies (inception dates to November 10, 2021) that had both asthma groups and control groups. We also manually searched the reference lists of correlative articles to include other eligible studies. Data for associations between asthma and all-cause mortality and CVD morbidity and mortality were needed.

Results

We summarized the findings from 30 cohort studies comprising 4,157,823 participants. Asthma patients had increased CVD morbidity [relative risk (RR) = 1.28, 95% confidence interval (CI) = 1.16–1.40] and increased CVD mortality (RR = 1.25, 95% CI = 1.14–1.38). Asthma patients also had increased risk of all-cause mortality (RR = 1.38, 95% CI = 1.07–1.77). In subgroup analyses, female asthma patients had a higher risk of CVD morbidity and all-cause mortality than male asthma patients, and late-onset asthma patients had a higher risk of CVD morbidity than early-onset asthma patients.

Conclusion

Asthma patients have increased risk of all-cause mortality and CVD morbidity and mortality. This information reminds clinicians to be aware of the risk of CVD and all-cause mortality in asthma patients.

Systematic Review Registration

http://www.crd.york.ac.uk/PROSPERO/, PROSPERO, identifier: CRD 42021290082.

2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure: Developed by the Task Force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC). With the special contribution of the Heart Failure Association (HFA) of the ESC

Document Reviewers: Rudolf A. de Boer (CPG Review Coordinator) (Netherlands), P. Christian Schulze (CPG Review Coordinator) (Germany), Magdy Abdelhamid (Egypt), Victor Aboyans (France), Stamatis Adamopoulos (Greece), Stefan D. Anker (Germany), Elena Arbelo (Spain), Riccardo Asteggiano (Italy), Johann Bauersachs (Germany), Antoni Bayes-Genis (Spain), Michael A. Borger (Germany), Werner Budts (Belgium), Maja Cikes (Croatia), Kevin Damman (Netherlands), Victoria Delgado (Netherlands), Paul Dendale (Belgium), Polychronis Dilaveris (Greece), Heinz Drexel (Austria), Justin Ezekowitz (Canada), Volkmar Falk (Germany), Laurent Fauchier (France), Gerasimos Filippatos (Greece), Alan Fraser (United Kingdom), Norbert Frey (Germany), Chris P. Gale (United Kingdom), Finn Gustafsson (Denmark), Julie Harris (United Kingdom), Bernard Iung (France), Stefan Janssens (Belgium), Mariell Jessup (United States of America), Aleksandra Konradi (Russia), Dipak Kotecha (United Kingdom), Ekaterini Lambrinou (Cyprus), Patrizio Lancellotti (Belgium), Ulf Landmesser (Germany), Christophe Leclercq (France), Basil S. Lewis (Israel), Francisco Leyva (United Kingdom), AleVs Linhart (Czech Republic), Maja-Lisa Løchen (Norway), Lars H. Lund (Sweden), Donna Mancini (United States of America), Josep Masip (Spain), Davor Milicic (Croatia), Christian Mueller (Switzerland), Holger Nef (Germany), Jens-Cosedis Nielsen (Denmark), Lis Neubeck (United Kingdom), Michel Noutsias (Germany), Steffen E. Petersen (United Kingdom), Anna Sonia Petronio (Italy), Piotr Ponikowski (Poland), Eva Prescott (Denmark), Amina Rakisheva (Kazakhstan), Dimitrios J. Richter (Greece), Evgeny Schlyakhto (Russia), Petar Seferovic (Serbia), Michele Senni (Italy), Marta Sitges (Spain), Miguel Sousa-Uva (Portugal), Carlo G. Tocchetti (Italy), Rhian M. Touyz (United Kingdom), Carsten Tschoepe (Germany), Johannes Waltenberger (Germany/Switzerland) All experts involved in the development of these guidelines have submitted declarations of interest. These have been compiled in a report and published in a supplementary document simultaneously to the guidelines. The report is also available on the ESC website www.escardio.org/guidelines For the Supplementary Data which include background information and detailed discussion of the data that have provided the basis for the guidelines see European Heart Journal online.

Recommendations for COPD management in Central and Eastern Europe

INTRODUCTION

The Global Initiative for Chronic Obstructive Lung Disease (GOLD) strategy report provides guidance on effective management of chronic obstructive pulmonary disease (COPD) according to local healthcare systems. However, COPD is a heterogenous disease and certain aspects, including prevalence, disease-time course and phenotype distribution, can differ between countries. Moreover, features of clinical practice and healthcare systems for COPD patients can vary widely, even in geographically close and economically similar countries.

AREAS COVERED

Based on an initial workshop of respiratory physicians from eleven countries across Central and Eastern Europe (CEE) in December 2018 and subsequent discussions, this article offers region-specific insights from clinical practice and healthcare systems in CEE. Taking GOLD 2020 recommendations into account, we suggest approaches to adapt these into national clinical guidelines for COPD management in CEE.

EXPERT OPINION

Several factors should be considered when optimizing management of COPD in CEE compared with other regions, including differences in smoking status, vaccination uptake, prevalence of tuberculosis and nontuberculous mycobacteria, and variations in healthcare systems. We provide guidance and algorithms for pharmacologic and non-pharmacologic management of COPD for the following scenarios: initial and follow-up treatment, treatment of patients with frequent exacerbations, and withdrawal of inhaled corticosteroids where appropriate.

Respiratory-related death in individuals with incident asthma and COPD: a competing risk analysis

Background

Distinguishing between mortality attributed to respiratory causes and other causes among people with asthma, COPD, and asthma-COPD overlap (ACO) is important. This study used electronic health records in England to estimate excess risk of death from respiratory-related causes after accounting for other causes of death.

Methods

We used linked Clinical Practice Research Datalink (CPRD) primary care and Office for National Statistics mortality data to identify adults with asthma and COPD from 2005 to 2015. Causes of death were ascertained using death certificates. Hazard ratios (HR) and excess risk of death were estimated using Fine-Gray competing risk models and adjusting for age, sex, smoking status, body mass index and socioeconomic status.

Results

65,021 people with asthma and 45,649 with COPD in the CPRD dataset were frequency matched 5:1 with people without the disease on age, sex and general practice. Only 14 in 100,000 people with asthma are predicted to experience a respiratory-related death up to 10 years post-diagnosis, whereas in COPD this is 98 in 100,000. Asthma is associated with an 0.01% excess incidence of respiratory related mortality whereas COPD is associated with an 0.07% excess. Among people with asthma-COPD overlap (N = 22,145) we observed an increased risk of respiratory-related death compared to those with asthma alone (HR = 1.30; 95% CI 1.21–1.40) but not COPD alone (HR = 0.89; 95% CI 0.83–0.94).

Conclusions

Asthma and COPD are associated with an increased risk of respiratory-related death after accounting for other causes; however, diagnosis of COPD carries a much higher probability. ACO is associated with a lower risk compared to COPD alone but higher risk compared to asthma alone.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12890-022-01823-4.

Unmet needs in the management of exacerbations of chronic obstructive pulmonary disease

Exacerbations of chronic obstructive pulmonary disease (COPD) are episodes of acute worsening of respiratory symptoms that require additional therapy. These events play a pivotal role in the natural course of the disease and are associated with a progressive decline in lung function, reduced health status, a low physical activity level, tremendous health care costs, and increased mortality. Although most exacerbations have an infectious origin, the underlying mechanisms are heterogeneous and specific predictors of their occurrence in individual patients are currently unknown. Accurate prediction and early diagnosis of exacerbations is essential to develop novel targets for prevention and personalized treatments to reduce the impact of these events. Several potential biomarkers have previously been studied, these however lack specificity, accuracy and do not add value to the available clinical predictors. At present, microbial composition and host-microbiome interactions in the lung are increasingly recognized for their role in affecting the susceptibility to exacerbations, and may steer towards a novel direction in the management of COPD exacerbations. This narrative review describes the current challenges and unmet needs in the management of acute exacerbations of COPD. Exacerbation triggers, biological clusters, current treatment strategies, and their limitations, previously studied biomarkers and prediction tools, the lung microbiome and its role in COPD exacerbations as well as future directions are discussed.

COPD Comorbidity Profiles and 2-Year Trajectory of Acute and Postacute Care Use

BACKGROUND

Multiple morbidity is the norm in advanced COPD and contributes to high symptom burden and worse outcomes.

RESEARCH QUESTION

Can distinct comorbidity profiles be identified and validated in a community-based sample of patients with COPD from a large integrated health care system using a standard, commonly used diagnostic code-based comorbidity index and downstream 2-year health care use data?

STUDY DESIGN AND METHODS

In this retrospective cohort study, we used latent class analysis (LCA) to identify comorbidity profiles in a population-based sample of 91,453 patients with a COPD diagnosis between 2011 and 2015. We included specific comorbid conditions from the Charlson Comorbidity Index (CCI) and accounted for variation in underlying prevalence of different comorbidities across the three study sites. Sociodemographic, clinical, and health-care use data were obtained from electronic health records (EHRs). Multivariate logistic regression analysis was used to compare rates of acute and postacute care use by class.

RESULTS

The mean age was 71 ± 11 years, 55% of patients were women, 23% of patients were people of color, and 80% of patients were former or current smokers. LCA identified four distinct comorbidity profiles with progressively higher CCI scores: low morbidity (61%; 1.9 ± 1.4), metabolic renal (21%; 4.7 ± 1.8), cardiovascular (12%; 4.6 ± 1.9), and multimorbidity (7%; 7.5 ± 1.7). In multivariate models, during 2 years of follow-up, a significant, nonoverlapping increase was found in the odds of having any all-cause acute (hospitalizations, observation stays, and ED visits) and postacute care use across the comorbidity profiles.

INTERPRETATION

Distinct comorbidity profiles can be identified in patients with COPD using standard EHR-based diagnostic codes, and these profiles are associated with subsequent acute and postacute care use. Population-based risk stratification schemes for end-to-end, comprehensive COPD management should consider integrating comorbidity profiles such as those found in this study.

Impacts of Comorbid Chronic Obstructive Pulmonary Disease and Congestive Heart Failure on Prognosis of Critically Ill Patients

Background

Comorbid congestive heart failure (CHF) was associated with worse prognosis in patients with chronic obstructive pulmonary disease (COPD), while few studies specially investigated critically ill patients. This study investigated the associations between comorbid COPD with or without CHF and prognosis of patients admitted to intensive care units (ICU).

Methods

We conducted a retrospective cohort study in the Medical Information Mart for Intensive Care III database. Adult ICU patients were included and categorized as patients without COPD and CHF, patients with COPD but without CHF, patients with CHF but without COPD, and patients with both COPD and CHF. The study outcomes were 28-day mortality and 90-day mortality after ICU admission. Kaplan–Meier curves were plotted to estimate the survival distributions between groups and multivariable Cox regression analyses were employed to evaluate the associations between comorbid COPD and/or CHF and the study outcomes.

Results

A total of 29,589 patients were included with 20,507 patients without COPD and CHF, 1575 patients with COPD, 6190 patients with CHF, and 1317 patients with both COPD and CHF. The highest 28-day mortality rate and 90-day mortality rate were found in patients with both COPD and CHF (15.95% and 25.74%, respectively), while patients with COPD and patients with CHF had similar mortality rates, also observed in Kaplan–Meier curves. Compared with patients without COPD or CHF, comorbid COPD or CHF both significantly increased the risk of 28-day mortality and 90-day mortality, but comorbid COPD and CHF together was associated with the highest risk of mortality (hazard ratio 1.55 (95% confidence interval (CI) 1.33–1.80) and 1.25 (95% CI 1.16–1.35) for 28-day mortality and 90-day mortality, respectively), while no significant interaction between COPD and CHF was found.

Conclusion

ICU patients with comorbid COPD or CHF both experienced greater mortalities, while these two risk factors seemed to play an independent role.

Evaluating the impact of chronic obstructive pulmonary disease on in-hospital outcomes following left ventricular assist device implantation

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is a cause of ventricular dysfunction. However, in the setting of patients with heart failure undergoing left ventricular assist device (LVAD) implantation, there is a paucity of data on the association between COPD and in-hospital outcomes.

METHODS AND RESULTS

Retrospective cohort study based on the NIS including patients ≥18 years who underwent LVAD implantation from 2011 to 2017. Multivariate regression was used to evaluate the impact of COPD on in-hospital outcomes. A total of 25,503 patients underwent LVAD implantation, of which 13.8% also had COPD. COPD group was older (median 62 vs. 58 years), and more males (82% vs. 76.4%, p < .001 for both). COPD group had more hypertension, diabetes, atrial tachyarrhythmias, dyslipidemia, prior stroke, coronary artery diseases, pulmonary hypertension, and chronic kidney disease (p < .001 for all). No differences in strokes, infections, mechanical circulatory support, and LVAD thrombosis. There was a higher incident of inpatient acute kidney injury, major bleeding, cardiac complications, thromboembolism, and cardiac arrest in patients without COPD (p < .05 for all). Compared with no-COPD group, COPD group had a lower mortality (6.2% vs. 12.4%; odds ratio, 0.59; confidence interval, 0.512-0.685; p < .05).

CONCLUSION

Patients with COPD undergoing LVAD implantation have more comorbidities, without an associated increase mortality.