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Sridharan K, Sivaramakrishnan G. Intraclass comparison of inhaled corticosteroids for the risk of pneumonia in chronic obstructive pulmonary airway disorder: a network meta-analysis and meta-regression. Int J Clin Pharm 2024; 46:831-842. [PMID: 38664319 DOI: 10.1007/s11096-024-01736-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Accepted: 03/30/2024] [Indexed: 07/30/2024]
Abstract
BACKGROUND Inhalational corticosteroids (ICS) were observed to increase the pneumonia risk in chronic obstructive pulmonary airway disorder (COPD). However, it is unknown whether any differences exist between the drugs within the ICS class. AIM This study aimed to evaluate the risk of pneumonia associated with different ICS and identify factors that predict pneumonia in patients with moderate-to-severe COPD using a network meta-analysis. METHOD Electronic databases (Medline, Cochrane CENTRAL and Google Scholar) were searched for trials comparing ICS in COPD patients. The outcomes were pneumonia and serious pneumonia. Odds ratios (OR) with 95% confidence interval (95% CI) were estimated. Meta-regression was used to identify the predictors. The strength of evidence was graded using the Grading of Recommendations, Assessment, Development, and Evaluations approach. RESULTS Sixty-six studies (103,347 participants) were included. Fluticasone (OR: 1.46; 95% CI: 1.26, 1.7), mometasone (OR: 2.2; 95% CI: 1.05, 4.6), and beclometasone (OR: 1.7; 95% CI: 1.1, 2.6) were observed with an increased pneumonia risk compared to placebo. Fluticasone (OR: 1.5; 95% CI: 1.3, 1.7) was observed with an increased risk of serious pneumonia. High doses (OR: 1.2; 95% CI: 1.03, 1.4), BMI ≥ 25 kg/m2 (OR: 1.6; 95% CI: 1.1, 2.2), and history of exacerbations in the preceding year predicted the pneumonia risk. Evidence strength was moderate. CONCLUSION ICS class differences in pneumonia risk were observed in terms of pooled effect estimates but it is unlikely that any clinically relevant differences exist. Risk-benefit analysis supports ICS use in moderate-severe COPD.
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Affiliation(s)
- Kannan Sridharan
- Department of Pharmacology and Therapeutics, College of Medicine and Medical Sciences, Arabian Gulf University, Manama, Kingdom of Bahrain.
| | - Gowri Sivaramakrishnan
- Department of Dental Postgraduate Training, Ministry of Health, Manama, Kingdom of Bahrain
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Zhang N, Fan X, Zhang Y, Xu N, Li L. Risk of Fracture and Osteoporosis in Patients With COPD and Inhaled Corticosteroids Treatment. Respir Care 2023; 68:1719-1727. [PMID: 37553218 PMCID: PMC10676258 DOI: 10.4187/respcare.10933] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/10/2023]
Abstract
BACKGROUND There are disputes whether inhaled corticosteroids (ICS) increase the incidence of fracture or osteoporosis among patients with COPD. The aim of this meta-analysis was to assess the effect of ICS treatment on the risk of fracture and osteoporosis in subjects with COPD. METHODS This study included parallel-group randomized controlled trials (RCTs) comparing ICS and control (non-ICS) therapy for subjects with COPD that reported adverse events including fractures or osteoporosis. Studies were found using MEDLINE/PubMed, Embase, and Cochrane Library databases between 1998-September 2022. Pooled risk ratios (RRs) and 95% CIs were calculated for primary outcomes. RESULTS A total of 61,380 participants from 26 RCTs were included in the meta-analysis. Exposure to ICS did not increase the risk of fracture (RR 1.10 [95% CI 0.98-1.23], P = .10) or osteoporosis risk (RR 0.93 [95% CI 0.49-1.79], P = .84) in subjects with COPD. CONCLUSIONS ICS use did not increase the incidence of fracture or osteoporosis in subjects with COPD.
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Affiliation(s)
- Nini Zhang
- Medical School of Yan'an University, Yan'an 716000, Shaanxi, China
| | - Xinhui Fan
- Medical School of Yan'an University, Yan'an 716000, Shaanxi, China
| | - Yuyu Zhang
- Department of General Practice, Xijing Hospital, Fourth Military Medical University, Xi'an 710032, Shaanxi, China
| | - Ning Xu
- Department of Critical Care Medicine, The First Hospital of Yulin, Yulin 719000, Shaanxi, China
| | - Li Li
- Department of Respiratory Medicine, The First Hospital of Yulin, Yulin 719000, Shaanxi, China.
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Kholis FN, Pratama KG, Hadiyanto JN. Association between inhaled corticosteroid use and risk of hyperglycemia in patients with chronic obstructive pulmonary disease: A systematic review and meta-analysis. Tzu Chi Med J 2023; 35:355-361. [PMID: 38035057 PMCID: PMC10683519 DOI: 10.4103/tcmj.tcmj_131_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Revised: 07/13/2023] [Accepted: 08/04/2023] [Indexed: 12/02/2023] Open
Abstract
Objectives Chronic obstructive pulmonary disease (COPD) patients have a higher risk of developing diabetes, and studies suggest that inhaled corticosteroids (ICSs) use may be associated with a higher risk of diabetes, particularly at higher doses. This study aims to investigate the effects of ICS use on the risk of diabetes and blood glucose levels in COPD patients. Materials and Methods A systematic search was carried out on the PubMed, EBSCOhost, and ProQuest databases using the terms "Inhaled Corticosteroids," "Diabetes," and "Chronic Obstructive Pulmonary Disease" for the period between 2013 and 2023. The systematic review adhered to the PRISMA 2020 guideline. A meta-analysis was conducted using a random-effects model using the RevMan 5 software. Results A total of 14 studies were included in the final analysis, with 10 randomized controlled trials (RCTs) and 4 observational studies. Two observational studies investigated the relationship between ICS dose and diabetes risk. A meta-analysis of the RCTs studies showed a nonstatistically significant tendency toward increased blood glucose (odds ratio [OR] 1.07 and 95% confidence interval [CI] 0.88-1.30) after a 52-week follow-up. Whereas the observational studies showed a tendency toward an increased risk of diabetes (OR 1.40 and 95% CI 0.96-2.03). Furthermore, a subgroup meta-analysis of high-dose ICS (>900 μg/day) showed a significant increase in the risk of diabetes (OR 1.20 and 95% CI 1.09-1.32). Conclusion Short-term use of ICS does not have a significant effect on blood glucose. However, long-term use, especially at higher doses, can increase the risk of developing diabetes.
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Affiliation(s)
- Fathur Nur Kholis
- Divison of Pulmonology, Department of Internal Medicine, Faculty of Medicine, Dr. Kariadi General Hospital, Diponegoro University, Semarang, Central Java, Indonesia
| | | | - Jessica Novia Hadiyanto
- Department of Internal Medicine, Faculty of Medicine, Dr. Kariadi General Hospital, Diponegoro University, Semarang, Central Java, Indonesia
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Peng S, Tan C, Du L, Niu Y, Liu X, Wang R. Effect of fracture risk in inhaled corticosteroids in patients with chronic obstructive pulmonary disease: a systematic review and meta-analysis. BMC Pulm Med 2023; 23:304. [PMID: 37592316 PMCID: PMC10436625 DOI: 10.1186/s12890-023-02602-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Accepted: 08/09/2023] [Indexed: 08/19/2023] Open
Abstract
BACKGROUND The fracture risk of patients with chronic obstructive pulmonary disease (COPD) treated with inhaled corticosteroids is controversial. And some large-scale randomized controlled trials have not solved this problem. The purpose of our systematic review and meta-analysis including 44 RCTs is to reveal the effect of inhaled corticosteroids on the fracture risk of COPD patients. METHODS Two reviewers independently retrieved randomized controlled trials of inhaled corticosteroids or combinations of inhaled corticosteroids in the treatment of COPD from PubMed, Embase, Medline, Cochrane Library, and Web of Science. The primary outcome was a fracture event. This study was registered at PROSPERO (CRD42022366778). RESULTS Forty-four RCTs were performed in 87,594 patients. Inhaled therapy containing ICSs (RR, 1.19; 95%CI, 1.04-1.37; P = 0.010), especially ICS/LABA (RR, 1.30; 95%CI, 1.10-1.53; P = 0.002) and triple therapy (RR, 1.49; 95%CI, 1.03-2.17; P = 0.04) were significantly associated with the increased risk of fracture in COPD patients when compared with inhaled therapy without ICSs. Subgroup analyses showed that treatment duration ≥ 12 months (RR, 1.19; 95%CI, 1.04-1.38; P = 0.01), budesonide therapy (RR, 1.64; 95%CI., 1.07-2.51; P = 0.02), fluticasone furoate therapy (RR, 1.37; 95%CI, 1.05-1.78; P = 0.02), mean age of study participants ≥ 65 (RR, 1.27; 95%CI, 1.01-1.61; P = 0.04), and GOLD stage III(RR, 1.18; 95%CI, 1.00-1.38; P = 0.04) were significantly associated with an increased risk of fracture. In addition, budesonide ≥ 320 ug bid via MDI (RR, 1.75; 95%CI, 1.07-2.87; P = 0.03) was significantly associated with the increased risk of fracture. CONCLUSION Inhalation therapy with ICSs, especially ICS/LABA or triple therapy, increased the risk of fracture in patients with COPD compared with inhaled therapy without ICS. Treatment duration, mean age of participants, GOLD stage, drug dosage form, and drug dose participated in this association. Moreover, different inhalation devices of the same drug also had differences in risk of fracture.
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Affiliation(s)
- Shisheng Peng
- Third Hospital of Shanxi Medical University, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Taiyuan, 030032, China
| | - Cong Tan
- Third Hospital of Shanxi Medical University, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Taiyuan, 030032, China
| | - Lirong Du
- Third Hospital of Shanxi Medical University, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Taiyuan, 030032, China
| | - Yanan Niu
- Third Hospital of Shanxi Medical University, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Taiyuan, 030032, China
| | - Xiansheng Liu
- Third Hospital of Shanxi Medical University, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Taiyuan, 030032, China
- Department of Respiratory and Critical Care Medicine, National Clinical Research Center of Respiratory Disease, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Ruiying Wang
- Third Hospital of Shanxi Medical University, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Taiyuan, 030032, China.
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Chen H, Deng ZX, Sun J, Huang Q, Huang L, He YH, Ma C, Wang K. Association of Inhaled Corticosteroids With All-Cause Mortality Risk in Patients With COPD: A Meta-analysis of 60 Randomized Controlled Trials. Chest 2023; 163:100-114. [PMID: 35921883 DOI: 10.1016/j.chest.2022.07.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2022] [Revised: 07/04/2022] [Accepted: 07/17/2022] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Inhaled corticosteroids (ICSs) have been used widely in the maintenance therapy of COPD. However, whether inhaled therapy containing ICSs can reduce the all-cause mortality risk and the possible benefited patient subgroups is unclear. RESEARCH QUESTION Does inhaled therapy containing ICSs reduce the all-cause mortality risk in patients with COPD compared with other inhaled therapies not containing ICSs? STUDY DESIGN AND METHODS We searched PubMed, Cochrane Library, Embase, and ClinicalTrials.gov for relevant randomized clinical trials (RCTs). Pooled results were calculated using Peto ORs with corresponding 95% CIs. RESULTS Sixty RCTs enrolling 103,034 patients were analyzed. Inhaled therapy containing ICSs (Peto OR, 0.90; 95% CI, 0.84-0.97), especially triple therapy (Peto OR, 0.73; 95% CI, 0.59-0.91), was associated with a reduction in the all-cause mortality risk among patients with COPD when compared with inhaled therapy without ICSs. Subgroup analyses revealed that treatment duration of > 6 months (Peto OR, 0.90; 95% CI, 0.83-0.97), medium-dose ICSs (Peto OR, 0.71; 95% CI, 0.56-0.91), low-dose ICSs (Peto OR, 0.88; 95% CI, 0.79-0.97), and budesonide (Peto OR, 0.75; 95% CI, 0.59-0.94) were involved in this association. The predictors of this association included eosinophil counts of ≥ 200/μL or percentage of ≥ 2%, documented history of ≥ 2 moderate and severe exacerbations in the previous year, Global Initiative for Chronic Obstructive Lung Disease stages III or IV, age younger than 65 years, and BMI of ≥ 25 kg/m2, among which eosinophil counts of ≥ 200/μL (Peto OR, 0.58; 95% CI, 0.36-0.95) were the strongest predictor. INTERPRETATION Inhaled therapy containing ICSs, especially triple therapy, of longer than 6 months was associated with a reduction in the all-cause mortality risk in patients with COPD. The predictors of this association included medication factors and patient characteristics, among which eosinophil counts of ≥ 200/μL were the strongest predictor. TRIAL REGISTRY PROSPERO; No.: CRD42022304725; URL: https://www.crd.york.ac.uk/prospero/.
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Affiliation(s)
- Hong Chen
- Department of Respiratory and Critical Care Medicine, Chengdu Second People's Hospital, Chengdu, China
| | - Zheng-Xu Deng
- Department of Respiratory and Critical Care Medicine, Chengdu Second People's Hospital, Chengdu, China
| | - Jian Sun
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Chengdu Medical College, Chengdu, China
| | - Qiang Huang
- Department of Respiratory and Critical Care Medicine, Chengdu Second People's Hospital, Chengdu, China
| | - Lan Huang
- Department of Respiratory and Critical Care Medicine, Chengdu Second People's Hospital, Chengdu, China
| | - Yong-Hong He
- Department of Respiratory and Critical Care Medicine, Chengdu Second People's Hospital, Chengdu, China
| | - Chunlan Ma
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Chengdu Medical College, Chengdu, China
| | - Ke Wang
- Department of Respiratory and Critical Care Medicine, West China Hospital, Sichuan University, Chengdu, China.
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Ding Y, Sun L, Wang Y, Zhang J, Chen Y. Efficacy of ICS versus Non-ICS Combination Therapy in COPD: A Meta-Analysis of Randomised Controlled Trials. Int J Chron Obstruct Pulmon Dis 2022; 17:1051-1067. [PMID: 35547781 PMCID: PMC9084385 DOI: 10.2147/copd.s347588] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Accepted: 03/24/2022] [Indexed: 12/15/2022] Open
Abstract
Background Several large randomized clinical trials (RCTs) have assessed the efficacy and safety of inhaled corticosteroid (ICS) combination regimens versus non-ICS therapy in patients with chronic obstructive pulmonary disease (COPD) at increased risk of exacerbation risk with mixed results. Methods We performed a systematic literature review and meta-analysis of RCTs comparing the effect of ICS-containing combination therapy and non-ICS regimen in patients with COPD. Results A total of 54 RCTs (N = 57,333) reported treatment effects on various outcomes and were eligible for inclusion. Overall, the number of patients experiencing moderate/severe exacerbations was significantly lower for ICS-containing combination therapy versus non-ICS therapy (RR: 0.86 [95% CI: 0.80-0.93]). The annual rate of exacerbations was also significantly reduced by 22% (0.78 [0.72-0.86]) with ICS-containing versus non-ICS therapy. The annual rate of exacerbations requiring hospitalisation was reduced by 31% versus non-ICS therapy (0.69 [0.54-0.88]); similar reduction was observed for exacerbations requiring oral steroids (0.69 [0.66-0.73]). Overall, the effect on trough FEV1 was comparable between ICS-containing and non-ICS therapies (follow-up: 6-52 weeks); however, a significant improvement in lung function (trough FEV1) was observed for ICS/LABA versus LABA (MD: +0.04 L [0.03-0.05]) and ICS/LABA/LAMA versus LAMA (MD: +0.09 L [0.05-0.13]) regimens. In addition, a significant improvement in QoL was observed with ICS-containing versus non-ICS therapy (MD in SGRQ score: -0.90 [-1.50, -0.31]). Conclusion This meta-analysis demonstrated that a wide range of patients with COPD could benefit from dual and triple ICS-containing therapy.
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Affiliation(s)
- Yanling Ding
- Department of Respiratory and Critical Care Medicine, Peking University Third Hospital, Beijing, People’s Republic of China
| | - Lina Sun
- Department of Respiratory and Critical Care Medicine, Peking University Third Hospital, Beijing, People’s Republic of China
| | - Ying Wang
- Department of Respiratory and Critical Care Medicine, Peking University Third Hospital, Beijing, People’s Republic of China
| | - Jing Zhang
- Department of Respiratory and Critical Care Medicine, Peking University Third Hospital, Beijing, People’s Republic of China
| | - Yahong Chen
- Department of Respiratory and Critical Care Medicine, Peking University Third Hospital, Beijing, People’s Republic of China
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Pu X, Liu L, Feng B, Zhang Z, Wang G. Association between ICS use and risk of hyperglycemia in COPD patients: systematic review and meta-analysis. Respir Res 2021; 22:201. [PMID: 34238280 PMCID: PMC8265114 DOI: 10.1186/s12931-021-01789-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Accepted: 06/29/2021] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND The effect of inhaled corticosteroids (ICS) on risk of hyperglycemia in patients with chronic obstructive pulmonary disease (COPD) remains ambiguous. The aim of this study is to evaluate the association between ICS use and the incidence of hyperglycemia related adverse effects in COPD patients. METHODS Medline/PubMed, Embase, the Cochrane Central Register of Controlled Trials (CENTRAL), and ClinicalTrials.gov were searched from inception to 25 May 2020. Randomized controlled trials (RCTs) of ICS versus control (non-ICS) treatment for COPD patients reporting on risk of hyperglycemia were included. The Mantel-Haenszel method with fixed-effects modeling was used to calculate pooled relative risks (RRs) and 95% confidence intervals (CIs). RESULTS Seventeen RCTs with 43,430 subjects were included in the meta-analysis. Pooled results suggested that there was no statistically significant difference in the risk of hyperglycemia between the ICS group and the control group (RR 1.02, 95% CI 0.90-1.16, P = 0.76). In addition, no significant difference was noted in the effect on glucose level (RR 1.20, 95% CI 0.79-1.82, P = 0.40), risk of diabetes progression (RR 0.84, 95% CI 0.20-3.51, P = 0.81) and new onset diabetes mellitus (RR 1.0, 95% CI 0.88-1.15, P = 0.95) between the ICS group and the control group. These findings also were consistent across all subgroup analyses. CONCLUSIONS Use of ICS does not have an effect on the blood glucose and is not associated with the risk of new onset diabetes mellitus and diabetes progression in patients with COPD. Further RCTs exploring the association between ICS use and risk of hyperglycemia in COPD patients are still needed to verify our results of this analysis.
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Affiliation(s)
- Xiaofeng Pu
- Department of Pharmacy, The Affiliated Hospital of Southwest Medical University, 25 Taiping Street, Luzhou, 646000, Sichuan, China
| | - Liang Liu
- Department of Clinical Pharmacy, School of Pharmacy, Southwest Medical University, Luzhou, 646000, China
| | - Bimin Feng
- Department of Clinical Pharmacy, School of Pharmacy, Southwest Medical University, Luzhou, 646000, China
| | - Zhengji Zhang
- Department of Pharmacy, The Affiliated Hospital of Southwest Medical University, 25 Taiping Street, Luzhou, 646000, Sichuan, China
| | - Guojun Wang
- Department of Pharmacy, The Affiliated Hospital of Southwest Medical University, 25 Taiping Street, Luzhou, 646000, Sichuan, China.
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Chen H, Sun J, Huang Q, Liu Y, Yuan M, Ma C, Yan H. Inhaled Corticosteroids and the Pneumonia Risk in Patients With Chronic Obstructive Pulmonary Disease: A Meta-analysis of Randomized Controlled Trials. Front Pharmacol 2021; 12:691621. [PMID: 34267661 PMCID: PMC8275837 DOI: 10.3389/fphar.2021.691621] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Accepted: 06/14/2021] [Indexed: 12/14/2022] Open
Abstract
Background: Whether all types of inhaled corticosteroids (ICSs) would increase the pneumonia risk in patients with chronic obstructive pulmonary disease (COPD) remains controversial. We aimed to assess the association between ICSs treatment and pneumonia risk in COPD patients, and the impact of medication details and baseline characteristics of patients on the association. Methods: Four databases (PubMed, Embase, Cochrane Library, and Clinical Trials.gov) were searched to identify eligible randomized controlled trials (RCTs) comparing ICSs treatment with non-ICSs treatment on the pneumonia risk in COPD patients. Pooled results were calculated using Peto odds ratios (Peto ORs) with corresponding 95% confidence intervals (CIs). Results: A total of 59 RCTs enrolling 103,477 patients were analyzed. All types of ICSs significantly increased the pneumonia risk (Peto OR, 1.43; 95% CI, 1.34–1.53). Subgroup analysis showed that there was a dose-response relationship between ICSs treatment and pneumonia risk (low-dose: Peto OR, 1.33; 95% CI, 1.22–1.45; medium-dose: Peto OR, 1.50; 95% CI, 1.28–1.76; and high-dose: Peto OR, 1.64; 95% CI, 1.45–1.85). Subgroup analyses based on treatment durations and baseline characteristics (severity, age, and body mass index) of patients were consistant with the above results. Subgroup analysis based on severity of pneumonia showed that fluticasone (Peto OR, 1.75; 95% CI, 1.44–2.14) increased the risk of serious pneumonia, while budesonide and beclomethasone did not. Conclusions: ICSs treatment significantly increased the risk of pneumonia in COPD patients. There was a dose-response relationship between ICSs treatment and pneumonia risk. The pneumonia risk was related with COPD severity.
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Affiliation(s)
- Hong Chen
- Department of Respiratory and Critical Care Medicine, Chengdu Second People's Hospital, Chengdu, China
| | - Jian Sun
- Department of Respiratory, The First Affiliated Hospital of Chengdu Medical College, Chengdu, China
| | - Qiang Huang
- Department of Respiratory and Critical Care Medicine, Chengdu Second People's Hospital, Chengdu, China
| | - Yongqi Liu
- Department of Respiratory and Critical Care Medicine, Chengdu Second People's Hospital, Chengdu, China
| | - Mengxin Yuan
- Department of Respiratory and Critical Care Medicine, Chengdu Second People's Hospital, Chengdu, China
| | - Chunlan Ma
- Department of Respiratory, The First Affiliated Hospital of Chengdu Medical College, Chengdu, China
| | - Hao Yan
- Department of Respiratory and Critical Care Medicine, Chengdu Second People's Hospital, Chengdu, China
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Horne BD, Ali R, Midwinter D, Scott-Wilson C, Crim C, Miller BE, Rubin DB. Validation of the Summit Lab Score in Predicting Exacerbations of Chronic Obstructive Pulmonary Disease Among Individuals with High Arterial Stiffness. Int J Chron Obstruct Pulmon Dis 2021; 16:41-51. [PMID: 33447025 PMCID: PMC7802087 DOI: 10.2147/copd.s279645] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2020] [Accepted: 12/11/2020] [Indexed: 12/29/2022] Open
Abstract
INTRODUCTION The presence of cardiovascular (CV) risk factors and CV disease in patients with chronic obstructive pulmonary disease (COPD) leads to worse outcomes. A number of tools are currently available to stratify the risk of adverse outcomes in these patients with COPD. This post hoc analysis evaluated the Summit Lab Score for validation as a predictor of the first episode of moderate-to-severe acute exacerbation of chronic obstructive pulmonary disease (AECOPD) and other outcomes, in patients with COPD and high arterial pulse wave velocity (aPWV). METHODS Data from a multicenter, randomized, placebo-controlled, double-blind study were retrospectively analyzed to evaluate treatment effects of once-daily fluticasone furoate/vilanterol 100/25 μg in patients with COPD and an elevated CV risk (aPWV≥11m/s) over 24 weeks. The previously derived Summit Lab Score and, secondarily, the Intermountain Risk Score (IMRS) were computed for each patient, with patients then stratified into tertiles for each score. Risk of moderate-to-severe AECOPD was analyzed across tertiles using Kaplan-Meier survival curve and Cox regression analyses. RESULTS In 430 patients with COPD, Kaplan-Meier probabilities of no moderate-to-severe AECOPD for Summit Lab Score tertiles 1, 2, and 3 were 92.3%, 95.5%, and 85.1%, respectively (P trend = 0.015), over 24 weeks. Grouped by IMRS tertiles, the respective probabilities were 92.9%, 91.2%, and 88.3%, respectively (P trend = 0.141). Length of stay in the hospital (P = 0.034) and the hospital ward (P = 0.042) were also significantly different between Summit Lab Score tertiles but not for intensive care (P = 0.191). CONCLUSION The Summit Lab Score was associated with the 24-week risk of moderate-to-severe AECOPD in COPD patients with elevated CV risk. Secondarily, IMRS showed a trend towards differences in the risk of AECOPD, which was not statistically significant.
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Affiliation(s)
- Benjamin D Horne
- Intermountain Medical Center Heart Institute, Salt Lake City, UT, USA
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University, Stanford, CA, USA
| | | | | | | | - Courtney Crim
- GlaxoSmithKline Plc., Research Triangle Park, Raleigh, NC, USA
| | | | - David B Rubin
- GlaxoSmithKline Plc., Research Triangle Park, Raleigh, NC, USA
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Urban MH, Kreibich N, Gleiss A, Funk GC, Hartl S, Burghuber OC. Effects of roflumilast on arterial stiffness in COPD (ELASTIC): A randomized trial. Respirology 2020; 26:153-160. [PMID: 32725799 DOI: 10.1111/resp.13914] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2020] [Revised: 04/30/2020] [Accepted: 06/03/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND AND OBJECTIVE Cardiovascular risk is substantially increased in patients with COPD and can be quantified via arterial stiffness. The PDE-IV inhibitor roflumilast revealed a potential reduction of COPD-related cardiovascular risk. We aimed to investigate the effects of roflumilast on arterial stiffness by quantification of pulse wave velocity (PWV) in stable COPD. METHODS In this randomized placebo-controlled trial, 80 COPD patients received roflumilast or placebo for 24 weeks. The primary outcome was the change in cf-PWV. Secondary outcomes comprised markers of vascular function (e.g. Aix and RHI), systemic inflammation (e.g. IL-6 and TNF-α) and clinical characteristics of COPD (e.g. CAT and 6MWT). RESULTS A total of 33 and 34 patients completed the roflumilast and placebo arm, respectively (age, median (IQR): 64.5 (61-69.5) vs 64.5 (56-72) years; FEV1 , median (IQR): 34.5 (25.5-48.6) vs 35.3 (27-46.8) % predicted; 6MWT, median (IQR): 428 (340-558) vs 456 (364-570) m). Change from baseline PWV did not show a significant difference between roflumilast and placebo (+5.0 (95% CI: -2.0 to +13.0) vs 0.0 (95% CI: -7.0 to +7.0)%, P = 0.268). Roflumilast did not improve markers of vascular function or systemic inflammation. We observed a significant improvement in change from baseline 6MWT with roflumilast versus placebo (+53.0 (95% CI: +19.1 to +86.9) vs -0.92 (95% CI: -35.1 to +33.3) m, P = 0.026). CONCLUSION Our study revealed no beneficial effects of roflumilast on arterial stiffness. Further studies are needed to test a potential improvement of exercise capacity with roflumilast in COPD.
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Affiliation(s)
- Matthias H Urban
- Department of Internal and Respiratory Medicine, Krankenhaus Nord - Klinik Floridsdorf and Ludwig Boltzmann Institute for COPD and Respiratory Epidemiology, Vienna, Austria
| | - Nicole Kreibich
- Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Andreas Gleiss
- Center for Medical Statistics, Informatics, and Intelligent Systems, Medical University of Vienna, Vienna, Austria
| | - Georg-Christian Funk
- Department of Internal and Respiratory Medicine, Wilhelminenspital, Vienna, Austria.,Karl-Landsteiner Institute for Respiratory Research and Pneumological Oncology, Vienna, Austria
| | - Sylvia Hartl
- Department of Respiratory Medicine and Ludwig Boltzmann Institute for COPD and Respiratory Epidemiology, Otto-Wagner-Hospital and Sigmund Freud University, Medical School, Vienna, Austria
| | - Otto C Burghuber
- Department of Respiratory and Critical Care Medicine and Ludwig Boltzmann Institute for COPD and Respiratory Epidemiology, Otto-Wagner-Hospital and Sigmund Freud University, Medical School, Vienna, Austria
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11
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Correlation of Inhaled Long-Acting Bronchodilators With Adverse Cardiovascular Outcomes in Patients With Stable COPD: A Bayesian Network Meta-Analysis of Randomized Controlled Trials. J Cardiovasc Pharmacol 2020; 74:255-265. [PMID: 31306366 DOI: 10.1097/fjc.0000000000000705] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
A majority of existing studies have focused on the efficacy of inhaled long-acting bronchodilators (ILABs), such as long-acting muscarinic antagonists (LAMAs) and long-acting β2-agonists (LABAs), and LABAs combined with LAMAs in treating chronic obstructive pulmonary disease (COPD). The current meta-analysis aimed to investigate the correlation of ILABs with specific cardiovascular adverse events (CAEs). Five electronic databases, including PubMed, Embase, Cochrane Library, Scopus, and Web of Science were systematically retrieved. Finally, 16 randomized controlled trials were enrolled into the current meta-analysis. Typically, the efficacy of 3 major classes of drugs (LABAs, LAMAs, and LABAs combined with LAMAs), and 7 specific drugs (including formoterol, glycopyrrolate, indacaterol, olodaterol, Salmeterol, tiotropium, and vilanterol) for 4 CAEs, including myocardial infarction, cardiac failure (CF), ischemic heart disease (IHD), and stroke in stable COPD patients, was examined. All the pooled results were analyzed through the odds ratios (ORs) with the corresponding 95% confidence intervals (CIs). The direct meta-analysis results suggested that LABAs could increase the risk of CF in patients with stable COPD compared with placebo controls (OR 1.70, 95% CI, 1.00-2.90). In addition, network meta-analysis results indicated that LAMAs combined with LABAs would result in an increased risk of CF in patients with stable COPD (OR 2.31, 95% CI, 1.10-5.09). According to the ILABs specific drug analysis, formoterol may potentially have protective effects on IHD compared with placebo controls (OR 0.45, 95% CI, 0.18-1.00). In conclusion, among these 3 kinds of ILABs, including LAMAs, LABAs, and LABAs/LAMAs, for stable COPD patients, LAMAs and LABAs are associated with the least possibility to induce myocardial infarction and stroke, respectively. However, the application of LABAs will probably increase the risk of CF; they should be used with caution for stable COPD patients with CF. In addition, in specific-drug analysis, the use of formoterol can reduce the risk of treatment-related IHD. Nevertheless, more studies on different drug doses are needed in the future to further validate this conclusion.
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12
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Crim C, Anderson JA, Calverley PMA, Celli BR, Cowans NJ, Martinez FJ, Newby DE, Vestbo J, Yates JC, Brook RD. Pulse Wave Velocity in Chronic Obstructive Pulmonary Disease and the Impact of Inhaled Therapy (SUMMIT): A Randomized Double-Blind Clinical Trial. Am J Respir Crit Care Med 2020; 201:1307-1310. [PMID: 32017597 DOI: 10.1164/rccm.201908-1639le] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Courtney Crim
- GlaxoSmithKline plcResearch Triangle Park, North Carolina
| | | | | | - Bartolome R Celli
- Brigham and Women's Hospital and Harvard Medical SchoolBoston, Massachusetts
| | | | | | | | - Jørgen Vestbo
- The University of Manchester Manchester, United Kingdom.,Manchester University NHS Foundation TrustManchester, United Kingdomand
| | - Julie C Yates
- GlaxoSmithKline plcResearch Triangle Park, North Carolina
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13
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Aziz MIA, Tan LE, Wu DBC, Pearce F, Chua GSW, Lin L, Tan PT, Ng K. Comparative efficacy of inhaled medications (ICS/LABA, LAMA, LAMA/LABA and SAMA) for COPD: a systematic review and network meta-analysis. Int J Chron Obstruct Pulmon Dis 2018; 13:3203-3231. [PMID: 30349228 PMCID: PMC6186767 DOI: 10.2147/copd.s173472] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
PURPOSE To assess the comparative efficacy of short-acting muscarinic antagonists (SAMAs), long-acting muscarinic antagonists (LAMAs), LAMA in combination with long-acting beta-agonists (LABAs; LAMA/LABAs) and inhaled corticosteroids (ICS) in combination with LABA (ICS/LABAs) for the maintenance treatment of COPD. MATERIALS AND METHODS We systematically reviewed 74 randomized controlled trials (74,832 participants) published up to 15 November 2017, which compared any of the interventions (SAMA [ipratropium], LAMA [aclidinium, glycopyrronium, tiotropium, umeclidinium], LAMA/LABA [aclidinium/formoterol, indacaterol/glycopyrronium, tiotropium/olodaterol, umeclidinium/vilanterol] and ICS/LABA [fluticasone/vilanterol, budesonide/formoterol, salmeterol/fluticasone]) with each other or with placebo. A random-effects network meta-analysis combining direct and indirect evidence was conducted to examine the change from baseline in trough FEV1, transition dyspnea index, St George's Respiratory Questionnaire and frequency of adverse events at weeks 12 and 24. RESULTS Inconsistency models were not statistically significant for all outcomes. LAMAs, LAMA/LABAs and ICS/LABAs led to a significantly greater improvement in trough FEV1 compared with placebo and SAMA monotherapy at weeks 12 and 24. All LAMA/LABAs, except aclidinium/formoterol, were statistically significantly better than LAMA monotherapy and ICS/LABAs in improving trough FEV1. Among the LAMAs, umeclidinium showed statistically significant improvement in trough FEV1 at week 12 compared to tiotropium and glycopyrronium, but the results were not clinically significant. LAMA/LABAs had the highest probabilities of being ranked the best agents in FEV1 improvement. Similar trends were observed for the transition dyspnea index and St George's Respiratory Questionnaire outcomes. There were no significant differences in the incidences of adverse events among all treatment options. CONCLUSION LAMA/LABA showed the greatest improvement in trough FEV1 at weeks 12 and 24 compared with the other inhaled drug classes, while SAMA showed the least improvement. There were no significant differences among the LAMAs and LAMA/LABAs within their respective classes.
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Affiliation(s)
| | - Ling Eng Tan
- Agency for Care Effectiveness, Ministry of Health, Singapore,
| | | | - Fiona Pearce
- Agency for Care Effectiveness, Ministry of Health, Singapore,
| | | | - Liang Lin
- Agency for Care Effectiveness, Ministry of Health, Singapore,
| | - Ping-Tee Tan
- Agency for Care Effectiveness, Ministry of Health, Singapore,
| | - Kwong Ng
- Agency for Care Effectiveness, Ministry of Health, Singapore,
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14
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Rabe KF, Hurst JR, Suissa S. Cardiovascular disease and COPD: dangerous liaisons? Eur Respir Rev 2018; 27:27/149/180057. [PMID: 30282634 DOI: 10.1183/16000617.0057-2018] [Citation(s) in RCA: 191] [Impact Index Per Article: 31.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2018] [Accepted: 08/20/2018] [Indexed: 12/12/2022] Open
Abstract
Chronic obstructive pulmonary disease (COPD) and cardiovascular disease (CVD) frequently occur together and their coexistence is associated with worse outcomes than either condition alone. Pathophysiological links between COPD and CVD include lung hyperinflation, systemic inflammation and COPD exacerbations. COPD treatments may produce beneficial cardiovascular (CV) effects, such as long-acting bronchodilators, which are associated with improvements in arterial stiffness, pulmonary vasoconstriction, and cardiac function. However, data are limited regarding whether these translate into benefits in CV outcomes. Some studies have suggested that treatment with long-acting β2-agonists and long-acting muscarinic antagonists leads to an increase in the risk of CV events, particularly at treatment initiation, although the safety profile of these agents with prolonged use appears reassuring. Some CV medications may have a beneficial impact on COPD outcomes, but there have been concerns about β-blocker use leading to bronchospasm in COPD, which may result in patients not receiving guideline-recommended treatment. However, there are few data suggesting harm with these agents and patients should not be denied β-blockers if required. Clearer recommendations are necessary regarding the identification and management of comorbid CVD in patients with COPD in order to facilitate early intervention and appropriate treatment.
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Affiliation(s)
- Klaus F Rabe
- Dept of Medicine, University of Kiel, Kiel, Germany .,Lung Clinic Großhansdorf, Airway Research Center North (ARCN), Groβhansdorf, Germany
| | - John R Hurst
- Centre for Inflammation and Tissue Repair, Division of Medicine, University College London, London, UK
| | - Samy Suissa
- Centre for Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital, Montreal, QC, Canada.,Dept of Epidemiology and Biostatistics, McGill University, Montreal, QC, Canada
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15
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Weir-McCall JR, Liu-Shiu-Cheong PS, Struthers AD, Lipworth BJ, Houston JG. Disconnection of pulmonary and systemic arterial stiffness in COPD. Int J Chron Obstruct Pulmon Dis 2018; 13:1755-1765. [PMID: 29881265 PMCID: PMC5978466 DOI: 10.2147/copd.s160077] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
Background Both pulmonary arterial stiffening and systemic arterial stiffening have been described in COPD. The aim of the current study was to assess pulse wave velocity (PWV) within these two arterial beds to determine whether they are separate or linked processes. Materials and methods In total, 58 participants with COPD and 21 healthy volunteers (HVs) underwent cardiac magnetic resonance imaging (MRI) and were tested with a panel of relevant biomarkers. Cardiac MRI was used to quantify ventricular mass, volumes, and pulmonary (pulse wave velocity [pPWV] and systemic pulse wave velocity [sPWV]). Results Those with COPD had higher pPWV (COPD: 2.62 vs HV: 1.78 ms−1, p=0.006), higher right ventricular mass/volume ratio (RVMVR; COPD: 0.29 vs HV: 0.25 g/mL, p=0.012), higher left ventricular mass/volume ratio (LVMVR; COPD: 0.78 vs HV: 0.70 g/mL, p=0.009), and a trend toward a higher sPWV (COPD: 8.7 vs HV: 7.4 ms−1, p=0.06). Multiple biomarkers were elevated: interleukin-6 (COPD: 1.38 vs HV: 0.58 pg/mL, p=0.02), high-sensitivity C-reactive protein (COPD: 6.42 vs HV: 2.49 mg/L, p=0.002), surfactant protein D (COPD: 16.9 vs HV: 9.13 ng/mL, p=0.001), N-terminal pro-brain natriuretic peptide (COPD: 603 vs HV: 198 pg/mL, p=0.001), and high-sensitivity troponin I (COPD: 2.27 vs HV: 0.92 pg/mL, p<0.001). There was a significant relationship between sPWV and LVMVR (p=0.01) but not pPWV (p=0.97) nor between pPWV and RVMVR (p=0.27). Conclusion Pulmonary arterial stiffening and systemic arterial stiffening appear to be disconnected and should therefore be considered independent processes in COPD. Further work is warranted to determine whether both these cause an increased morbidity and mortality and whether both can be targeted by similar pharmacological therapy or whether different strategies are required for each.
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Affiliation(s)
- Jonathan R Weir-McCall
- Division of Molecular and Clinical Medicine, Medical Research Institute, University of Dundee, Dundee, UK
| | | | - Allan D Struthers
- Division of Molecular and Clinical Medicine, Medical Research Institute, University of Dundee, Dundee, UK
| | - Brian J Lipworth
- Scottish Centre for Respiratory Research, Medical Research Institute, University of Dundee, Dundee, UK
| | - J Graeme Houston
- Division of Molecular and Clinical Medicine, Medical Research Institute, University of Dundee, Dundee, UK
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16
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Fisk M, McEniery CM, Gale N, Mäki-Petäjä K, Forman JR, Munnery M, Woodcock-Smith J, Cheriyan J, Mohan D, Fuld J, Tal-Singer R, Polkey MI, Cockcroft JR, Wilkinson IB. Surrogate Markers of Cardiovascular Risk and Chronic Obstructive Pulmonary Disease: A Large Case-Controlled Study. Hypertension 2018; 71:499-506. [PMID: 29358458 PMCID: PMC5805278 DOI: 10.1161/hypertensionaha.117.10151] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2017] [Revised: 08/31/2017] [Accepted: 12/13/2017] [Indexed: 01/13/2023]
Abstract
Cardiovascular disease is a common comorbidity and cause of mortality in chronic obstructive pulmonary disease. A better understanding of mechanisms of cardiovascular risk in chronic obstructive pulmonary disease patients is needed to improve clinical outcomes. We hypothesized that such patients have increased arterial stiffness, wave reflections, and subclinical atherosclerosis compared with controls and that these findings would be independent of smoking status and other confounding factors. A total of 458 patients with a diagnosis of chronic obstructive pulmonary disease and 1657 controls (43% were current or ex-smokers) with no airflow limitation were matched for age, sex, and body mass index. All individuals underwent assessments of carotid-femoral (aortic) pulse wave velocity, augmentation index, and carotid intima-media thickness. The mean age of the cohort was 67±8 years and 58% were men. Patients with chronic obstructive pulmonary disease had increased aortic pulse wave velocity (9.95±2.54 versus 9.27±2.41 m/s; P<0.001), augmentation index (28±10% versus 25±10%; P<0.001), and carotid intima-media thickness (0.83±0.19 versus 0.74±0.14 mm; P<0.001) compared with controls. Chronic obstructive pulmonary disease was associated with increased levels of each vascular biomarker independently of physiological confounders, smoking, and other cardiovascular risk factors. In this large case-controlled study, chronic obstructive pulmonary disease was associated with increased arterial stiffness, wave reflections, and subclinical atherosclerosis, independently of traditional cardiovascular risk factors. These findings suggest that the cardiovascular burden observed in this condition may be mediated through these mechanisms and supports the concept that chronic obstructive pulmonary disease is an independent risk factor for cardiovascular disease.
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Affiliation(s)
- Marie Fisk
- From the Division of Experimental Medicine and Immunotherapeutics, University of Cambridge, United Kingdom (M.F., C.M.M., K.M.-P., J.W.-S., J.C., I.B.W.); School of Healthcare Sciences (N.G.) and Department of Cardiology, Wales Heart Research Institute (M.M., J.R.C.), Cardiff University, United Kingdom; Cambridge Clinical Trials Unit (J.R.F., J.C., I.B.W.) and Division of Respiratory Medicine (J.F.), Cambridge University Hospitals NHS Foundation Trust, United Kingdom; GSK R&D, King of Prussia, PA (D.M., R.T.S.); and NIHR Respiratory Biomedical Research Unit, Royal Brompton & Harefield NHS Foundation Trust and Imperial College, London, United Kingdom (D.M., M.I.P.).
| | - Carmel M McEniery
- From the Division of Experimental Medicine and Immunotherapeutics, University of Cambridge, United Kingdom (M.F., C.M.M., K.M.-P., J.W.-S., J.C., I.B.W.); School of Healthcare Sciences (N.G.) and Department of Cardiology, Wales Heart Research Institute (M.M., J.R.C.), Cardiff University, United Kingdom; Cambridge Clinical Trials Unit (J.R.F., J.C., I.B.W.) and Division of Respiratory Medicine (J.F.), Cambridge University Hospitals NHS Foundation Trust, United Kingdom; GSK R&D, King of Prussia, PA (D.M., R.T.S.); and NIHR Respiratory Biomedical Research Unit, Royal Brompton & Harefield NHS Foundation Trust and Imperial College, London, United Kingdom (D.M., M.I.P.)
| | - Nichola Gale
- From the Division of Experimental Medicine and Immunotherapeutics, University of Cambridge, United Kingdom (M.F., C.M.M., K.M.-P., J.W.-S., J.C., I.B.W.); School of Healthcare Sciences (N.G.) and Department of Cardiology, Wales Heart Research Institute (M.M., J.R.C.), Cardiff University, United Kingdom; Cambridge Clinical Trials Unit (J.R.F., J.C., I.B.W.) and Division of Respiratory Medicine (J.F.), Cambridge University Hospitals NHS Foundation Trust, United Kingdom; GSK R&D, King of Prussia, PA (D.M., R.T.S.); and NIHR Respiratory Biomedical Research Unit, Royal Brompton & Harefield NHS Foundation Trust and Imperial College, London, United Kingdom (D.M., M.I.P.)
| | - Kaisa Mäki-Petäjä
- From the Division of Experimental Medicine and Immunotherapeutics, University of Cambridge, United Kingdom (M.F., C.M.M., K.M.-P., J.W.-S., J.C., I.B.W.); School of Healthcare Sciences (N.G.) and Department of Cardiology, Wales Heart Research Institute (M.M., J.R.C.), Cardiff University, United Kingdom; Cambridge Clinical Trials Unit (J.R.F., J.C., I.B.W.) and Division of Respiratory Medicine (J.F.), Cambridge University Hospitals NHS Foundation Trust, United Kingdom; GSK R&D, King of Prussia, PA (D.M., R.T.S.); and NIHR Respiratory Biomedical Research Unit, Royal Brompton & Harefield NHS Foundation Trust and Imperial College, London, United Kingdom (D.M., M.I.P.)
| | - Julia R Forman
- From the Division of Experimental Medicine and Immunotherapeutics, University of Cambridge, United Kingdom (M.F., C.M.M., K.M.-P., J.W.-S., J.C., I.B.W.); School of Healthcare Sciences (N.G.) and Department of Cardiology, Wales Heart Research Institute (M.M., J.R.C.), Cardiff University, United Kingdom; Cambridge Clinical Trials Unit (J.R.F., J.C., I.B.W.) and Division of Respiratory Medicine (J.F.), Cambridge University Hospitals NHS Foundation Trust, United Kingdom; GSK R&D, King of Prussia, PA (D.M., R.T.S.); and NIHR Respiratory Biomedical Research Unit, Royal Brompton & Harefield NHS Foundation Trust and Imperial College, London, United Kingdom (D.M., M.I.P.)
| | - Margaret Munnery
- From the Division of Experimental Medicine and Immunotherapeutics, University of Cambridge, United Kingdom (M.F., C.M.M., K.M.-P., J.W.-S., J.C., I.B.W.); School of Healthcare Sciences (N.G.) and Department of Cardiology, Wales Heart Research Institute (M.M., J.R.C.), Cardiff University, United Kingdom; Cambridge Clinical Trials Unit (J.R.F., J.C., I.B.W.) and Division of Respiratory Medicine (J.F.), Cambridge University Hospitals NHS Foundation Trust, United Kingdom; GSK R&D, King of Prussia, PA (D.M., R.T.S.); and NIHR Respiratory Biomedical Research Unit, Royal Brompton & Harefield NHS Foundation Trust and Imperial College, London, United Kingdom (D.M., M.I.P.)
| | - Jean Woodcock-Smith
- From the Division of Experimental Medicine and Immunotherapeutics, University of Cambridge, United Kingdom (M.F., C.M.M., K.M.-P., J.W.-S., J.C., I.B.W.); School of Healthcare Sciences (N.G.) and Department of Cardiology, Wales Heart Research Institute (M.M., J.R.C.), Cardiff University, United Kingdom; Cambridge Clinical Trials Unit (J.R.F., J.C., I.B.W.) and Division of Respiratory Medicine (J.F.), Cambridge University Hospitals NHS Foundation Trust, United Kingdom; GSK R&D, King of Prussia, PA (D.M., R.T.S.); and NIHR Respiratory Biomedical Research Unit, Royal Brompton & Harefield NHS Foundation Trust and Imperial College, London, United Kingdom (D.M., M.I.P.)
| | - Joseph Cheriyan
- From the Division of Experimental Medicine and Immunotherapeutics, University of Cambridge, United Kingdom (M.F., C.M.M., K.M.-P., J.W.-S., J.C., I.B.W.); School of Healthcare Sciences (N.G.) and Department of Cardiology, Wales Heart Research Institute (M.M., J.R.C.), Cardiff University, United Kingdom; Cambridge Clinical Trials Unit (J.R.F., J.C., I.B.W.) and Division of Respiratory Medicine (J.F.), Cambridge University Hospitals NHS Foundation Trust, United Kingdom; GSK R&D, King of Prussia, PA (D.M., R.T.S.); and NIHR Respiratory Biomedical Research Unit, Royal Brompton & Harefield NHS Foundation Trust and Imperial College, London, United Kingdom (D.M., M.I.P.)
| | - Divya Mohan
- From the Division of Experimental Medicine and Immunotherapeutics, University of Cambridge, United Kingdom (M.F., C.M.M., K.M.-P., J.W.-S., J.C., I.B.W.); School of Healthcare Sciences (N.G.) and Department of Cardiology, Wales Heart Research Institute (M.M., J.R.C.), Cardiff University, United Kingdom; Cambridge Clinical Trials Unit (J.R.F., J.C., I.B.W.) and Division of Respiratory Medicine (J.F.), Cambridge University Hospitals NHS Foundation Trust, United Kingdom; GSK R&D, King of Prussia, PA (D.M., R.T.S.); and NIHR Respiratory Biomedical Research Unit, Royal Brompton & Harefield NHS Foundation Trust and Imperial College, London, United Kingdom (D.M., M.I.P.)
| | - Jonathan Fuld
- From the Division of Experimental Medicine and Immunotherapeutics, University of Cambridge, United Kingdom (M.F., C.M.M., K.M.-P., J.W.-S., J.C., I.B.W.); School of Healthcare Sciences (N.G.) and Department of Cardiology, Wales Heart Research Institute (M.M., J.R.C.), Cardiff University, United Kingdom; Cambridge Clinical Trials Unit (J.R.F., J.C., I.B.W.) and Division of Respiratory Medicine (J.F.), Cambridge University Hospitals NHS Foundation Trust, United Kingdom; GSK R&D, King of Prussia, PA (D.M., R.T.S.); and NIHR Respiratory Biomedical Research Unit, Royal Brompton & Harefield NHS Foundation Trust and Imperial College, London, United Kingdom (D.M., M.I.P.)
| | - Ruth Tal-Singer
- From the Division of Experimental Medicine and Immunotherapeutics, University of Cambridge, United Kingdom (M.F., C.M.M., K.M.-P., J.W.-S., J.C., I.B.W.); School of Healthcare Sciences (N.G.) and Department of Cardiology, Wales Heart Research Institute (M.M., J.R.C.), Cardiff University, United Kingdom; Cambridge Clinical Trials Unit (J.R.F., J.C., I.B.W.) and Division of Respiratory Medicine (J.F.), Cambridge University Hospitals NHS Foundation Trust, United Kingdom; GSK R&D, King of Prussia, PA (D.M., R.T.S.); and NIHR Respiratory Biomedical Research Unit, Royal Brompton & Harefield NHS Foundation Trust and Imperial College, London, United Kingdom (D.M., M.I.P.)
| | - Michael I Polkey
- From the Division of Experimental Medicine and Immunotherapeutics, University of Cambridge, United Kingdom (M.F., C.M.M., K.M.-P., J.W.-S., J.C., I.B.W.); School of Healthcare Sciences (N.G.) and Department of Cardiology, Wales Heart Research Institute (M.M., J.R.C.), Cardiff University, United Kingdom; Cambridge Clinical Trials Unit (J.R.F., J.C., I.B.W.) and Division of Respiratory Medicine (J.F.), Cambridge University Hospitals NHS Foundation Trust, United Kingdom; GSK R&D, King of Prussia, PA (D.M., R.T.S.); and NIHR Respiratory Biomedical Research Unit, Royal Brompton & Harefield NHS Foundation Trust and Imperial College, London, United Kingdom (D.M., M.I.P.)
| | - John R Cockcroft
- From the Division of Experimental Medicine and Immunotherapeutics, University of Cambridge, United Kingdom (M.F., C.M.M., K.M.-P., J.W.-S., J.C., I.B.W.); School of Healthcare Sciences (N.G.) and Department of Cardiology, Wales Heart Research Institute (M.M., J.R.C.), Cardiff University, United Kingdom; Cambridge Clinical Trials Unit (J.R.F., J.C., I.B.W.) and Division of Respiratory Medicine (J.F.), Cambridge University Hospitals NHS Foundation Trust, United Kingdom; GSK R&D, King of Prussia, PA (D.M., R.T.S.); and NIHR Respiratory Biomedical Research Unit, Royal Brompton & Harefield NHS Foundation Trust and Imperial College, London, United Kingdom (D.M., M.I.P.)
| | - Ian B Wilkinson
- From the Division of Experimental Medicine and Immunotherapeutics, University of Cambridge, United Kingdom (M.F., C.M.M., K.M.-P., J.W.-S., J.C., I.B.W.); School of Healthcare Sciences (N.G.) and Department of Cardiology, Wales Heart Research Institute (M.M., J.R.C.), Cardiff University, United Kingdom; Cambridge Clinical Trials Unit (J.R.F., J.C., I.B.W.) and Division of Respiratory Medicine (J.F.), Cambridge University Hospitals NHS Foundation Trust, United Kingdom; GSK R&D, King of Prussia, PA (D.M., R.T.S.); and NIHR Respiratory Biomedical Research Unit, Royal Brompton & Harefield NHS Foundation Trust and Imperial College, London, United Kingdom (D.M., M.I.P.)
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