The impact of atrial fibrillation in patients with COPD during hospitalization

Low-dose azithromycin prophylaxis in patients with atrial fibrillation and chronic obstructive pulmonary disease

Low-dose azithromycin prophylaxis is associated with improved outcomes in people suffering frequent exacerbations of chronic obstructive pulmonary disease (COPD), but the use of macrolides in patients with cardiovascular disease has been debated. To investigate the risk of adverse events after COPD exacerbations in patients with atrial fibrillation (AF) treated with azithromycin prophylaxis. Retrospective cohort study within the TriNetX Platform, including AF patients with COPD exacerbations. Risks of primary and secondary outcomes were recorded up to 30 days post-COPD exacerbations and compared between azithromycin users and azithromycin non-users. The primary outcomes were the risks for a composite of (1) cardiovascular (all-cause death, heart failure, ventricular arrhythmias, ischemic stroke, myocardial infarction, and cardiac arrest), and (2) hemorrhagic events (intracranial hemorrhage (ICH), and gastro-intestinal bleeding). Cox-regression analyses compared outcomes between groups after propensity score matching (PSM). After PSM, azithromycin users (n = 2434, 71 ± 10 years, 49% females) were associated with a lower 30-day risk of post-exacerbation cardiovascular (HR 0.67, 95% CI 0.61-0.73) and hemorrhagic composite outcome (HR 0.45, 95% CI 0.32-0.64) compared to azithromycin non-users (n = 2434, 72 ± 11 years, 51% females). The beneficial effect was consistent for each secondary outcomes, except ICH. On sensitivity analyses, the reduced risk of adverse events in azithromycin users was irrespective of smoking status, exacerbation severity, and type of oral anticoagulation. Azithromycin prophylaxis is associated with a lower risk of all-cause death, thrombotic and hemorrhagic events in AF patients with COPD. The possible role of azithromycin prophylaxis as part of the integrated care management of AF patients with COPD needs further study.

Detrimental Impact of Atrial Fibrillation among Patients Hospitalized for Acute Exacerbation of COPD: Results of a Population-Based Study in Spain from 2016 to 2021

Background/Objectives: To analyze changes in the prevalence of atrial fibrillation (AF) in patients hospitalized for acute exacerbation of chronic obstructive pulmonary disease (AE-COPD); to evaluate hospital outcomes according to AF status, assessing sex differences; to identify factors associated with AF presence; and to analyze variables associated with in-hospital mortality (IHM) in AE-COPD patients with AF. Methods: We used data from the Registry of Specialized Care Activity-Basic Minimum Data Set (RAE-CMBD) to select patients aged ≥40 years with COPD in Spain (2016-2021). We stratified the study population according to AF presence and sex. The propensity score matching (PSM) methodology was employed to create comparable groups based on age, admission year, and comorbidities at the time of hospitalization. Results: We identified 399,196 hospitalizations that met the inclusion criteria. Among them, 20.58% had AF. The prevalence of AF rose from 2016 to 2021 (18.26% to 20.95%), though the increase was only significant in men. The median length of hospital stay (LOHS) and IHM were significantly higher in patients with AF than in those without AF. After PSM, IHM remained significantly higher for man and women with AF. Older age, male sex, and several comorbidities were factors associated with AF. Additionally, older age, male sex, different comorbidities including COVID-19, hospitalization in the year 2020, mechanical ventilation, and intensive care unit (ICU) admission were associated with higher IHM in patients with AE-COPD and AF. Conclusions: AF prevalence was high in patients hospitalized for AE-COPD, was higher in men than in women, and increased over time. AF presence was associated with worse outcomes. The variables associated with IHM in hospitalized AE-COPD patients with AF were older age, male sex, different comorbidities including COVID-19 presence, hospitalization in the year 2020, need of mechanical ventilation, and ICU admission.

Risk of Death and Cardiovascular Events in Asian Patients With Atrial Fibrillation and Chronic Obstructive Pulmonary Disease: A Report From the Prospective APHRS Registry

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is associated with an increased risk of adverse events in patients with atrial fibrillation (AF); however, few data are available on this topic in Asian populations.

METHODS AND RESULTS

Prospective observational study conducted on patients with AF enrolled in the Asia-Pacific Heart Rhythm Society (APHRS) AF Registry. The diagnosis of COPD was based on data reported in the case report form by the investigators. Cox-regression models were used to assess the 1-year risk of a primary composite outcome of all-cause death, thromboembolic events, acute coronary syndrome, and heart failure. Analysis on single outcomes and cardiovascular death was also performed. Interaction analysis was used to assess the risk of composite outcome and all-cause death in different subgroups. The study included 4094 patients with AF (mean±SD age 68.5±12 years, 34.6% female), of whom 112 (2.7%) had COPD. Patients with COPD showed a higher incidence of the primary composite outcome (25.1% versus 6.3%, P<0.001), all-cause death (14.9% versus 2.6%, P<0.001), cardiovascular death (2.0% versus 0.6%, P<0.001), and heart failure (8.3% versus 6.0%, P<0.001). On multiple Cox-regression analysis, COPD was associated with a higher risk of the primary composite outcome (hazard ratio [HR], 3.17 [95% CI, 2.05-4.90]), all-cause death (HR, 3.59 [95% CI, 2.04-6.30]), and heart failure (HR, 3.32 [95% CI, 1.56-7.03]); no statistically significant differences were found for other outcomes. The association between COPD and mortality was significantly modified by the use of beta blockers (Pint=0.018).

CONCLUSIONS

In Asian patients with AF, COPD is associated with worse prognosis. In patients with AF and COPD, the use of beta blockers was associated with a lower mortality.

REGISTRATION INFORMATION

clinicaltrials.gov Identifier: NCT04807049.

Prescribing patterns in patients with chronic obstructive pulmonary disease and atrial fibrillation

Patients with chronic obstructive pulmonary disease (COPD) had higher risk of atrial fibrillation (AF). The treatment of AF includes medicines to control heart rate and reduce the risk of stroke, and procedures such as cardioversion to restore normal heart rhythm. To reduce the stroke, patients with AF may prescribe some type of antithrombotic medication (such as warfarin, one of the new non-vitamin K antagonist oral anticoagulants [NOACs] - dabigitran, apixaban, rivoraxaban, or edoxaban) or maybe aspirin. The aim of our study was to exam the prescription pattern in patients with COPD and AF. We selected COPD population in Taiwan older than 40 years and less than 90 years old with an COPD diagnosis at least two outpatient claims or at least one inpatient claim coded and also need at least one prescription of bronchodilators. We followed this COPD cohort until they have AF and their prescription pattern. We included 267,740 patients with COPD who meet the inclusion and exclusion criteria and 6,582 patients concomitant with COPD and AF. The mean age was 75 years, and about 77% of the patients were older than 70 years. Three-fourths of patients with COPD were male. The common comorbidities were hypertension (17.58%), diabetes (7.47%), ischemic heart disease (4.66%), and dyslipidemia (3.68%). we found that most patients received aspirin which accounting for 31%, followed by coumadin (8.22%) and clopidogrel. Prescribing NOAC within 30 days after AF diagnosis was low in patients with COPD and the percentage of NOAC usage was also lower than warfarin.

Spirometry in atrial fibrillation: what's the catch?

INTRODUCTION

People with COPD rarely have COPD alone, and the commonest co-morbidities occurring with COPD are cardiovascular. Whilst multiple studies have explored the association between major cardiovascular events and COPD, less attention has been paid to arrhythmias, specifically atrial fibrillation (AF). AF and COPD frequently occur together, posing challenges in diagnosis and management. In this review, we describe the relationship between AF and COPD epidemiologically and physiologically, demonstrating the role of spirometry as a diagnostic and disease management tool.

AREAS COVERED

We provide epidemiological evidence that COPD and AF are independent risk factors for one another, that either disease is highly prevalent amongst people with the other, and that they have shared risk factors; all of which contribute to adverse prognostic. We elucidated common pathophysiological mechanisms implicated in AF-COPD. We ultimately present the epidemiological and physiological evidence with a view to highlight specific areas where we feel spirometry is of value in the management of AF-COPD.

EXPERT OPINION

AF and COPD commonly co-occur, there is often diagnostic delay, increased risk of reduced cardioversion success, and missed opportunity to intervene to reduce stroke risk. Greater awareness and timelier diagnosis and guideline directed management may improve outcomes for people with both diseases.

Combining bioinformatics and machine learning to identify common mechanisms and biomarkers of chronic obstructive pulmonary disease and atrial fibrillation

Background

Patients with chronic obstructive pulmonary disease (COPD) often present with atrial fibrillation (AF), but the common pathophysiological mechanisms between the two are unclear. This study aimed to investigate the common biological mechanisms of COPD and AF and to search for important biomarkers through bioinformatic analysis of public RNA sequencing databases.

Methods

Four datasets of COPD and AF were downloaded from the Gene Expression Omnibus (GEO) database. The overlapping genes common to both diseases were screened by WGCNA analysis, followed by protein-protein interaction network construction and functional enrichment analysis to elucidate the common mechanisms of COPD and AF. Machine learning algorithms were also used to identify key biomarkers. Co-expression analysis, “transcription factor (TF)-mRNA-microRNA (miRNA)” regulatory networks and drug prediction were performed for key biomarkers. Finally, immune cell infiltration analysis was performed to evaluate further the immune cell changes in the COPD dataset and the correlation between key biomarkers and immune cells.

Results

A total of 133 overlapping genes for COPD and AF were obtained, and the enrichment was mainly focused on pathways associated with the inflammatory immune response. A key biomarker, cyclin dependent kinase 8 (CDK8), was identified through screening by machine learning algorithms and validated in the validation dataset. Twenty potential drugs capable of targeting CDK8 were obtained. Immune cell infiltration analysis revealed the presence of multiple immune cell dysregulation in COPD. Correlation analysis showed that CDK8 expression was significantly associated with CD8+ T cells, resting dendritic cell, macrophage M2, and monocytes.

Conclusions

This study highlights the role of the inflammatory immune response in COPD combined with AF. The prominent link between CDK8 and the inflammatory immune response and its characteristic of not affecting the basal expression level of nuclear factor kappa B (NF-kB) make it a possible promising therapeutic target for COPD combined with AF.

Atrial fibrillation and chronic obstructive pulmonary disease: diagnostic sequence and mortality risk

BACKGROUND AND AIMS

Chronic obstructive pulmonary disease (COPD) is present in 13% of atrial fibrillation (AF) patients. In patients diagnosed with both AF and COPD, we aimed to assess overall mortality risk and its association with temporal sequence in AF and COPD diagnosis.

METHODS

This nationwide study assessed all patients aged 18-85 years diagnosed with both COPD and AF between 1999 and 2018 in Denmark. Three groups were defined according to the temporal sequence of diagnosis: COPD diagnosed at least 6 months before AF (COPD-First), AF diagnosed at least 6 months before COPD (AF-First) and COPD, and AF diagnosed within a 6-months' time frame (AF∼COPD).

RESULTS

We included 62 806 patients (75.0 years; 56.5% males). After 5 years of follow-up, 31 494 (50.1%) died. Mortality was highest in the COPD-First group (COPD-First: 52.8%; AF-First: 46.0%; AF∼COPD 50.6%). In a multivariable Cox-regression model adjusted for age, sex, type 2 diabetes, history of acute myocardial infarction, hypertension, heart failure, dyslipidemia, cancer, chronic kidney disease, and stroke, the AF∼COPD group (HR 1.19, 95% CI 1.16-1.23; P < 0.001) and COPD-First group (HR 1.30, 95% CI 1.27-1.33; P < 0.001) had a higher risk of death compared with the AF-First group. A restricted cubic spline analysis showed that the earlier the COPD was diagnosed, the worse is the prognosis.

CONCLUSION

Patients with concomitant AF and COPD had a very poor prognosis and the temporal sequence in diagnosis was differentially associated with prognosis, where a COPD diagnosis preceding an AF diagnosis was accompanied with a higher mortality risk compared with a COPD diagnosis following an AF diagnosis.

Integrated Care in Atrial Fibrillation: A Road Map to the Future

Atrial fibrillation (AF) is the most commonly encountered arrhythmia in clinical practice with an epidemiological coupling appreciated with advancing age, cardiometabolic risk factors, and structural heart disease. This has resulted in a significant public health burden over the years, evident through increasing rates of hospitalization and AF-related clinical encounters. The resultant gap in health care outcomes is largely twinned with suboptimal rates of anticoagulation prescription and adherence, deficits in symptom identification and management, and insufficient comorbid cardiovascular risk factor investigation and modification. In view of these shortfalls in care, the establishment of integrated chronic care models serves as a road map to best clinical practice. The expansion of integrated chronic care programs, which include multidisciplinary team care, nurse-led AF clinics, and use of telemedicine, are expected to improve AF-related outcomes in the coming years. This review will delve into current gaps in AF care and the role of integrated chronic care models in bridging fragmentations in its management.

Risk factors for new-onset atrial fibrillation in patients with chronic obstructive pulmonary disease: a systematic review and meta-analysis

BACKGROUND

New-onset atrial fibrillation (AF) in patients with chronic obstructive pulmonary disease (COPD) is associated with an accelerated decline in lung function, and a significant increase in mortality rate. A deeper understanding of the risk factors for new-onset AF during COPD will provide insights into the relationship between COPD and AF and guide clinical practice. This systematic review and meta-analysis is designed to identify risk factors for new-onset AF in patients with COPD, and to formulate recommendations for preventing AF in COPD patients that will assist clinical decision making.

METHODS

PubMed, Embase, Web of Science and Cochrane Library databases were searched for studies, which reported the results of potential risk factors for new-onset AF in COPD patients.

RESULTS

Twenty studies involving 8,072,043 participants were included. Fifty factors were examined as potential risk factors for new-onset AF during COPD. Risk factors were grouped according to demographics, comorbid conditions, and COPD- and cardiovascular-related factors. In quantitative analysis, cardiovascular- and demographic-related factors with a greater than 50% increase in the odds of new-onset AF included age (over 65 years and over 75 years), acute care encounter, coronary artery disease, heart failure and congestive heart failure. Only one factor is related to the reduction of odds by more than 33.3%, which is black race (vs white). In qualitative analysis, the comparison of the risk factors was conducted between COPD-associated AF and non-COPD-associated AF. Cardiovascular-related factors for non-COPD-associated AF were also considered as risk factors for new-onset AF during COPD; however, the influence tended to be stronger during COPD. In addition, comorbid factors identified in non-COPD-associated AF were not associated with an increased risk of AF during COPD.

CONCLUSIONS

New-onset AF in COPD has significant demographic characteristics. Older age (over 65 years), males and white race are at higher risk of developing AF. COPD patients with a history of cardiovascular disease should be carefully monitored for new-onset of AF, and appropriate preventive measures should be implemented. Even patients with mild COPD are at high risk of new-onset AF. This study shows that risk factors for new-onset AF during COPD are mainly those associated with the cardiovascular-related event and are not synonymous with comorbid factors for non-COPD-associated AF. The pathogenesis of COPD-associated AF may be predominantly related to the cardiac dysfunction caused by the chronic duration of COPD, which increases the risk of cardiovascular-related factors and further increases the risk of AF during COPD.

PROSPERO REGISTRATION NUMBER

CRD42019137758.

Risk factors for and predictive nomogram of postoperative hypoxaemia in elderly patients with femoral neck fractures

Objective

To investigate the related risk factors and predictive nomogram of postoperative hypoxaemia in elderly patients with femoral neck fractures.

Methods

This study included patients aged ≥65 years who underwent surgical treatment of acute femoral neck fractures. Univariate and multivariate logistic analyses were performed to determine the incidence of and risk factors for postoperative hypoxaemia. A predictive nomogram was constructed based on the multivariable model. Using the bootstrap method, discrimination was determined by the C-index and calibration plot.

Results

The logistic regression analysis showed that the anaesthesia type, surgical procedure, American Society of Anesthesiologists (ASA) classification, preoperative hypoxaemia occurrence, and age were independent predictors of development of postoperative hypoxaemia. The predictive formula for hypoxaemia was established as follows: hypoxaemia=−0.8668×spinal anaesthesia (whether)+0.1162×nerve anaesthesia (whether)+1.9555×plate/screw fixation (whether)+1.4950×hip replacement (whether)+0.4883×ASA classification+1.7153×preoperative oxygenation index+0.1608×age. With the bootstrap method, the prediction curve fit well with the ideal curve, suggesting that the prediction curve constructed in this study has good predictive ability.

Conclusions

Anaesthesia type, surgical procedure, ASA classification, preoperative hypoxaemia occurrence, and age were risk factors for postoperative hypoxaemia in elderly patients with femoral neck fractures. The predictive nomogram was designed for preoperative assessment of the risk of postoperative hypoxaemia by calculating the risk score.

Drivers of hospitalization in atrial fibrillation: A contemporary review

Atrial fibrillation (AF)-related hospitalization has risen over the last 2 decades and is the most influential determinant of total disease-related expenditure. In this review article, we describe several identified drivers of hospitalization from several registries and large-scale clinical trials, including key cardiovascular and non-traditional risk factors. We also discuss available assessment tools for discerning overall risk of hospitalization, including AF symptom scores, thrombosis and bleeding disposition, and non-invasive cardiac structural assessment. Finally, we highlight the different treatment paradigms that have been proven to reduce AF burden, progression, and hospitalization in the literature.

Atrial arrhythmias in chronic lung disease-associated pulmonary hypertension

Atrial arrhythmias are common during episodes of acute respiratory failure in patients with chronic lung disease-associated pulmonary hypertension. Expert opinion suggests that management of atrial arrhythmias in patients with pulmonary hypertension should aim to restore sinus rhythm. This is clinically challenging in pulmonary hypertension patients with coexisting chronic lung disease, as there is controversy on the use of rhythm control agents; generally, in regard to either their pulmonary toxicity profile or the lack of evidence supporting their use. Rate control methods are largely focused on the use of beta blockers and calcium channel blockers. Concerns regarding their use involve their negative inotropic properties in cor pulmonale, the risk of bronchospasm associated with beta blockers, and the potential for ventilation/perfusion mismatching associated with calcium channel blockers. While digoxin has been associated with promising outcomes during acute right ventricular failure, there is limited evidence to suggest its routine use. Electrical cardioversion is associated with a high failure rate and it frequently requires multiple attempts. Radiofrequency catheter ablation is a more definitive approach, but concerns surrounding mechanical ventilation and sedation limit its applicability in decompensated pulmonary hypertension. Individual approaches are needed to address atrial arrhythmia management during acute episodes of respiratory failure.

Relationship of Atrial Fibrillation to Outcomes in Patients Hospitalized for Chronic Obstructive Pulmonary Disease Exacerbation

INTRODUCTION

Chronic Obstructive Pulmonary Disease (COPD) is a major cause of hospitalization and is associated with an increased incidence of atrial fibrillation (AF). The impact of AF on in-hospital outcomes, including mortality, in patients hospitalized for COPD exacerbation is not well elucidated.

METHODS

We used the National Inpatient Sample database to examine discharges with the primary diagnosis of COPD exacerbation and compared mortality, length of stay and costs in patients with AF compared to those without AF. The study adjusted the outcomes for known cardiovascular risk factors and confounders using logistic regression and propensity score matching analysis.

RESULTS

Among 1,377,795 discharges with COPD exacerbation, 16.6% had AF. Patients with AF were older and had more comorbidities. Mortality was higher (2.4%) in the AF group than in the no AF group (1%), p <0.001. After adjustment to age, sex and confounders, AF remained an independent predictor for mortality, OR:1.44 (95% CI 133 - 1.56, p <0.001), prolonged length of stay, OR:1.63 (95% CI 1.57 - 1.69, p <0.001) and increased cost, OR: 1.45 (95% CI: 1.40 - 1.49, p <0.001).

CONCLUSIONS

among patients with COPD exacerbation, AF was associated with increased mortality and higher resource utilization.

Detrimental Impact of Chronic Obstructive Pulmonary Disease in Atrial Fibrillation: New Insights from Umbria Atrial Fibrillation Registry

Background and objectives: Chronic obstructive pulmonary disease (COPD) is a leading cause of morbidity and mortality worldwide. Among extra-pulmonary manifestations of COPD, atrial fibrillation (AF) is commonly observed in clinical practice. The coexistence of COPD and AF significantly affects the risk of cardiovascular morbidity and mortality. Nonetheless, the mechanisms explaining the increased risk of vascular events and death associated to the presence of COPD in AF are complex and not completely understood. We analyzed data from an Italian network database to identify markers and mediators of increased vascular risk among subjects with AF and COPD. Materials and Methods: Cross-sectional analysis of the Umbria Atrial Fibrillation (Umbria-FA) Registry, a multicenter, observational, prospective on-going registry of patients with non-valvular AF. Of the 2205 patients actually recruited, 2159 had complete clinical data and were included in the analysis. Results: the proportion of patients with COPD was 15.6%. COPD patients had a larger proportion of permanent AF when compared to the control group (49.1% vs. 34.6%, p < 0.0001) and were more likely to be obese and current smokers. Other cardiovascular risk factors including chronic kidney disease (CKD), peripheral artery disease and subclinical atherosclerosis were more prevalent in COPD patients (all p < 0.0001). COPD was also significantly associated with higher prevalence of previous vascular events and a history of anemia (all p < 0.0001). The thromboembolic and bleeding risk, as reflected by the CHA2DS2VASc and HAS-BLED scores, were higher in patients with COPD. Patients with COPD were also more likely to have left ventricular (LV) hypertrophy at standard ECG than individuals forming the cohort without COPD (p = 0.018). Conclusions: AF patients with COPD have a higher risk of vascular complications than AF patients without this lung disease. Our analysis identified markers and mediators of increased risk that can be easily measured in clinical practice, including LV hypertrophy, CKD, anemia, and atherosclerosis of large arteries.

The burden and impact of arrhythmia in chronic obstructive pulmonary disease: Insights from the National Inpatient Sample

BACKGROUND

We aimed to analyze the burden and predictors of arrhythmias and in-hospital mortality in chronic obstructive pulmonary disease (COPD)-related hospitalizations using the nationwide cohort.

METHODS

We queried the National Inpatient Sample (NIS) (2010-2014) databases to identify adult COPD hospitalizations with arrhythmia. Categorical and continuous variables were compared using Chi-square and Student's t-test/ANOVA. Predictors of any arrhythmia including AF and in-hospital mortality were evaluated by multivariable analyses.

RESULTS

Out of 21,596,342 COPD hospitalizations, 6,480,799 (30%) revealed co-existent arrhythmias including 4,767,401 AF-arrhythmias (22.1%) and 1,713,398 non AF-arrhythmias (7.9%). The AF or non-AF arrhythmia cohort consisted mostly of older (mean age~ 75.8 & 69.1 vs. 67.5 years) white male (53.3% & 51.9% vs. 46.9%) patients compared to those without arrhythmias (p < 0.001). The all-cause mortality (5.7% & 5.2 vs. 2.9%), mean length of stay (LOS) (6.4 & 6.5 vs. 5.3 days), and hospital charges ($52,699.49 & $58,102.39 vs. $41,208.02) were higher with AF and non AF-arrhythmia compared to the non-arrhythmia group (p < 0.001). Comorbidities such as cardiomyopathy (OR 2.11), cardiogenic shock (OR 1.88), valvular diseases (OR 1.60), congestive heart failure (OR 1.48) and pulmonary circulation disorders (OR 1.25) predicted in-hospital arrhythmias. Invasive mechanical ventilation (OR 6.41), cardiogenic shock (OR 5.95), cerebrovascular disease (OR 3.95), septicemia (OR 2.30) and acute myocardial infarction (OR 2.24) predicted higher mortality (p < 0.001) in the COPD-arrhythmia cohort.

CONCLUSIONS

About 30% of COPD hospitalizations revealed co-existent arrhythmias (AF 22.1%). All-cause mortality, LOS and hospital charges were significantly higher with arrhythmias. We observed racial and sex-based disparities for arrhythmias and related mortality.