The association between COPD and heart failure risk: a review

Influence of heart failure (HF) comorbidity in chronic obstructive pulmonary disease (COPD) and isolated forms of HF and COPD on cardiovascular function during hospitalization

INTRODUCTION

Coexistence of chronic obstructive pulmonary disease(COPD) and heart failure(HF) is associated with systemic inflammation, myocardial injury, and arterial stiffening, impacting cardiovascular risk and prognosis in patients. Arterial stiffness, reduced nitric oxide synthesis, and altered cardiac autonomic control further link COPD and HF pathophysiology, emphasizing the need for comprehensive cardiovascular assessment.

OBJECTIVE

To investigate a cardiovascular profile in patients hospitalized with exacerbation COPD(ECOPD) in coexistence with HF compared with isolated diseases.

METHODS

A cross-sectional study including patients diagnosed with ECOPD and decompensated HF, approached between 24 and 48 h after hospital admission. Assessments included: endothelial function by brachial artery flow-mediated vasodilation(FMD); hemodynamic through analysis of pulse wave and arterial stiffness by carotid-femoral pulse wave velocity(cfPWV) and cardiac autonomic modulation(CAM) by heart rate variability(HRV).

RESULTS

The mean FMD was 4.45 %, indicating endothelial dysfunction in all patients. Date is present in mean(confidence interval) sequency COPD(n = 12), COPD-HF(n = 21) and HF(n = 21). FMD: 5.47(3.96-6.91); 2.66(0.09-3.48); 4.60(2.30-6.43) p < 0.01. However, COPD-HF had worse FMD. Arterial stiffens (AIx: 29.0(19.0-42.6); 34.6(24.3-43.2); 14.5(8.0-24.0)p < 0.01; cfPWV: (6.5(5.4-7.2); 7.7(7.0-8.5); 6.0(5.0-6.5)); COPD-HF also showed greater activation of the sympathetic nervous system compared to patients with isolated diseases (PNS: 1.32(-2.53 to -0.62); -2.33(-2.60 to -2.12); -1.32(-1.42 to -1.01) p < 0.01; SNS: 3.50(1.40-8.55); 7.11(5.70-8.29); 2.32(1.78-5.01) p < 0.01). In addition, rMSSD, NN50, pNN50, and TINN also indicate worse CAM in the COPD-HF group compared to isolated diseases.

CONCLUSION

During hospitalization, the worst impairment in vascular function and cardiac autonomic modulation were found in patients with COPD and HF comorbidity compared to the isolated diseases(HF or COPD).

Comparing the diagnostic considerations between general practitioners with a special interest in cardiovascular disease and those without in patients with symptoms suggestive of heart failure: a vignette study

BACKGROUND

General practitioners (GPs) specialized in cardiovascular disease (GPSI-CVD) may suspect heart failure (HF) more easily than GPs not specialized in CVD. We assessed whether GPSI-CVD consider investigations aimed at detecting HF more often than other GPs in two clinical scenarios of an older male person with respiratory and suggestive HF symptoms.

METHODS

In this vignette study, Dutch GPs evaluated two vignettes. The first involved a 72-year-old man with hypertension and a 30 pack-year smoking history who presented himself with symptoms of a common cold, but also shortness of breath, reduced exercise tolerance, and signs of fluid overload. The second vignette was similar but now the 72-year-old man was known with chronic obstructive pulmonary disease (COPD). GPs could select diagnostic tests from a multiple-choice list with answer options targeted at HF, COPD or exacerbation of COPD, or lower respiratory tract infection. With Pearson Chi-square or Fisher's exact test differences between the two GP groups were assessed regarding the chosen diagnostic tests.

RESULTS

Of the 148 participating GPs, 25 were GPSI-CVD and 123 were other GPs. In the first vignette, GPSI-CVD more often considered performing electrocardiography (ECG) than other GPs (64.0% vs. 32.5%, p = 0.003). In the second vignette, GPSI-CVD were more inclined to perform both ECG (36.0% vs. 12.2%, p = 0.003) and natriuretic peptide testing (56.0% vs. 32.5%, p = 0.006).

CONCLUSIONS

Most GPs seemed to consider multiple diagnoses, including HF, with GPSI-CVD more likely performing ECG and natriuretic peptide testing in an older male person with both respiratory and suggestive HF symptoms.

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.

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

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

Self-efficacy and healthcare costs in patients with chronic heart failure or chronic obstructive pulmonary disease

AIMS

This study aims to explore possible associations between self-efficacy and healthcare and drug expenditures (i.e. direct costs) in patients with chronic heart failure (CHF) or chronic obstructive pulmonary disease (COPD) in a study investigating the effects of person-centred care delivered by telephone.

METHODS AND RESULTS

This exploratory analysis uses data from an open randomized controlled trial conducted between January 2015 and November 2016, providing remote person-centred care by phone to patients with CHF, COPD, or both. Patients hospitalized due to worsening of CHF or COPD were eligible for the study. Randomization was based on a computer-generated list, stratified for age ≥ 75 and diagnosis. At a 6 month follow-up, 118 persons remained in a control group and 103 in an intervention group. The intervention group received person-centred care by phone as an addition to usual care. Trial data were linked to register data on healthcare and drug use. Group-based trajectory modelling was applied to identify trajectories for general self-efficacy and direct costs. Next, associations between self-efficacy trajectories and costs were assessed using regression analysis. Five trajectories were identified for general self-efficacy, of which three indicated different levels of increasing or stable self-efficacy, while two showed a decrease over time in self-efficacy. Three trajectories were identified for costs, indicating a gradient from lower to higher accumulated costs. Increasing or stable self-efficacy was associated with lower direct costs (P = 0.0013).

CONCLUSIONS

The findings show that an increased or sustained self-efficacy is associated with lower direct costs in patients with CHF or COPD. Person-centred phone contacts used as an add-on to usual care could result in lower direct costs for those with stable or increasing self-efficacy.

The Interplay of Comorbidities in Chronic Heart Failure: Challenges and Solutions

BACKGROUND

Chronic heart failure (HF) is frequently associated with various comorbidities. These comorbid conditions, such as anemia, diabetes mellitus, renal insufficiency, and sleep apnea, can significantly impact the prognosis of patients with HF.

OBJECTIVE

This review aims to synthesize current evidence on the prevalence, impact, and management of comorbidities in patients with chronic HF.

METHODS

A comprehensive review was conducted, with a rigorous selection process. Out of an initial pool of 59,030 articles identified across various research modalities, 134 articles were chosen for inclusion. The selection spanned various research methods, from randomized controlled trials to observational studies.

RESULTS

Comorbidities are highly prevalent in patients with HF and contribute to increased hospitalization rates and mortality. Despite advances in therapies for HF with reduced ejection fraction, options for treating HF with preserved ejection fraction remain sparse. Existing treatment protocols often lack standardization, reflecting a limited understanding of the intricate relationships between HF and associated comorbidities.

CONCLUSION

There is a pressing need for a multidisciplinary, tailored approach to manage HF and its intricate comorbidities. This review underscores the importance of ongoing research efforts to devise targeted treatment strategies for HF patients with various comorbid conditions.

The alveolar-capillary unit in the physiopathological conditions of heart failure: identification of a potential marker

In this review, we describe the structure and function of the alveolar-capillary membrane and the identification of a novel potential marker of its integrity in the context of heart failure (HF). The alveolar-capillary membrane is indeed a crucial structure for the maintenance of the lung parenchyma gas exchange capacity, and the occurrence of pathological conditions determining lung fluids accumulation, such as HF, might significantly impair lung diffusion capacity altering the alveolar-capillary membrane protective functions. In the years, we found that the presence of immature forms of the surfactant protein-type B (proSP-B) in the circulation reflects alterations in the alveolar-capillary membrane integrity. We discussed our main achievements showing that proSP-B, due to its chemical properties, specifically binds to high-density lipoprotein, impairing their antioxidant activity, and likely contributing to the progression of the disease. Further, we found that immature proSP-B, not the mature protein, is related to lung abnormalities, more precisely than the lung function parameters. Thus, to the list of the potential proposed markers of HF, we add proSP-B, which represents a precise marker of alveolar-capillary membrane dysfunction in HF, correlates with prognosis, and represents a precocious marker of drug therapy.

A Literature Review on the Coexisting Chronic Obstructive Pulmonary Disease and Heart Failure

The convergence of chronic obstructive pulmonary disease (COPD) and heart failure (HF) is a prevalent yet often overlooked medical scenario. This coexistence poses diagnostic challenges due to symptom similarities. This comprehensive review extensively examines the impact of COPD and HF on pharmacological management. Furthermore, the concurrent presence of these conditions amplifies both mortality rates and societal financial strain. Addressing these intertwined ailments necessitates a multidisciplinary approach. Within this review, we delve into the foundational mechanisms, diagnostic intricacies, and available management choices for these closely related conditions.

SCOPE: predicting future diagnoses in office visits using electronic health records

We propose an interpretable and scalable model to predict likely diagnoses at an encounter based on past diagnoses and lab results. This model is intended to aid physicians in their interaction with the electronic health records (EHR). To accomplish this, we retrospectively collected and de-identified EHR data of 2,701,522 patients at Stanford Healthcare over a time period from January 2008 to December 2016. A population-based sample of patients comprising 524,198 individuals (44% M, 56% F) with multiple encounters with at least one frequently occurring diagnosis codes were chosen. A calibrated model was developed to predict ICD-10 diagnosis codes at an encounter based on the past diagnoses and lab results, using a binary relevance based multi-label modeling strategy. Logistic regression and random forests were tested as the base classifier, and several time windows were tested for aggregating the past diagnoses and labs. This modeling approach was compared to a recurrent neural network based deep learning method. The best model used random forest as the base classifier and integrated demographic features, diagnosis codes, and lab results. The best model was calibrated and its performance was comparable or better than existing methods in terms of various metrics, including a median AUROC of 0.904 (IQR [0.838, 0.954]) over 583 diseases. When predicting the first occurrence of a disease label for a patient, the median AUROC with the best model was 0.796 (IQR [0.737, 0.868]). Our modeling approach performed comparably as the tested deep learning method, outperforming it in terms of AUROC (p < 0.001) but underperforming in terms of AUPRC (p < 0.001). Interpreting the model showed that the model uses meaningful features and highlights many interesting associations among diagnoses and lab results. We conclude that the multi-label model performs comparably with RNN based deep learning model while offering simplicity and potentially superior interpretability. While the model was trained and validated on data obtained from a single institution, its simplicity, interpretability and performance makes it a promising candidate for deployment.

Noninvasive assessment of pulmonary congestion in heart failure: Need of the hour

Early pulmonary congestion detection and surveillance in acute heart failure patients can prevent decompensation, minimize hospitalizations, and improve prognosis. In India, the warm and wet types of HF are still the most common types and residual congestion at discharge is still a significant concern. Thus, there is an urgent need for a reliable and sensitive means of identifying residual and subclinical congestion. Two such monitoring systems are available and approved by US FDA. These include CardioMEMS HF System (Abbott, Sylmar, California) and ReDS System (Sensible Medical Innovations, Ltd., Nanya, Israel). CardioMEMS is a wireless pressure-sensitive implantable device, while ReDS is a wearable noninvasive device for measurement of the lung fluid and hence direct detection of PC. This review discusses the role of noninvasive assessment in PC monitoring in patients with heart failure and its implications from an Indian perspective.

Etiologies and Predictors of 30-Day Readmission in Heart Failure: An Updated Analysis

BACKGROUND AND OBJECTIVES

Readmissions in heart failure (HF), historically reported as 20%, contribute to significant patient morbidity and high financial cost to the healthcare system. The changing population landscape and risk factor dynamics mandate periodic epidemiologic reassessment of HF readmissions.

METHODS

National Readmission Database (NRD, 2019) was used to identify HF-related hospitalizations and evaluated for demographic, admission characteristics, and comorbidity differences between patients readmitted vs. those not readmitted at 30-days. Causes of readmission and predictors of all-cause, HF-specific, and non-HF-related readmissions were analyzed.

RESULTS

Of 48,971 HF patients, the readmitted cohort was younger (mean 67.4 vs. 68.9 years, p≤0.001), had higher proportion of males (56.3% vs. 53.7%), lowest income quartiles (33.3% vs. 28.9%), Charlson comorbidity index (CCI) ≥3 (61.7% vs. 52.8%), resource utilization including large bed-size hospitalizations, Medicaid enrollees, mean length of stay (6.2 vs. 5.4 days), and disposition to other facilities (23.9% vs. 20%) than non-readmitted. Readmission (30-day) rate was 21.2% (10,370) with cardiovascular causes in 50.3% (HF being the most common: 39%), and non-cardiac in 49.7%. Independent predictors for readmission were male sex, lower socioeconomic status, nonelective admissions, atrial fibrillation, chronic obstructive pulmonary disease, chronic kidney disease, anemia, and CCI ≥3. HF-specific readmissions were significantly associated with prior coronary artery disease and Medicaid enrollment.

CONCLUSIONS

Our analysis revealed cardiac and noncardiac causes of readmission were equally common for 30-day readmissions in HF patients with HF itself being the most common etiology highlighting the importance of addressing the comorbidities, both cardiac and non-cardiac, to mitigate the risk of readmission.

High-Flow Nasal Cannula versus Noninvasive Ventilation in AECOPD Patients with Respiratory Acidosis: A Retrospective Propensity Score-Matched Study

Background

Limited data are available about the clinical outcomes of AECOPD patients with respiratory acidosis treated with HFNC versus NIV.

Methods

We conducted a retrospective study to compare the efficacy of HFNC with NIV as initial ventilation support strategy in AECOPD patients with respiratory acidosis. Propensity score matching (PSM) was implemented to increase between-group comparability. Kaplan-Meier analysis was utilized to evaluate differences between the HFNC success, HFNC failure, and NIV groups. Univariate analysis was performed to identify the features that differed significantly between the HFNC success and HFNC failure groups.

Results

After screening 2219 hospitalization records, 44 patients from the HFNC group and 44 from the NIV group were successfully matched after PSM. The 30-day mortality (4.5% versus 6.8%, p = 0.645) and 90-day mortality (4.5% versus 11.4%, p = 0.237) did not differ between the HFNC and NIV groups. Length of ICU stay (median: 11 versus 18 days, p = 0.001), length of hospital stay (median: 14 versus 20 days, p = 0.001), and hospital cost (median: 4392 versus 8403 $USD, p = 0.001) were significantly lower in the HFNC group compared with NIV group. The treatment failure rate was much higher in the HFNC group than in the NIV group (38.6% versus 11.4%, p = 0.003). However, patients who experienced HFNC failure and switched to NIV showed similar clinical outcomes to those who first received NIV. Univariate analysis showed that log NT-proBNP was an important factor for HFNC failure (p = 0.007).

Conclusions

Compared with NIV, HFNC followed by NIV as rescue therapy may be a viable initial ventilation support strategy for AECOPD patients with respiratory acidosis. NT-proBNP may be an important factor for HFNC failure in these patients. Further well-designed randomized controlled trials are needed for more accurate and reliable results.

Burden, Trends, and Inequalities of Heart Failure Globally, 1990 to 2019: A Secondary Analysis Based on the Global Burden of Disease 2019 Study

Background Heart failure is a public health issue worldwide. However, no comprehensive study on the global burden of heart failure and its contributing causes has been reported. The present study aimed to quantify the burden, trends, and inequalities of heart failure globally. Methods and Results Heart failure data were extracted from the Global Burden of Diseases 2019 study. The number of cases, age-standardized prevalence, and years lived with disability in different locations from 1990 to 2019 were presented and compared. Joinpoint regression analysis was performed to assess trends in heart failure from 1990 to 2019. In 2019, the global age-standardized prevalence and years lived with disability rates for heart failure were 711.90 (95% uncertainty interval [UI], 591.15-858.29) and 63.92 (95% UI, 41.49-91.95) per 100 000 population, respectively. In general, the age-standardized rate decreased globally at an average annual percentage change of 0.3% (95% UI, 0.2-0.3). However, the rate increased at an average annual percentage change of 0.6% (95% UI, 0.4-0.8) from 2017 to 2019. Several nations and territories demonstrated an increased trend from 1990 to 2019, especially in less-developed countries. Ischemic heart disease and hypertensive heart disease accounted for the highest proportion of heart failure in 2019. Conclusions Heart failure remains a major health problem, with increased trends possible in the future. Efforts for prevention and control of heart failure should focus more on less-developed regions. It is essential to prevent and treat primary diseases such as ischemic heart disease and hypertensive heart disease for the control of heart failure.

Clinical features and outcomes of elderly hospitalised patients with chronic obstructive pulmonary disease, heart failure or both

BACKGROUND AND OBJECTIVE

Chronic obstructive pulmonary disease (COPD) and heart failure (HF) mutually increase the risk of being present in the same patient, especially if older. Whether or not this coexistence may be associated with a worse prognosis is debated. Therefore, employing data derived from the REPOSI register, we evaluated the clinical features and outcomes in a population of elderly patients admitted to internal medicine wards and having COPD, HF or COPD + HF.

METHODS

We measured socio-demographic and anthropometric characteristics, severity and prevalence of comorbidities, clinical and laboratory features during hospitalization, mood disorders, functional independence, drug prescriptions and discharge destination. The primary study outcome was the risk of death.

RESULTS

We considered 2,343 elderly hospitalized patients (median age 81 years), of whom 1,154 (49%) had COPD, 813 (35%) HF, and 376 (16%) COPD + HF. Patients with COPD + HF had different characteristics than those with COPD or HF, such as a higher prevalence of previous hospitalizations, comorbidities (especially chronic kidney disease), higher respiratory rate at admission and number of prescribed drugs. Patients with COPD + HF (hazard ratio HR 1.74, 95% confidence intervals CI 1.16-2.61) and patients with dementia (HR 1.75, 95% CI 1.06-2.90) had a higher risk of death at one year. The Kaplan-Meier curves showed a higher mortality risk in the group of patients with COPD + HF for all causes (p = 0.010), respiratory causes (p = 0.006), cardiovascular causes (p = 0.046) and respiratory plus cardiovascular causes (p = 0.009).

CONCLUSION

In this real-life cohort of hospitalized elderly patients, the coexistence of COPD and HF significantly worsened prognosis at one year. This finding may help to better define the care needs of this population.

Influence of chronic obstructive pulmonary disease on long-term hospitalization and mortality in patients with heart failure with reduced ejection fraction

BACKGROUND

Heart failure with reduced ejection fraction (HFrEF) can coexist with chronic obstructive pulmonary disease (COPD), which complicates the clinical situation and worsens quality of life. The study used standard diagnostic criteria for detecting COPD in hospitalized HFrEF patients and to survey the influence of other comorbidities and medications on the long-term outcomes of HFrEF + COPD patients.

METHODS

We retrospectively recruited patients hospitalized due to HFrEF in a tertiary medical center and examined and followed up clinical outcomes, including length of hospital stay, mortality, and readmission episodes, for a 5-year period. Risk factors for mortality were analyzed using multivariate analysis.

RESULTS

Of the 118 hospitalized HFrEF study participants, 68 had concurrent COPD whereas 50 did not. There was a significant increase in the male predominance, smoking history, higher hemoglobin level and increased length of hospital stay in the HF + COPD group than in the HF-only group. Lower left ventricular ejection fraction was found in the HF and COPD comorbidity group. In multivariate analysis, angiotensin-converting enzyme inhibitor/angiotensin receptor blocker (ACEI/ARB) use independently associated with a beneficial effect on survival in HF patients with COPD. Oral corticosteroid uses and stroke as a comorbidity were independently associated with a shorter time to the first readmission episode.

CONCLUSION

In HFrEF patients, COPD was associated with a prolonged length of hospital stay. ACEI/ARB use might relate to a beneficial effect on survival in HF patients with COPD. The use of maintenance oral corticosteroid in patients with both HF and COPD should be crucially evaluated to determine the clinical benefit and disadvantages.

A systematic review and meta-analysis of heart rate variability in COPD

Background

Chronic obstructive pulmonary disease (COPD) is associated with disruption in autonomic nervous control of the heart rhythm. We present here quantitative evidence of the reduction in HRV measures as well as the challenges to clinical application of HRV in COPD clinics.

Method

Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, we search in June 2022 Medline and Embase databases for studies reporting HRV in COPD patients using relevant medical subject headings (MeSH) terms. The quality of included studies was assessed using the modified version of the Newcastle-Ottawa Scale (NOS). Descriptive data were extracted, while standardized mean difference was computed for changes in HRV due to COPD. Leave-one-out sensitivity test was performed to assess exaggerated effect size and funnel plots to assess publication bias.

Results

The databases search yielded 512 studies, of which we included 27 that met the inclusion criteria. The majority of the studies (73%) had a low risk of bias and included a total of 839 COPD patients. Although there were high between-studies heterogeneity, HRV time and frequency domains were significantly reduced in COPD patients compared with controls. Sensitivity test showed no exaggerated effect sizes and the funnel plot showed general low publication bias.

Conclusion

COPD is associated with autonomic nervous dysfunction as measured by HRV. Both sympathetic and parasympathetic cardiac modulation were decreased, but there is still a predominance of sympathetic activity. There is high variability in the HRV measurement methodology, which affects clinical applicability.

[Factors associated with patient participation in early return to the home Heart Failure program : a case-control study at the Centre Hospitalier de Troyes in 2017-2018]

OBJECTIVES

In 2013, the French National Health Insurance set up a programme to help patients with heart failure to return home and stay there (PRADO). During a hospitalization for cardiac decompensation, the medical team decides on the inclusion of the patient in the programme based on eligibility criteria defined. The objective of this study was to identify the factors most associated with the inclusion of heart failure patients in the PRADO program.

MATERIALS AND METHODS

This was a monocentric retrospective analytical stratified case-control study. It focused on the analysis of patient records hospitalized for cardiac decompensation between 01/01/2017 and 31/12/2018 in the cardiology department of the Centre Hospitalier de Troyes. For each patient included in the PRADO Heart Failure programme, one or two controls, not included in the PRADO Heart Failure programme were matched. The matching was exact without discounting. It was performed on the following criteria: age in 10-year increments, sex, main diagnosis of the stay, major category of diagnosis of the stay and its type (medical or surgical), the severity score of the Homogeneous Group of Patients of the stay and the Charlson score.

RESULTS

A total of 40 patients included in PRADO Heart Failure were matched to 56 controls not included in PRADO Heart Failure. Patients with respiratory disease (3.77 [1.07 - 13.29]), as well as patients on renin-angiotensin system inhibitors (2.24 [1.61 - 5.31]) were more often included in the PRADO Heart Failure programme. The most frequent criteria for non-eligibility were the need to transfer the patient to a specialised institution and significant impairment of higher functions.

CONCLUSION

Respiratory comorbidity and renin-angiotensin system blocker treatment are the factors most associated with the inclusion of heart failure patients in the PRADO Heart Failure programme.

Kravchenko A, Budnevsky AV, Ovsyannikov ES. Functional Status And Cytokine Profile Assessment In Patients With Chronic Obstructive Pulmonary Disease And Chronic Heart Failure

Objective — to evaluate the effect of chronic obstructive pulmonary disease (COPD) on the level of cytokines and the functional status of patients with chronic heart failure (CHF) with different categories of left ventricular ejection fraction. Methods — The study included 240 patients 40–70 years of age with CHF. All patients were divided into four groups: 69 CHF patients with preserved ejection fraction (CHFpEF), 91 CHF patients with reduced ejection fraction (CHFrEF), 36 COPD patients with CHFpEF and 44 COPD patients with CHFrEF. All participants underwent echocardiography, six-minute walk test (6MWT), the results of which were compared with the predicted six-minute walk distance: 6МWD (i). Additionally, we assessed the levels of NT-terminal fragment of pro-brain natriuretic peptide (NT-proBNP), high-sensitivity C-reactive protein (hs-CRP), IL-1β, IL-6, TNF-α, suppression of tumorigenicity 2 (ST2) in patient blood samples. Results — Patients with CHFpEF had higher levels of hs-CRP and proinflammatory cytokines as compared with patients with CHFrEF. The levels of NT-proBNP were higher in patients with COPD and CHF, compared with patients with CHF alone. A negative effect of COPD on the functional status of CHF patients with different EF values was established by the lower 6MWT values and 6MWD/6MWD ratio (i). An increase in the level of suppression of tumorigenicity 2 soluble forms (sST2) was noted in patients with COPD and CHF as compared with the isolated course of cardiac pathology patients. Conclusion — We established that unfavorable effect of COPD on patients with CHF was caused by disadvantageous values of NT-proBNP, ST2, 6MWT, and 6MWD/6MWD (i) ratio.

Factors affecting length of hospital stay in chronic obstructive pulmonary disease patients in a tertiary hospital of Nepal: A retrospective cross-sectional study

Background

Despite the increasing burden of chronic obstructive pulmonary disease in Nepal, studies analyzing the factors associated with inpatient length of hospital stay are lacking.

Methods

This is a retrospective, cross-sectional hospital-based study conducted between July 2020 and July 2021 on patients admitted to the inpatient ward of Pulmonary and Critical Care Medicine of Tribhuvan University Teaching Hospital with a primary diagnosis of acute exacerbation of chronic obstructive pulmonary disease. The sample size of our study was 90. Clinical and demographic factors, blood investigation parameters, and treatment received were analyzed via univariate and multivariate analysis to find the factors associated with length of stay.

Results

The mean age of chronic obstructive pulmonary disease patients was 68.84 ± 10.22 years, with 42.2% of males and 43.3% of current smokers. The length of hospital stay ranged from 2 to 25 days, with an average stay of 6.69 ± 4.02 days. Factors associated with length of stay are the number of comorbidities (p = 0.007), blood eosinophils at admission (p = 0.022), and use of mechanical ventilatory support (p < 0.001).

Conclusions

Proper management of comorbidities and eosinophilic exacerbations as well as careful use of mechanical ventilatory support are required to further reduce the duration of hospital stay in chronic obstructive pulmonary disease patients.

•

This study is the first of its kind identifying the factors associated with the length of hospital stay in COPD patients in Nepal.

•

COPD is the fifth most common cause of inpatient admission in Nepal and per our study the length of stay was 6.69 days.

•

The culprits identified for the increase length of stay were the number of comorbidities, blood eosinophils at admission and use of mechanical ventilator support.

Natriuretic peptides in elderly patients with chronic obstructive pulmonary disease

Background

Natriuretic peptides (NPs) are considered a useful tool for diagnosing the cardiac or pulmonary origin of acute dyspnea in the emergency department. The aim of this study was to evaluate NP in elderly patients with chronic obstructive pulmonary disease (COPD).

Materials and methods

In the PubMed and Hinari databases, we identified 465 comprehensive articles in English, published in the years 1990–2021, which provided information on natriuretic peptides in elderly patients with COPD. The final bibliography contains 49 relevant sources.

Results

NP, specially BNP/NT-proBNP values are frequently elevated in patients with COPD, reflecting three complex aspects of the interrelated cardio-pulmonary continuum: (1) left ventricular systolic and diastolic dysfunction, (2) pulmonary vascular and right heart remodeling, (3) global cardiovascular risk and comorbidities. The additional increase in BNP/NT-proBNP values during acute exacerbation of COPD is probably a marker for both, acute estate of COPD and varying degrees of underlying cardiopulmonary disease.

The results of the studies suggest the role of natriuretic peptides as relevant prognostic biomarkers not only for patients with cardiovascular disease, but also for patients with chronic obstructive pulmonary disease, which has an important clinical implication. The determination of these biomarkers in patients with chronic obstructive pulmonary disease allows stratification for prognosis: it is able to select a subgroup of patients at higher risk, which requires increased attention and optimization of treatment.

Conclusion

NPs, especially BNP/NT-proBNP are relevant prognostic biomarkers not only for patients with cardiovascular disease, but also for patients with COPD, acute exacerbations and haemodynamic disorders like PH and cor pulmonale. Estimating BNP/NT-proBNP in COPD patients has an important clinical implication: it allows the selection of a subgroup of patients at higher risk, which requires increased attention and treatment optimization.

The Impact of COPD on Hospitalized Patients with Diabetes: A Propensity Score Matched Analysis on Discharge Records

(1) Background: Type 2 diabetes is a common comorbidity of chronic obstructive pulmonary disease. Despite the lack of knowledge of the pathophysiological link between diabetes and chronic obstructive pulmonary disease, the presence of diabetes among those with chronic obstructive pulmonary disease is associated with worse outcomes, such as mortality and hospitalization. The aim of this study was to evaluate the impact of chronic obstructive pulmonary disease on in-hospital mortality and prolonged length of stay (PLOS) among patients with diabetes. (2) Methods: The study considered all hospital admissions of patients with diabetes aged over 65 years performed from 2006 to 2015 in Abruzzo, Italy. To compare outcomes between patients with and without chronic obstructive pulmonary disease, a propensity score matching procedure was performed. (3) Results: During the study period, 140,556 admissions of patients with diabetes were performed. After matching, 18,379 patients with chronic obstructive pulmonary disease and 18,379 controls were included in the analyses. Logistic regression analyses showed as chronic obstructive pulmonary disease was associated with in-hospital mortality (OR: 1.10; p = 0.036) and PLOS (OR: 1.18; p = 0.002). (4) Conclusions: In a cohort of Italian patients, diabetic patients with chronic obstructive pulmonary disease were associated with in-hospital mortality and PLOS. The definition of the causes of these differences aims to implement public health surveillance and policies.

Responses to incremental exercise and the impact of the coexistence of HF and COPD on exercise capacity: a follow-up study

Our aim was to evaluate: (1) the prevalence of coexistence of heart failure (HF) and chronic obstructive pulmonary disease (COPD) in the studied patients; (2) the impact of HF + COPD on exercise performance and contrasting exercise responses in patients with only a diagnosis of HF or COPD; and (3) the relationship between clinical characteristics and measures of cardiorespiratory fitness; (4) verify the occurrence of cardiopulmonary events in the follow-up period of up to 24 months years. The current study included 124 patients (HF: 46, COPD: 53 and HF + COPD: 25) that performed advanced pulmonary function tests, echocardiography, analysis of body composition by bioimpedance and symptom-limited incremental cardiopulmonary exercise testing (CPET) on a cycle ergometer. Key CPET variables were calculated for all patients as previously described. The [Formula: see text]E/[Formula: see text]CO2 slope was obtained through linear regression analysis. Additionally, the linear relationship between oxygen uptake and the log transformation of [Formula: see text]E (OUES) was calculated using the following equation: [Formula: see text]O2 = a log [Formula: see text]E + b, with the constant 'a' referring to the rate of increase of [Formula: see text]O2. Circulatory power (CP) was obtained through the product of peak [Formula: see text]O2 and peak systolic blood pressure and Ventilatory Power (VP) was calculated by dividing peak systolic blood pressure by the [Formula: see text]E/[Formula: see text]CO2 slope. After the CPET, all patients were contacted by telephone every 6 months (6, 12, 18, 24) and questioned about exacerbations, hospitalizations for cardiopulmonary causes and death. We found a 20% prevalence of HF + COPD overlap in the studied patients. The COPD and HF + COPD groups were older (HF: 60 ± 8, COPD: 65 ± 7, HF + COPD: 68 ± 7). In relation to cardiac function, as expected, patients with COPD presented preserved ejection fraction (HF: 40 ± 7, COPD: 70 ± 8, HF + COPD: 38 ± 8) while in the HF and HF + COPD demonstrated similar levels of systolic dysfunction. The COPD and HF + COPD patients showed evidence of an obstructive ventilatory disorder confirmed by the value of %FEV1 (HF: 84 ± 20, COPD: 54 ± 21, HF + COPD: 65 ± 25). Patients with HF + COPD demonstrated a lower work rate (WR), peak oxygen uptake ([Formula: see text]O2), rate pressure product (RPP), CP and VP compared to those only diagnosed with HF and COPD. In addition, significant correlations were observed between lean mass and peak [Formula: see text]O2 (r: 0.56 p < 0.001), OUES (r: 0.42 p < 0.001), and O2 pulse (r: 0.58 p < 0.001), lung diffusing factor for carbon monoxide (DLCO) and WR (r: 0.51 p < 0.001), DLCO and VP (r: 0.40 p: 0.002), forced expiratory volume in first second (FEV1) and peak [Formula: see text]O2 (r: 0.52; p < 0.001), and FEV1 and WR (r: 0.62; p < 0.001). There were no significant differences in the occurrence of events and deaths contrasting both groups. The coexistence of HF + COPD induces greater impairment on exercise performance when compared to patients without overlapping diseases, however the overlap of the two diseases did not increase the probability of the occurrence of cardiopulmonary events and deaths when compared to groups with isolated diseases in the period studied. CPET provides important information to guide effective strategies for these patients with the goal of improving exercise performance and functional capacity. Moreover, given our findings related to pulmonary function, body composition and exercise responses, evidenced that the lean mass, FEV1 and DLCO influence important responses to exercise.

Why small particle fixed dose triple therapy? An excursus from COPD pathology to pharmacological treatment evolution

Although bronchodilators are the cornerstone in chronic obstructive pulmonary disease (COPD) therapy, the treatment with a single-agent bronchodilator may not provide adequate symptoms control in COPD. The combination of drugs with different mechanisms of action may be more effective in inducing bronchodilation and preventing exacerbations, with a lower risk of side-effects in comparison with the increase of the dose of a single molecule. Several studies comparing the triple therapy with the association of long-acting ß2 agonist (LABA)/inhaled corticosteroid (ICS) or long-acting muscarinic antagonist (LAMA)/LABA reported improvement of lung function and quality of life. A significant reduction in moderate/severe exacerbations has been observed with a fixed triple combination of beclometasone dipropionate (BDP), formoterol fumarate (FF) and glycopyrronium (G) in a single inhaler. The TRILOGY, TRINITY and TRIBUTE studies have provided confirming evidence for a clinical benefit of triple therapy over ICS/LABA combination treatment, LAMA monotherapy and LABA/LAMA combination, with prevention of exacerbations being a key finding. A pooled post hoc analysis of the published clinical studies involving BDP/FF/G fixed combination demonstrated a reduction in fatal events in patients treated with ICS-containing medications, with a trend of statistical significance [hazard ratio = 0.72, 95% confidence interval (CI) 0.50-1.02, p = 0.066], that becomes significant if we consider reduction in fatal events for non-respiratory reasons (hazard ratio = 0.65, 95% CI 0.43-0.97, p = 0.037). In conclusion, a fixed combination of more drugs in a single inhaler can improve long-term adherence to the therapy, reducing the risk of exacerbations and hospital resources utilization. The twice a day administration may provide a better coverage of night, particularly in COPD patients who are highly symptomatic. The inhaled extrafine formulation that allows drug deposition in both large and small - peripheral - airways, is the value added.

COPD - do the right thing

A gap exists between guidelines and real-world clinical practice for the management and treatment of chronic obstructive pulmonary disease (COPD). Although this has narrowed in the last decade, there is room for improvement in detection rates, treatment choices and disease monitoring. In practical terms, primary care practitioners need to become aware of the huge impact of COPD on patients, have non-judgemental views of smoking and of COPD as a chronic disease, use a holistic consultation approach and actively motivate patients to adhere to treatment.This article is based on discussions at a virtual meeting of leading Nordic experts in COPD (the authors) who were developing an educational programme for COPD primary care in the Nordic region. The article aims to describe the diagnosis and lifelong management cycle of COPD, with a strong focus on providing a hands-on, practical approach for medical professionals to optimise patient outcomes in COPD primary care.

Exercise-Based Rehabilitation Delivery Models in Comorbid Chronic Pulmonary Disease and Chronic Heart Failure

Among the most prevalent multimorbidities that accompany the aging process, chronic obstructive pulmonary disease (COPD) and chronic heart failure (CHF) stand out, representing the main causes of hospital admissions in the world. The prevalence of COPD coexistence in patients with CHF is higher than in control subjects, given the common risk factors associated with a complex process of chronic diseases developing in the aging process. COPD-CHF coexistence confers a marked negative impact on mechanical-ventilatory, cardiocirculatory, autonomic, gas exchange, muscular, ventilatory, and cerebral blood flow, further impairing the reduced exercise capacity and health status of either condition alone. In this context, integrated approach to the cardiopulmonary based on pharmacological optimization and non-pharmacological treatment (i.e., exercise-based cardiopulmonary and metabolic rehabilitation) can be emphatically encouraged by health professionals as they are safe and well-tolerated, reducing hospital readmissions, morbidity, and mortality. This review aims to explore aerobic exercise, the cornerstone of cardiopulmonary and metabolic rehabilitation, resistance and inspiratory muscle training and exercise-based rehabilitation delivery models in patients with COPD-CHF multimorbidities across the continuum of the disease. In addition, the review address the importance of adjuncts to enhance exercise capacity in these patients, which may be used to optimize the gains obtained in these programs.

Association of Chronic Obstructive Pulmonary Disease With Arrhythmia Risks: A Systematic Review and Meta-Analysis

Background: A large number of studies have shown that the arrhythmia risks may be the potential causes of death among chronic obstructive pulmonary disease (COPD) patients. However, the association of COPD with risks of arrhythmias has never been systematically reviewed. Therefore, we performed a meta-analysis to assess the relationship between COPD and arrhythmia risks.

Methods: An updated systematic retrieval was carried out within the databases of Embase and PubMed until June 27, 2021.The random-effects model was used to pool studies due to the potential heterogeneity across the included studies. The risk ratios (RRs) with 95% confidence intervals (CIs) were regarded as effect estimates.

Results: A total of 21 studies were included in our meta-analysis. In the pooled analysis by the random-effects model, the results showed that COPD was significantly related to the risk of atrial fibrillation (AF) (RR = 1.99, 95% CI: 1.46–2.70), ventricular arrhythmias (VA) (RR = 2.01, 95% CI: 1.42–2.85), and sudden cardiac death (SCD) (RR = 1.68, 95% CI: 1.28–2.21). The corresponding results were not changed after exclusion one study at a time. The pooled results were also stable when we re-performed the analysis using the fixed-effects model.

Conclusions: Our current data suggested that COPD was associated with increased risks of AF, VA, and SCD.

The Coexistence of Chronic Obstructive Pulmonary Disease and Heart Failure

Chronic obstructive pulmonary disease (COPD) is a chronic illness that is widely prevalent within the United States and has been frequently associated with heart failure (HF). COPD is associated with progressive damage and inflammation of the airways leading to airflow obstruction and inadequate gas exchange. HF represents a decline in the normal functioning of the heart resulting in insufficient pumping of blood through the circulatory system. COPD and HF present with similar signs and symptoms with some variation.

There are many specific diagnostic tests and treatment modalities which we use to diagnose COPD and HF, but it becomes an issue when you come across a patient who has both conditions simultaneously. For example, attempting to use an X-ray to diagnose HF in a COPD patient is next to impossible because the results are manipulated by the COPD disease process. This is the case with many other diagnostic tests such as an electrocardiogram (ECG), chest radiography (X-ray), B-type natriuretic peptide (BNP), echocardiogram, cardiac magnetic resonance imaging (CMR), pulmonary function test (PFT), arterial blood gas (ABG), and exercise stress testing.

When a patient has both COPD and HF, it becomes more difficult to treat. Many treatments for HF have negative impacts on COPD patients and vice-versa, whereas some have also shown positive clinical outcomes in both diseases. It is agreeable that treatment has to be patient-centered and it can vary from case to case depending on the severity of the disease. Ultimately, in this review, we discuss COPD and HF and how they interplay in their diagnostic and treatment modalities to gain a better understanding of how to effectively manage patients who have been diagnosed with both conditions.

Trends in Incidence, and Mortality of Acute Exacerbation of Chronic Obstructive Pulmonary Disease in the United States Emergency Department (2010-2018)

Literature regarding trends of incidence, mortality, and complications of acute exacerbation of chronic obstructive pulmonary disease (COPD) in the emergency departments (ED) is limited. What are trends of COPD exacerbation in ED? Data were obtained from the Nationwide Emergency Department Sample (NEDS) that constitutes a 20% sample of hospital-owned EDs and inpatient sample in the US. All ED encounters were included in the analysis. Complications of AECOPD were obtained by using ICD codes. Out of 1.082 billion ED encounters, 5,295,408 (mean age 63.31 ± 12.63 years, females 55%) presented with COPD exacerbation. Among these patients, 353,563(6.7%) had AECOPD-plus (features of pulmonary embolism, acute heart failure and/or pneumonia) while 4,941,845 (93.3%) had exacerbation without associated features or precipitating factors which we grouped as AECOPD. The AECOPD-plus group was associated with statistically significantly higher proportion of cardiovascular complications including AF (5.6% vs 3.5%; p < 0.001), VT/VF (0.14% vs 0.06%; p < 0.001), STEMI (0.22% vs 0.11%; p < 0.001) and NSTEMI (0.65% vs 0.2%; p < 0.001). The in-hospital mortality rates were greater in the AECOPD-plus population (0.7% vs 0.1%; p < 0.001). The incidence of both AECOPD and AECOPD-plus had worsened (p-trend 0.004 and 0.0003) and the trend of mortality had improved (p-trend 0.0055 and 0.003, respectively). The prevalence of smoking for among all COPD patients had increased (p-value 0.004), however, the prevalence trend of smoking among AECOPD groups was static over the years 2010-2018. There was an increasing trend of COPD exacerbation in conjunction with smoking; however, mortality trends improved significantly. Moreover, the rising burden of AECOPD would suggest improvement in diagnostics and policy making regarding management.

A review of therapies for the overlap syndrome of obstructive sleep apnea and chronic obstructive pulmonary disease

Obstructive sleep apnea (OSA) and chronic obstructive pulmonary disease (COPD) are common chronic diseases. These two noncommunicable diseases (NCDs) are prevalent among approximately 10% of the general population. Approximately 1% of the population is affected by the co-existence of both conditions, known as the overlap syndrome (OS). OS patients suffer from greater degrees of nocturnal oxygen desaturation and cardiovascular consequences than those with either condition in isolation. Besides OS, patients with COPD may suffer from a spectrum of sleep-related breathing disorders, including hypoventilation and central sleep apnea. The article provides an overview of the pathogenesis, associated risk factors, prevalence, and management of sleep-related breathing disorders in COPD. It examines respiratory changes during sleep caused by COPD and OSA. It elaborates upon the factors that link the two conditions together to lead to OS. It also discusses the clinical evaluation and diagnosis of these patients. Subsequently, it reviews the pathophysiological basis and the current evidence for three potential therapies: positive airway pressure therapy [including continuous positive airway pressure (CPAP) and bilevel positive airway pressure], oxygen therapy, and pharmacological therapy. It also proposes a phenotypic approach toward the diagnosis and treatment of OS and the entire spectrum of sleep-related breathing disorders in COPD. It concludes with the current evidence gaps and future areas of research in the management of OS.

Acute decompensated heart failure (ADHF) during COVID-19 pandemic-insights from South India

AIM

This retrospective study compares admissions and outcomes due to acute decompensated heart failure (ADHF) during the COVID-19 pandemic from 25 March to 25 July 2020 with the historical patient control who were admitted during the same period in 2019.

METHODS AND RESULTS

Data of the participating hospitals was collected and analysed from the ICC NHFR (Indian College of Cardiology National Heart Failure Registry) for 2019 and 2020. Total number of ADHF admissions, demographics, aetiology, co-morbid conditions and in-hospital mortality was compared and analysed. A significant decrease in the number of hospital admissions due to ADHF from 2019 to 2020 (1056 vs. 526 respectively) was noted. Incidence of admissions with <40% ejection fraction (EF) reduced in 2020 (72.4% and 80.2% in2020 and 2019)and >40% (EF) increased (27.6% and 19.8% in 2019 and 2020 respectively, p = 0.0005). Ischemic heart disease (IHD) was the most common aetiology (78.59% in 2019 and 80.98% in 2020, p = 0.268). The in-hospital mortality was numerically higher in 2020 (10%) than in 2019 (8%), but not statistically significant (p = 0.161).

CONCLUSION

This study from the registry shows that the incidence of ADHF admissions during COVID-19 lockdown significantly reduced compared to the previous year. Demographic patterns remained similar but patients presenting with de-novo HF increased; IHD was the most common cause. The in-hospital mortality was numerically higher during the lockdown. The impact of lockdown perhaps led to fewer hospitalisations and this is to be factored in future strategies to address health care delivery during such crises.

Temporal Trends in the Incidence of Heart Failure among Patients with Chronic Obstructive Pulmonary Disease and Its Association with Mortality

Rationale: Heart failure (HF) is a common comorbidity in the chronic obstructive pulmonary disease (COPD) population, but previous research has shown underrecognition.Objectives: The objectives of this study were to determine the incidence of HF in a prevalent COPD cohort and to determine the association of incident HF with short- and long-term mortality of patients with COPD.Methods: Crude incidence of HF in the HF-naive primary care COPD population was calculated for each year from 2006 to 2016 using UK data from the Clinical Practice Research Datalink (CPRD). Patients with COPD were identified using a validated code list and were required to be >35 years old at COPD diagnosis, have a history of smoking, and have documented airflow obstruction. The Office of National Statistics provided mortality data for England. Adjusted mortality rate ratios (aMRRs) from Poisson regression were calculated for patients with COPD and incident HF (COPD-iHF) in 2006, 2011, and 2015, and compared temporally with patients with COPD and without incident HF (COPD-no HF) in those years. Regression was adjusted for age, sex, body mass index, severity of airflow limitation, smoking status, history of cardiovascular disease, and diabetes.Results: We identified 95,987 HF-naive patients with COPD. Crude incidence of HF was steady from 2006 to 2016 (1.18 per 100 person-years; 95% confidence interval [CI], 1.09-1.27). Patients with COPD-iHF experienced greater than threefold increase in 1-year mortality and twofold increase in 5-year and 10-year mortality compared with patients with COPD-no HF, with no change on the basis of year of HF diagnosis. Mortality of patients with COPD-iHF did not improve over time, comparing incident HF in 2011 (1-yr aMRR, 1.26; 95% CI, 0.83-1.90; 5-yr aMRR, 1.26; 95% CI, 0.98-1.61) and 2015 (1-yr aMRR, 1.63; 95% CI, 0.98-2.70) with incident HF in 2006.Conclusions: The incidence of HF in the UK COPD population was stable in the last decade. Survival of patients with COPD and incident HF has not improved over time in England. Bespoke guidelines for the diagnosis and management of HF in the COPD population are needed to improve identification and survival of patients.

Factors Influencing the Length of Hospital Stay Among Patients with Chronic Obstructive Pulmonary Disease (COPD) in Macao Population: A Retrospective Study of Inpatient Health Record

Purpose

This study aims to identify the effects of patient and clinical therapy factors on the length of hospital stay (LOS) for admission due to chronic obstructive pulmonary disease (COPD) in Macao.

Patients and Methods

Health record of patients with COPD admitted to Kiang Wu Hospital from January 2017 to December 2019 was retrospectively analyzed. Demographic information, blood test results, clinical therapies, and LOS were described and analyzed by multivariable regression.

Results

A total of 1116 admissions were included with the average LOS being 12.28 (±9.23) days. Among them, 735 (66.6%) were male with mean age 79.42 (±10.35) years old, 697 were current or previous smokers (62.5%), and 360 (32.2%) had 3 or more comorbidities. During hospitalization, the most common treatments received were oxygen therapy (n=991,88.8%), antibiotics (n=828,74.2%), and systemic steroids (n=596,53.4%); only 120 (10.8%) had pulmonary rehabilitation (PR) and 128 (11.5%) received noninvasive ventilation (NIV). Inhaled medications were used during nearly 95% of hospitalization cases, while 2 and 3 types of inhaled medications were used during 230 (20.6%) and 582 (52.2%) hospitalization cases, respectively. Patient factors including age (B=0.178, 95% CI:0.535–1.072), being female (B=−1.147, 95% CI:-0.138–0.056), being current (B=−0.086, 95% CI:-0.124–0.018) or previous smoker (B=0.072, 95% CI:0.004–0.087), having 1, 2, 3 and over 3 comorbidities (B=0.126, 95% CI:0.034–0.147; B=0.125, 95% CI:0.031–0.144; B=0.116, 95% CI:0.028–0.146, B=0.090, 95% CI:0.021–0.166) and having low hemoglobin level (B=−0.118, 95% CI:-0.629- −0.214) exhibited significant associations with LOS. The use of NIV (B=0.080, 95% CI:0.022–0.138), pulmonary rehabilitation (B=0.269, 95% CI:0.212–0.327), two and three types of inhaled medications (B=0.109, 95% CI:0.003–0.166, B=0.255, 95% CI:0.083–0.237) were significantly associated with longer LOS (P<0.05).

Conclusion

NIV, PR and combined inhaled medications, which are often used for AECOPD, are the main clinical therapies associated with longer LOS in Macao. Smoking cessation, early treatments of comorbidities may be crucial to avoiding AECOPD and reducing LOS and disease burden.

Safety of diuretic administration during the early management of dyspnea patients who are not finally diagnosed with acute heart failure

OBJECTIVES

Investigating whether it is safe or not to administrate diuretics to patients arriving at emergency departments in a stage of acute dyspnea but without a final diagnosis of acute heart failure.

METHODS

We analyzed an unselected multinational sample of patients with dyspnea without a final diagnosis of acute heart failure from Global Research on Acute Conditions Team (France, Lithuania, Tunisia) and Basics in Acute Shortness of Breath Evaluation (Switzerland) registries. Thirty-day all-cause mortality and 30-day postdischarge all-cause readmission rate of treated patients with diuretics at emergency departments were compared with untreated patients by unadjusted and adjusted hazard and odds ratios. Interaction and stratified analyses were performed.

RESULTS

We included 2505 patients. Among them, 365 (14.6%) received diuretics in emergency departments. Thirty-day mortality was 4.5% (treated/untreated = 5.2%/4.3%, hazard ratio: 1.22; 95% confidence interval, 0.75-2.00) and 30-day readmission rate was 11.3% (14.7%/10.8%, odds ratio: 1.41; 95% confidence interval, 0.95-2.11). After adjustment, no differences were found between two groups in mortality (hazard ratio: 0.86; 95% confidence interval, 0.51-1.44) and readmission (odds ratio: 1.15; 95% confidence interval, 0.72-1.82). Age significantly interacted with the use of diuretics and readmission (P = 0.03), with better prognosis when used in patients >80 years (odds ratio: 0.27; 95% confidence interval, 0.07-1.03) than in patients ≤80 years (odds ratio: 1.56; 95% confidence interval, 0.94-2.63).

CONCLUSIONS

Diuretic administration to patients presenting to emergency departments with dyspnea while they were undiagnosed and in whom acute heart failure was finally excluded was not associated with 30-day all-cause mortality and 30-day postdischarge all-cause readmission rate.

[Incidence of severe exacerbation in patients diagnosed with diabetes and chronic obstructive pulmonary disease: Cohort study]

Objetivo

Estimar en una cohorte de pacientes diagnosticados de EPOC y diabetes la incidencia de hospitalizaciones por exacerbación grave de la EPOC y sus factores asociados.

Diseño

Estudio prospectivo de cohorte.

Emplazamiento

Centros de Atención Primaria de Lleida ciudad (en total 7 centros).

Participantes

Se estudiaron 761 pacientes codiagnosticados de EPOC y diabetes. Los criterios de inclusión fueron pacientes de ambos sexos, igual o mayores de 40 años, residentes en el área geográfica de Lleida ciudad, con el diagnóstico de EPOC según los criterios de la guía GOLD, con espirometría reciente y una fracción FEV₁/FVC < 0,7; diagnosticados de DM2 según la guía de la International Diabetes Federation. Los criterios de exclusión fueron padecer alguna enfermedad física o psíquica grave.

Mediciones principales

Las variables del estudio fueron: el sexo, la edad, su área básica de salud en Lleida, índice de masa corporal, perímetro de cintura, hábito tabáquico y enólico, hipertensión arterial, insuficiencia cardiaca, insuficiencia renal crónica, FEV₁, FEV₁/FVC, categorización GOLD, HbA1c. Se registró la vacuna antigripal y antineumocócica. La variable dependiente fue la exacerbación grave. En el análisis estadístico la asociación de la variable dependiente con las variables independientes se determinó mediante el cálculo de la hazard ratio (HR) con el intervalo de confianza del 95%. La HR se estimó de forma ajustada mediante modelos de regresión de Cox no condicional.

Resultados

La incidencia de hospitalización por exacerbación grave de la EPOC fue del 9,98%; se objetivó un aumento del riesgo de exacerbación grave en pacientes diagnosticados de insuficiencia cardiaca (HR = 2,27; p = 0,002), y con una menor fracción de FEV₁/FVC. La vacuna antigripal y antineumocócica presentaron un papel protector débil sin ser estadísticamente significativa.

Conclusión

Se documenta una incidencia de exacerbaciones elevada en los pacientes codiagnosticados de EPOC y DM2. La insuficiencia cardiaca y una menor fracción FEV₁/FVC podrían aumentar el riesgo de exacerbación.

Treatable cardiac disease in hospitalised COPD exacerbations

Introduction

Acute exacerbations of COPD (AECOPD) are accompanied by escalations in cardiac risk superimposed upon elevated baseline risk. Appropriate treatment for coronary artery disease (CAD) and heart failure with reduced ejection fraction (HFrEF) could improve outcomes. However, securing these diagnoses during AECOPD is difficult, so their true prevalence remains unknown, as does the magnitude of this treatment opportunity. We aimed to determine the prevalence of severe CAD and severe HFrEF during hospitalised AECOPD using dynamic computed tomography (CT).

Methods

A cross-sectional study of 148 patients with hospitalised AECOPD was conducted. Dynamic CT was used to identify severe CAD (Agatston score ≥400) and HFrEF (left ventricular ejection fraction ≤40% and/or right ventricular ejection fraction ≤35%).

Results

Severe CAD was detected in 51 of 148 patients (35%), left ventricular systolic dysfunction was identified in 12 cases (8%) and right ventricular systolic dysfunction was present in 18 (12%). Clinical history and examination did not identify severe CAD in approximately one-third of cases and missed HFrEF in two-thirds of cases. Elevated troponin and brain natriuretic peptide did not differentiate subjects with severe CAD from nonsevere CAD, nor distinguish HFrEF from normal ejection fraction. Undertreatment was common. Of those with severe CAD, only 39% were prescribed an antiplatelet agent, and 53% received a statin. Of individuals with HFrEF, 50% or less received angiotensin blockers, beta blockers or antimineralocorticoids.

Conclusion

Dynamic CT detects clinically covert CAD and HFrEF during AECOPD, identifying opportunities to improve outcomes via well-established cardiac treatments.

Severe, treatable cardiac disease is present during hospitalised #AECOPD exacerbations, and is often clinically unsuspected. This cardiac disease can be detected with dynamic CT. Appropriate treatment could change outcomes.https://bit.ly/2Is45wO

Oral treatment for diabetes using α-glucosidase inhibitors was a risk factor for chronic obstructive pulmonary disease: a cohort study

Objectives: Currently, diabetes mellitus (DM) and chronic obstructive pulmonary disease (COPD) have proven to be risk factors for each other. This study aimed to determine the risk relationship between COPD and five common oral medications for DM among patients with DM. Methods: This population-based cohort study was conducted from 2008 to 2013. Patient data were retrieved from the Longitudinal Health Insurance Database (LHID) of the National Health Insurance Research Database (NHIRD). After pairing by gender, age, and index date, time-to-event analysis and multiple regression analysis were performed to determine the factors associated with COPD in patients taking oral medication for DM, including age, gender, income, and comorbidities. We identified 1,028 patients who took oral medication for DM and 1,028 controls who did not take oral medication for DM. Results: We observed that the use of α-glucosidase inhibitors was associated with a higher risk of COPD (hazard ratio [HR]: 1.964, 95% confidence interval [CI]: 1.207-2.380). Furthermore, compared with the control group, α-glucosidase inhibitor users had a higher risk of COPD (HR: 2.295, 95% CI: 1.304-4.038), and no significant difference was observed in other oral medications for DM. Conclusions: Based on present results, we could suggest that patients with DM who used α-glucosidase inhibitors are probably a higher risk of COPD. We recommend that in the future, treatment with α-glucosidase inhibitors upregulate the occurrence of COPD might through gastrointestinal side effects and malnutrition.

Optimized combination of circulating biomarkers as predictors of prognosis in AECOPD patients complicated with Heart Failure

Background: Systematic inflammation, nutritional status, and cardiovascular function have been associated with the outcomes of acute exacerbation of chronic obstructive pulmonary disease (AECOPD) patients with heart failure (HF). However, the value of their relevant biomarkers in predicting mortality has not been well defined yet. We aimed to investigate the prognostic value of circulating biomarkers including C-reaction protein (CRP)/albumin (ALB), neutrophil-lymphocyte ratio (NLR), platelet-lymphocyte ratio (PLR), and N-terminal pro-brain natriuretic peptide (NT-proBNP) for AECOPD patients with HF. Methods: A retrospective study was carried out in the Second Clinical College of Jinan University from January 1, 2013 to January 31, 2019. A total of 146 cases of AECOPD complicated with HF were enrolled and classified into survivor group (n=94) and non-survivor group (n=52). The baseline characteristics, CRP/ALB ratio, NLR, PLR, serum levels of NT-proBNP, and other indicators were collected. The predictors for prognosis were analyzed by multivariate logistic regression, and the ability to predict 28-day mortality was evaluated by receiver operating characteristics curve (ROC) and the area under the curve (AUC). Results: The patients in non-survivors had significantly higher levels of CRP, CRP/ALB, NLR, PCT and NT-proBNP, but lower ALB levels compared to the survivors [111.7 (56.9, 186.5) VS. 43.8 (10.3, 96.1) mg/L, 4.6 (2.0, 8.0) VS. 1.4 (0.3, 3.4), 22.2 (11.1, 40.1) VS. 12.0 (6.2, 24.8), 2.6 (0.2, 10.3) VS. 0.08 (0.1, 0.5) ng/ml, 17912.5 (9344.0, 34344.5) VS. 9809.0 (4415.9, 16387.2) ng/ml, 25.8 (23.2, 30.5) VS. 30.7 (27.9, 34.1) g/L; P < 0.001, <0.001, 0.001, <0.001, <0.001, and < 0.001, respectively]. No significant difference in PLR was found between the two groups (P=0.413). The logistic analysis revealed that CRP/ALB (OR=1.303, 95%CI: 1.145-1.483, P<0.001), NT-proBNP (OR=1.041, 95%CI: 1.010-1.073, P=0.009) and NLR (OR=1.010, 95%CI: 0.999-1.022, P<0.001) are independent risk factors for predicting the 28-day mortality. The AUC of the ROC curves were 0.768, 0.767, 0.757, 0.723, 0.716, and 0.668 for CRP/ALB, PCT, CRP, NT-proBNP, ALB, and NLR, respectively. The combination of CRP/ALB, NLR and NT-proBNP as biomarkers was shown to have better accuracy for predicting prognosis (AUC=0.830, 95%CI: 0.761-0.899, P<0.001), with a higher specificity of 80.8% and specificity of 77.7% as compared with each single biomarkers. Conclusions: High levels of NLR, CRP/ALB and NT-proBNP may be clinical usefully predictors for death in AECOPD patients with HF. Combination of NLR with CRP/ALB and NT-proBNP can provide a higher accuracy for predicting 28-day mortality in these patients.

Influence of Comorbidities on the Survival of COPD Patients According to Phenotypes

Background

Chronic obstructive pulmonary disease (COPD) usually occurs alongside other conditions. Few studies on comorbidities have taken into account the phenotypes of COPD patients. The objective of this study is to evaluate the prevalence of comorbidities included in the Charlson index and their influence on the survival of patients with COPD, taking phenotypes into account.

Methods

An observational study was conducted on a group of 273 patients who had COPD and underwent spirometry in the first half of 2011, with a median prospective follow-up period of 68.15 months. The survival of these patients was analyzed according to the presence of various comorbidities.

Results

Of the 273 patients, 93 (34.1%) died within the follow-up period. An increased presence of chronic ischemic heart disease (CIHD), chronic heart failure (CHF), chronic kidney disease (CKD), and malignancy was found in deceased patients. All of these conditions shorten the survival of COPD patients globally; however, when considering phenotypes, only CHF influences the exacerbator with chronic bronchitis phenotype, CKD influences the non-exacerbator phenotype, and malignancy influences the positive bronchodilator test (BDT) and exacerbator with chronic bronchitis phenotypes. In the multivariate model, advanced age (hazard ratio, HR: 1.05; p=0.001), CHF (HR: 1.74; p=0.030), and the presence of malignancy (HR: 1.78; p=0.010) were observed as independent mortality risk factors.

Conclusion

The survival is shorter in the presence of CIHD in overall COPD patients and also CHF, CKD, and malignancy for certain phenotypes. It is important to pay attention to these comorbidities in the comprehensive care of COPD patients.

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.

Targeting Aging Pathways in Chronic Obstructive Pulmonary Disease

Chronic obstructive pulmonary disease (COPD) has become a global epidemic and is the third leading cause of death worldwide. COPD is characterized by chronic airway inflammation, loss of alveolar-capillary units, and progressive decline in lung function. Major risk factors for COPD are cigarette smoking and aging. COPD-associated pathomechanisms include multiple aging pathways such as telomere attrition, epigenetic alterations, altered nutrient sensing, mitochondrial dysfunction, cell senescence, stem cell exhaustion and chronic inflammation. In this review, we will highlight the current literature that focuses on the role of age and aging-associated signaling pathways as well as their impact on current treatment strategies in the pathogenesis of COPD. Furthermore, we will discuss established and experimental COPD treatments including senolytic and anti-aging therapies and their potential use as novel treatment strategies in COPD.

Treatment of COPD and COPD-heart failure comorbidity in primary care in different stages of the disease

Background:

Chronic obstructive pulmonary disease (COPD) is a chronic respiratory disease that may have a negative impact on both patients’ quality of life and survival. Patients with COPD frequently suffer from heart failure (HF), likely owing to several shared risk factors.

Aim:

To evaluate the differences in treatment of COPD with and without HF comorbidity according to COPD severity in the general practitioner setting.

Methods:

We conducted an observational, retrospective study using data obtained from the Italian Health Search Database, which collects information generated by the routine activity of general practitioners. The study sample included 225 patients with COPD, alone or combined with HF.

Findings:

It has been found that the prevalence of some comorbidities such as diabetes and HF significantly increases with the severity of COPD. Regarding pharmacological treatment, a reduction in the prescription of individually administered long-acting β 2-agonists (LABAs) and long-acting anticholinergics (LAMAs) has been observed with increasing severity of the disease. Moreover, an increase in the prescription of both the combination of the two bronchodilators (LABA + LAMA) and their association with inhaled corticosteroids has been observed with increasing severity of COPD. The prescription of β-blockers in patients with COPD suffering from HF comorbidity decreases from 100% in stage I to less than 50% in the other stages of COPD. This study shows that general practitioners do not follow the guidelines recommendations for the management of patients with COPD in the different stages of the disease, with and without HF comorbidity, as well as in the management of HF. Further efforts must be made to ensure adequate treatment for these patients.

Management of the COPD Patient with Comorbidities: An Experts Recommendation Document

Background

Chronic obstructive pulmonary disease (COPD) is associated with multiple comorbidities, which impact negatively on patients and are often underdiagnosed, thus lacking a proper management due to the absence of clear guidelines.

Purpose

To elaborate expert recommendations aimed to help healthcare professionals to provide the right care for treating COPD patients with comorbidities.

Methods

A modified RAND-UCLA appropriateness method consisting of nominal groups to draw up consensus recommendations (6 Spanish experts) and 2-Delphi rounds to validate them (23 Spanish experts) was performed.

Results

A panel of Spanish internal medicine experts reached consensus on 73 recommendations and 81 conclusions on the clinical consequences of the presence of comorbidities. In general, the experts reached consensus on the issues raised with regard to cardiovascular comorbidity and metabolic disorders. Consensus was reached on the use of selective serotonin reuptake inhibitors in cases of depression and the usefulness of referring patients with anxiety to respiratory rehabilitation programmes. The results also showed consensus on the usefulness of investigating the quality of sleep, the treatment of pain with opioids and the evaluation of osteoporosis by lateral chest radiography.

Conclusion

This study provides conclusions and recommendations that are intended to improve the management of the complexity of patients with COPD and important comorbidities, usually excluded from clinical trials.

Endothelial dysfunction is not a predictor of outcome in chronic obstructive pulmonary disease

Background

Local airway inflammation may cause systemic changes which result in endothelial dysfunction. Only a few studies have used reactive hyperemia peripheral arterial tonometry (RH-PAT) in patients with chronic obstructive pulmonary disease (COPD) in order to measure their endothelial dysfunction.

Objective

To determine the efficacy of endothelial dysfunction, measured by RH-PAT, in assessing disease severity and systemic burden in a cohort of COPD patients.

Methods

In this prospective, monocentric study, 157 patients with moderate to very severe COPD (GOLD class II-IV) were examined for endothelial dysfunction using RH-PAT (Itamar medical Ltd., Caesarea, Israel). In a nested-cohort, examination was repeated at exacerbation. The association between reactive hyperemia index (RHI), augmentation index (AI) and disease severity and outcome parameters was analysed.

Results

57% of the COPD patients had a dysfunctional endothelium and the median (IQR) RHI was 1.42 (1.27–1.53). Exacerbation of COPD was not associated with a significant change in RHI (p = 0.625) or ΑΙ (p = 0.530). None of the diagnostic or clinical outcomes of COPD was associated with RHI or arterial stiffness.

Conclusion

Endothelial dysfunction is common in COPD. However, it does not seem to be a predictor neither of disease severity, nor of outcome and does not change during exacerbations of the disease.