Relationship of peak expiratory flow rate with mortality and ischaemic heart disease in elderly Australians

Reduced peak expiratory flow predicts increased risk of cardiovascular disease: A 10-year prospective cohort study in Eastern China

BACKGROUND

The correlation between impaired lung function and cardiovascular diseases (CVD) has attracted more and more attention. We aimed to assess the longitudinal association between decreased peak expiratory flow (PEF) and cardiovascular risk among Eastern Chinese general population.

METHODS

In total, 6295 participants aged>30 years and free of CVD at baseline were followed for up to 10 years in Eastern China. The adjusted hazard ratios (HRs) for CVD and mortality associated with decreased PEF were analyzed.

RESULTS

Among all participants, 421 CVD incident events were reported during 10-year follow-up, and a total of 272 participants died during the follow-up period, 94 of them from CVD. The HRs in the lowest group of PEF (PEF ≤218.33 L/min) were 1.31 (95% confidence interval [CI]:1.01 to 1.68) for high CVD incidence (172 vs 116), 2.43 (95% CI:1.72 to 3.42) for all-cause mortality (156 vs 48), and 3.94 (95% CI:1.96 to 7.92) for CVD mortality (59 vs 10) when compared with the highest group (PEF ≥321.68 L/min).

CONCLUSION

The decreased PEF was associated with increased CVD incidence, CVD and all-cause mortality in Eastern Chinese general population.

Systematic short-term pulmonary rehabilitation before lung cancer lobectomy: a randomized trial

OBJECTIVES

The goal of this study was to assess the impact of a preoperative 1-week, systematic, high-intensity inpatient exercise regimen on patients with lung cancer who had risk factors for postoperative pulmonary complications (PPCs).

METHODS

We conducted a randomized controlled trial with 101 subjects of a preoperative, 7-day systematic, integrated, high-intensity pulmonary exercise regimen. The control group received standard preoperative care. We analysed the occurrence of PPCs in both groups as the primary outcome; other outcomes included changes in blood gas, quality of life, peak expiratory flow rate, the 6-min walk distance and others.

RESULTS

The 6-min walk distance showed an increase of 22.9 ± 25.9 m in the intervention group compared with 4.2 ± 9.2 m in the control group, giving a between-group difference of 18.7 m (95% confidence interval: 8.8-28.6; P < 0.001); the peak expiratory flow increased by 25.2 ± 24.6 l/min, compared with 4.2 ± 7.7 l/min (between-group difference: 21.0 m, 95% confidence interval: 7.2-34.8; P = 0.003). The intervention group had a shorter average total (15.6 ± 3.6 vs 17.7 ± 5.3 days, P = 0.023) and postoperative length of stay (6.1 ± 3.0 vs 8.7 ± 4.6 days, P = 0.001) than the control group; the incidence of PPCs (9.8%, 5/51 vs 28.0%, 14/50, P = 0.019) was significantly lower. A multivariable analysis of the risk of PPCs identified short-term rehabilitation intervention to be an independent risk factor (odds ratio = 0.156, 95% confidence interval: 0.037-0.649, P = 0.011).

CONCLUSIONS

The study results suggested that a systematic, high-intensity pulmonary exercise programme was a practical strategy when performed preoperatively in patients with lung cancer with risk factors for PPCs.

CLINICAL TRIAL REGISTRATION

ChiCTR-IOR-16008109.

[Impact and Effect of Preoperative Short-term Pulmonary Rehabilitation Training on Lung Cancer Patients with Mild to Moderate Chronic Obstructive Pulmonary Disease: A Randomized Trial]

BACKGROUND

Pulmonary rehabilitation (PR) is proposed as an effective strategy to decrease surgical morbidity. However, appropriate rehabilitation plan, initiation time, and optimal duration of PR remain unclear. Lung cancer patients with chronic obstructive pulmonary disease (COPD) are considered high-risk population for postoperative pulmonary complications (PPCs) because of poor lung fitness and cardiopulmonary endurance. This study aims to assess the impact of a one-week, systematic and highly-intensive rehabilitation on surgical lung cancer patients with mild to moderate COPD.

METHODS

A randomized controlled trial with 48 subjects was conducted (24 patients each for the intervention and groups). The intervention group received seven days of systematic, integrated and highly-intensive PR before surgical treatment, including: pharmacotherapy with atomizing terbutaline, pulmicort and infusion of ambroxol; and physical rehabilitation with respiratory training and endurance training. The control group underwent standard preoperative care.

RESULTS

For the intervention group, the postoperative length of stay was shorter [(6.17±2.91) d vs (8.08±2.21) d; P=0.013]; likewise for the duration of antibiotics use [(3.61±2.53) d vs (5.36±3.12) d; P=0.032]. No significant difference was found between the groups in total in-hospital cost [(46,455.6±5,080.9) ¥ vs (45,536.0±4,195.8) ¥, P=0.498], medicine cost [(7,760.3±2,366.0) vs (6,993.0±2,022.5), P=0.223], and material cost [(21,155.5±10,512.1) ¥ vs (21,488.8±3,470.6) ¥, P=0.883]. In the intervention group, peak expiratory flow [(268.40±123.94) L/min vs (343.71±123.92) L/min; P<0.001], 6-min walk distance (6-MWD) [(595.42±106.74) m vs (620.90±99.27) m; P=0.004], and energy consumption [(59.93±10.61) kcal vs (61.03±10.47) kcal; P=0.004] were statistically different after the seven-day exercise, compared with those on the first day. Finally, for the intervention group the incidence of PPCs (8.3%, 2/24 vs 20.8%, 5/24, 20.8%; P=0.416) were lower.

CONCLUSIONS

The systematic and highly-intensive pulmonary rehabilitation combining abdominal respiration training, respiratory exercise with incentive spirometry, and aerobic exercise could improve the cardiorespiratory endurance of lung cancer patients with mild to moderate COPD. The proposed program may be a practicable preoperative strategy.
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Predischarge screening for chronic obstructive pulmonary disease in patients with acute coronary syndrome and smoking history

BACKGROUND

Several studies suggested that chronic obstructive pulmonary disease (COPD) is largely underdiagnosed in patients with acute coronary syndrome (ACS) contributing to further affect clinical outcome. Our aim was to validate a screening procedure to identify, in ACS patients, those with negligible risk of undiagnosed COPD.

METHODS

From December 2014 to August 2015, 169 ACS patients with smoking history underwent screening procedure. Screening procedure combined peak expiratory flow rate (PEFR, defined as positive if <80% of predicted) and respiratory health status questionnaire (RHSQ, defined as positive if >19.5 points). The screening was considered negative if both tests provided negative results, positive if both were positive, uncertain in presence of discrepancy. Spirometry was planned after 2months to identify or not the presence of irreversible airflow obstruction (undiagnosed COPD). The primary endpoint was the negative predictive value of screening for undiagnosed COPD.

RESULTS

Overall, 137 (81%) patients received spirometry (final study population). Screening was negative, uncertain and positive in 58 (42%), 46 (34%) and 33 (24%) patients, respectively. We found undiagnosed COPD in 39 (29%) patients. Only 3 patients with negative screening showed undiagnosed COPD. Negative screening showed the best ability to discriminate patients without COPD (negative predictive value 95%). Two-month health status in patients with undiagnosed COPD was significantly poor.

CONCLUSIONS

Undiagnosed COPD is relatively frequent in ACS patients with smoking history and a simple screening procedure including PEFR and RHSQ can be administered before hospital discharge to discriminate those at negligible risk of undiagnosed COPD (ClinicalTrials.gov, NCT02324660).

Peak flow as a predictor of cause-specific mortality in China: results from a 15-year prospective study of ∼170 000 men

Background Forced expiratory volume in one second (FEV1) is inversely associated with mortality in Western populations, but few studies have assessed the associations of peak expiratory flow (PEF) with subsequent cause-specific mortality, or have used populations in developing countries, including China, for such assessments.

Methods A prospective cohort study followed ∼170 000 Chinese men ranging in age from 40–69 years at baseline (1990–1991) for 15 years. In the study, height-adjusted PEF (h-PEF), which was uncorrelated with height, was calculated by dividing PEF by height. Hazard ratios (HR) for cause-specific mortality and h-PEF, adjusted for age, area of residence, smoking, and education, were calculated through Cox regression analyses.

Results Of the original study population, 7068 men died from respiratory causes (non-neoplastic) and 22 490 died from other causes (including 1591 from lung cancer, 5469 from other cancers, and 10 460 from cardiovascular disease) before reaching the age of 85 years. Respiratory mortality was strongly and inversely associated with h-PEF. For h-PEF ≥ 250 L/min, the association was log-linear, with a hazard ratio (HR) of 1.29 (95% CI: 1.25–1.34) per 100 L/min reduction in h-PEF. The association was stronger but not log-linear for lower values of h-PEF. Mortality from combined other causes was also inversely associated with h-PEF, and the association was log-linear for all values of h-PEF, declining with follow-up, with HRs per 100 L/min reduction in h-PEF of 1.13 (1.10–1.15), 1.08 (1.06–1.11), and 1.06 (1.03–1.08) in three consecutive 5-year follow-up periods. Specifically, lower values of h-PEF were associated with higher mortality from cardiovascular disease and lung cancer, but not from other cancers.

Conclusions A lower value of h-PEF was associated with increased mortality from respiratory and other causes, including lung cancer and cardiovascular disease, but its associations with the other causes of death declined across the follow-up period.

Delaying dementia and nursing home placement: the Dubbo study of elderly Australians over a 14-year follow-up

In order to capture the "longevity dividend," modifiable risk factors for a diagnosis of dementia and nursing home placement were examined in a longitudinal study of an elderly cohort living in Dubbo, New South Wales, Australia. One thousand two-hundred thirty-three men and 1572 women 60 years and older living in the community were examined in 1988 and followed to 2002 for diagnosis of dementia and nursing home placement. There were 244 (8.7%) nursing home placements and 44% of these placements were primarily due to dementia, but dementia was a secondary diagnosis in another 20% of cases. In a proportional hazards model for dementia, any intake of alcohol predicted a 34% lower risk, and daily gardening a 36% lower risk. Daily walking predicted a 38% lower risk of dementia in men, but there was no significant prediction in women. The lowest tertile of peak expiratory flow predicted an 84% higher risk of dementia, the upper tertile of depression score predicted a 50% higher risk. The Cox proportional hazards model for nursing home placement, showed placement increased significantly with age, urinary incontinence, impaired peak expiratory flow, physical disability, and depression. The hazard of placement was significantly reduced by alcohol intake and female gender. Socioeconomic factors were not significant. Similar risk factors for dementia and nursing home placement indicate that the continuation of moderate alcohol intake, the maintenance of physical activity, especially daily gardening, and improvement of respiratory function, and the treatment of depression are recommended targets for interventions to delay or prevent major negative late-life experiences.

Nested case-control study on associations between lung function, smoking and mortality in Japanese population

OBJECTIVES

Only a few long-term follow-up studies with a focus on the association between lung function and mortality in the Japanese population have been undertaken. In this study, we examined the associations of lung function, smoking and the results of allergy skin tests with mortality in a longitudinal study of the Japanese population.

METHODS

Baseline measurements were performed on residents of Fukui, Japan in 1972, and a follow-up survey was conducted in 2002. By employing a nested case-control design, 596 cases (deaths) and 596 age and sex-matched controls (survivals) were selected. Lung function was assessed using forced vital capacity (FVC) expressed as the normal percent predicted (FVC %pred) and the ratio of forced expiratory volume in 1 second (FEV(1)) to FVC (FEV(1)/FVC). Allergy skin tests were performed with extracts of house dust, candidia and mixed fungal samples (bronchomycosis). The Brinkman index was used to assess smoking intensity. The Cox proportional hazards model was used to evaluate whether lung function was associated with mortality after adjustment for other potential confounding variables.

RESULTS

Those categorized into the first- or second-lowest quartile of FVC %pred had a higher mortality [hazard ratios (HRs) and 95% confidence intervals (CIs): 2.01 (1.26-3.19) and 1.84 (1.11-3.05)], respectively. On top of these, heavy smoking (BI≥400) was associated with a higher mortality [HR and 95% CI: 1.73 (1.18-2.53)]. There were only weak of associations between the results of allergy skin tests and mortality.

CONCLUSIONS

These results suggest that FVC %pred of lung function and smoking can serve as long-term independent predictors of mortality.

Cholesterol and other lipids predict coronary heart disease and ischaemic stroke in the elderly, but only in those below 70 years

The prediction of coronary heart disease (CHD) and stroke by total and low density lipoprotein (LDL) cholesterol in older persons remains problematical. This study tests the hypothesis that cholesterol and other risk factors may be differentially predictive of CHD and ischaemic stroke in older persons when they are segregated into different age groups. CHD and ischaemic stroke outcomes were recorded during 129 months follow-up in a cohort of 2805 men and women of 60 years and older. There were 899 CHD events (32/100) and 326 stroke events (12/100). Using Cox proportional hazards, outcomes were modelled for the total cohort and for age groups 60-69, 70-79, and 80+ years. Total cholesterol, LDL cholesterol, serum apo-B, total cholesterol/high density lipoprotein (HDL) cholesterol and apo-B/apo-A1 were significant predictors of CHD in the total cohort, but significant only in the sub-group of 60-69 years. The respective hazard ratios (CI 95%) were 1.21 (1.09-1.35), 1.21 (1.09-1.35), 1.25 (1.13-1.39), 1.25 (1.14-1.37) and 1.21 (1.10-1.38). Similar findings were applicable with respect to ischaemic stroke in the age group of 60-69 years. Total cholesterol predicted CHD in men above a threshold value of 7.06 mmol/l and in women above 7.8 mmol/l, but with stroke the prediction was incremental. Other risk factors such as HDL cholesterol, triglycerides, lipoprotein(a), diabetes, hypertension and smoking predicted CHD, although only HDL and hypertension similarly predicted ischaemic stroke. The findings support a case for cholesterol testing in older subjects up to 70 years, in whom there is ancillary evidence of CHD and stroke prevention through treatment designed to reduce LDL cholesterol.

Peak flow as predictor of overall mortality in asthma and chronic obstructive pulmonary disease

Lung function is a strong predictor of overall mortality in asthma and chronic obstructive pulmonary disease (COPD). FEV1 is considered to be the "gold standard," whereas peak expiratory flow (PEF) is mostly used in absence of FEV1 measurements. We compared the predictive power of PEF and FEV1, measured after maximal bronchodilation, which included a short course of oral corticosteroids. The study population comprised 491 asthmatics and 1,095 subjects with COPD. Pulmonary function tests were performed between 1983 and 1988, and survival data were obtained by September 1997, when 127 asthmatics and 723 subjects with COPD had died. Predictors of survival were examined by Cox proportional hazards analyses. After controlling for age, smoking, sex, and body mass index, we found best PEF to be at least equal to best FEV1 as predictor of overall mortality in subjects with COPD. The predictive power of best PEF was in part maintained after controlling for best FEV1. In asthma, best FEV1 seemed to be a better predictor of mortality than best PEF. Despite close correlation to FEV1, PEF apparently provides independent prognostic information in patients with COPD. This may be due to PEF and FEV1 reflecting different components of COPD, i.e., chronic bronchitis, small airways disease, and emphysema. Furthermore, extrapulmonary components such as muscle mass and general "vigour" probably affect PEF to a greater extent than they affect FEV1.

Lung function, respiratory symptoms, and mortality: results from the Busselton Health Study

PURPOSE

This study examines the association between lung function [percentage predicted FEV, (forced expiratory volume in 1 s)] and respiratory symptoms (asthma, bronchitis, wheeze, dyspnea) and mortality from all causes; coronary heart disease, stroke, cancer, and respiratory disease in a cohort of 2,100 men and 2,177 women in the Busselton Health Study followed for 20-26 years for mortality.

METHODS

A total of 840 men and 637 women died during the follow-up period, and Cox proportional hazards regression was used to assess the relationships between risk factors and mortality.

RESULTS

Lung function was significantly and independently predictive of mortality from all causes, coronary heart disease, cancer, and respiratory disease in both men and women, and of mortality from stroke in women. There was evidence that, among men, the association was stronger in current and former smokers as compared to those who never smoked. After adjustment for age, smoking, lung function, coronary heart disease, blood pressure, treatment for hypertension, total cholesterol, body mass index, and alcohol consumption, dyspnea was significantly related to total mortality in men and women and to respiratory disease mortality in men, and asthma was significantly related to respiratory disease mortality in women.

CONCLUSIONS

Lung function is associated with mortality from many diseases independent of smoking and respiratory symptoms. Although most respiratory symptoms are associated with smoking and lung function, after controlling for smoking and lung function, only dyspnea is associated with mortality from nonrespiratory causes.

Risk factors for ischemic stroke: Dubbo Study of the elderly

BACKGROUND AND PURPOSE

One in 10 deaths in Australia is due to stroke. The predictors of ischemic stroke have not been well defined, although hypertension, atrial fibrillation, and previous stroke have been consistently reported. We report on 98 months' follow-up in a prospective study of cardiovascular disease in the Australian elderly, the Dubbo Study.

METHODS

The cohort, first examined in 1988, was composed of 2805 men and women 60 years and older. The prediction of ischemic stroke by potential risk factors was examined in a Cox proportional hazards model, after linkage to hospital and death records.

RESULTS

Three hundred six men and women manifested an ischemic stroke event (ICD-9-CM 433 to 437), and 95 subjects suffered a fatal stroke event. In the multivariate model, the significant independent predictors of stroke were advancing age, female sex (48% lower risk), being married (30% lower risk), prior history of stroke (227% higher risk), use of antihypertensive drugs (37% higher risk), belonging to the highest category of blood pressure reading (67% higher risk), presence of atrial fibrillation (58% higher risk), HDL cholesterol (36% lower risk for each 1-mmol/L increment), impaired peak expiratory flow (77% higher risk for tertile I than for tertile III), physical disability (59% higher risk), and depression score (41% higher risk for tertile III than for tertile I).

CONCLUSIONS

These findings suggest that morbidity and mortality associated with ischemic stroke can be predicted by various clinical indicators, some of which may be amenable to intervention. The matters of impaired peak expiratory flow, depression score, and ischemic stroke require further study.