[Cardiopulmonary axis and cardiovascular mortality in patients with COPD]

Effect of triple inhaled therapy on cardiovascular and all-cause mortality compared with dual inhaled therapy in COPD: A systematic review and meta-analysis

BACKGROUND

There is uncertainty about the role of triple inhaled therapy with LAMA/LABA/ICS (long-acting muscarinic antagonist/long-acting β2-agonist/inhaled glucocorticoids) in chronic obstructive pulmonary disease (COPD) on cardiovascular mortality. We estimated the effect of triple inhaled therapy (TT) compared with dual inhaled therapy (DT, including either LAMA/LABA or LABA/ICS) on all-cause and cardiovascular mortality in an evidence synthesis, METHODS: Following prospective registration (https://osf.io/gtfvm), a comprehensive search strategy of PubMed, Scopus, and Embase was performed, without language or time restrictions until September 30, 2024. All randomized clinical trials (RCTs) evaluating TT vs. DT and reporting cardiovascular or all-cause mortality were included. We assessed risk of bias and conducted a random effect meta-analysis estimating summary relative risk (RR) with 95% confidence intervals (CI), evaluating heterogeneity using I2. A network meta-analysis (NMA) was undertaken to hierarchically rank the therapies using P-score.

RESULTS

From 781 citations, 5 RCTs were selected. There were 3 three-arm RCTs comparing TT vs. LABA/ICS vs. LAMA/LABA, 1 two-arm RCT comparing TT vs. LABA/ICS, and 1 two-arm RCT comparing TT vs. LAMA/LABA (total of 7855 patients receiving TT, 7003 LABA/ICS and 5059 LAMA/LABA). The risk of bias was moderate in 2 (40%), and low in 3 (60%) RCTs. TT reduced cardiovascular mortality by 48% vs. LAMA/LABA (RR 0.52, 95% CI 0.32-0.86, 3 RCTs, I2=0%) and by a non-significant 11% vs. LABA/ICS (RR 0.89, 95% CI 0.57-1.37, 3 RCTs, I2=0%). TT reduced all-cause mortality by 34% vs. LAMA/LABA (RR 0.66, 95% CI 0.48-0.90, 4 RCTs, I2=23.7%) and by 10% vs. LABA/ICS (RR 0.90, 95% CI 0.71-1.13, 4 RCTs, I2=0%). For both cardiovascular and all-cause mortality, NMA P-score showed that TT ranked first (81%/91%), LABA/ICS ranked second (58%/57%) and LAMA/LABA ranked last (11%/<1%) in effectiveness.

CONCLUSIONS

In patients with moderate to very severe COPD and previous exacerbations, TT inhaled significantly reduces cardiovascular and all-cause mortality compared to LAMA/LABA dual therapy, but not when compared to LABA/ICS.

COPD patient profiles in primary care. Referral criteria

COPD is a disease with a high prevalence that diminishes the quality of life of many patients. Despite this, there are still high rates of under-diagnosis in Spain, partly due to a lack of recognition of the pathology by patients. In this context, the role played by primary care teams becomes fundamental, as they are one of the first lines of entry into the health system. In this paper we explain the different COPD profiles that may be present, and update the tools for diagnosis and treatment, which, together with an attitude of active suspicion of the disease, can help in the correct management of patients, whether they are undiagnosed or have subsequent complications.

Exosome-mediated regulation of inflammatory pathway during respiratory viral disease

Viruses have developed many mechanisms by which they can stimulate or inhibit inflammation and cause various diseases, including viral respiratory diseases that kill many people every year. One of the mechanisms that viruses use to induce or inhibit inflammation is exosomes. Exosomes are small membrane nanovesicles (30-150 nm) released from cells that contain proteins, DNA, and coding and non-coding RNA species. They are a group of extracellular vesicles that cells can take up to produce and mediate communication. Intercellular effect exosomes can deliver a broad confine of biological molecules, containing nucleic acids, proteins, and lipids, to the target cell, where they can convey therapeutic or pathogenic consequences through the modulation of inflammation and immune processes. Recent research has shown that exosomes can deliver entire virus genomes or virions to distant target cells, then the delivered viruses can escape the immune system and infect cells. Adenoviruses, orthomyxoviruses, paramyxoviruses, respiratory syncytial viruses, picornaviruses, coronaviruses, and rhinoviruses are mostly related to respiratory diseases. In this article, we will first discuss the current knowledge of exosomes. We will learn about the relationship between exosomes and viral infections, and We mention the inflammations caused by viruses in the airways, the role of exosomes in them, and finally, we examine the relationship between the viruses as mentioned earlier, and the regulation of inflammatory pathways that play a role in causing the disease.

[Protocol for the management of patients with chronic obstructive pulmonary disease after exacerbation in the emergency department]

In chronic obstructive pulmonary disease, an acute exacerbation of chronic obstructive pulmonary disease (AECOPD) is an episode of clinical instability due to the worsening of expiratory airflow limitation or of the underlying inflammatory process. The severity of AECOPD depends on baseline risk stratification and the intensity of the acute episode. Primary Care is the epicenter of the AECOPD care circuit, but it can be extended to the out-of-hospital emergency department and the hospital itself depending on the clinical situation, the level of severity, the availability of complementary tests, and the therapeutic resources required for each patient. Recording clinical data, history, triggering factors, treatment, and evolution of previous episodes of AECOPD in the electronic medical record is an essential aspect to adjust current treatment and prevent the occurrence of future episodes.