Impact of cancers and cardiovascular diseases in chronic obstructive pulmonary disease:

Efficacy and safety of ensifentrine, a novel phosphodiesterase 3 and 4 inhibitor, in chronic obstructive pulmonary disease: A systematic review and meta-analysis

BACKGROUND

We evaluated the efficacy and safety of Ensifentrine in COPD via a systematic review and meta-analysis of randomized controlled trials (RCTs).

METHODS

We performed a detailed literature search on Medline (via PubMed), Scopus, Google Scholar, and Cochrane on the basis of pre-specified eligibility criteria. We used Review Manager to calculate pooled mean differences (MD) and 95% Confidence Interval (CI) using a random effects model. The Cochrane's Risk of Bias 2 (RoB-2) tool was used to assess the risk of bias in the included RCTs.

RESULTS

A total of 4 studies, consisting of 2020 patients, were included in the meta-analysis. The mean age ranged from 62.5 years to 65.5 years in the included studies. All the included studies were at low risk of bias. Ensifentrine 3 mg dose significantly improved the mean peak Forced Expiratory Volume-1 (FEV-1), morning trough FEV-1, TDI score, ERS score, and SGRQ-C score as compared to the placebo, yielding a pooled MD of 149.76 (95% CI, 127.9 to 171.6), 43.93 (95% CI, 23.82 to 64.05), 0.92 (95% CI, 0.64 to 1.21, -1.20 (95% CI, -1.99 to -0.40), and -1.92 (95% CI, -3.24 to -0.59), respectively.

CONCLUSION

Ensifentrine is associated with improvements in outcomes related to COPD symptoms such as peak FEV-1, morning trough FEV-1 and TDI in the patients suffering from this chronic disease. It is also associated with improved quality of life as seen by E-RS score and SGRQ-C score.

The genetic etiology of body fluids on chronic obstructive airways disease

BACKGROUND

Numerous studies have documented significant alterations in the bodily fluids of Chronic Obstructive Pulmonary Disease (COPD) patients. However, existing literature lacks causal inference due to residual confounding and reverse causality.

METHODS

Summary-level data for COPD were obtained from two national biobanks: the UK Biobank, comprising 1,605 cases and 461,328 controls, and FinnGen, with 6,915 cases and 186,723 controls. We also validated our findings using clinical data from 2,690 COPD patients and 3,357 healthy controls from the First Affiliated Hospital of Guangzhou Medical University. A total of 44 bodily fluid biomarkers were selected as candidate risk factors. Mendelian randomization (MR) and meta-analyses were used to evaluate the causal effects of these bodily fluids on COPD and lung function (FEV1/FVC).

RESULTS

Mendelian randomization (MR) and meta-analyses, by integrating data from the UK Biobank and FinnGen cohort, found that 3 bodily fluids indicators (HDLC, EOS, and TP) were causally associated with the risk of COPD, two (EOS and TP) of which is consistent with our observational findings. Moreover, we noticed EOS and TP were causally associated with the risk of lung function (FEV1/FVC).

CONCLUSIONS

The MR findings and clinical data highlight the independent and significant roles of EOS and TP in the development of COPD and lung function (FEV1/FVC), which might provide a deeper insight into COPD risk factors and supply potential preventative strategies.

Does chronic obstructive pulmonary disease relate to poor prognosis in patients with lung cancer?: A meta-analysis

BACKGROUND

Nowadays, there is growing recognition that chronic obstructive pulmonary disease (COPD) may have influence on lung cancer. However, coexisted COPD related to prognosis of lung cancer is still elusive. We conducted this meta-analysis to examine the association between COPD and 5-year overall survival (OS) and postoperative pulmonary complications of patients with lung cancer.

METHODS

A comprehensive computer-based online search was conducted using PubMed, Embase, Medline, and the Cochrane Library for articles published before September 30, 2017. We identified 29 eligible studies, which included 70,111 patients in the related literature.

RESULTS

Twenty-two of the 29 studies provided hazard ratio for OS (1.18, 95% confidence interval: 1.11-1.25; P < .001), it suggested that the presence of COPD indicated poor survival for the patients with lung cancer. In subgroup analysis, the relationship between COPD and OS occurrence remained statistically prominent in the subgroups stratified by study designs, COPD diagnosis timing, lung cancer surgery, cancer stage, and origins of patients. The presence of COPD increased the risk of bronchopleural fistula, pneumonia, prolonged air leakage, and prolonged mechanical ventilation.

CONCLUSIONS

The present meta-analysis suggested that coexisting COPD is associated with poor survival outcomes in patients with lung cancer and higher rates of postoperative pulmonary complications.

Prognostic implications of heart failure with preserved ejection fraction in patients with an exacerbation of chronic obstructive pulmonary disease

Diagnosing heart failure with preserved ejection fraction (HFpEF) in patients with chronic obstructive pulmonary disease (COPD) is difficult due to overlapping pathophysiological pathways, risk factors and clinical presentations. We investigated the prevalence and prognostic implications of coexisting HFpEF in patients hospitalized for acute exacerbation of COPD. A total of 116 consecutive patients with an acute exacerbation of COPD were evaluated for HFpEF and followed for an average period of 22 ± 9 months for the occurrence of death from any cause. HFpEF was diagnosed in 22 (19 %) patients with COPD, who were older, and also had higher LV mass, left atrial size, and mitral E/Ea ratio than those without HFpEF (p < 0.05 for all comparisons). HFpEF was not independently associated with all-cause mortality [hazard ratio (HR) 1.07, 95 % confidence interval (CI) 0.44-2.62]. Global initiative for chronic Obstructive Lung Disease (GOLD) stage (IV vs. I-III, HR 2.37, CI 1.23-4.59) and N-terminal pro B-type natriuretic peptide (NT-proBNP) levels (HR 2.79, CI 1.12-6.98) were independent predictors of long-term survival. HFpEF is present in one-fifth of patients with exacerbated COPD. Non-invasively diagnosed HFpEF may not be an independent predictor of all-cause mortality. Elevated NT-proBNP levels and very severe COPD were independently associated with unfavorable overall survival.

Risk factors for cardiovascular disease in patients with COPD: mild-to-moderate COPD versus severe-to-very severe COPD

OBJECTIVE

To assess and compare the prevalence of comorbidities and risk factors for cardiovascular disease (CVD) in COPD patients according to disease severity.

METHODS

The study included 25 patients with mild-to-moderate COPD (68% male; mean age, 65 ± 8 years; mean FEV1, 73 ± 15% of predicted) and 25 with severe-to-very severe COPD (males, 56%; mean age, 69 ± 9 years; mean FEV1, 40 ± 18% of predicted). Comorbidities were recorded on the basis of data obtained from medical charts and clinical evaluations. Comorbidities were registered on the basis of data obtained from medical charts and clinical evaluations. The Charlson comorbidity index was calculated, and the Hospital Anxiety and Depression Scale (HADS) score was determined.

RESULTS

Of the 50 patients evaluated, 38 (76%) had been diagnosed with at least one comorbidity, 21 (42%) having been diagnosed with at least one CVD. Twenty-four patients (48%) had more than one CVD. Eighteen (36%) of the patients were current smokers, 10 (20%) had depression, 7 (14%) had dyslipidemia, and 7 (14%) had diabetes mellitus. Current smoking, depression, and dyslipidemia were more prevalent among the patients with mild-to-moderate COPD than among those with severe-to-very severe COPD (p < 0.001, p = 0.008, and p = 0.02, respectively). The prevalence of high blood pressure, diabetes mellitus, alcoholism, ischemic heart disease, and chronic heart failure was comparable between the two groups. The Charlson comorbidity index and HADS scores did not differ between the groups.

CONCLUSIONS

Comorbidities are highly prevalent in COPD, regardless of its severity. Certain risk factors for CVD, themselves classified as diseases (including smoking, dyslipidemia, and depression), appear to be more prevalent in patients with mild-to-moderate COPD.

OBJETIVO

Avaliar e comparar a prevalência de comorbidades e de fatores de risco de doença cardiovascular (DCV) em pacientes com DPOC de acordo com a gravidade da doença.

MÉTODOS

O estudo incluiu 25 pacientes com DPOC leve/moderada (homens: 68%; média de idade: 65 ± 8 anos; média de VEF1: 73 ± 15% do previsto) e 25 com DPOC grave/muito grave (homens: 56%; média de idade: 69 ± 9 anos; média de VEF1, 40 ± 18% do previsto). As comorbidades foram registradas com base nos dados dos prontuários médicos e avaliações clínicas. O índice de comorbidades de Charlson foi calculado, e a pontuação na Hospital Anxiety and Depression Scale (HADS) foi determinada.

RESULTADOS

Dos 50 pacientes avaliados, 38 (76%) receberam diagnóstico de pelo menos uma comorbidade, sendo que 21 (42%) receberam diagnóstico de pelo menos uma DCV. Vinte e quatro pacientes (48%) apresentavam mais de uma DCV. Dezoito pacientes (36%) eram fumantes, 10 (20%) tinham depressão, 7 (14%) apresentavam dislipidemia, e 7 (14%) tinham diabetes mellitus. Tabagismo atual, depressão e dislipidemia foram mais prevalentes nos pacientes com DPOC leve/moderada que naqueles com DPOC grave/muito grave (p < 0,001, p = 0,008 e p = 0,02, respectivamente). A prevalência de pressão arterial elevada, diabetes mellitus, alcoolismo, doença isquêmica do coração e insuficiência cardíaca crônica foi semelhante nos dois grupos. O índice de comorbidades de Charlson e a pontuação na HADS não diferiram entre os grupos.

CONCLUSÕES

Comorbidades são muito prevalentes na DPOC, independentemente da gravidade da doença. Certos fatores de risco de DCV, eles próprios considerados doenças (incluindo tabagismo, dislipidemia e depressão), parecem ser mais prevalentes nos pacientes com DPOC leve/moderada.

Respiratory effects of sulfur mustard exposure, similarities and differences with asthma and COPD

CONTEXT

Previous research has found relationships between sulfur mustard (SM) toxicity and its adverse effects.

OBJECTIVE

SM is highly toxic to the respiratory system, leading to hacking cough, rhinorrheachest tightness, acute pharyngitis and laryngitis, chronic bronchitis and lung fibrosis. In this review, based on the scientific literature, we provide an updated summary of information on SM exposures and their differences with asthma and COPD.

METHOD

Information of this review was obtained by searching Medline/PubMed, ScienceDirect, Scopus, Google Scholar, ISI Web of Knowledge and Chemical Abstracts.

RESULTS

SM exposure can decrease pulmonary function tests (PFTs) values. In addition, inflammatory cell accumulation in the respiratory tract and increased expression of some pro-inflammatory cytokines including tumor necrosis factor-α (TNFα), IL-1a, IL-1β, and reactive oxygen radicals due to SM exposure have been shown. Matrix metalloproteinase (MMP) which degrade extracellular matrix proteins, contributing to inflammatory cell recruitment, tissue injury and fibrosis are also up-regulated in the lung after SM exposure. In the lung, SM exposure also can cause serious pathological changes including airway inflammation, parenchymal tissue destruction and airway obstruction which can lead to asthma or chronic obstructive pulmonary disease (COPD). Following SM poisoning, DNA damage, apoptosis and autophagy are observed in the lung along with the increased expression of activated caspases and DNA repair enzymes.

CONCLUSION

In the present article, respiratory symptoms, changes in PFTs, lung pathology and lung inflammation due to SM exposure and the similarities and differences between them and those observed in asthma and COPD were reviewed.

Lipid profile and statin use: the paradox of survival after acute exacerbation of chronic obstructive pulmonary disease

BACKGROUND

A paradoxical association between cholesterol level and clinical outcome has been suggested, yet never previously established, in patients with chronic obstructive pulmonary disease (COPD).

OBJECTIVES

The authors sought to investigate the interaction between long-term survival, lipid profile and statin use in patients after acute exacerbation of COPD (AECOPD).

METHODS

A retrospective study evaluating demographic, clinical and laboratory data of 615 consecutive patients admitted for AECOPD over a mean follow-up period of 24.8 months. Kaplan-Meier survival curves and multivariate analysis were used to identify independent prognostic predictors for all-cause mortality.

RESULTS

Mean ± standard deviation (SD) age of the study population was 71.8 ± 11.4 years. Unexpectedly, mean serum cholesterol ± SD levels were significantly higher in survivors (N = 340) versus nonsurvivors (N = 275): 181.5 ± 43.6 versus 171.6 ± 57.2 mg/dL, respectively, (P = 0.0043). Median survival for patients with cholesterol levels <150 and >200 mg/dL were 16.0 and 64.4 months, respectively (P = 0.0173). On multivariate analysis, cholesterol level <150 mg/dL was an independent predictor of mortality, irrespective of cardiovascular risk factors (hazard ratio [HR] = 1.8430, 95% confidence interval [CI] = 1.2547-2.7072, P = 0.0019). Statin use had an independent protective effect, regardless of cholesterol level (HR = 0.4924, 95% CI = 0.2924-0.8292, P = 0.0080).

CONCLUSIONS

Low cholesterol levels are significantly associated with increased mortality after AECOPD. Nonetheless, as statin treatment was associated with reduced mortality over the entire range of cholesterol levels, its use should be considered in all COPD patients.

Increased risk of acute coronary syndrome among leptospirosis patients: A nationwide cohort analysis

BACKGROUND

Studies on the association between leptospirosis and acute coronary syndrome (ACS) are lacking. Therefore, this study identifies the effects of leptospirosis on the risks of developing ACS with a nationwide retrospective cohort study.

METHODS

We identified adult patients aged ≥20 years who were newly diagnosed with leptospirosis. We also randomly selected a comparison cohort from the general population by using a propensity score matching method. We analyzed the risks of ACS by using Cox proportional hazard regression models.

RESULTS

Among the 23.74 million people in the cohort, 3690 patients with leptospirosis (68% men, mean age of 52.2 years) and 3690 controls were followed for 13,677 and 15,652 person-years, respectively. The overall incidence of ACS was higher in the leptospirosis cohort than in the nonleptospirosis cohort (4.68 vs 3.71 per 1000 person-years), with a hazard ratio (HR) of 1.69 (95% confidence interval [CI]=1.12-2.56). Men exhibited a 1.88-fold greater HR of ACS than women did (95% CI=1.20-2.94). The risk of developing ACS was highest for leptospirosis patients aged ≥65 years (HR=7, 51% CI=4.35-12.9) compared with patients aged ≤49 years.

CONCLUSION

Leptospirosis is not a previously identified risk factor for ACS. The findings of this nationwide retrospective cohort study indicate that leptospirosis may become an independent risk factor for ACS. Future research to investigate the mechanism is warranted.

Adult asthmatics increase the risk of acute coronary syndrome: A nationwide population-based cohort study

OBJECTIVES

Few studies have examined the risk of acute coronary syndrome (ACS) in asthmatics. We investigate the effects of asthma on the risk of ACS development in an Asian population.

METHODS

Asthma patients aged ≥ 18 years were identified, and asthma-free controls were randomly selected from the general population and frequency-matched according to age, sex, index year, and baseline comorbidity by using the National Health Insurance Research Database. Both cohorts were followed up until the end of 2011 to measure the incidence of ACS. The risk of ACS was analyzed using Cox proportional hazards regression models.

RESULTS

We observed the asthmatic patients for 97,506 person-years and followed the nonasthmatic people for 193,423 person-years. The incidence density rate of ACS increased in all groups of the asthmatic patients compared with those of the controls when the data were stratified according to sex, age, and comorbidities. The hazard ratio (HR) of ACS was 1.66-fold greater in the asthmatic cohort than in the nonasthmatic cohort, after adjusting for sex, age, and comorbidities (95% confidence interval [CI]: 1.31-2.11). The adjusted HR of developing ACS increased substantially as age and the frequency of asthmatic exacerbation and hospitalization increased.

CONCLUSIONS

Asthma is an independent risk factor of ACS, and poor control of asthma increases the risk of ACS development in a dose-dependent manner.

Association between left ventricular diastolic dysfunction and severity of chronic obstructive pulmonary disease

OBJECTIVES

The prevalence of electrocardiographic and echocardiographic abnormalities in chronic obstructive pulmonary disease according to disease severity has not yet been established. The aim of this study was to assess the prevalence of electrocardiographic and echocardiographic abnormalities in chronic obstructive pulmonary disease patients according to disease severity.

METHODS

The study included 25 mild/moderate chronic obstructive pulmonary disease patients and 25 severe/very severe chronic obstructive pulmonary disease patients. All participants underwent clinical evaluation, spirometry and electrocardiography/echocardiography.

RESULTS

Electrocardiography and echocardiography showed Q-wave alterations and segmental contractility in five (10%) patients. The most frequent echocardiographic finding was mild left diastolic dysfunction (88%), independent of chronic obstructive pulmonary disease stage. The proportion of right ventricular overload (p<0.05) and blockage of the anterosuperior division of the left bundle branch were higher in patients with greater obstruction. In an echocardiographic analysis, mild/moderate chronic obstructive pulmonary disease patients showed more abnormalities in segmental contractility (p<0.05), whereas severe/very severe chronic obstructive pulmonary disease patients showed a higher prevalence of right ventricular overload (p<0.05), increased right cardiac chamber (p<0.05) and higher values of E-wave deceleration time (p<0.05). Age, sex, systemic arterial hypertension, C-reactive protein and disease were included as independent variables in a multiple linear regression; only disease severity was predictive of the E-wave deceleration time [r²=0.26, p=0.01].

CONCLUSION

Chronic obstructive pulmonary disease patients have a high prevalence of left ventricular diastolic dysfunction, which is associated with disease severity. Because of this association, it is important to exclude decompensated heart failure during chronic obstructive pulmonary disease exacerbation.

Elevated cardiovascular risk among adults with obstructive and restrictive airway functioning in the United States: a cross-sectional study of the National Health and Nutrition Examination Survey from 2007-2010

BACKGROUND

Reasons for the excess risk for cardiovascular disease among people with chronic obstructive pulmonary disease remain unclear. Our objective was to examine the cardiovascular risk profile for adults with obstructive and restrictive impairments of lung functioning in a representative sample of adults from the United States.

METHODS

We used data from adults aged 20-79 years who participated in the National Health and Nutrition Examination Survey from 2007 to 2010 and had a pulmonary function test. The severity of obstructive impairment was defined by adapting the Global Initiative for Chronic Obstructive Lung Disease criteria.

RESULTS

Among 7249 participants, 80.9% had a normal pulmonary function test, 5.7% had a restrictive impairment, 7.9% had mild obstructive impairment, and 5.5% had moderate or severe/very severe obstructive impairment. Participants with obstructive impairment had high rates of smoking and increased serum concentrations of cotinine. Compared to participants with normal pulmonary functioning, participants with at least moderate obstructive impairment had elevated concentrations of C-reactive protein but lower concentrations of total cholesterol and non-high-density lipoprotein cholesterol. Among participants aged 50-74 years, participants with at least a moderate obstructive impairment or a restrictive impairment had an elevated predicted 10-year risk for cardiovascular disease.

CONCLUSIONS

The high rates of smoking among adults with impaired pulmonary functioning, particularly those with obstructive impairment, point to a need for aggressive efforts to promote smoking cessation in these adults. In addition, adults with restrictive impairment may require increased attention to and fine-tuning of their cardiovascular risk profile.

Coronary artery disease is under-diagnosed and under-treated in advanced lung disease

BACKGROUND

Coronary artery disease is a potentially treatable comorbidity observed frequently in both chronic obstructive pulmonary disease and interstitial lung disease. The prevalence of angiographically proven coronary artery disease in advanced lung disease is not well described. We sought to characterize the treatment patterns of coronary artery disease complicating advanced lung disease and to describe the frequency of occult coronary artery disease in this population.

METHODS

We performed a 2-center, retrospective cross-sectional study of patients with either chronic obstructive pulmonary disease or interstitial lung disease evaluated for lung transplantation. Medications and diagnoses before the transplant evaluation were recorded in conjunction with left heart catheterization results.

RESULTS

Of 473 subjects, 351 had chronic obstructive pulmonary disease, and 122 had interstitial lung disease. In subjects diagnosed clinically with coronary artery disease, medical regimens included a statin in 78%, antiplatelet therapy in 62%, angiotensin-converting enzyme inhibitor or angiotensin receptor blocker in 42%, and a beta-blocker in 37%. Ten percent were on no medication from these 4 classes. Fifty-seven percent of these subjects were on an antiplatelet agent as well as a statin, and 13% were on neither. Beta-blockers were less frequently prescribed in chronic obstructive pulmonary disease than interstitial lung disease (23% vs 58%, P=.007). Coronary angiography was available in 322 subjects. It demonstrated coronary artery disease in 60% of subjects, and severe coronary artery disease in 16%. Occult coronary artery disease and severe occult coronary artery disease were found in 53% and 9%, respectively. There were no significant differences in angiographic results between chronic obstructive pulmonary disease and interstitial lung disease, despite imbalanced risk factors.

CONCLUSIONS

Coronary artery disease is common in patients with advanced lung disease attributable to chronic obstructive pulmonary disease or interstitial lung disease and is under-diagnosed. Guideline-recommended cardioprotective medications are suboptimally utilized in this population.

The average lifespan of patients discharged from hospital with heart failure

BACKGROUND

There are no life-tables quantifying the average life-spans of post-hospitalized heart failure populations across various strata of risk.

OBJECTIVE

To quantify the life-expectancies (i.e., average life-spans) of heart failure patients at the time of hospital discharge according to age, gender, predictive 30-day mortality heart failure risk index, and comorbidity burden.

DESIGN

Population-based retrospective cohort study.

SETTING

Ontario, Canada.

PATIENTS

7,865 heart failure patients discharged from Ontario hospitals between 1999 and 2000.

MEASUREMENTS

Data were obtained from the Enhanced Feedback for Effective Cardiac Treatment EFFECT provincial quality improvement initiative. All patients were linked to administrative data, and tracked longitudinally until March 31, 2010. Detailed clinical variables were obtained from medical chart abstraction, and death data were obtained from vital statistics. Average life-spans were calculated using Cox Proportion Hazards models in conjunction with the Declining Exponential Approximation of Life Expectancy (D.E.A.L.E) method to extrapolate life-expectancy, adjusting for age, gender, predicted 30-day mortality, left ventricular function and comorbidity, and was reported according to key prognostic risk-strata.

RESULTS

The average life-span of the cohort was 5.5 years (STD +/- 10.0) ranging from 19.5 years for low-risk women of less than 50 years old to 2.9 years for high-risk octogenarian males. Average life-spans were lower by 0.13 years among patients with impaired as compared with preserved left ventricular function, and by approximately one year among patients with three or more as compared with no concomitant comorbidities. In total, 17.4 % and 27 % of patients had died within 6 months and 1 year respectively, despite having predicted life-spans exceeding one-year.

LIMITATIONS

Data regarding changes in patient clinical status over time were unavailable.

CONCLUSIONS

The development of risk-adjusted life-tables for heart failure populations is feasible and mirrored those with advanced malignant diseases. Average life span varied widely across clinical risk strata, and may be less accurate among those at or near their end of life.

Prevalence of cardiovascular disease in subjects hospitalized due to chronic obstructive pulmonary disease in Beijing from 2000 to 2010

OBJECTIVES

To investigate the overall prevalence of cardiovascular disease (CVD) in subjects hospitalized for chronic obstructive pulmonary disease (COPD), and explore the prevalence of the major CVD complications and trends in patients with COPD over a 10-year period.

METHODS

Medical records in the PLA General Hospital, Beijing Union Medical College Hospital, and Beijing Hospital from 2000/01/01 to 2010/03/03 were retrospectively reviewed. A total of 4960 patients with COPD were reviewed in the study (3570 males, mean age, 72.2 ± 10.5 years; 1390 females, mean age, 72.0 ± 10.4 years).

RESULTS

The prevalence of CVD in COPD patients was 51.7%. The three most prevalent CVDs were ischemic heart disease (28.9%), heart failure (19.6%), and arrhythmia (12.6%). During the 10-year study period, the prevalence of various CVDs in COPD patients showed a gradual increasing trend with increasing age. There was higher morbidity due to ischemic heart disease (P < 0.01) in male COPD patients than in the female counterparts. However, heart failure (P < 0.01) and hypertension (P < 0.01) occurred less frequently in male COPD patients than in female COPD patients. Furthermore, the prevalence of ischemic heart disease decreased year by year. In addition to heart failure, various types of CVD complications in COPD patients tended to occur in younger subjects. The prevalence of all major types of CVD in women tended to increase year by year.

CONCLUSIONS

The prevalence of CVD in patients hospitalized for COPD in Beijing was high. Age, sex and CVD trends, as well as life style changes, should be considered when prevention and control strategies are formulated.

Impact of lung transplantation on serum lipids in COPD

BACKGROUND

Severe chronic obstructive pulmonary disease is associated with high HDL cholesterol (HDL-C). We sought to examine the effect of lung transplantation on lipid profiles in patients with COPD.

METHODS

We analyzed 101 lung transplant recipients in a retrospective cohort of patients from two centers in whom lipid values were available both before as well as after transplantation. Sixty-one subjects were transplanted for severe COPD (93% GOLD stage 4).

RESULTS

Eighty-nine percent of subjects with COPD exhibited a decline in HDL-C. Median decline for the COPD cohort was 25 mg/dL (IQR 12-38 mg/dL, p < 0.0001). Non-COPD subjects exhibited no significant changes in HDL-C. Other lipid changes in the COPD cohort included a rise in triglycerides of 70 mg/dL (IQR 35 to 140, p < 0.0001). Decreases in HDL-C levels were independent from the rise in triglyceride levels. Neither LDL-C nor non-HDL-C demonstrated significant changes. Subjects with greater increases in prednisone exposure post-transplant exhibited lesser declines in HDL-C. Compared with tacrolimus, cyclosporine had no effect on observed changes in HDL-C or triglycerides, but was associated with a greater median rise in LDL-C.

CONCLUSIONS

In patients with COPD, lung transplantation results in reductions in the serum levels of HDL-C. These changes are not observed in patients undergoing lung transplantation for diagnoses other than COPD.

Statin therapy is associated with decreased pulmonary vascular pressures in severe COPD

BACKGROUND

Pulmonary hypertension (PH) in COPD carries a poor prognosis. Statin therapy has been associated with numerous beneficial clinical effects in COPD, including a possible improvement in PH. We examined the association between statin use and pulmonary hemodynamics in a well-characterized cohort of patients undergoing evaluation for lung transplantation.

METHODS

We conducted a cross-sectional analysis of 112 subjects evaluated for lung transplant with a diagnosis of COPD. Clinical characteristics, pulmonary function, cardiac catheterization findings and medical comorbidities were compared between statins users and non-users.

RESULTS

Thirty-four (30%) subjects were receiving statin therapy. Statin users were older and had an increased prevalence of systemic hypertension and coronary artery disease (CAD). Mean pulmonary arterial pressure (mPAP) in the statin group was lower [26 ± 7 vs 29 ± 7 mmHg, p = 0.02], as was pulmonary artery wedge pressure (PAWP) [12 ± 5 vs. 15 ± 6 mmHg, p = 0.02]. Pulmonary vascular resistance did not differ between the groups. In multiple regression analysis, statin use was associated with a 4.2 mmHg (95% CI: 2 to 6.4, p = <0.001) lower PAWP and a 2.6 mmHg (95% CI: 0.3 to 4.9, p = 0.03) reduction in mPAP independent of PAWP.

CONCLUSIONS

In patients with severe COPD, statin use is associated with significantly lower PAWP and mPAP. These finding should be evaluated prospectively.

Role of emphysema and airway obstruction in prognosis of lung cancer

BACKGROUND AND OBJECTIVE

It has been reported that the presence of COPD and emphysema is associated with an increased risk of lung cancer, but the prognosis significance of these two conditions is not well known. The aim of our study was to analyze the influence of COPD and emphysema in the prognosis of non-small cell lung cancer (NSCLC).

METHODS

Three hundred and fifty-three patients with cytohistologic diagnosis of NSCLC were prospectively collected. The relationship between survival at two years and the following variables: age, sex, smoking habit, comorbid diseases (cardiovascular diseases, previous tumour and COPD), weight loss, presence of emphysema on CT scan, performance status (PS) and treatment, was analyzed. The Kaplan-Meier method and log-rank test were used for survival analysis. A multivariate Cox proportional hazard model, stratified by TNM stage, was used to evaluate prognostic factors.

RESULTS

Emphysema was present in 110 patients, associated with COPD in 78 (70.9%). In univariate analysis, survival decreased with age>70 years (p=0.01), presence of emphysema (p=0.02), weight loss (p=0.00001), PS≥2 (p=0.00001) and symptomatic treatment (p=0.0001). Multivariate analyses identified emphysema (HR=1.49 (95% CI 1.11-2.01)), PS≥2 (HR=2.12 (95% CI 1.31-3.38)) and treatment: surgery (HR=0.3 (95% CI 0.15-0.56)) and chemotherapy (HR=0.34 (95% CI 0.31-0.57)) as independent prognostic factors.

CONCLUSION

The presence of emphysema affects the prognostic outcome of patients with non-small cell lung cancer. Emphysema should therefore be considered for prognostic studies on comorbidity.

Influencing the decline of lung function in COPD: use of pharmacotherapy

Chronic obstructive pulmonary disease (COPD) is a common and deadly disease. One of the hallmarks of COPD is an accelerated decline in lung function, as measured by spirometry. Inflammation, oxidative stress and other pathways are hypothesized to be important in this deterioration. Because progressive airflow obstruction is associated with considerable morbidity and mortality, a major goal of COPD treatment has been to slow or prevent the accelerated decline in lung function. Until recently, the only known effective intervention was smoking cessation. However, newly reported large clinical trials have shown that commonly used medications may help slow the rate of lung function decline. The effect of these medications is modest (and thus required such large, expensive trials) and to be of clinical benefit, therapy would likely need to start early in the course of disease and be prolonged. Such a treatment strategy aimed at preservation of lung function would need to be balanced against the side effects and costs of prolonged therapy. A variety of newer classes of medications may help target other pathophysiologically important pathways, and could be used in the future to prevent lung function decline in COPD.

C-reactive protein and risk of lung cancer

PURPOSE

Chronic inflammation could play a role in lung carcinogenesis, underscoring the potential for lung cancer prevention and screening. We investigated the association of circulating high-sensitivity C-reactive protein (CRP, an inflammation biomarker) and CRP single nucleotide polymorphisms (SNPs) with prospective lung cancer risk.

PATIENTS AND METHODS

We conducted a nested case-control study of 592 lung cancer patients and 670 controls with available prediagnostic serum and 378 patients and 447 controls with DNA within the screening arm of the Prostate, Lung, Colorectal, and Ovarian Cancer Screening Trial (N = 77,464). Controls were matched to patients on age, sex, entry year, follow-up time, and smoking. We measured CRP levels in baseline serum samples and genotyped five common CRP SNPs.

RESULTS

Elevated CRP levels were associated with increased lung cancer risk (odds ratio [OR], 1.98; 95% CI, 1.35 to 2.89; P-trend < .001 for fourth quartile [Q4, > or = 5.6 mg/L] v Q1 [< 1.0 mg/L]). The CRP association did not differ significantly by histology, follow-up time, or smoking status, but was most apparent for squamous cell carcinomas (OR, 2.92; 95% CI, 1.30 to 6.54), 2 to 5 years before lung cancer diagnosis (OR, 2.33; 95% CI, 1.24 to 4.39), and among former smokers (OR, 2.48; 95% CI, 1.53 to 4.03) and current smokers (OR, 1.90; 95% CI, 1.06 to 3.41). Although CRP SNPs and haplotypes were associated with CRP levels, they were not associated with lung cancer risk. Ten-year standardized absolute risks of lung cancer were higher with elevated CRP levels among former smokers (Q4: 2.55%; 95% CI, 1.98% to 3.27% v Q1: 1.39%; 95% CI, 1.07% to 1.81%) and current smokers (Q4: 7.37%; 95% CI, 5.81% to 9.33% v Q1: 4.03%; 95% CI, 3.01% to 5.40%).

CONCLUSION

Elevated CRP levels are associated with subsequently increased lung cancer risk, suggesting an etiologic role for chronic pulmonary inflammation in lung carcinogenesis.

Trends in mortality from COPD in selected U.S. States differing in tobacco control efforts

U.S. state tobacco control programs have been associated with both temporal increases in smoking cessation rates in young adults and temporal declines in tobacco-related chronic diseases, but mortality from chronic obstructive pulmonary disease apparently has not been studied. Annual percent change (APC) (1990-2005) in age standardized mortality rate at ages 35-64 and 65+ years from this cause was analyzed for California (which started a comprehensive tobacco control program in 1989), the "U.S. exclusive of California," New Jersey and New York (which had relatively high cigarette prices in the 1990s), and a group of six southern tobacco-growing states (which had limited tobacco control efforts and low cigarette prices in the 1990s). Declines in mortality rates from 1990-2005 for age 35-64 were larger and statistically significant in California (annual % change -1.6%) and New Jersey-New York (annual % change -1.8%), while declines the "U.S. exclusive of California" (annual % change -0.5%) and in six southern tobacco-growing states (annual % change -0.3%). Declines in mortality at age 65+ years were small or nonexistent. The geographic differences in mortality for age 35-64 years after 1990 were not a continuation of earlier trends (in 1980-89), and may be related to differences in tobacco control efforts. This suggests that states should increase their tobacco-control efforts, to reduce chronic obstructive pulmonary disease mortality in the entire U.S.

Do inhaled anticholinergics increase or decrease the risk of major cardiovascular events?: a synthesis of the available evidence

There has been recent uncertainty about whether the inhaled anticholinergic agents ipratropium bromide and tiotropium bromide increase or decrease cardiovascular risk in the treatment of patients with chronic obstructive pulmonary disease (COPD). This article synthesizes the available data in order to understand the controversy. COPD is a common cause of hospitalizations and is a rapidly increasing cause of mortality worldwide. Despite the heavy burden of COPD-related illness, the leading cause of hospitalization in COPD patients is cardiovascular disease. This link between COPD and cardiovascular disease is in part due to the fact that both diseases share common risk factors, such as tobacco smoking and advanced age. It is also hypothesized that systemic inflammation in COPD increases the risk for cardiac events such as myocardial infarction. Inhaled anticholinergics reduce COPD-related hospitalizations and respiratory deaths compared with placebo, and tiotropium bromide is more effective than ipratropium bromide. In randomized trials, patients receiving tiotropium bromide have lower discontinuation rates than those receiving placebo and, therefore, contribute more person-years to the analyses. In a recent large 4-year tiotropium bromide trial, the proportion of patients who died was similar in the tiotropium bromide and placebo groups, whereas the death rate per person-years was lower with tiotropium bromide, indicating longer overall survival. There has been conflicting evidence concerning cardiovascular risk associated with inhaled anticholinergics. One meta-analysis found that the risk for major cardiovascular events was higher with anticholinergics compared with placebo or active comparator controls, whereas two subsequent meta-analyses that included new trial data found no difference in risk. In a recent pooled safety analysis, when incidence rates of events over time were evaluated, tiotropium bromide was associated with a lower rate of major cardiovascular events and cardiovascular deaths compared with placebo. This risk reduction was mainly because of a reduction in serious cardiac events such as myocardial infarction and congestive heart failure. In conclusion, inhaled anticholinergics, especially tiotropium bromide, reduce COPD-related hospitalizations and deaths, and may improve total survival over time. Many COPD patients have concomitant cardiovascular disease processes. Thus, trials may observe more cardiovascular events associated with anticholinergics than with placebo, but this differential is eliminated when evaluating the rate of events per person-years of exposure. New evidence indicates that tiotropium bromide may actually reduce the incidence of cardiovascular events and deaths over time. It is possible that the reduction in respiratory morbidity could improve functional status and reduce adverse cardiac outcomes over time. Further studies are needed to address this important issue.

Bibliography. Current world literature

This bibliography is compiled by clinicians from the journals listed at the end of this publication. It is based on literature entered into our database between 1 November 2007 and 31 October 2008 (articles are generally added to the database about two and a half months after publication). In addition, the bibliography contains every paper annotated by reviewers; these references were obtained from a variety of bibliographic databases and published between the beginning of the review period and the time of going to press. The bibliography has been grouped into topics that relate to the reviews in this issue.

The possible role of granzyme B in the pathogenesis of chronic obstructive pulmonary disease

Chronic obstructive pulmonary disease (COPD) is a highly prevalent inflammatory lung condition characterized by airways disease and emphysema, and the precise mechanism of pathogenesis is poorly understood. The consistent features of COPD include protease-antiprotease imbalance, inflammation and accelerated aging caused by apoptosis or senescence. One family of molecules involved in all of these processes is the granzymes, serine proteases with the best-known member being granzyme B (GzmB). The majority of GzmB is released unidirectionally towards target cells, but GzmB can also be released nonspecifically and escape into the extracellular environment. GzmB is capable of cleaving extracellular matrix (ECM) proteins in vitro, and the accumulation of GzmB in the extracellular milieu during chronic inflammation in COPD could contribute to ECM degradation and remodelling and, consequently, the emphysematous phenotype in the lung. Preliminary studies suggest that increased GzmB expression is associated with increased COPD severity, and this may represent a promising new target for drug and biomarker discovery in COPD. In this paper, we review the potential pathogenic contributions of GzmB to the pathogenesis of COPD.

Role of T-lymphocytes and pro-inflammatory mediators in the pathogenesis of chronic obstructive pulmonary disease

Chronic obstructive pulmonary disease (COPD) is the fourth leading cause of death in the US and a major worldwide healthcare problem. The pathophysiologic mechanisms that drive development and progression of this disease are complex and only poorly understood. While tobacco smoking is the primary risk factor, other disease processes also appear to play a role. Components of the innate immune system (eg, macrophages and neutrophils) have long been believed to be important in the development of COPD. More recent evidence also suggests involvement of the adaptive immune system in pathogenesis of this disease. Here we will review the literature supporting the participation of T-cells in the development of COPD, and comment on the potential antigenic stimuli that may account for these responses. We will further explore the prospective contributions of T-cell derived mediators that could contribute to the inflammation, alveolar wall destruction, and small airway fibrosis of advanced COPD. A better understanding of these complex immune processes will lead to new insights that could result in improved preventative and/or treatment strategies.