Link between chronic obstructive pulmonary disease and coronary artery disease: Implication for clinical practice

Can apelins guide the diagnosis of coronary artery disease in COPD patients?

BACKGROUND

Apelins are adipokines known for their anti-inflammatory, vasodilator, and antiatherosclerotic effects. They are involved in the pathogenesis of chronic diseases like chronic obstructive pulmonary disease (COPD) and coronary artery disease (CAD).

OBJECTIVES

This study aims to investigate apelin as a potential biomarker for early diagnosis and management of CAD in COPD patients.

METHODS

The study included 73 stable COPD patients admitted between June 2023 and June 2024 and 35 healthy volunteers matched by age and gender. COPD patients were categorized into two groups: those without CAD (Group 1) and those with CAD (Group 2). Serum levels of apelin 12, 13, 17, and 36 were measured using ELISA.

RESULTS

Serum apelin levels were significantly lower in COPD patients than in controls (p < 0.001). Among COPD patients, those with CAD showed lower serum apelin levels compared to those without CAD (p = 0.005 for apelin 12, p < 0.001 for apelin 13, 17, and 36). ROC analysis indicated high sensitivity and specificity for apelin 13 and 36 in predicting CAD in COPD patients. Apelin 13 and 36 were positively correlated with ejection fraction (EF) (R = 0.43, p = 0.01; R = 0.4, p = 0.01), and apelin 12 was positively correlated with FEV1 and FVC (R = 0.24, p = 0.04; R = 0.27, p = 0.02).

CONCLUSION

While CAD worsens the prognosis in COPD patients, it remains underdiagnosed. Serum apelin, especially apelin 13 and 36, may assist in the early diagnosis and management of CAD in COPD patients.

The cardiovascular effects of long-acting bronchodilators inhalers and inhaled corticosteroids purchases among asthma and COPD patients

BACKGROUND

Confounding reports of cardiovascular disease (CVD) with the use of Inhaled corticosteroids (ICS), long-acting beta-agonists, and muscarinic antagonists (LABA and LAMA) have been reported.

OBJECTIVE

To explore the relationship between the purchase of ICS, LABA and LAMA inhalers and the incidence of CVDs.

METHODS

This retrospective study included patients with COPD and/or asthma, aged ≥ 18 years, who purchased LABA, LAMA, and ICS inhalers alone or in combination between 2017 and 2019. We calculated the odds ratios (ORs) for CVD for patients who purchased at least one inhaler during the 12 months before the diagnosis and those without any purchase from the same inhaler group. We also analyzed the risk among asthma patients and COPD patients.

RESULTS

Of the 94,834-study population, 74,974 had asthma, 46,907 had COPD, and 27,047 had an asthma-COPD overlap. Average age was 57.9±19.7, and 44% were males. The most prominent effects of ICS were reduced risks for myocarditis (OR 0.35, 95%CI 0.14, 0.9), ischemic heart disease (IHD) (OR 0.45, 95%CI 0.41, 0.49), valvular disease (OR 0.47, 95%CI 0.39, 0.55) and hypertension (HTN) (OR 0.47, 95%CI 0.42, 0.52). LABA inhalers had a significantly lower risk for conduction disorders and arrhythmias (OR 0.71, 95%CI 0.55, 0.92), HTN (OR 0.76, 95%CI 0.63, 0.92), and cerebrovascular diseases (OR 0.83, 95%CI 0.74, 0.94). In comparison, patients with COPD had a significantly lower risk for heart failure (OR 0.62, 95%CI 0.48, 0.8). LAMA inhalers conferred a substantially lower risk of HTN (OR 0.66, 95%CI 0.57, 0.76), peripheral vascular diseases (OR 0.75, 95%CI 0.61, 0.92), IHD (OR 0.8, 95%CI 0.72, 0.89), and cerebrovascular disease (OR 0.85, 95%CI 0.78, 0.92).

CONCLUSION

ICS inhalers were associated with a significant reduction in the incidence of CVD, with lesser but significant effects observed among those using LABA and LAMA inhalers.

Beyond the Heart: The Predictive Role of Coronary Artery Calcium Scoring in Non-Cardiovascular Disease Risk Stratification

Coronary artery calcium scoring (CACS), a non-invasive measure of coronary atherosclerosis, has significantly enhanced cardiovascular (CV) risk assessment and stratification in asymptomatic individuals. More recently, a higher score for CAC has been associated with an increased risk of non-CV diseases and all-cause mortality. This review consolidated evidence supporting the role of CAC in assessing non-CV diseases, emphasizing its potential in early diagnosis and prognosis. We observed a strong association between CACS and non-CV diseases, viz., chronic obstructive pulmonary disease, pulmonary embolism, pneumonia, diabetes, chronic kidney disease, osteoporosis, metabolic dysfunction-associated steatotic liver disease, nephrolithiasis, stroke, dementia, malignancies, and several autoimmune diseases. Also, CAC may aid in evaluating the risk of CV conditions developing secondary to the non-CV diseases mentioned earlier. Further evidence from prospective studies, intervention trials, and population-based behavioral studies is needed to establish CAC cutoff values and explore preventative care applications, facilitating their broader integration into healthcare practices.

Disease Burden and Health-Related Quality of Life (HRQoL) of Chronic Obstructive Pulmonary Disease (COPD) in the US - Evidence from the Medical Expenditure Panel Survey (MEPS) from 2016-2019

Purpose

Chronic obstructive pulmonary disease (COPD) is a progressive disease associated with reduced life expectancy, increased morbidity, mortality, and cost. This study characterized the US COPD burden, including socioeconomic and health-related quality of life (HRQoL) outcomes.

Study Design and Methods

In this retrospective, cross-sectional study using nationally representative estimates from Medical Expenditures Survey (MEPS) data (2016-2019), adults (≥18 years) living with and without COPD were identified. Adults living without COPD (control cohort) and with COPD were matched 5:1 on age, sex, geographic region, and entry year. Demographics, clinical characteristics, socioeconomic, and generic HRQoL measures were examined to include a race-stratified analysis of people living with COPD.

Results

A total of 4,135 people living with COPD were identified; the matched dataset represented a weighted non-institutionalized population of 11.3 million with and 54.2 million people without COPD. Among people living with COPD, 66.3% had ≥1 COPD-related condition; 62.7% had ≥1 cardiovascular condition, compared to 33.5% and 50.5% without COPD. More people living with COPD were unemployed (56.2% vs 45.3%), unable to work due to illness/disability (30.1% vs 12.1%), had problems paying bills (16.1% vs 8.8%), reported poorer perceived health (fair/poor: 36.2% vs 14.4%), missed more working days due to illness/injury per year (median, 2.5 days vs 0.0 days), and had limitations in physical functioning (40.1% vs 19.4%) (all P<0.0001). In race-stratified analyses for people living with COPD, people self-reporting as Black had higher prevalence of cardiovascular-risk conditions, poorer socioeconomic and HRQoL outcomes, and higher healthcare expenses than White or Other races.

Conclusion

Adults living with COPD had higher clinical disease burden, lower socioeconomic status, and reduced HRQoL than those without, with greater disparities among Black people living with COPD compared to White and other races. Understanding the characteristics of patients helps address care disparities and access challenges.

Cardiovascular Prognosis of Subclinical Chronic Obstructive Pulmonary Disease in Patients with Suspected or Confirmed Coronary Artery Disease

Background

Chronic obstructive pulmonary disease (COPD) worsens prognosis in patients with coronary artery disease (CAD). However, the cardiovascular prognosis in patients with stable or mildly symptomatic COPD remains unclear. Here, we sought to determine the long-term cardiovascular events in patients with subclinical or early-stage COPD with concomitant CAD.

Methods

This was a longitudinal analytical study involving 117 patients with suspected or established CAD who underwent assessment of pulmonary function by spirometry and who were followed up for six years (March 2015-January 2021). The patients were divided into two groups, one comprising COPD (n=44) and the other non-COPD (n=73) patients. Cox regression was used to evaluate the association between COPD and cardiovascular events, with adjustment for the established CAD risk factors, and the effect size was measured by the Cohen test.

Results

COPD patients were older (p=0.028), had a greater frequency of diabetes (p=0.026), were more likely to be smokers (p<0.001), and had higher modified Medical Research Council scores (p<0.001). There was no difference between the groups regarding gender, body mass index, hypertension, dyslipidemia, family history of CAD, and type of angina. CAD frequency and the proportion of patients with severe and multivessel CAD were significantly higher among COPD than among non-COPD patients (all p<0.001). At six-year follow-up, patients with COPD were more likely to have experienced adverse cardiovascular events than those without COPD (p<0.001; effect size, 0.720). After adjusting for established CAD risk factors, COPD occurrence remained an independent predictor for long-term adverse cardiovascular events (OR: 5.13; 95% CI: 2.29-11.50; p<0.0001).

Conclusion

COPD was associated with increased severity of coronary lesions and a greater number of adverse cardiovascular events in patients with suspected or confirmed CAD. COPD remained a predictor of long-term cardiovascular events in stable patients with subclinical or early-stage of COPD, independently of the established CAD risk factors.

Cardiovascular Diseases in COPD: From Diagnosis and Prevalence to Therapy

Chronic obstructive pulmonary disease (COPD) is considered one of the leading causes of mortality. Cardiovascular comorbidities are diagnosed often in COPD patients, not only because of the common risk factors these two diseases share, but also because of the systemic inflammation which characterizes COPD and has deleterious effects in the cardiovascular system. The comorbid cardiovascular diseases in COPD result in several difficulties in the holistic treatment of these patients and affect outcomes such as morbidity and mortality. Several studies have reported that mortality from cardiovascular causes is common among COPD patients, while the risk for acute cardiovascular events increases during COPD exacerbations and remains high for a long time even after recovery. In this review, we focus on the prevalence of cardiovascular comorbidities in COPD patients, presenting the evidence regarding the interaction of the pathophysiological pathways which characterize each disease. Furthermore, we summarize information regarding the effects of cardiovascular treatment on COPD outcomes and vice versa. Finally, we present the current evidence regarding the impact of cardiovascular comorbidities on exacerbations, quality of life and survival of COPD patients.

Deep learning to detect significant coronary artery disease from plain chest radiographs AI4CAD

BACKGROUND

The predictive role of chest radiographs in patients with suspected coronary artery disease (CAD) is underestimated and may benefit from artificial intelligence (AI) applications.

OBJECTIVES

To train, test, and validate a deep learning (DL) solution for detecting significant CAD based on chest radiographs.

METHODS

Data of patients referred for angina and undergoing chest radiography and coronary angiography were analysed retrospectively. A deep convolutional neural network (DCNN) was designed to detect significant CAD from posteroanterior/anteroposterior chest radiographs. The DCNN was trained for severe CAD binary classification (absence/presence). Coronary angiography reports were the ground truth. Stenosis severity of ≥70% for non-left main vessels and ≥ 50% for left main defined severe CAD.

RESULTS

Information of 7728 patients was reviewed. Severe CAD was present in 4091 (53%). Patients were randomly divided for algorithm training (70%; n = 5454) and fine-tuning/model validation (10%; n = 773). Internal clinical validation (model testing) was performed with the remaining patients (20%; n = 1501). At binary logistic regression, DCNN prediction was the strongest severe CAD predictor (p < 0.0001; OR: 1.040; CI: 1.032-1.048). Using a high sensitivity operating cut-point, the DCNN had a sensitivity of 0.90 to detect significant CAD (specificity 0.31; AUC 0.73; 95% CI DeLong, 0.69-0.76). Adding to the AI chest radiograph interpretation angina status improved the prediction (AUC 0.77; 95% CI DeLong, 0.74-0.80).

CONCLUSION

AI-read chest radiographs could be used to pre-test significant CAD probability in patients referred for suspected angina. Further studies are required to externally validate our algorithm, develop a clinically applicable tool, and support CAD screening in broader settings.

Standardized airway wall thickness Pi10 from routine CT scans of COPD patients as imaging biomarker for disease severity, lung function decline, and mortality

BACKGROUND

Chest computed tomography (CT) is increasingly used for phenotyping and monitoring of patients with COPD. The aim of this work was to evaluate the association of Pi10 as a measure of standardized airway wall thickness on CT with exacerbations, mortality, and response to triple therapy.

METHODS

Patients of GOLD grades 1-4 of the COSYCONET cohort with prospective CT scans were included. Pi10 was automatically computed and analyzed for its relationship to COPD severity, comorbidities, lung function, respiratory therapy, and mortality over a 6-year period, using univariate and multivariate comparisons.

RESULTS

We included n = 433 patients (61%male). Pi10 was dependent on both GOLD grades 1-4 (p = 0.009) and GOLD groups A-D (p = 0.008); it was particularly elevated in group D, and ROC analysis yielded a cut-off of 0.26 cm. Higher Pi10 was associated to lower FEV₁ % predicted and higher RV/TLC, moreover the annual changes of lung function parameters (p < 0.05), as well as to an airway-dominated phenotype and a history of myocardial infarction (p = 0.001). These associations were confirmed in multivariate analyses. Pi10 was lower in patients receiving triple therapy, in particular in patients of GOLD groups C and D. Pi10 was also a significant predictor for mortality (p = 0.006), even after including multiple other predictors.

CONCLUSION

In summary, Pi10 was found to be predictive for the course of the disease in COPD, in particular mortality. The fact that Pi10 was lower in patients with severe COPD receiving triple therapy might hint toward additional effects of this functional therapy on airway remodeling.

REGISTRATION

ClinicalTrials.gov, Identifier: NCT01245933.

Short-Term Associations between Size-Fractioned Particles and Cardiopulmonary Function in COPD Patients: A Panel Study in Shanghai, China, during 2014-2021

It remains unknown which size fractions dominate the adverse cardiopulmonary effects of particulate matter (PM). Therefore, this study aimed to explore the differential associations between size-fractioned particle number concentrations (PNCs) and cardiopulmonary function measures, including the forced expiratory volume in one second (FEV₁), the forced vital capacity (FVC), and the left ventricular ejection fraction (LVEF). We conducted a panel study among 211 patients with chronic obstructive pulmonary disease (COPD) in Shanghai, China, between January 2014 and December 2021. We applied linear mixed-effect models to determine the associations between cardiopulmonary function measures and PNCs ranging from 0.01 to 10 μm in diameter. Generally, only particles <1 μm showed significant associations, i.e., ultrafine particles (UFPs, <0.1 μm) for FVC and particles ranging from 0.1 to 1 µm for FEV₁ and LVEF. An interquartile range (IQR) increment in UFP was associated with decreases of 78.4 mL in FVC. PNC_0.1-0.3 and PNC_0.3-1 corresponded to the strongest effects on FEV₁ (119.5 mL) and LVEF (1.5%) per IQR increment. Particles <1 µm might dominate the cardiopulmonary toxicity of PM, but UFPs might not always have the strongest effect. Tailored regulations towards particles <1 µm should be intensified to reduce PM pollution and protect vulnerable populations.

Common physiologic and proteomic biomarkers in pulmonary and coronary artery disease

Objective

Chronic obstructive pulmonary disease (COPD) and coronary artery disease (CAD) are leading causes of global morbidity and mortality. There is a well-known comorbidity between COPD and CAD, which is only partly explained by smoking and other known common risk factors. In order to better understand the relationship between COPD and CAD, we analyzed myocardial perfusion, pulmonary function and novel cardiovascular biomarkers in patients with symptoms suggesting myocardial ischemia.

Methods

A total of 396 subjects from the Swedish Biomarkers and Genetics CardioPulmonary Physiology Study (BiG CaPPS) were included, all of whom had been referred to myocardial perfusion imaging due to suspected myocardial ischemia. Subjects performed myocardial perfusion imaging (MPI), pulmonary function tests (PFT) and analysis of 92 proteomic biomarkers, previously associated with cardiovascular disease. Linear regression was used to study the relationship between MPI and PFT results and proteomic biomarkers.

Results

Subjects with CAD (n = 159) had lower diffusing capacity (D_LCO) than patients without CAD (6.64 versus 7.17 mmol/(min*kPa*l); p = 0.004) in models adjusted for common covariates such as smoking, but also diabetes and brain natriuretic peptide (BNP). The association remained significant after additional adjustment for forced expiratory volume in one second (FEV₁) (p = 0.009). Subjects with CAD, compared with subjects without CAD, had higher total airway resistance (0.37 vs 0.36 kPa/(l/s); p = 0.036). Among 92 protein biomarkers, nine were associated with a combined diagnosis of CAD and airflow obstruction: VSIG2, KIM1, FGF-23, REN, XCL1, GIF, ADM, TRAIL-R2 and PRSS8.

Significance

Diffusing capacity for carbon monoxide is decreased in patients with CAD, independently of decreased FEV₁, diabetes, and elevated BNP. Several cardiovascular biomarkers are associated with co-existent CAD and airflow obstruction, but none with airflow obstruction only. The current findings indicate that the interaction between CAD and lung function is complex, including mechanisms beyond the known association between CAD and reduced ventilation.

Undiagnosed Chronic Obstructive Pulmonary Disease is Highly Prevalent in Patients Referred for Dobutamine Stress Echocardiography with Shortness of Breath

PURPOSE

Shortness of breath (SOB) is a common symptom referral for dobutamine stress echocardiography (DSE). Patients with SOB and a normal DSE have worse long-term outcome than the general population. This suggests multiple aetiologies are involved. The purpose of this study was to assess the prevalence and clinical significance of undiagnosed COPD amongst patients referred for a DSE with SOB.

METHODS

We prospectively studied 114 patients referred for DSE with SOB without prior evidence of lung disease (mean age 64.9 ± 18.5 years, 60 male). Respiratory function testing using spirometry was performed on all patients on the day of their DSE. The study end-points were cardiac events and total mortality.

RESULTS

Respiratory function testing and DSE was performed in all patients and COPD was highly prevalent (n = 93). Multivariate Cox regression analysis was used to estimate the effect of dyspnoea on non-fatal cardiac events (NFCE) and all-cause mortality. Over a mean follow-up of 4.5 ± 2.6 years, the composite end-point of NFCE and all-cause mortality occurred in 62.7% and 16.7% patients, respectively. COPD (HR 1.27; 95% CI 1.17-1.93), previous myocardial infarction (HR 1.84; 95% CI 1.06-3.2), myocardial ischaemia (HR 2.56; 95% CI 1.48-4.43), peak wall motion score index (HR 4.66; 95% CI 2.26-9.6), and mitral E/E' (HR 1.21; 95% CI 1.1-1.33) were significantly associated with a NFCE. Myocardial ischaemia (HR 4.43; 95% CI 1.24-15.81) was the only independent predictor of all-cause mortality.

CONCLUSION

Undiagnosed COPD is highly prevalent and independently associated with worse outcome amongst patients with SOB referred for DSE. Symptom presentation is therefore an important consideration when interpreting DSE results.

Advances in understanding of mechanisms related to increased cardiovascular risk in COPD

INTRODUCTION

Chronic obstructive pulmonary disease (COPD) represents a serious global health issue that is commonly associated with cardiovascular (CV) disease (CVD). The close relationship between COPD and CVD could be explained by different factors, first and foremost a chronic low-grade systemic inflammation implicated in the pathogenesis of both diseases and several stimuli enhancing the inflammatory processes and causing a mixed condition with worse outcomes than either disorder alone.

AREAS COVERED

The present narrative review considers the mechanisms underlying the increased CV risk in COPD, and it provides insights on biomarkers and predictive models to predict CVD in COPD patients.

EXPERT OPINION

COPD patients often remain asymptomatic of CVD, with respiratory symptoms generally attributed to the preexisting pulmonary disease. It is fundamental to understand the mechanistic pathways that underpin the intimate relationship between the two disorders. However, it is still not clear what is the origin of the common background of low-grade systemic inflammation, it could be a 'spillover' or a general inflammatory state. Primary prevention, cross-collaboration between specialists and early detection via predictive biomarkers and validated models are fundamental to stratify COPD patients according to CV risk.

Circulating antibodies against age-modified proteins in patients with coronary atherosclerosis

Advanced glycation endproducts (AGEs) are formed in a series of non-enzymatic reactions between reducing sugars and the amino groups of proteins and accumulate during aging, diabetes mellitus, chronic kidney disease and other chronic diseases. Accumulation of AGE-modifications alters protein structure and function, transforming these molecules into potential targets of the immune system, presumably triggering the production of autoantibodies against AGEs. In this study, we detected autoantibodies against AGE-modified proteins with ELISA in plasma samples of 91 patients with documented coronary artery disease (CAD), who underwent coronary artery bypass grafting (CABG) surgery. Patients with high levels of autoantibodies had a higher body mass index (BMI 28.6 vs 27.1 kg/m²; p = 0.046), were more likely to suffer from chronic obstructive pulmonary disease (COPD 30% vs 9.8%; p = 0.018), and more likely to need dialysis after the surgery (10% vs 0%; p = 0.037). Our findings show a weak link between the levels of autoantibodies against AGEs and diabetes mellitus (DM 44% vs 24.4%; p = 0.05). In a small subpopulation of patients, antibodies against native bovine serum albumin (BSA) were detected. A growing body of research explores the potential role of antibodies against AGE-modified proteins in pathogenesis of different chronic diseases; our data confirms the presence of AGE-autoantibodies in patients with CAD and that in parallel to the AGEs themselves, they may have a potential role in concomitant clinical conditions in patients undergoing CABG surgery. Further research is necessary to verify the molecular role of these antibodies in different pathological conditions.

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.

Lung Function in Young Adults and Risk of Cardiovascular Events Over 29 Years: The CARDIA Study

Background

Diminished peak lung function in young adulthood is a risk factor for future chronic obstructive pulmonary disease. The association between lung disease and cardiovascular disease later in life is well documented. Whether peak lung function measured in young adulthood is associated with risk of future cardiovascular events is unknown.

Methods and Results

CARDIA (The Coronary Artery Risk Development in Young Adults) study is a prospective, multicenter, community‐based, longitudinal cohort study including 4761 participants aged 18 to 30 years with lung function testing we investigated the association between lung health in young adulthood and risk of subsequent cardiovascular events. We performed Cox proportional hazards regression to test the association between baseline and years 10 and 20 pulmonary function with incident cardiovascular events. Linear and logistic regression was performed to explore the associations of lung function with development of risk factors for cardiovascular disease as well as carotid intima‐media thickness and coronary artery calcified plaque. At baseline, mean age (±SD) was 24.9±3.6 years. Baseline forced expiratory volume in 1 second (hazard ratio) per −10‐unit decrement in percent predicted forced expiratory volume in 1 second (hazard ratio, 1.18; 95% CI, 1.06–1.31 [P=0.002]) and FVC per −10‐unit decrement in percent predicted FVC (hazard ratio, 1.19; 95% CI, 1.06–1.33 [P=0.003]) were associated with future cardiovascular events independent of traditional cardiovascular risk factors. Baseline lung function was associated with heart failure and cerebrovascular events but not coronary artery disease events.

Conclusions

Lung function in young adulthood is independently associated with cardiovascular events into middle age. This association appears to be driven by heart failure and cerebrovascular events rather than coronary heart disease.

Clinical Trial Registration

URL: https://www.clinicaltrials.gov. Unique identifier: NCT00005130.

Increased mortality and ICD therapies in ischemic versus non-ischemic dilated cardiomyopathy patients with cardiac resynchronization having survived until first device replacement

INTRODUCTION

Cardiac resynchronization therapy combined with an implantable cardioverter defibrillator (CRT-D) is widely applied in heart failure patients. Sufficient data on arrhythmia and defibrillator therapies during long-term follow-up of more than 4 years are lacking and data on mortality are conflicting. We aimed to characterize the occurrence of ventricular arrhythmia, respective defibrillator therapies and mortality for several years following CRT-D implantation or upgrade.

MATERIAL AND METHODS

Eighty-eight patients with ischemic (ICM) or non-ischemic dilated cardiomyopathy (DCM) and at least one CRT-D replacement were included in this study and analyzed for incidence of non-sustained ventricular tachycardia (NSVT), defibrillator shocks, anti-tachycardia pacing (ATP) and mortality.

RESULTS

ICM was the underlying disease in 59%, DCM in 41% of patients. During a mean follow-up of 76.4 ±24.8 months the incidence of appropriate defibrillator therapies (shock or ATP) was 46.6% and was elevated in ICM compared to DCM patients (57.7% vs. 30.6%, respectively; p = 0.017). Kaplan-Meier analysis revealed significantly higher ICD therapy-free survival rates in DCM patients (p = 0.031). Left ventricular ejection fraction, NSVT per year and ICM (vs. DCM) were independent predictors of device intervention. The ICM patients showed increased mortality compared to DCM patients, with cumulative all-cause mortality at 9 years of follow-up of 45.4% and 10.6%, respectively. Chronic renal failure, peripheral artery disease and chronic obstructive pulmonary disease were independent predictors of mortality.

CONCLUSIONS

The clinical course of patients with ICM and DCM treated with CRT-D differs significantly during long-term follow-up, with increased mortality and incidence of ICD therapies in ICM patients.

Left ventricular dysfunction in relation with systemic inflammation in chronic obstructive pulmonary disease patients

BACKGROUND/AIMS

Most important cause of mortality in chronic obstructive pulmonary disease (COPD) patients is known to be cardiovascular disease (CVD). The objective of the present study was to evaluate the echocardiographic parameters in COPD patients with or without pre-diagnosed CVD and to investigate the relationship between echocardiographic parameters and systemic inflammation markers.

METHODS

A total of 60 stable COPD patients (23 patients with CVD, group 1; 37 patients without CVD, group 2) and 21 healthy controls (group 3) were included in the study. Six-minute walking test (6MWT), COPD assessment test (CAT), and Body mass index, airflow Obstruction, Dyspnea, and Exercise (BODE) index results were recorded. High-sensitivity C-reactive protein (HsCRP), interleukin 8 (IL-8), fetuin-A, Clara cell protein (CCL-16), N-terminal pro-brain natriuretic peptide levels were studied in serum. Parameters of left and right ventricular systolic and diastolic function were measured by echocardiography.

RESULTS

Patients with COPD had higher levels of systemic inflammation markers and lower level of inflammation inhibitor fetuin-A. When three groups were compared, group 1 had lower 6MWT result. HsCRP was highest in group 2 while other inflammatory markers were similar in groups 1 and 2. Regarding echocardiographic parameters, left ventricular ejection fraction (LVEF) was lower and left ventricle end-diastolic diameter (LVED), left ventricle end-systolic diameter (LVES) diameters were higher in group 1. The aortic diameter was higher in COPD patients. Fetuin-A was correlated with diameter of aorta and LVES. LVEF, LVED, and LVES were found to be correlated with functional parameters of COPD cases.

CONCLUSION

In COPD, left ventricular functions are affected as well as right ventricle before prominent clinical findings of cardiac disease and these echocardiographic parameters correlate with functional parameters of COPD patients.

Carotid intima-media thickness in chronic obstructive pulmonary disease and survival: A multicenter prospective study

INTRODUCTION

Chronic obstructive pulmonary disease (COPD) is associated with increased cardiovascular morbidity and mortality. Carotid intima-media thickness (CIMT) is a noninvasive method assessing atherosclerosis.

OBJECTIVE

It was aimed to determine relationship and survival between COPD and CIMT.

METHODS

CIMT was measured using Doppler ultrasound (USG) in 668 stable COPD patients at 24 centers. Patients were followed-up for 2 years.

RESULTS

There were 610 patients who completed the study. There were 200 patients CIMT with <0.78 mm (group 1), and 410 with CIMT ≥ 0.78 mm (group 2). There was a significant difference at the parameters of age, gender, smoking load, biomass exposure, GOLD groups and degree of airway obstruction (FEV1) between groups 1 and 2. Our results revealed positive correlations between mean CIMT and age, smoking load (pack-years), biomass exposure (years), exacerbation rate (last year), duration of hypertension (years) and cholesterol level; negative correlations between CIMT and FEV₁ (P < 0.05). According to logistic regression model, compared with group A, risk of CIMT increase was 2.2-fold in group B, 9.7-fold in group C and 4.4-fold in group D (P < 0.05). Risk of CIMT increase was also related with cholesterol level (P < 0.05). Compared with infrequent exacerbation, it was 2.8-fold in the patients with frequent exacerbation (P < 0.05). The mean survival time was slightly higher in group 1, but not significant (23.9 vs 21.8 months) (P > 0.05).

CONCLUSION

This study is the first regarding CIMT with combined GOLD assessment groups. It has revealed important findings supporting the increase in atherosclerosis risk in COPD patients. We recommend Doppler USG of the carotid artery in COPD patients at severe stages.

Genetic overlap of chronic obstructive pulmonary disease and cardiovascular disease-related traits: a large-scale genome-wide cross-trait analysis

BACKGROUND

A growing number of studies clearly demonstrate a substantial association between chronic obstructive pulmonary disease (COPD) and cardiovascular diseases (CVD), although little is known about the shared genetics that contribute to this association.

METHODS

We conducted a large-scale cross-trait genome-wide association study to investigate genetic overlap between COPD (Ncase = 12,550, Ncontrol = 46,368) from the International COPD Genetics Consortium and four primary cardiac traits: resting heart rate (RHR) (N = 458,969), high blood pressure (HBP) (Ncase = 144,793, Ncontrol = 313,761), coronary artery disease (CAD)(Ncase = 60,801, Ncontrol = 123,504), and stroke (Ncase = 40,585, Ncontrol = 406,111) from UK Biobank, CARDIoGRAMplusC4D Consortium, and International Stroke Genetics Consortium data.

RESULTS

RHR and HBP had modest genetic correlation, and CAD had borderline evidence with COPD at a genome-wide level. We found evidence of local genetic correlation with particular regions of the genome. Cross-trait meta-analysis of COPD identified 21 loci jointly associated with RHR, 22 loci with HBP, and 3 loci with CAD. Functional analysis revealed that shared genes were enriched in smoking-related pathways and in cardiovascular, nervous, and immune system tissues. An examination of smoking-related genetic variants identified SNPs located in 15q25.1 region associated with cigarettes per day, with effects on RHR and CAD. A Mendelian randomization analysis showed a significant positive causal effect of COPD on RHR (causal estimate = 0.1374, P = 0.008).

CONCLUSION

In a set of large-scale GWAS, we identify evidence of shared genetics between COPD and cardiac traits.

Cardiovascular Comorbidities in Chronic Obstructive Pulmonary Disease (COPD)-Current Considerations for Clinical Practice

In patients with chronic obstructive pulmonary disease (COPD), cardiovascular comorbidities are highly prevalent and associated with considerable morbidity and mortality. This coincidence is increasingly seen in context of a “cardiopulmonary continuum” rather than being simply attributed to shared risk factors such as cigarette smoking. Overlapping symptoms such as dyspnea or chest pain lead to a worse prognosis due to missed concomitant diagnoses. Moreover, medication is often withheld as a result of unfounded concerns about side effects. Despite the frequent coincidence, current guidelines are still mostly restricted to the management of the individual disease. Future diagnostic and therapeutic strategies should therefore be guided by an integrative perspective as well as a refined phenotyping of disease entities.

The Role of Cardiopulmonary Exercise Testing (CPET) in Pulmonary Rehabilitation (PR) of Chronic Obstructive Pulmonary Disease (COPD) Patients

Chronic obstructive pulmonary disease (COPD) is a common multisystem inflammatory disease with ramifications involving essentially all organ systems. Pulmonary rehabilitation is a comprehensive program designed to prevent and mitigate these disparate systemic effects and improve patient quality of life, functional status, and social functioning. Although initial patient assessment is a prominent component of any pulmonary rehabilitation (PR) program, cardiopulmonary exercise testing (CPET) is not regularly performed as a screening physiologic test prior to PR in COPD patients. Further, CPET is not often used to assess or document the improvement in exercise capacity related to completion of PR. In this review we will describe the classic physiologic abnormalities related to COPD on CPET parameters, the role of CPET in Risk Stratification/Safety prior to PR, the physiologic changes that occur in CPET parameters with PR, and the literature regarding the use of CPET to assess PR results. Finally, we will compare CPET to 6MW in COPD PR, the common minimal clinically important difference (MCID) is associated with CPET, and the potential future roles of CPET in PR and Research.

GOLD stage predicts thoracic aortic calcifications in patients with COPD

Although some of the associations between chronic obstructive pulmonary disease (COPD) and atherosclerosis are based on shared risk factors such as smoking, recent epidemiological evidence suggests that COPD is a risk factor for vascular disease due to systemic inflammation. The present study assessed the hypothesis that disease severity (as expressed by the GOLD stage) independently predicts the extent of vascular calcifications. A total of 160 smokers diagnosed with COPD (GOLD I-IV, 40 subjects of each GOLD stage) and 40 smokers at risk (GOLD 0; median age of 60 years old; Q1:56;Q3:65; 135 males and 65 females) underwent non-contrast, non-electrocardiography synchronized chest computerised tomography. The volume of thoracic aortic calcifications was quantified semi-automatically within a region from T1 through T12. Multiparametric associations with GOLD stage, smoking history, sex, age, body mass index and emphysema index were evaluated using generalized linear regression analysis. Thoracic aortic calcifications were highly prevalent in this cohort (187/200 subjects, 709 (Q1:109;Q3:2163) mm³). Analysis of variance on ranks demonstrated a significant difference in calcium between different GOLD-stages as well as patients at risk of COPD (F=36.8, P<0.001). In the multivariable analysis, GOLD-stages were indicated to be predictive of thoracic aortic calcifications (P≤0.0033) besides age (P<0.0001), while age appeared to be the strongest predictor. Other variables were not statistically linked to thoracic aortic calcifications in the multivariable model. COPD severity, as expressed by the GOLD-stage, is a significant predictor of thoracic aortic calcifications, independent of covariates such as age or tobacco consumption.

High prevalence of undiagnosed COPD among patients evaluated for suspected myocardial ischaemia

Objective

Chronic obstructive pulmonary disease (COPD) and coronary artery disease (CAD) are leading causes of global morbidity and mortality. Despite the well-known comorbidity between COPD and CAD, the presence of COPD may be overlooked in patients undergoing coronary evaluation. We aimed to assess the prevalence of undiagnosed COPD among outpatients evaluated due to suspected myocardial ischemia.

Methods

Among 500 outpatients who were referred to myocardial perfusion imaging due to suspected stable myocardial ischaemia, 433 patients performed spirometry. Of these, a total of 400 subjects (age 66 years; 45% women) had no previous COPD diagnosis and were included in the current study. We compared the prevalence of previously undiagnosed COPD according to spirometry criteria from The Global Initiative for Chronic Obstructive Lung Disease (GOLD) or lower limit of normal (LLN) and reversible myocardial ischaemia according to symptoms and clinical factors.

Results

A total of 134 (GOLD criteria; 33.5 %) or 46 patients (LLN criteria; 11.5%) had previously undiagnosed COPD, whereas 55 patients (13.8 %) had reversible myocardial ischaemia. The presenting symptoms (chest discomfort, dyspnoea) did not differ between COPD, myocardial ischaemia and normal findings. Except for smoking, no clinical factors were consistently associated with previously undiagnosed COPD.

Conclusions

Among middle-aged outpatients evaluated due to suspected myocardial ischaemia, previously undiagnosed COPD is at least as common as reversible myocardial ischaemia and the presenting symptoms do not differentiate between these entities. Patients going through a coronary ischaemia evaluation should be additionally tested for COPD, especially if there is a positive history of smoking.

Evaluation of the protective effects of β-blockers in the management of acute exacerbations of chronic obstructive pulmonary disease

WHAT IS KNOWN AND OBJECTIVE

The purpose of this study was to evaluate the association between early β-blocker continuation and major inpatient events in patients hospitalized for an acute exacerbation of chronic obstructive pulmonary disease (AECOPD).

METHODS

This single centre, retrospective, investigational review board approved cohort study evaluated patients admitted for a primary diagnosis of AECOPD. Patients were evaluated based on early continuation of a β-blocker whether a β-blocker was initiated within 24 hours of admission and continued for at least 72 hours. Patients with AECOPD who did not receive β-blockers were assigned to the control group. Major inpatient events were a composite outcome composed of arrhythmias, myocardial infarction (MI) and death. Safety data were collected on the incidences of bradycardia, bronchospasms and hypotension.

RESULTS AND DISCUSSION

Of the 96 patients admitted for AECOPD, fifty-five patients were included in the early β-blocker group and forty-one patients in the control group. Early β-blocker utilization was associated with a significantly lower rate of major inpatient events compared with the control group (40% vs 80.5%; P < 0.001). Arrhythmias were significantly less common in the early β-blocker group (30.9% vs 65.9%; P = 0.001); however, there were no significant differences in the rates of MI (9.1% vs 14.6%; P = 0.54), death (0 vs 0) or safety outcomes between groups.

WHAT IS NEW AND CONCLUSION

β-blocker therapy could result in a paradigm shift in managing chronic obstructive pulmonary disease patients from a true cardiopulmonary approach. This retrospective cohort study demonstrated early β-blocker continuation in patients admitted for an AECOPD was associated with less major inpatient events, primarily arrhythmias.

The potential role of endothelial dysfunction and platelet activation in the development of thrombotic risk in COPD patients

INTRODUCTION

Despite lack of knowledge in the field, several studies have underlined the role of endothelium dysfunction and platelet activation as significant players in the development and progression of chronic obstructive pulmonary disease (COPD). Indeed, endothelium plays a crucial role in vascular homeostasis and impairment, due to the inflammation process enhanced by smoking. Chronic inflammation and endothelial dysfunction have been proved to drive platelet activity. Consequently, thrombotic risk is enhanced in COPD, and might explain the higher percentage of cardiovascular death in such patients. Areas covered: This review aims to clarify the role of endothelium function and platelet hyper-activity as the pathophysiological mechanisms of the increased thrombotic risk in COPD. Expert commentary: In COPD patients, chronic inflammation does not impact only on lung parenchyma, but potentially involves all systems, including the endothelium of blood vessels. Impaired endothelium has several consequences, such as reduced vasodilatation capacity, enhanced blood coagulation, and increased platelet activation resulting in higher risk of thrombosis in COPD patients. Endothelium dysfunction and platelet activation are potential targets of therapy in patients with COPD aiming to reduce their risk of cardiovascular events.

Arterial stiffness in symptomatic smokers with normal lung function

Chronic obstructive pulmonary disease (COPD) is associated with cardiovascular morbidity and mortality. Arterial stiffness and endothelial dysfunction index are validated surrogate cardiovascular markers and are increased in subjects with COPD. We tested whether increased arterial stiffness and endothelial dysfunction occur in symptomatic smokers with no evidence of bronchial obstruction. Clinical and lung functional assessments were conducted in smoker subjects with chronic respiratory symptoms and in COPD patients. Pulse wave velocity (PWV), aortic augmentation index (AIx) and reactive hyperaemia index (RHI) were measured to estimate the cardiovascular risk. 48 smokers (male n=37, female n=11; mean age 70±8.4 years) were studied. Smokers with respiratory symptoms without bronchial obstruction (n=13) did not differ from COPD patients (n=35) in terms of mean±sd PWV (12±3.2 m·s-1versus 14±3.8 m·s-1; p=0.10), aortic AIx (25.2±11.8% versus 24.8±9.7%, p=0.89) and RHI (1.66±1.49 versus 1.62±1.43; p=0.79). The current investigation shows that the cardiovascular risk occurs in smokers with respiratory symptoms in the absence of bronchial obstruction. These findings need to be confirmed in larger populations in order to inform the design of intensive preventive programmes.

Paradigms in chronic obstructive pulmonary disease: phenotypes, immunobiology, and therapy with a focus on vascular disease

Chronic obstructive pulmonary disease (COPD) is a complex and heterogeneous syndrome that represents a major global health burden. COPD phenotypes have recently emerged based on large cohort studies addressing the need to better characterize the syndrome. Though comprehensive phenotyping is still at an early stage, factors such as ethnicity and radiographic, serum, and exhaled breath biomarkers have shown promise. COPD is also an immunological disease where innate and adaptive immune responses to the environment and tobacco smoke are altered. The frequent overlap between COPD and other systemic diseases, such as cardiovascular disease, has influenced COPD therapy, and treatments for both conditions may lead to improved patient outcomes. Here, we discuss current paradigms that center on improving the definition of COPD, understanding the immunological overlap between COPD and vascular inflammation, and the treatment of COPD-with a focus on comorbid cardiovascular disease.

The Level of Cholesterol in COPD Patients with Severe and Very Severe Stage of the Disease

BACKGROUND

High blood cholesterol is part of metabolic syndrome and can be caused by medical conditions or bad dietary habits.

AIM

The aim of the study was to investigate the prevalence of hypercholesterolemia in privies diagnosed patients with the severe and very severe stage of COPD, which were stable.

MATERIAL AND METHODS

We investigated 100 subjects, all of them smokers, with smoking status >10 years, stratified into two groups: with severe and very severe stage of the disease. It was clinical, randomized, cross-sectional study. Besides demographic parameters and functional parameters, body mass index, cholesterol, LDL, and HDL were investigated.

RESULTS

In the group of patients with very severe COPD were recorded significantly higher average values of cholesterol (6.16 ± 1.5 vs. 5.61 ± 1.1, p = 0.039). As independent significant factors influencing cholesterol in the group with a very severe COPD were confirmed the age of the patients (p = 0.005), LDL (p = 0.004) and HDL (p = 0.002). In the group with severe COPD, only LDL was confirmed as an independent significant factor that has an impact on cholesterol (p < 0.0001).

CONCLUSION

The results of our survey demonstrated a high level of blood cholesterol and LDL, and low level of blood HDL in both investigated group's patients with COPD.

Chronic obstructive pulmonary disease and ischemic heart disease comorbidity: overview of mechanisms and clinical management

In the last few years, many studies focused their attention on the relationship between chronic obstructive pulmonary disease (COPD) and ischemic heart disease (IHD), showing that these diseases are mutually influenced. Many different biological processes such as hypoxia, systemic inflammation, endothelial dysfunction, heightened platelet reactivity, arterial stiffness and right ventricle modification interact in the development of the COPD-IHD comorbidity, which therefore deserves special attention in early diagnosis and treatment. Patients with COPD-IHD comorbidity have a worst outcome, when compared to patients with only COPD or only IHD. These patients showed a significant increase on risk of adverse events and of hospital readmissions for recurrent myocardial infarction, heart failure, coronary revascularization, and acute exacerbation of COPD. Taken together, these complications determine a significant increase in mortality. In most cases death occurs for cardiovascular cause, soon after an acute exacerbation of COPD or a cardiovascular adverse event. Recent data regarding incidence, mechanisms and prognosis of this comorbidity, along with the development of new drugs and interventional approaches may improve the management and long-term outcome of COPD-IHD patients. The aim of this review is to describe the current knowledge on COPD-IHD comorbidity. Particularly, we focused our attention on underlying pathological mechanisms and on all treatment and strategies that may improve and optimize the clinical management of COPD-IHD patients.

Effects of simvastatin in chronic obstructive pulmonary disease: Results of a pilot, randomized, placebo-controlled clinical trial

Introduction

Statins may have pleiotropic effects in COPD, but mechanisms remain unclear.

Objectives

To assess the pleiotropic effect of statins in patients with stable COPD on (1): lung function (2); pulmonary and systemic inflammation (3); endothelial function (vascular stiffness) and circulating vascular growth factors; and (4), serum uric acid levels.

Method

Pilot, double-blind, randomized, placebo-controlled clinical trial in 24 patients with stable COPD, all statin-naïve, who were randomized (1:1) to receive simvastatin 40 mg/24 h during 12 weeks (n = 12; 69.0 ± 7.3 years; post-bd FEV₁ 53.4 ± 10.0% pred.) or placebo (n = 12; 66.4 ± 4.6 years; post-bd FEV₁ 48.2 ± 12.6% pred.). Nine patients per group (total n = 18) completed the study.

Results

Lung function, pulmonary and systemic inflammatory markers and the degree of vascular stiffness did not change significantly in any group. However, treatment with simvastatin increased the plasma levels of erythropoietin (Epo) (4.2 ± 2.2 mIU/mL to 6.8 ± 3.2 mlU/mL, p < 0.05) and reduced those of serum uric acid (7.1 ± 1.3 mg/dL to 6.5 ± 1.4 mg/dL, p < 0.01).

Conclusions

Short-term treatment with simvastatin in stable COPD patients did not modify lung function, pulmonary and systemic inflammation, or vascular stiffness, but it changed Epo and uric acid levels.

Inhaled Long-Acting β2-Agonists Do Not Increase Fatal Cardiovascular Adverse Events in COPD: A Meta-Analysis

BACKGROUND

The cardiovascular safety of inhaled long-acting β2-agonists (LABAs) in patients with chronic obstructive pulmonary disease (COPD) is a controversial problem. Certain studies have suggested that inhaled LABAs lead to an increased risk of cardiovascular events in patients with COPD. This meta-analysis aimed to assess the cardiovascular safety of inhaled LABAs in COPD.

METHODS

A meta-analysis of randomized, double-blind, parallel-group, placebo-controlled trials for LABA treatment of COPD with at least 3 months of follow-up was performed. The fixed-effects model was used to evaluate the effects of LABAs on fatal cardiovascular adverse events. Adverse events were collected for each trial, and the relative risk (RR) and 95% confidence intervals (CI) for LABA/placebo were estimated.

RESULTS

There were 24 trials included in this meta-analysis. Compared with placebo, inhaled LABAs significantly decreased fatal cardiovascular adverse events in COPD patients (RR 0.65, 95% CI 0.50 to 0.86, P = 0.002). In sensitivity analysis, there was still no increased risk of fatal cardiovascular events (RR 0.68, 95%CI 0.46 to 1.01, P = 0.06) after excluding the trial with the largest weight. Among the different types of LABAs, only salmeterol had a significant effect (RR 0.64, 95% CI 0.46 to 0.90). In subgroup analyses, inhaled LABAs were able to significantly decrease fatal cardiovascular events in long-term trials (RR 0.64, 95% CI 0.47 to 0.87) and in trials with severe COPD patients (RR 0.69, 95% CI 0.50 to 0.96).

CONCLUSION

Inhaled LABAs do not increase the risk of fatal cardiovascular events in COPD patients.

Obesity-induced adipokine imbalance impairs mouse pulmonary vascular endothelial function and primes the lung for injury

Obesity is a risk factor for the development of acute respiratory distress syndrome (ARDS) but mechanisms mediating this association are unknown. While obesity is known to impair systemic blood vessel function, and predisposes to systemic vascular diseases, its effects on the pulmonary circulation are largely unknown. We hypothesized that the chronic low grade inflammation of obesity impairs pulmonary vascular homeostasis and primes the lung for acute injury. The lung endothelium from obese mice expressed higher levels of leukocyte adhesion markers and lower levels of cell-cell junctional proteins when compared to lean mice. We tested whether systemic factors are responsible for these alterations in the pulmonary endothelium; treatment of primary lung endothelial cells with obese serum enhanced the expression of adhesion proteins and reduced the expression of endothelial junctional proteins when compared to lean serum. Alterations in pulmonary endothelial cells observed in obese mice were associated with enhanced susceptibility to LPS-induced lung injury. Restoring serum adiponectin levels reversed the effects of obesity on the lung endothelium and attenuated susceptibility to acute injury. Our work indicates that obesity impairs pulmonary vascular homeostasis and enhances susceptibility to acute injury and provides mechanistic insight into the increased prevalence of ARDS in obese humans.

Cardiac troponin elevation predicts all-cause mortality in patients with acute exacerbation of chronic obstructive pulmonary disease: Systematic review and meta-analysis

BACKGROUND

Cardiovascular disease, especially ischemic heart disease, is a major comorbidity in chronic obstructive pulmonary disease (COPD) patients. Several studies suggested that after acute exacerbation of COPD (AECOPD), there is a significant increase of mortality (cardiac and all-cause) and of myocardial infarction. Whether cardiac troponin (Tn) elevation during AECOPD could be considered a prognostic marker of all-cause mortality is still debated.

METHODS

To assess the prognostic role of cardiac Tn elevation during AECOPD, we performed a systematic review and meta-analysis. We included studies with patients admitted to the hospital for AECOPD, with at least one Tn assessment and reporting the relationship (after multivariable analysis) between Tn elevation and all-cause mortality. Secondarily, studies were stratified according to: i) type of troponin (Tn I or Tn T), and ii) follow-up length (≤6 months vs. >6 months).

RESULTS

Ten studies were included in the systematic review and 8 in the meta-analysis. Cardiac Tn elevation ranges from 18% to 73%. We found that cardiac Tn elevation was significantly related to an increased risk for all-cause mortality (OR 1.69; 95% CI 1.25-2.29; I(2) 40%). This finding was independent to the follow-up length of studies (≤6 months: OR 3.22; 95% CI 1.31-7.91; >6 months: OR 1.38; 95% CI 1.02-1.86). Finally, Tn T seems to be more helpful in predicting all-cause mortality as compared to Tn I (OR 1.54; 95% CI 1.2-1.96 vs. OR 3.39, 95% CI 0.86-13.36, respectively).

CONCLUSIONS

In patients admitted to the hospital for AECOPD, cardiac Tn elevation emerged as an independent predictor of increased risk of all-cause mortality.

Electronic health records and improved nursing management of chronic obstructive pulmonary disease

This paper identifies evolving trends in the diagnosis and treatment of chronic obstructive pulmonary disease (COPD), and recommends the integration of nursing strategies in COPD management via widespread implementation of electronic health records. COPD is a complex lung disease with diverse origins, both physical and behavioral, manifested in a wide range of symptoms that further increase the patient's risk for comorbidities. Early diagnosis and effective management of COPD require monitoring of a dizzying array of COPD symptoms over extended periods of time, and nurses are especially well positioned to manage potential progressions of COPD, as frontline health care providers who obtain, record, and organize patient data. Developments in medical technology greatly aid nursing management of COPD, from the deployment of spirometry as a diagnostic tool at the family practice level to newly approved treatment options, including non-nicotine pharmacotherapies that reduce the cravings associated with tobacco withdrawal. Among new medical technologies, electronic health records have proven particularly advantageous in the management of COPD, enabling providers to gather, maintain, and reference more patient data than has ever been possible before. Thus, consistent and widespread implementation of electronic health records facilitates the coordination of diverse treatment strategies, resulting in increased positive health outcomes for patients with COPD.

Coronary artery calcification on computed tomography correlates with mortality in chronic obstructive pulmonary disease

OBJECTIVE

This cross-sectional study assessed the prognostic implications of computed tomography (CT) coronary artery calcification (CAC), independent of emphysema, in patients with chronic obstructive pulmonary disease (COPD).

MATERIALS AND METHODS

Coronary artery calcification and emphysema were assessed on noncontrast, ungated chest CT scans of patients with COPD using the validated CAC ordinal visual scale (CAC OVS; range, 0-12) and visual CT emphysema index.

RESULTS

A total of 200 CT images were analyzed. All-cause mortality was associated with CAC OVS greater than 4 (hazard ratio, 2.03; 95% confidence interval, 1.08-3.82; P = 0.028) and with moderate to severe CT emphysema index (hazard ratio, 4.34; 95% confidence interval, 1.53-12.33; P = 0.006). Increased emphysema severity, myocardial infarction, hypertension, and male sex independently correlated with CAC OVS greater than 4.

CONCLUSIONS

Coronary artery calcification severity and emphysema severity on CT images are related and are strongly as well as independently associated with prognosis in patients with moderate to severe COPD. The potential to use CAC OVS on unenhanced nongated CT as a screening tool for coronary artery disease and as a prognostic marker in patients with COPD needs further investigation in prospective studies.

[Chronic obstructive pulmonary disease: a cardiologist's point of view]

Chronic obstructive pulmonary disease is often associated with cardiovascular diseases, such as pulmonary hypertension, ischemic heart disease, arrhythmias or heart failure. These co-morbidities may cause diagnostic or therapeutic difficulties and significantly worsen the morbidity and mortality of patients with chronic obstructive pulmonary disease. In this work the author reviews special considerations for the treatment of patients with chronic obstructive pulmonary disease who have cardiovascular co-morbidities.

Systemic inflammation in patients with chronic obstructive pulmonary disease undergoing percutaneous coronary intervention

BACKGROUND AND OBJECTIVE

Systemic inflammation plays an important role in both chronic obstructive pulmonary disease (COPD) and coronary artery disease (CAD). The purpose of the present study was to assess the association of high-sensitivity C-reactive protein (hs-CRP), a biomarker of systemic inflammation, with in-hospital outcomes in patients with COPD undergoing percutaneous coronary intervention (PCI).

METHODS

A total of 378 patients with COPD who were treated with PCI from January 2007 through January 2012, were divided into two groups according to hs-CRP level at admission. Demographics, clinical, angiographic data and in-hospital outcomes were compared.

RESULTS

Patients with elevated hs-CRP (≥3 mg/L) were more likely to be female and current smokers, had more severe airflow limitation, more hypertension, diabetes and cardiac dysfunction and had increased incidence of three-vessel disease and more type C lesions. Subjects with elevated hs-CRP were also less likely to have been prescribed with statins and B-blockers, perhaps. Rate of in-hospital composite major adverse cardiovascular events (MACEs) was higher (15.5% vs. 8.2%, P = 0.041) and hospital stay was longer (8.2 ± 2.0 vs. 7.5 ± 1.7 days, P < 0. 001) in patients with elevated hs-CRP. A combined analysis of MACE on the basis of airflow limitation and hs-CRP showed an exaggerated hazard ratio in the presence of both severe airflow limitation and elevated hs-CRP. In a multivariate analysis, elevated periprocedural hs-CRP was independently related with MACEs and hospital stay.

CONCLUSIONS

Elevated periprocedural hs-CRP is independently and additively related with increased incidence of in-hospital adverse outcomes in COPD patients undergoing PCI.

Cardiovascular function and prognosis of patients with heart failure coexistent with chronic obstructive pulmonary disease

BACKGROUND

Chronic obstructive pulmonary disease (COPD) often coexists with heart failure (HF), and is considered to be associated with adverse outcomes in HF patients. However, the features of cardiovascular function and the detailed all-cause mortality of HF with COPD remain unclear.

METHODS AND RESULTS

Consecutive 378 patients admitted for HF who underwent spirometry were divided into three groups: HF without COPD (non-COPD group, n=272), HF with mild COPD (GOLD I group, n=82), and HF with moderate COPD (GOLD II group, n=24). The GOLD II group, as compared to non-COPD group, had (1) higher troponin T (p=0.009); (2) greater cardio-ankle vascular index (p=0.032); and (3) similar cardiac systolic and diastolic function of the right and left ventricle. In addition, rates of cardiac (p=0.049), non-cardiac (p=0.001), and all-cause mortality (p=0.002) were higher in GOLD II group than in non-COPD and GOLD I groups. Importantly, in the Cox proportional hazard analyses, the GOLD stage II was an independent predictor of cardiac (p=0.038), non-cardiac (p=0.036), and all-cause mortality (p=0.015) in HF patients.

CONCLUSIONS

HF patients with coexistent moderate COPD (GOLD stage II) have greater myocardial damage, greater arterial stiffness, and higher cardiac and non-cardiac mortality.

Coronary artery disease concomitant with chronic obstructive pulmonary disease

BACKGROUND

Numerous epidemiologic studies have linked the presence of chronic obstructive pulmonary disease (COPD) to coronary artery disease (CAD). However, prevalence, pathological processes, clinical manifestations and therapy are still debated, as progress towards uncovering the link between these two disorders has been hindered by the complex nature of multimorbidity.

METHODS

Articles targeting CAD in patients with COPD were identified from the searches of MEDLINE and EMBASE databases in July 2013. Three authors reviewed available evidence, focusing on the latest development on disease prevalence, pathogenesis, clinical manifestations and therapeutic strategies. Both clinical trial and previous reviews have been included in this work.

RESULTS

The most accredited hypothesis asserts that the main common risk factors, that is, cigarette smoke and ageing, elicit a chronic low-grade systemic inflammatory response, which affects both cardiovascular endothelial cells and airways/lung parenchyma. The development of CAD in patients with COPD potentiates the morbidity of COPD, leading to increased hospitalizations, mortality and health costs. Moreover, correct diagnosis is challenging and therapies are not clearly defined.

CONCLUSIONS

Evidence from recently published articles highlights the importance of multimorbidity in patient management and future research. Moreover, many authors emphasize the importance of low-grade systemic inflammation as a common pathological mechanism and a possible future therapeutic target.

Echocardiography, spirometry, and systemic acute-phase inflammatory proteins in smokers with COPD or CHF: an observational study

Chronic obstructive pulmonary disease (COPD) and chronic heart failure (CHF) may coexist in elderly patients with a history of smoking. Low-grade systemic inflammation induced by smoking may represent the link between these 2 conditions. In this study, we investigated left ventricular dysfunction in patients primarily diagnosed with COPD, and nonreversible airflow limitation in patients primarily diagnosed with CHF. The levels of circulating high-sensitive C-reactive protein (Hs-CRP), pentraxin 3 (PTX3), interleukin-1β (IL-1 β), and soluble type II receptor of IL-1 (sIL-1RII) were also measured as markers of systemic inflammation in these 2 cohorts. Patients aged ≥50 years and with ≥10 pack years of cigarette smoking who presented with a diagnosis of stable COPD (n=70) or stable CHF (n=124) were recruited. All patients underwent echocardiography, N-terminal pro-hormone of brain natriuretic peptide measurements, and post-bronchodilator spirometry. Plasma levels of Hs-CRP, PTX3, IL-1 β, and sIL-1RII were determined by using a sandwich enzyme-linked immuno-sorbent assay in all patients and in 24 healthy smokers (control subjects). Although we were unable to find a single COPD patient with left ventricular dysfunction, we found nonreversible airflow limitation in 34% of patients with CHF. On the other hand, COPD patients had higher plasma levels of Hs-CRP, IL1 β, and sIL-1RII compared with CHF patients and control subjects (p < 0.05). None of the inflammatory biomarkers was different between CHF patients and control subjects. In conclusion, although the COPD patients had no evidence of CHF, up to one third of patients with CHF had airflow limitation, suggesting that routine spirometry is warranted in patients with CHF, whereas echocardiography is not required in well characterized patients with COPD. Only smokers with COPD seem to have evidence of systemic inflammation.

Personalizing and targeting therapy for COPD: the role of molecular and clinical biomarkers

Chronic obstructive pulmonary disease (COPD) is a heterogeneous disease characterized by persistent airflow limitation. It is the third leading cause of death worldwide, and there are currently no curative strategies for this disease. Many factors contribute to COPD susceptibility, progression and exacerbations. These include cigarette smoking, environmental and occupational pollutants, respiratory infections and comorbidities. As the clinical phenotypes of COPD are so variable, it has been difficult to devise an individualized treatment plan for patients with this complex chronic disease. This review will highlight how potential clinical, inflammatory, genomic and epigenomic biomarkers for COPD could be used to personalize treatment, leading to improved disease management and prevention for our patients.