Incidence of venous thromboembolism in COPD: linking inflammation and thrombosis?

Thrombelastography and Conventional Coagulation Markers in Chronic Obstructive Pulmonary Disease: A Prospective Paired-Measurements Study Comparing Exacerbation and Stable Phases

Chronic Obstructive Pulmonary Disease (COPD) exacerbation is known for its substantial impact on morbidity and mortality among affected patients, creating a significant healthcare burden worldwide. Coagulation abnormalities have emerged as potential contributors to exacerbation pathogenesis, raising concerns about increased thrombotic events during exacerbation. The aim of this study was to explore the differences in thrombelastography (TEG) parameters and coagulation markers in COPD patients during admission with exacerbation and at a follow-up after discharge. This was a multi-center cohort study. COPD patients were enrolled within 72 h of hospitalization. The baseline assessments were Kaolin-TEG and blood samples. Statistical analysis involved using descriptive statistics; the main analysis was a paired t-test comparing coagulation parameters between exacerbation and follow-up. One hundred patients participated, 66% of whom were female, with a median age of 78.5 years and comorbidities including atrial fibrillation (18%) and essential arterial hypertension (45%), and sixty-five individuals completed a follow-up after discharge. No significant variations were observed in Kaolin-TEG or conventional coagulation markers between exacerbation and follow-up. The Activated Partial Thromboplastin Clotting Time (APTT) results were near-significant, with p = 0.08. In conclusion, TEG parameters displayed no significant alterations between exacerbation and follow-up.

A phenome-wide approach to identify causal risk factors for deep vein thrombosis

Deep vein thrombosis (DVT) is the formation of a blood clot in a deep vein. DVT can lead to a venous thromboembolism (VTE), the combined term for DVT and pulmonary embolism, a leading cause of death and disability worldwide. Despite the prevalence and associated morbidity of DVT, the underlying causes are not well understood. Our aim was to leverage publicly available genetic summary association statistics to identify causal risk factors for DVT. We conducted a Mendelian randomization phenome-wide association study (MR-PheWAS) using genetic summary association statistics for 973 exposures and DVT (6,767 cases and 330,392 controls in UK Biobank). There was evidence for a causal effect of 57 exposures on DVT risk, including previously reported risk factors (e.g. body mass index-BMI and height) and novel risk factors (e.g. hyperthyroidism and varicose veins). As the majority of identified risk factors were adiposity-related, we explored the molecular link with DVT by undertaking a two-sample MR mediation analysis of BMI-associated circulating proteins on DVT risk. Our results indicate that circulating neurogenic locus notch homolog protein 1 (NOTCH1), inhibin beta C chain (INHBC) and plasminogen activator inhibitor 1 (PAI-1) influence DVT risk, with PAI-1 mediating the BMI-DVT relationship. Using a phenome-wide approach, we provide putative causal evidence that hyperthyroidism, varicose veins and BMI enhance the risk of DVT. Furthermore, the circulating protein PAI-1 has a causal role in DVT aetiology and is involved in mediating the BMI-DVT relationship.

Obesity impacts hypoxia adaptation of the lung

Obesity is mostly associated with adverse health consequences, but may also elicit favorable effects under chronic conditions. This "obesity paradox" is under debate for pulmonary diseases. As confounding factors complicate conclusions from human studies, this study used a controlled animal model combining diet-induced obesity and chronic hypoxia as a model for pulmonary hypertension and chronic obstructive pulmonary disease. Male C57BL/6 mice were fed control or high-fat diet for 30 wk, and half of the animals were exposed to chronic hypoxia (13% O2) for 3 wk. Hypoxia induced right ventricular hypertrophy, thickening of pulmonary arterial and capillary walls, higher lung volumes, and increased hemoglobin concentrations irrespective of the body weight. In contrast, lung proteomes differed substantially between lean- and obese-hypoxic mice. Many of the observed changes were linked to vascular and extracellular matrix (ECM) proteins. In lean-hypoxic animals, circulating platelets were reduced and abundances of various clotting-related proteins were altered, indicating a hypercoagulable phenotype. Moreover, the septal ECM composition was changed, and airspaces were significantly distended pointing to lung hyperinflation. These differences were mostly absent in the obese-hypoxic group. However, the obesity-hypoxia combination induced the lowest blood CO2 concentrations, indicating hyperventilation for sufficient oxygen supply. Moreover, endothelial surface areas were increased in obese-hypoxic mice. Thus, obesity exerts differential effects on lung adaptation to hypoxia, which paradoxically include not only adverse but also rather protective changes. These differences have a molecular basis in the lung proteome and may influence the pathogenesis of lung diseases. This should be taken into account for future individualized prevention and therapy.NEW & NOTEWORTHY An "obesity paradox" is discussed for pulmonary diseases. By linking lung proteome analyses to pulmonary structure and function, we demonstrate that diet-induced obesity affects lung adaptation to chronic hypoxia in various ways. The observed changes include not only adverse but also protective effects and are associated with altered abundances of vascular and extracellular matrix proteins. These results highlight the existence of relevant differences in individuals with obesity that may influence the pathogenesis of lung diseases.

Spirometry in atrial fibrillation: what's the catch?

INTRODUCTION

People with COPD rarely have COPD alone, and the commonest co-morbidities occurring with COPD are cardiovascular. Whilst multiple studies have explored the association between major cardiovascular events and COPD, less attention has been paid to arrhythmias, specifically atrial fibrillation (AF). AF and COPD frequently occur together, posing challenges in diagnosis and management. In this review, we describe the relationship between AF and COPD epidemiologically and physiologically, demonstrating the role of spirometry as a diagnostic and disease management tool.

AREAS COVERED

We provide epidemiological evidence that COPD and AF are independent risk factors for one another, that either disease is highly prevalent amongst people with the other, and that they have shared risk factors; all of which contribute to adverse prognostic. We elucidated common pathophysiological mechanisms implicated in AF-COPD. We ultimately present the epidemiological and physiological evidence with a view to highlight specific areas where we feel spirometry is of value in the management of AF-COPD.

EXPERT OPINION

AF and COPD commonly co-occur, there is often diagnostic delay, increased risk of reduced cardioversion success, and missed opportunity to intervene to reduce stroke risk. Greater awareness and timelier diagnosis and guideline directed management may improve outcomes for people with both diseases.

Pulmonary embolism and deep vein thrombosis—comorbidities and temporary provoking factors in a register‐based study of 1.48 million people

Background

Knowledge on differences in patients who present with deep vein thrombosis (DVT) and those with pulmonary embolism (PE) is incomplete.

Objective

To determine comorbidities and temporary provoking factors in patients with a first‐time PE or DVT.

Methods

This was a nationwide Swedish registry‐based, retrospective, case‐control study including 298 172 patients with first‐time venous thromboembolism (VTE) and 1 185 079 controls matched for age, sex, and county of residence, free of VTE at the time of matching.

Results

Patients with PE were older than those with DVT (mean age, 69 vs 66 years) and included slightly more women (PE, 53.4% vs DVT, 52.1%). After multivariable adjustment for comorbidities (within 7 years) and temporary provoking factors (within 3 months), heart failure (PE: adjusted odds ratio [aOR], 2.64 [99% confidence interval [CI], 2.55‐2.73]; DVT: aOR, 1.66 [99% CI, 1.60‐1.72]), ischemic heart disease (PE: aOR, 1.51 [99% CI, 1.47‐1.56]; DVT: aOR, 1.01 [99% CI, 0.98‐1.04]), and chronic obstructive pulmonary disease (PE: aOR, 2.51 [99% CI, 2.40‐2.63]; DVT, 1.54 [99% CI, 1.47‐1.62]) were among diseases that showed higher odds ratios in patients with PE than in those with DVT, compared with controls. Comorbidities registered within 6 months were associated with higher aORs than those within 7 years. The highest population attributable risks for PE were for cancer (13.0%) and heart failure (11.7%).

Conclusion

Cardiopulmonary diseases, particularly with recent onset, imply a higher risk for PE, whereas orthopedic surgery and lower‐extremity fractures carry a higher risk of DVT.

Prothrombotic state in patients with stable COPD: an observational study

Background

COPD patients have an increased risk of cardiovascular disease and venous thromboembolism.

Methods

This study aimed to investigate whether patients with stable COPD have a prothrombotic state compared to COPD-free smokers. We conducted an observational study comparing levels of: D-dimers, INR, aPTT, coagulation factors; fibrinogen, FII, FV, FVII, FVIII, FIX, FX and coagulation inhibitors; protein S, proteins C and antithrombin between stable COPD patients and control subjects.

Results

A total of 103 COPD patients and 42 controls with similar age, sex, current smoking status, comorbidity burden and cardiovascular risk met the inclusion criteria. Compared to controls, COPD patients had higher levels of D-dimers (median (interquartile range): 360 (230–600) ng·mL⁻¹versus 240 (180–400) ng·mL⁻¹, p=0.001), fibrinogen (mean±sd: 399±82 mg·dL⁻¹versus 346±65 mg·dL⁻¹, p<0.001), FII (122±22% versus 109±19%, p=0.004), FV (131±25% versus 121±19%, p=0.015), FVIII (143±32% versus 122±20%, p<0.001) and FX (111 (94–134)% versus 98 (88–107)%, p=0.002), and lower levels of protein S (95 (85–105)% versus 116 (98–121)%, p<0.001) and antithrombin (94.4±11.5% versus 102.3±13.2%, p=0.001). In the COPD group, patients with more severe airflow limitation and frequent exacerbations had significantly higher levels of FII, FV and FX, whereas patients with higher COPD assessment test score had significantly higher levels of FX and lower levels of protein S.

Conclusion

Patients with stable COPD exhibited increased levels of key coagulation factors and decreased levels of coagulation inhibitors, namely protein S and antithrombin, compared to COPD-free smokers. Among COPD patients, increased levels of FII, FV and FX and decreased levels of protein S were found in patients with more severe disease.

Patients with stable COPD exhibit increased levels of key coagulation factors and decreased levels of coagulation inhibitors, namely protein S and antithrombin, compared to COPD-free smokers, indicating a prothrombotic state in stable COPDhttps://bit.ly/2VmR1PP

Hypercoagulation in COPD: the clot thickens

There is a growing body of evidence that hypercoagulability is present in stable COPD, involves changes in multiple coagulation factors, and is not simply associated with major causes of inflammation and thrombosis https://bit.ly/3F5NnfN.

Causes of erythrocytosis and its impact as a risk factor for thrombosis according to etiology: experience in a referral center in Mexico City

Background

Thrombotic events are well documented in primary erythrocytosis, but it is uncertain if secondary etiologies increase the risk of thrombosis. This study aimed to determine the causes of erythrocytosis and to identify its impact as a risk factor for thrombosis.

Methods

Data were obtained from patients with erythrocytosis between 2000 and 2017 at a referral hospital in Mexico City. Erythrocytosis was defined according to the 2016 WHO classification. Time to thrombosis, major bleeding, or death were compared among groups of patients defined by the etiology of erythrocytosis using a Cox regression model, adjusting for cardiovascular risk factors.

Results

In total, 330 patients with erythrocytosis were studied. The main etiologies of erythrocytosis were obstructive sleep apnea (OSA) in 29%, polycythemia vera (PV) in 18%, and chronic lung disease (CLD) in 9.4% of the patients. The incidence rate of thrombosis was significantly higher in patients with PV and CLD than that in patients with OSA (incidence rates of 4.51 and 6.24 vs. 1.46 cases per 100 person-years, P=0.009), as well as the mortality rate (mortality rates of 2.72 and 2.43 vs. 0.17 cases per 100 person-years, P =0.003).

Conclusion

The risk of thrombosis in CLD with erythrocytosis was comparable to that in patients with PV. Further larger-scale studies are needed to confirm these findings and evaluate the benefits of preventive management of COPD with erythrocytosis similar to PV.

Hypercoagulable State in COPD-A Comprehensive Literature Review

Chronic Obstructive Pulmonary Disease (COPD) is a chronic inflammatory disease with multisystemic manifestations. Studies either held on stable disease patients or during exacerbations have demonstrated that COPD is strongly related to venous thromboembolism and cardiovascular events. The aim of the present review of the literature was to provide an in-depth overview regarding the alterations of coagulation factors and prothrombotic changes generated in patients with stable COPD and during COPD exacerbations.

'Pulmonary thrombosis in situ': risk factors, clinic characteristics and long-term evolution

: Pulmonary embolism typically occurs from deep venous thrombosis (DVT). However, not always a DVT can be identified, and 'in situ' generation of pulmonary embolism has been considered, referred to in the literature as 'De novo pulmonary embolism' (DNPE). The objective of the study is to assess risk factors, comorbidities, clinic characteristics and long-term evolution of patients with pulmonary embolism in the absence of an identified source. Retrospective study of 280 patients with pulmonary embolism, 190 pulmonary embolisms with DVT group and 90 (32%) pulmonary embolism without DVT (DNPE group), admitted to an Internal Medicine Department of a tertiary hospital from January 2012 to December 2015. In the DNPE group, segmental and subsegmental arteries were more frequently affected (P = 0.01). As compared with pulmonary embolisms with DVT group: older age, female sex, sedentary lifestyle, diabetes mellitus, arterial hypertension, heart failure, respiratory infections and chronic obstructive pulmonary disease (COPD) were significantly more frequent in DNPE. In multivariate analysis, respiratory infection [odds ratio (OR) 12.2, P < 0.0001], COPD (OR 8.7, P < 0.0001) and female sex (OR 3.0, P = 0.003) were independently associated risk factors. Long-term mortality (median follow-up 15 months) was also higher in DNPE group (34 vs. 16%, P = 0.01). De novo pulmonary embolism occurred in 32% of cases of pulmonary embolisms and was more frequent in female and COPD patients or those with respiratory infections as compared with pulmonary embolisms in which DVT was identified as a source of embolism.

Changes in expression of serum chemokine CXCL13 and IL-6 after hip replacement, and the relationship with lower limb vein thrombus

Changes in the expression of serum chemokine CXC ligand 13 (CXCL13) and interleukin-6 (IL-6), and the relationship with lower limb vein thrombus were explored. A total of 128 patients undergoing hip replacement in The First Affiliated Hospital of Guizhou University of Traditional Chinese Medicine from May 2017 to June 2019 were selected, and the patients suffering from lower limb vein thrombus were enrolled as group A and other patients not suffering from it were enrolled as group B. Enzyme-linked immuno-sorbent assay was employed to determine the levels of serum chemokine CXCL13 and IL-6, and receiver operating characteristic curves of serum chemokine CXCL13 and IL-6 levels in diagnosing restenosis after surgery were drawn. Pearson's correlation coefficient was adopted to analyze the correlation between serum chemokine CXCL13 and IL-6, and the logistic regression analysis to analyze the risk factors affecting hip replacement in patients. The levels of serum CXCL13 and IL-6 in group A were significantly higher than those in group B (both P<0.001). The specificity and sensitivity of serum CXCL13 level in diagnosis of lower limb vein thrombus after hip replacement were 61.76 and 80.00%, respectively, and those of serum IL-6 level in diagnosis were 70.59 and 66.67%, respectively. Serum CXCL13 level was positively correlated with serum IL-6 level (P<0.001), and age, body mass index (BMI), CXCL13 level and IL-6 level of the patients were independent risk factors affecting the efficacy of hip replacement. Serum CXCL13 level and serum IL-6 level can be used as biological indexes for prediction of early lower limb vein thrombus after hip replacement, and logistic regression analysis revealed that the age of the patients, BMI, diabetes history, hyperlipidemia history, hypertension history, CXCL13 level and IL-6 level are independent risk factors affecting the efficacy of hip replacement.

Feasibility of mean platelet volume as a biomarker for chronic obstructive pulmonary disease: A systematic review and meta-analysis

Objective

To evaluate the feasibility of mean platelet volume (MPV) as a biomarker for chronic obstructive pulmonary disease (COPD).

Methods

A systematic search for studies published up to March 2019 was performed in the PubMed and Web of Science databases. Three independent investigators screened the titles and abstracts of including studies according to eligibility criteria. The Newcastle–Ottawa Scale was used to assess the quality of eligible studies, and statistical analyses were performed using Review Manager version 5.3.

Results

A total of eight studies with 1230 COPD patients and 443 healthy controls were included in our meta-analysis. No significant differences in MPV level were identified in pairwise comparisons of the acute exacerbations of COPD (AECOPD), stable COPD, and control groups. Furthermore, no significant correlation was observed between MPV level and systemic inflammatory biomarkers.

Conclusions

MPV does not appear to represent a suitable biomarker of disease phase or inflammatory burden in COPD. However, future large-scale studies should be performed to further investigate the relationship between MPV and COPD.

Impact of chronic obstructive pulmonary disease on the outcomes of patients with peripheral artery disease

BACKGROUND

Peripheral artery disease (PAD) and chronic obstructive pulmonary disease (COPD) are both related with high in-hospital mortality. We aimed to investigate the impact of COPD on the in-hospital outcomes in PAD.

METHODS

PAD patients were selected based on ICD-code I70.2 of the German nationwide database, stratified for COPD and compared regarding adverse in-hospital outcomes.

RESULTS

Between 01/2005-12/2015, 5,611,827 inpatients (64.8% males) were diagnosed with PAD; of those, 13.6% were coded additionally with COPD. Overall, 277,894 PAD patients (5.0%) died during in-hospital course. Prevalence of cardiovascular diseases as well as cancer (12.1% vs. 7.0%, P < 0.001) was higher in PAD patients with COPD compared to PAD patients without COPD. PAD patients with COPD showed more often lower PAD stages according to Fontaine classification (PAD stage I: 27.1% vs. 19.3%, P < 0.001; PAD stage IIa: 34.9% vs. 35.5%, P < 0.001; PAD stage IIb: 14.5% vs. 13.6%, P < 0.001; PAD stage III: 11.8% vs. 14.8%, P < 0.001; PAD stage IV: 13.8% vs. 19.6%, P < 0.001). The all-cause in-hospital mortality was significantly higher in PAD patients with COPD compared to those without COPD (6.5% vs. 4.7%, P < 0.001). Cardiovascular events comprising pulmonary embolism and myocardial infarction occurred more often in coprevalence with PAD and COPD. COPD was an independent predictor of in-hospital death (OR 1.16 (95%CI 1.15-1.17) P < 0.001) and an independent predictor for pulmonary embolism (PE, OR 1.44 (1.40-1.49), P < 0.001) in PAD patients.

CONCLUSION

COPD was associated with a high in-hospital mortality in PAD patients probably driven by higher frequencies of PE and cancer.

Intrapulmonary arteriovenous anastomoses in humans with chronic obstructive pulmonary disease: implications for cryptogenic stroke?

What is the central question of this study? Do individuals with chronic obstructive pulmonary disease have blood flow through intrapulmonary arteriovenous anastomoses at rest or during exercise? What is the main finding and its importance? Individuals with chronic obstructive pulmonary disease have a greater prevalence of blood flow through intrapulmonary arteriovenous anastomoses at rest than age-matched control subjects. Given that the intrapulmonary arteriovenous anastomoses are large enough to permit venous emboli to pass into the arterial circulation, patients with chronic obstructive pulmonary disease and an elevated risk of thrombus formation may be at risk of intrapulmonary arteriovenous anastomosis-facilitated embolic injury (e.g. stroke or transient ischaemic attack). The pulmonary capillaries prevent stroke by filtering venous emboli from the circulation. Intrapulmonary arteriovenous anastomoses are large-diameter (≥50 μm) vascular connections in the lung that may compromise the integrity of the pulmonary capillary filter and have recently been linked to cryptogenic stroke and transient ischaemic attack. Prothrombotic populations, such as individuals with chronic obstructive pulmonary disease (COPD), may be at increased risk of stroke and transient ischaemic attack facilitated by intrapulmonary arteriovenous anastomoses, but the prevalence and degree of blood flow through intrapulmonary arteriovenous anastomoses in this population has not been fully examined and compared with age-matched healthy control subjects. We used saline contrast echocardiography to assess blood flow through intrapulmonary arteriovenous anastomoses at rest (n = 29 COPD and 19 control subjects) and during exercise (n = 10 COPD and 10 control subjects) in subjects with COPD and age-matched healthy control subjects. Blood flow through intrapulmonary arteriovenous anastomoses was detected in 23% of subjects with COPD at rest and was significantly higher compared with age-matched healthy control subjects. Blood flow through intrapulmonary arteriovenous anastomoses at rest was reduced or eliminated in subjects with COPD after breathing hyperoxic gas. Sixty per cent of subjects with COPD who did not have blood flow through the intrapulmonary arteriovenous anastomoses at rest had blood flow through them during exercise. The combination of blood flow through intrapulmonary arteriovenous anastomoses and potential for thrombus formation in individuals with COPD may permit venous emboli to pass into the arterial circulation and cause stroke and transient ischaemic attack. Breathing supplemental oxygen may reduce this risk in COPD. The link between blood flow through intrapulmonary arteriovenous anastomoses, stroke and transient ischaemic attack is worthy of future investigation in COPD and other populations.

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.