Left ventricular diastolic dysfunction in non-severe chronic obstructive pulmonary disease - a step forward in cardiovascular comorbidome

Effect of twice daily inhaled albuterol on cardiopulmonary exercise outcomes, dynamic hyperinflation, and symptoms in secondhand tobacco-exposed persons with preserved spirometry and air trapping: a randomized controlled trial

BACKGROUND

In tobacco-exposed persons with preserved spirometry (active smoking or secondhand smoke [SHS] exposure), air trapping can identify a subset with worse symptoms and exercise capacity. The physiologic nature of air trapping in the absence of spirometric airflow obstruction remains unclear. The aim of this study was to examine the underlying pathophysiology of air trapping in the context of preserved spirometry and to determine the utility of bronchodilators in SHS tobacco-exposed persons with preserved spirometry and air trapping.

METHODS

We performed a double-blinded placebo-controlled crossover randomized clinical trial in nonsmoking individuals at risk for COPD due to exposure to occupational SHS who had preserved spirometry and air trapping defined as either a residual volume-to-total lung capacity ratio (RV/TLC) > 0.35 or presence of expiratory flow limitation (EFL, overlap of tidal breathing on maximum expiratory flow-volume loop) on spirometry at rest or during cardiopulmonary exercise testing (CPET). Those with asthma or obesity were excluded. Participants underwent CPET at baseline and after 4-week trials of twice daily inhalation of 180 mcg of albuterol or placebo separated by a 2-week washout period. The primary outcome was peak oxygen consumption (VO2) on CPET. Data was analyzed by both intention-to-treat and per-protocol based on adherence to treatment prescribed.

RESULTS

Overall, 42 participants completed the entire study (66 ± 8 years old, 91% female; forced expiratory volume in 1 s [FEV1] = 103 ± 16% predicted; FEV1 to forced vital capacity [FVC] ratio = 0.75 ± 0.05; RV/TLC = 0.39 ± 0.07; 85.7% with EFL). Adherence was high with 87% and 93% of prescribed doses taken in the treatment and placebo arms of the study, respectively (P = 0.349 for comparison between the two arms). There was no significant improvement in the primary or secondary outcomes by intention-to-treat or per-protocol analysis. In per-protocol subgroup analysis of those with RV/TLC > 0.35 and ≥ 90% adherence (n = 27), albuterol caused an improvement in peak VO2 (parameter estimate [95% confidence interval] = 0.108 [0.014, 0.202]; P = 0.037), tidal volume, minute ventilation, dynamic hyperinflation, and oxygen-pulse (all P < 0.05), but no change in symptoms or physical activity.

CONCLUSIONS

Albuterol may improve exercise capacity in the subgroup of SHS tobacco-exposed persons with preserved spirometry and substantial air trapping. These findings suggest that air trapping in pre-COPD may be related to small airway disease that is not considered significant by spirometric indices of airflow obstruction.

Risk factors for perioperative acute heart failure in older hip fracture patients and establishment of a nomogram predictive model

AIM

This study aims to explore the risk factors for perioperative acute heart failure in older patients with hip fracture and establish a nomogram prediction model.

METHODS

The present study was a retrospective study. From January 2020 to December 2021, patients who underwent surgical treatment for hip fracture at the Third Hospital of Hebei Medical University were included. Heart failure was confirmed by discharge diagnosis or medical records. The samples were randomly divided into modeling and validation cohorts in a ratio of 7:3. Relevant demographic and clinic data of patients were collected. IBM SPSS Statistics 26.0 performed univariate and multivariate logistic regression analysis, to obtain the risk factors of acute heart failure. The R software was used to construct the nomogram prediction model.

RESULTS

A total of 751 older patients with hip fracture were enrolled in this study, of which 138 patients (18.37%, 138/751) developed acute heart failure. Heart failure was confirmed by discharge diagnosis or medical records. Respiratory disease (odd ratio 7.68; 95% confidence interval 3.82-15.43; value of P 0.001), history of heart disease (chronic heart failure excluded) (odd ratio 2.21, 95% confidence interval 1.18-4.12; value of P 0.010), ASA ≥ 3 (odd ratio 14.46, 95% confidence interval 7.78-26.87; value of P 0.001), and preoperative waiting time ≤ 2 days (odd ratio 3.32, 95% confidence interval 1.33-8.30; value of P 0.010) were independent risk factors of perioperative acute heart failure in older patients with hip fracture. The area under the curve (AUC) of the prediction model based on these factors was calculated to be 0.877 (95% confidence interval 0.836-0.918). The sensitivity and specificity were 82.8% and 80.9%, respectively, and the fitting degree of the model was good. In the internal validation group, the AUC was 0.910, and the 95% confidence interval was 0.869-0.950.

CONCLUSIONS

Several risk factors are identified for acute heart failure in older patients, based on which pragmatic nomogram prediction model is developed, facilitating detection of patients at risk early.

New concepts in heart failure with preserved ejection fraction and hypertension

PURPOSE OF REVIEW

Hypertension (HTN) remains the most common and strongest contributing factor to the development of heart failure with preserved ejection fraction (HFpEF). In this review, we aim to summarize the pathophysiological processes linking HTN to HFpEF and highlight novel concepts in medical and device-based management of HFpEF and HTN.

RECENT FINDINGS

Despite the global increase in the prevalence of HFpEF, there has been limited benefit in current medication and device-based therapy for this complex syndrome. The hallmark of HFpEF is an elevated left intra-atrial and ventricular pressure and exertional dyspnea. Traditional medications used for treating HTN in patients with reduced left ventricular ejection fraction have unclear benefits in patients with HFpEF. Careful analysis of emerging medications such as angiotensin receptor-neprilysin inhibitor and sodium-glucose co-transporter-2 inhibitors showed benefit in reducing not only blood pressure but also hospitalizations in patients with HFpEF. Current data on device-based therapy aims to reduce left intra-atrial pressure, ventricular pressure and stimulate baroreceptors to lower blood pressure; however, needs further investigation.

SUMMARY

The nexus of HTN and HFpEF remains strong and complex. Although traditional medications for treating HFrEF did not affect long-term outcomes, novel therapies with angiotensin receptor neprilysin-inhibitor and sodium-glucose co-transporter-2 inhibitor offer promising results. Many device-based interventions in the HFpEF population are being developed with the aim to reduce left intra-atrial and ventricular pressure; however, their role in HFpEF hypertensive patients needs to be further investigated.

[Chronic obstructive pulmonary disease, sleep-disordered breathing and hypoventilation-Influence on the cardiorenal system]

Comorbidities are frequently observed in patients suffering from pulmonary diseases due to shared risk factors and intricate interactions between various organ systems. This article aims to characterize the effects of selected diseases of the respiratory system on the cardiovascular system and kidneys. Advanced chronic obstructive pulmonary disease (COPD) often leads to a prognostically unfavorable increased pressure in the pulmonary circulation. In this respect treatment of these patients is primarily aimed at the underlying pulmonary disease and targeted treatment of the pulmonary hypertension should only be carried out according to invasive diagnostics and in an individualized manner. So far, the fact that there is a substantial overlap between COPD and heart failure with preserved ejection fraction has been completely ignored, which should be considered in the diagnostic procedure. Obstructive sleep apnea (OSA) has several unfavorable effects on the cardiovascular system and has been identified as an independent risk factor for cardiovascular diseases. The established treatment of OSA with continuous positive airway pressure (CPAP) has been shown to improve daytime sleepiness and the quality of life; however, an effect of CPAP on the occurrence of cardiovascular events, especially in asymptomatic patients, has so far not been demonstrated in randomized trials. Peripheral edema is frequently observed in patients suffering from chronic hypercapnia, which can be explained by several pathophysiological mechanisms, including pulmonary vasoconstriction and a direct effect of the hypercapnia on renal blood flow. Apart from the administration of diuretics, recompensation of such patients always requires treatment of the hypercapnia by noninvasive ventilation.