Arterial Stiffness Measured Via Carotid Femoral Pulse Wave Velocity Is Associated With Disease Severity in COPD

Functional capacity, physical activity, and arterial stiffness in patients with systemic sclerosis

OBJECTIVES

Systemic sclerosis (SSc) is a complex immune-mediated connective tissue disease, involving skin manifestations, vascular features, and organ-based complications that may affect functional capacity and physical activity. Functional capacity and physical activity are associated with arterial stiffness; however, this relationship has not been evaluated in patients with SSc. Therefore, the objective of this study was to investigate the association of functional capacity and physical activity with arterial stiffness in patients with SSc.

METHODS

Sixty-five patients with SSc were enrolled in this cross-sectional study. Arterial stiffness was evaluated with carotid-femoral pulse wave velocity (cf-PWV). Functional capacity and physical activity were assessed with a six-min walk test (6MWT) and International Physical Activity Questionnaire-Short Form (IPAQ-SF), respectively.

RESULTS

All participants were women, and the mean age was 54.91 ± 11.18 years. 6MWT distance and IPAQ-SF were inversely associated with cf-PWV in crude analysis (p < 0.05). The relationship between 6MWT distance and cf-PWV was maintained in the fully adjusted model (β =  - 0.007, 95% CI, - 0.013 to 0.000). Similarly, the association between IPAQ-SF and cf-PWV remained significant in the fully adjusted model (β =  - 0.001, 95% CI, - 0.002 to - 0.001).

CONCLUSION

The present study indicates that functional capacity and self-reported physical activity are independently associated with arterial stiffness in patients with SSc. Exercise interventions targeted to increase functional capacity and physical activity may help to regulate arterial stiffness in patients with SSc. Key Points • Arterial stiffness is an independent predictor of cardiovascular risk. • SSc patients exhibit decreased exercise capacity and functional capacity. • The association of functional capacity and physical activity with arterial stiffness in patients with SSc is unknown. • Functional capacity and self-reported physical activity are independently associated with arterial stiffness in patients with SSc.

[Take-home messages from the 2nd COPD 2023 Biennial of the French Society of Respiratory Diseases. Placing the patient at the center of the care pathway]

INTRODUCTION

The second COPD Biennial organized by the COPD working group of the French Society of Respiratory Diseases took place in Paris (Cochin) on 13th December 2023.

STATE OF THE ART

Major trends in 2023 were discussed; they encompassed concepts, definitions, biologics, care pathways, pulmonary rehabilitation and complex situations entailed by respiratory infections, cardiovascular comorbidities and pulmonary hypertension, and modalities of oxygen therapy and ventilation.

PERSPECTIVES

The different talks underlined major changes in COPD including the concepts of pre-COPD, etiotypes, health trajectories and new definitions of exacerbation. Recent results in biologics for COPD open the door to new pharmacological options. Assessment of current care pathways in France highlighted some causes for concern. For example, pulmonary rehabilitation is a key but insufficiently practiced element. Respiratory infections require careful assessment and treatments. Diagnosis and treatment of cardiovascular comorbidities and pulmonary hypertension are of paramount importance. As of late, oxygen therapy and ventilation modalities have evolved, and are beginning to afford more personalized options.

CONCLUSIONS

As regards COPD, a personalized approach is crucial, placing the patient at the center of the care pathway and facilitating coordination between healthcare providers.

Feasibility, Repeatability, and Correlation to Lung Function of Phase-Resolved Functional Lung (PREFUL) MRI-derived Pulmonary Artery Pulse Wave Velocity Measurements

BACKGROUND

Pulse wave velocity (PWV) in the pulmonary arteries (PA) is a marker of vascular stiffening. Currently, only phase-contrast (PC) MRI-based options exist to measure PA-PWV.

PURPOSE

To test feasibility, repeatability, and correlation to clinical data of Phase-Resolved Functional Lung (PREFUL) MRI-based calculation of PA-PWV.

STUDY TYPE

Retrospective.

SUBJECTS

79 (26 female) healthy subjects (age range 19-78), 58 (24 female) patients with chronic obstructive pulmonary disease (COPD, age range 40-77), 60 (33 female) patients with suspected pulmonary hypertension (PH, age range 28-85).

SEQUENCE

2D spoiled gradient echo, 1.5T.

ASSESSMENT

PA-PWV was measured from PREFUL-derived cardiac cycles based on the determination of temporal and spatial distance between lung vasculature voxels using a simplified (sPWV) method and a more comprehensive (cPWV) method including more elaborate distance calculation. For 135 individuals, PC MRI-based PWV (PWV-QA) was measured.

STATISTICAL TESTS

Intraclass-correlation-coefficient (ICC) and coefficient of variation (CoV) were used to test repeatability. Nonparametric tests were used to compare cohorts. Correlation of sPWV/cPWV, PWV-QA, forced expiratory volume in 1 sec (FEV1 ) %predicted, residual volume (RV) %predicted, age, and right heart catheterization (RHC) data were tested. Significance level α = 0.05 was used.

RESULTS

sPWV and cPWV showed no significant differences between repeated measurements (P-range 0.10-0.92). CoV was generally lower than 15%. COPD and PH patients had significantly higher sPWV and cPWV than healthy subjects. Significant correlation was found between sPWV or cPWV and FEV1 %pred. (R = -0.36 and R = -0.44), but not with RHC (P-range -0.11 - 0.91) or age (P-range 0.23-0.89). Correlation to RV%pred. was significant for cPWV (R = 0.42) but not for sPWV (R = 0.34, P = 0.055). For all cohorts, sPWV and cPWV were significantly correlated with PWV-QA (R = -0.41 and R = 0.48).

DATA CONCLUSION

PREFUL-derived PWV is feasible and repeatable. PWV is increased in COPD and PH patients and correlates to airway obstruction and hyperinflation.

LEVEL OF EVIDENCE

3 TECHNICAL EFFICACY: Stage 2.

The Role of Oxidative Stress and Antioxidants in Cardiovascular Comorbidities in COPD

Oxidative stress driven by several environmental and local airway factors associated with chronic obstructive bronchiolitis, a hallmark feature of COPD, plays a crucial role in disease pathomechanisms. Unbalance between oxidants and antioxidant defense mechanisms amplifies the local inflammatory processes, worsens cardiovascular health, and contributes to COPD-related cardiovascular dysfunctions and mortality. The current review summarizes recent developments in our understanding of different mechanisms contributing to oxidative stress and its countermeasures, with special attention to those that link local and systemic processes. Major regulatory mechanisms orchestrating these pathways are also introduced, with some suggestions for further research in the field.

The interaction effect of grip strength and lung function (especially FVC) on cardiovascular diseases: a prospective cohort study in Jiangsu Province, China

OBJECTIVE

Lung function and grip strength (GS) are associated with cardiovascular disease (CVD), but whether these risk factors interact to affect CVD is unknown. This study aimed to explore the interactions between lung function and GS with major CVD (defined as fatal/non-fatal myocardial infarction, stroke, and heart failure) incidence.

METHODS

We conducted a prospective cohort study on the Chinese population in Jiangsu Province. Cox proportional hazards models were used to explore the associations between GS, lung function, and major CVD incidence.

RESULTS

A total of 5967 participants were included in our study; among them, 182 participants developed major CVD. Participants with low forced vital capacity (FVC) had a higher risk of major CVD (hazard ratio (HR) = 1.45; 95% confidence interval (CI): 1.05-2.01; P < 0.05) compared with normal FVC. The risk of major CVD incidence (HR = 0.54; 95% CI: 0.35-0.83; P < 0.01) was significantly lower in participants with high GS than in individuals with low GS. The interaction between FVC and GS for major CVD incidence (P = 0.006) was statistically significant. Compared with normal FVC participants with high GS, low FVC participants with low GS had the highest risk of major CVD incidence (HR = 2.50; 95% CI: 1.43-4.36; P < 0.01).

CONCLUSION

Among people with low FVC, the risk of major CVD is lower with high GS. Participants with low FVC and low GS have the highest risk of major CVD. Therefore, more attention should be paid to the incidence of major CVD in individuals with low FVC, especially those who have lower GS.

Central Haemodynamics Are Associated With Pulmonary Function in Postmenopausal Women

PURPOSE

Increased arterial stiffness predicts cardiovascular disease, which is associated with deteriorated pulmonary function and worsened chronic obstructive pulmonary disease. The present study examined whether arterial function was associated with pulmonary function in postmenopausal women.

METHODS

This study evaluated 41 postmenopausal women (age range: 59-85 years). Arterial function was measured as central systolic blood pressure (cSBP), central pulse pressure (cPP), brachial systolic BP (bSBP), brachial diastolic BP (bDBP), brachial PP (bPP), brachial mean arterial pressure (bMAP) and the augmentation index (AIx). AIx was adjusted for a heart rate of 75 beats per minute (bpm) (AIx@75) and served as the index of arterial stiffness determined by the reflected wave at the central artery. Pulmonary function was measured as forced vital capacity (FVC), forced expiratory volume in 1 second (FEV₁) and the FEV₁/FVC ratio.

RESULTS

Univariate regression analysis demonstrated that cPP, bDBP and bPP were correlated with FVC and FEV₁ (p<0.05, respectively), while AI@75 was correlated with FVC, FEV₁ and FEV₁/FVC ratio (p<0.01, respectively). A stepwise multivariate regression analysis revealed that bDBP was independently associated with FVC (p=0.032), while AI@75 was independently associated with FVC, FEV₁ and FEV₁/FVC ratio (p=0.001, p=0.003 and p=0.017, respectively). The FVC, FEV₁ and FEV₁/FVC ratio were lower in participants with a high AIx versus with a low AIx (p=0.0001, p=0.001 and p=0.044, respectively).

CONCLUSION

These results suggest that increased AIx is associated with lower pulmonary function in postmenopausal women.

The association between carotid-femoral pulse-wave velocity and lung function in the Swedish CArdioPulmonary bioImage study (SCAPIS) cohort

BACKGROUND

Arterial ageing is characterised by degradation of elastic fibres and increased stiffness of elastic arteries. Although low lung function and arterial stiffness are strongly related to age, the association between lung function and arterial ageing has not been widely explored. We used a large population-based study of 50-64 year olds to assess the association between lung function (measured by spirometry and CO diffusing capacity (D_LCO)) and arterial stiffness (measured by carotid-femoral pulse-wave velocity (c-f PWV)).

METHODS

Participants from the Swedish CArdioPulmonary bioImage Study (SCAPIS) cohort with information on spirometry (n = 8941) and D_LCO (n = 8616) were included. General linear models (lung function quartiles) and linear regression was used to determine the association between lung function and c-f PWV.

RESULTS

FEV₁ (L), FVC (L), D_LCO (mmol/(min kPa)) and D_LCO/V_A (mmol/(min kPa L)) were significantly and inversely associated with c-f PWV after adjustments; mean PWV (m/s) in Q1 (highest lung function) vs Q4: FEV₁; 8.45 vs 8.60, p-value 0.001; FVC; 8.45 vs 8.57, p-value 0.018; D_LCO; 8.46 vs 8.60, p-value 0.002; and D_LCO/V_A; 8.47 vs 8.58, p-value 0.001. In sex-stratified analyses, significant findings were reflected for FEV₁ and D_LCO in men only. The results remained significant for D_LCO in all never smokers and in all participants without COPD or airflow limitation on spirometry.

CONCLUSIONS

A reduction in spirometry and D_LCO is associated with elevated arterial stiffness in middle-aged men. A reduction in D_LCO is associated with higher c-f PWV even in never smokers and in those without COPD or airflow limitation on spirometry.

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.

Arterial stiffness can occur early in mild-to-moderate chronic obstructive pulmonary disease

Background

Chronic obstructive pulmonary disease (COPD) is a well-known respiratory system disorder impacting patient’s morbidity and mortality. Many COPD patients die from cardiovascular diseases. Criteria of arterial stiffness might be the early clue for cardiovascular affection in COPD patients. This study aimed to evaluate the occurrence of arterial stiffness as an early subclinical change in stable mild to moderate COPD patients.

Results

This cross-sectional study included 80 mild-to-moderate COPD patients and another 80 healthy controls. The carotid-femoral pulse wave velocity (cf-PWV) and the heart rate adjusted augmentation index (AIx75) were statistically significantly higher (13.8 ± 2.6 and 23.9 ± 10.8, respectively) among studied mild-to-moderate COPD patients when compared to healthy controls (10.7 ± 1.1 and 18.1 ± 8.9, respectively) (p < 0.001). FEV1 (forced expiratory volume in 1 s) % of predicted correlated negatively with both AIx75 (r = − 0.84, p < 0.001) and cf-PWV (r = − 0.85, p < 0.001), while BODE (body mass index, airflow obstruction, dyspnea, and exercise capacity) index correlated positively with both AIx75 (r = 0.58, p < 0.001) and cf-PWV (r = 0.52, p < 0.001) in patients with mild-to-moderate COPD.

Conclusions

Pulse wave velocity and augmentation index correlated with FEV1% of predicted and BODE index in patients with mild-to-moderate COPD.

Arterial Stiffness Increases Over Time in Relation to Lung Diffusion Capacity: A Longitudinal Observation Study in COPD

Background

Cardiovascular events are, after cancer, the most common cause of death in COPD patients. Arterial stiffness is an independent predictor of all-cause mortality and cardiovascular events. Several cross-sectional studies have confirmed increased arterial stiffness in patients with COPD. Various mechanisms in the development of arterial stiffness in COPD such as reduced lung function or systemic inflammation have been proposed. However, clinical predictors of arterial stiffness that had been reported in cross-sectional studies have not yet been confirmed in a longitudinal setting. We have assessed the course of augmentation index (AIx) - a measure of systemic arterial stiffness - and possible predictors in a cohort of COPD patients over a period of up to 7 years.

Methods

COPD patients underwent annual AIx measurement by applanation tonometry for a maximum duration of 7 years. Additionally, we performed annual assessments of lung function, blood gases, systemic inflammation, serum lipids and blood pressure. Associations between the course of AIx and potential predictors were investigated through a mixed effect model.

Results

Seventy-six patients (mean (SD) age 62.4 (7.1), male 67%) were included. The AIx showed a significant annual increase of 0.91% (95% CI 0.21/1.60) adjusted for baseline. The change in diffusion capacity (DLco), low-density lipoprotein (LDL), and high-sensitivity c-reactive protein (hsCRP) was independently associated with the increasing evolution of AIx (Coef. - 0.10, p<0.001, Coef. 1.37, p=0.003, and Coef. 0.07, p=0.033, respectively).

Conclusion

This study demonstrated a meaningful increase in arterial stiffness in COPD over time. A greater annual increase in arterial stiffness was associated with the severity of emphysema (measured by DLco), systemic inflammation, and dyslipidaemia.

Clinical Trial Registration

www.ClinicalTrials.gov, NCT01527773.

Aortic Pulse Wave Velocity as a Measure of Cardiovascular Risk in Chronic Obstructive Pulmonary Disease: Two-Year Follow-Up Data from the ARCADE Study

Background and objectives: Cardiovascular (CV) disease is a major cause of morbidity and mortality in chronic obstructive pulmonary disease (COPD). Patients with COPD have increased arterial stiffness, which may predict future CV risk. However, the development of arterial stiffness in COPD has not yet been studied prospectively. The Assessment of Risk in Chronic Airways Disease Evaluation (ARCADE) is a longitudinal study of CV risk and other comorbidities in COPD. The aims of this analysis were to explore factors associated with aortic pulse wave velocity (aPWV) at baseline and to describe the progression of aPWV in patients with COPD and comparators over two years. Materials and methods: At baseline, 520 patients with COPD (confirmed by spirometry) and 150 comparators free from respiratory disease were assessed for body composition, blood pressure, aPWV, noninvasive measures of cardiac output, inflammatory biomarkers, and exercise capacity. This was repeated after two years, and mortality cases and causes were also recorded. Results: At baseline, aPWV was greater in COPD patients 9.8 (95% confidence interval (CI) 9.7–10) versus comparators 8.7 (8.5–9.1) m/s (p < 0.01) after adjustments for age, mean arterial pressure (MAP), and heart rate. Mean blood pressure was 98 ± 11 in COPD patients and 95 ± 10 mmHg in comparators at baseline (p = 0.004). After two years, 301 patients and 105 comparators were fully reassessed. The mean (95% CI) aPWV increased similarly in patients 0.44 (0.25–0.63) and comparators 0.46 (0.23–0.69) m/s, without a change in blood pressure. At the two-year follow-up, there were 29 (6%) deaths in COPD patients, with the majority due to respiratory causes, with an overall dropout of 43% of patients with COPD and 30% of comparators. Conclusions: This was the first large longitudinal study of CV risk in COPD patients, and we confirmed greater aPWV in COPD patients than comparators after adjustments for confounding factors. After two years, patients and comparators had a similar increase of almost 0.5 m/s aPWV.

Biomarkers and clinical outcomes in COPD: a systematic review and meta-analysis

Background

Conventional measures to evaluate COPD may fail to capture systemic problems, particularly musculoskeletal weakness and cardiovascular disease. Identifying these manifestations and assessing their association with clinical outcomes (ie, mortality, exacerbation and COPD hospital admission) is of increasing clinical importance.

Objective

To assess associations between 6 min walk distance (6MWD), heart rate, fibrinogen, C reactive protein (CRP), white cell count (WCC), interleukins 6 and 8 (IL-6 and IL-8), tumour necrosis factor-alpha, quadriceps maximum voluntary contraction, sniff nasal inspiratory pressure, short physical performance battery, pulse wave velocity, carotid intima-media thickness and augmentation index and clinical outcomes in patients with stable COPD.

Methods

We systematically searched electronic databases (August 2018) and identified 61 studies, which were synthesised, including meta-analyses to estimate pooled HRs, following Meta-analysis of Observational Studies in Epidemiology (MOOSE) and Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.

Results

Shorter 6MWD and elevated heart rate, fibrinogen, CRP and WCC were associated with higher risk of mortality. Pooled HRs were 0.80 (95% CI 0.73 to 0.89) per 50 m longer 6MWD, 1.10 (95% CI 1.02 to 1.18) per 10 bpm higher heart rate, 3.13 (95% CI 2.14 to 4.57) per twofold increase in fibrinogen, 1.17 (95% CI 1.06 to 1.28) per twofold increase in CRP and 2.07 (95% CI 1.29 to 3.31) per twofold increase in WCC. Shorter 6MWD and elevated fibrinogen and CRP were associated with exacerbation, and shorter 6MWD, higher heart rate, CRP and IL-6 were associated with hospitalisation. Few studies examined associations with musculoskeletal measures.

Conclusion

Findings suggest 6MWD, heart rate, CRP, fibrinogen and WCC are associated with clinical outcomes in patients with stable COPD. Use of musculoskeletal measures to assess outcomes in patients with COPD requires further investigation.

Trial registration number

CRD42016052075.

Surrogate Markers of Cardiovascular Risk and Chronic Obstructive Pulmonary Disease: A Large Case-Controlled Study

Cardiovascular disease is a common comorbidity and cause of mortality in chronic obstructive pulmonary disease. A better understanding of mechanisms of cardiovascular risk in chronic obstructive pulmonary disease patients is needed to improve clinical outcomes. We hypothesized that such patients have increased arterial stiffness, wave reflections, and subclinical atherosclerosis compared with controls and that these findings would be independent of smoking status and other confounding factors. A total of 458 patients with a diagnosis of chronic obstructive pulmonary disease and 1657 controls (43% were current or ex-smokers) with no airflow limitation were matched for age, sex, and body mass index. All individuals underwent assessments of carotid-femoral (aortic) pulse wave velocity, augmentation index, and carotid intima-media thickness. The mean age of the cohort was 67±8 years and 58% were men. Patients with chronic obstructive pulmonary disease had increased aortic pulse wave velocity (9.95±2.54 versus 9.27±2.41 m/s; P<0.001), augmentation index (28±10% versus 25±10%; P<0.001), and carotid intima-media thickness (0.83±0.19 versus 0.74±0.14 mm; P<0.001) compared with controls. Chronic obstructive pulmonary disease was associated with increased levels of each vascular biomarker independently of physiological confounders, smoking, and other cardiovascular risk factors. In this large case-controlled study, chronic obstructive pulmonary disease was associated with increased arterial stiffness, wave reflections, and subclinical atherosclerosis, independently of traditional cardiovascular risk factors. These findings suggest that the cardiovascular burden observed in this condition may be mediated through these mechanisms and supports the concept that chronic obstructive pulmonary disease is an independent risk factor for cardiovascular disease.

Systemic vascular dysfunction is associated with emphysema burden in mild COPD

BACKGROUND

Cardiovascular diseases play a major role in morbidity and mortality in the earlier stages of COPD. We hypothesized that systemic vascular dysfunction would be present even in patients who are currently considered at "low-risk" for negative cardiovascular outcomes, i.e., those with largely preserved FEV₁, few exacerbations and only mild burden of respiratory symptoms (GOLD spirometric grade 1, clinical group A).

METHODS

16 patients (FEV₁ = 86 ± 13%) and 16 age- and gender-matched controls underwent measurements of: a) central arterial stiffness by pulse wave velocity, b) brachial flow-mediated dilation and c) forearm muscle oxygenation by near-infrared spectroscopy. Computed tomography quantified emphysema (% of low attenuation areas (LAA)) and airway disease.

RESULTS

Patients and controls were well matched for key clinical variables including co-morbidities burden. Thirteen patients presented with more than 5% LAA: emphysema extension was negatively related to transfer factor for carbon monoxide (TL_CO) (r = -0.63; p = .01). Compared to controls, patients had higher central arterial stiffness, lower normalized (to shear stress) flow-mediated dilation, delayed time to peak flow-mediated dilation and poorer muscle oxygenation (p < .05). TL_CO and emphysema, but not airway disease, were significantly related to each of these functional abnormalities (r values ranging from 0.51 to 0.66; p < .05).

CONCLUSION

Systemic vascular dysfunction is present in the earlier stages of COPD, particularly in patients with greater emphysema burden and low TL_CO. Regardless FEV₁, patients showing those structural and functional abnormalities might be at higher risk of negative events thereby deserving closer follow-up for early detection of cardiovascular disease.

Does peripheral arterial occlusive disease influence muscle strength and exercise capacity in COPD patients?

Background

The pathophysiology of chronic obstructive pulmonary disease (COPD) is complex and understanding of it has been changing in recent years, with regard to its multisystemic manifestations, especially peripheral dysfunction and its influence on intolerance to exercise.

Objectives

To evaluate the relationship between peripheral arterial occlusive disease (PAOD) and peripheral muscle strength and exercise capacity in COPD patients.

Methods

We conducted a cross-sectional study of 35 patients with COPD who were evaluated with the Ankle-Brachial Index, handgrip strength test, 1 repetition maximum (1RM) of knee extensors and flexors, and distance covered in the incremental shuttle walking test (dISWT).

Results

COPD patients with coexisting PAOD had lower dominant handgrip strength test results (33.00 vs. 26.66 kgf, p = 0.02) and worse performance in the dISWT (297.32 vs. 219.41 m, p = 0.02) when compared to the COPD patients without PAOD. Strong correlations were found between the result of the handgrip strength test and both the dISWT (r = 0.78; p < 0.001) and the 1RM/knee extension (r = 0.71; p = 0.03); and also between the dISWT and both the 1RM/knee extension (r = 0.72; p = 0.02) and the 1RM/knee flexion (r = 0.92; p < 0.001). The linear regression model showed that the dISWT variable alone explains 15.3% of the Ankle-Brachial Index result (p = 0.01).

Conclusion

COPD patients with PAOD exhibit reduced muscle strength and lower exercise capacity than COPD patients without PAOD.

Subclinical cardiovascular disease in patients with chronic obstructive pulmonary disease: a systematic review

BACKGROUND

Cardiovascular disease (CVD) accounts for a significant portion of deaths in patients with COPD; however, evidence for early detection strategies for CVD in this population remain limited. Our paper aims to summarize existing data regarding subclinical CVD in patients with COPD with a view to identifying screening strategies in these patients.

METHODS

A systematic review of published literature was conducted for studies examining the relationship of COPD and markers of subclinical disease such as coronary artery calcification (CAC), carotid intima media thickness (cIMT), endothelial dysfunction, arterial stiffness as measured by pulse wave velocity (PWV) and augmentation indices (AIx). Both MEDLINE and EMBASE databases were searched till October 2015.

RESULTS

A total of 22 studies were included in the review. Compared with control subjects, patients with COPD had significantly higher cIMT (SMD 0.53, 95% CI 0.16-0.90), PWV (SMD 0.91, 95% CI 0.67-1.16) and AIx (SMD 0.86, 95% CI 0.52-1.19). Additionally, an overall higher prevalence of subclinical CVD as assessed by CAC, ABI and FMD was noted in our review.

CONCLUSION

Although our findings need further evaluation in prospective studies, our review presents significant evidence in support of increased subclinical CVD burden in COPD patients independent of smoking status. Further large-scale case-control studies are required to highlight the significance of subclinical CVD screening in COPD patients.

Restrictive Spirometry Pattern Is Associated With Increased Arterial Stiffness in Men and Women

BACKGROUND

There is growing evidence that pulmonary function impairment is related to cardiovascular events and death. Some studies have shown that the level of FVC is negatively related to arterial stiffness, but most studies were confined to men, and none of them examined the association of the presence of restrictive spirometry pattern with arterial stiffness. Therefore, this study aimed to investigate the association of restrictive spirometry pattern with arterial stiffness by sex.

METHODS

This study recruited 2,961 subjects after excluding those with (1) obstructive lung disease, as defined by history and pulmonary function test; (2) history of asthma, lung cancer, tuberculosis, coronary heart disease, stroke, or any pulmonary structural deformities; and (3) medications influencing BP, plasma glucose, lipid profile, and pulmonary function test. Restrictive spirometry pattern was diagnosed as an FVC < 80% of the predicted value and an FEV₁/FVC ratio ≥ 70%. Increased arterial stiffness was defined as right brachial ankle pulse wave velocity (baPWV) ≥ 1,400 cm/s.

RESULTS

In both men and women, FVC was negatively associated with the baPWV level. Restrictive spirometry pattern was positively associated with increased arterial stiffness in both men and women (men: OR, 2.16; 95% CI, 1.33-3.50; women: OR, 1.95; 95% CI, 1.02-3.72) after adjustment for other clinical variables.

CONCLUSIONS

Both restrictive spirometry pattern and reduced FVC were associated with a higher risk of arterial stiffness, not only in men but also in women. Clinically, assessment of arterial stiffness might be considered in individuals with restrictive spirometry pattern.

Relationship between FEV1 and arterial stiffness in elderly people with chronic obstructive pulmonary disease

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is highly prevalent in the elderly, and both COPD and age per se are associated with cardiovascular morbidity.

AIMS

We tested the hypothesis that in elderly COPD patients airflow limitation is associated with arterial stiffness and the relationship, if any, is related to endothelial function and systemic inflammation.

METHODS

We evaluated lung function, augmentation index (AIx), flow-mediated dilation (FMD), Interleukin-6 (IL-6), and asymmetric dymethilarginine (ADMA) levels in 76 subjects (mean age 73.9 years, SD 6.2) attending a geriatric outpatient clinic.

RESULTS

Participants with COPD (N = 41) and controls (N = 35) did not differ in terms of AIx (30 vs 28.2 %, P = 0.30) and FMD (14.2 vs 12.3 %, P = 0.10). Similarly, the two groups did not differ with respect to mean concentrations of inflammation markers (IL-6 and C-reactive protein) and ADMA. Among COPD participants there was an inverse correlation between AIx and Forced Expiratory Volume in the first second (r = -0.349, P = 0.02). This relationship remained significant after correction for potential confounders, including markers of inflammation and ADMA levels (β = -0.194, P = 0.001).

DISCUSSION

According to the results of this study, among COPD patients, bronchial patency and AIx are inversely related, and the relationship is explained neither by endothelial function nor by systemic inflammation.

CONCLUSIONS

In elderly COPD people, increased arterial stiffness is related to reduced pulmonary function and it seems worth testing as a potential marker of higher cardiovascular risk.

Age and cigarette smoking modulate the relationship between pulmonary function and arterial stiffness in heart failure patients

The aim of this study was to assess the relationship between arterial stiffness and pulmonary function in chronic heart failure (CHF).Outpatients previously diagnosed as CHF were enrolled between April 2008 and March 2010, and submitted to arterial stiffness measurement and lung function assessment. Spirometry was performed by measuring forced vital capacity (FVC), the fraction of predicted FVC, forced expiratory volume in 1 second (FEV1), the percentage of predicted FEV1 in 1 second, FEV1 to FVC ratio, and the percentage of predicted FEV1/FVC. Cardio-ankle vascular index (CAVI) was considered for the estimation of arterial stiffness.The 354 patients assessed included 315 nonsmokers, and were 68.2 ± 7.2 years' old. Unadjusted correlation analyses demonstrated CAVI was positively related to age (r = 0.3664, P < 0.0001), and negatively related to body mass index (BMI, r = -0.2040, P = 0.0001), E/A ratio (r = -0.1759, P = 0.0010), and FEV1 (r = -0.2987, P < 0.0001). Stepwise multivariate regression analyses showed age (r = 0.2391, P < 0.0001), BMI (r = -0.2139, P < 0.0001), smoking (r = 0.1211, P = 0.0130), E/A ratio (r = -0.1082, P = 0.0386), and FEV1 (r = -0.2550, P < 0.0001) were independent determinants of CAVI. In addition, there is a significant interaction between CAVI and forced expiratory volume in 1 second (FEV1) in relation to age (Pint < 0.0001) and smoking (Pint = 0.0001). Meanwhile, pulmonary function was not associated with BMI or E/A ratio.These findings demonstrated that reduced pulmonary function is associated with the increased CAVI, and had an interactive effect with age and smoking on CAVI in patients with CHF.

Subclinical atherosclerosis risk markers in patients with chronic obstructive pulmonary disease: A systematic review and meta-analysis

BACKGROUND AND AIMS

Chronic obstructive pulmonary disease (COPD) is associated with increased cardiovascular morbidity and mortality. Identifying early changes of cardiovascular system before the occurrence of fatal clinical event is critical for the management of COPD. We performed a meta-analysis to investigate the associations between COPD and subclinical markers of cardiovascular risk.

METHODS

We searched PUBMED, EMBASE for studies published before Aug 1st, 2016, on the association between COPD and carotid intima-media thickness (CIMT), prevalence of carotid plaques, flow-mediated dilation (FMD), pulse-wave velocity (PWV) and augmentation index (AIx).

RESULTS

Thirty-two studies (3198 patients, 13867 controls) were included. Compared with controls, COPD patients had significantly higher CIMT (MD: 0.10 mm; 95% CI: 0.04, 0.16; p = 0.0007), PWV (SMD: 0.70; 95% CI: 0.52, 0.88; p < 0.0001), AIx (MD: 4.60%; 95% CI: 0.52, 8.68; p = 0.03), AIx@75 (AIx normalized to a heart rate of 75 beats per minute) (MD: 4.59%; 95% CI: 2.80, 6.38; p < 0.0001), prevalence of carotid plaque (OR: 2.54; 95% CI: 2.04, 3.15; p < 0.0001), and significantly lower FMD (MD: -4.21%; 95% CI: -6.71, -1.71; p = 0.001). Sensitivity and subgroups analyses substantially confirmed our results. Meta-regression analysis revealed that spirometry (as expressed by FEV₁%predicted) might influence on PWV.

CONCLUSIONS

These findings indicate that COPD, even in mild to moderate patients, had greater impaired markers of subclinical atherosclerosis and cardiovascular risk. However, further studies are still needed to address confounders, such as age, smoking, hypertension, diabetes etc, which might affect the associations in COPD patients.

Association between airflow limitation severity and arterial stiffness as determined by the brachial-ankle pulse wave velocity: a cross-sectional study

Objective Chronic obstructive pulmonary disease (COPD) is often associated with concomitant systemic manifestations and comorbidities, such as cardiovascular disease. There are limited data regarding airflow limitation (AL) and atherosclerosis in Japanese patients, and the potential association between AL and arterial stiffness has not yet been investigated in Japanese patients. Therefore, the purpose of this study was to investigate the association between AL severity and arterial stiffness using the brachial-ankle pulse wave velocity (baPWV). Methods This cross-sectional study included 1,356 subjects aged 40-79 years without clinical cardiovascular diseases who underwent a comprehensive health screening that included spirometry, the baPWV measurement, and blood sampling during medical check-ups in 2009 at the Japanese Red Cross Kumamoto Health Care Center. AL was defined in accordance with the Global Initiative for COPD criteria (forced expiratory volume in one second / forced vital capacity of < 0.7). A cut-off baPWV value of >1,400 cm/s was used for risk prediction and screening. Results The average baPWV (SD) results were 1,578.0 (317.9), 1,647.3 (374.4), and 1,747.3 (320.1) cm/s in the patients with a normal pulmonary function, mild AL, and moderate-to-severe AL, respectively (p< 0.001). Using logistic regression models adjusted for the age, body mass index, smoking status, hypersensitive C-reactive protein levels, hypertension, hyperglycemia, and dyslipidemia, an increased baPWV (>1,400 cm/s) was significantly associated with moderate-to-severe AL compared with a normal pulmonary function (odds ratio=2.76; 95% confidence intervals, 1.37-5.55; p=0.004). Conclusion Our results indicated an association between AL and increased arterial stiffness. Arterial stiffness may therefore worsen with an increase in the severity of AL.

Arterial stiffness in COPD

In patients with COPD, cardiovascular diseases are the most common concomitant chronic diseases, a leading cause of hospitalization, and one of the main causes of death. A close connection exists between COPD and cardiovascular diseases. Cardiovascular risk scores aim to predict the effect of cardiovascular comorbidities on COPD mortality, but there is a need to better characterize occult and suboccult cardiovascular disease, even in patients with mild to moderate COPD. Among various surrogate markers of cardiovascular risk, arterial stiffness plays a central role and is a strong independent predictor of cardiovascular events beyond classic cardiovascular risk factors. Its measurement is highly suitable, validated, and relatively easy to perform in routine COPD clinical practice. The growing awareness of the increased cardiovascular risk associated with COPD has led to a call for respiratory physicians to measure arterial pulse wave velocity in routine practice. Cross-sectional data establish elevated arterial stiffness as being independently linked to COPD. Candidate mechanisms have been proposed, but surprisingly, only limited data are available regarding the impact of the different COPD treatment modalities on arterial stiffness, although initial studies have suggested a significant positive impact. In this review, we present the various surrogate markers of cardiovascular morbidity in COPD and the central role of arterial stiffness and the underlying mechanisms explaining vascular remodeling in COPD. We also consider the therapeutic impact of COPD medications and exercise training on arterial stiffness and the assessments that should be implemented in COPD care and follow-up.

Arterial stiffness in adult patients after Fontan procedure

Objectives

Increased arterial stiffness is a risk factor of atherosclerosis and cardio-vascular complications. The aim of the study was to determine whether peripheral vascular function might be an early marker of impaired health status in patients with a single ventricle after Fontan procedure.

Methods and results

Twenty five consecutive adults (11 women and 14 men) aged 24.7 ± 6.2 years after the Fontan procedure and 25 sex, age and BMI match healthy volunteers underwent physical examination, blood analysis, transthoracic echocardiography and noninvasive assessment of aortic stiffness. Augmented pressure and Augmentation Index (AIx) were both significantly elevated in Fontan when compared to the controls (6,08 ± 0,7 vs. 2,0 ± 3,7; p = 0.002 and 17,01 ± 3,3 vs. 6,05 ± 11; p < 0.001, respectively). There were no differences in pulse wave velocity (PWV), mean blood pressure (BP), brachial pulse pressure (PP), central: systolic BP, diastolic BP and PP. In Fontan group we find negative correlation between PWV and SatO2 (r = −0.68; p = 0.04) and positive correlation with WBC (0.72; p = 0.72; p = 0.013), INR (0.81; p = 0.008), TNFα (r = 0.45; p = 0.04), and postoperative time (r = 0.77; p = 0.02). AIx correlates positively only with age at surgery (r = 0.45; p = 0.04). Bilirubin level correlates positively with brachial PP (r = 0.71; p = 0.02) and central PP (r = 0.68; p = 0.03).

The multivariate model showed that SatO2 (β = −0.44, p = 0.04) was the only independent predictor of PWV (R² = 0.32, p = 0.03).

Conclusion

Adult Fontan patients have an increased arterial stiffness assessed by a noninvasive technique. Low arterial oxygen saturation postoperative time, age at surgery, white blood cells, TNFα and bilirubin level are associated with arterial stiffening in these patients. The combination of blood parameters of the hepatic function and noninvasive measurements of arterial stiffness could be helpful in comprehensive care of patients with Fontan circulation.

Acute exacerbation of chronic obstructive pulmonary disease: cardiovascular links

Chronic obstructive pulmonary disease (COPD) is a chronic, progressive lung disease resulting from exposure to cigarette smoke, noxious gases, particulate matter, and air pollutants. COPD is exacerbated by acute inflammatory insults such as lung infections (viral and bacterial) and air pollutants which further accelerate the steady decline in lung function. The chronic inflammatory process in the lung contributes to the extrapulmonary manifestations of COPD which are predominantly cardiovascular in nature. Here we review the significant burden of cardiovascular disease in COPD and discuss the clinical and pathological links between acute exacerbations of COPD and cardiovascular disease.