Concurrent Chronic Obstructive Pulmonary Disease Research Articles

Management of dyspnea in palliative care.

Dyspnea is a symptom commonly experienced by cancer patients that causes significant suffering, worsens throughout a patient's disease trajectory, and can be more difficult to manage than other symptoms. Assessment of dyspnea is best accomplished by a subjective description; physiologic measures are only weakly correlated with the patient's experience. It is important to consider a wide range of possible malignant and nonmalignant causes of dyspnea in cancer patients and to correct underlying causes where possible. For patients with refractory dyspnea, opioids are a safe and effective treatment. Benzodiazepines can be considered, but the evidence for their use is weak. Supplemental oxygen is beneficial if patients are hypoxemic, or if they have concurrent chronic obstructive pulmonary disease. Nonpharmacologic strategies such as fan therapy, exercise programs, and pulmonary rehabilitation can also be beneficial. One important diagnosis to consider in all cancer patients is venous thromboembolism. Prompt evaluation and treatment are vital to improving symptoms and outcomes for patients. Although dyspnea is common and potentially debilitating in cancer patients, it can be effectively managed with a structured approach to rule out reversible causes while concurrently treating the patient using appropriate therapeutic strategies.

Concomitant treatment with omalizumab and cyclosporine for chronic spontaneous urticaria

Abstract Background Severe asthma (SA) often requires subspecialist management and treatment with biologic therapies and/or maintenance systemic corticosteroids (mSCS). Objective: To describe contemporary, real-world biologic and mSCS use among U.S., subspecialist-treated patients with SA. Methods CHRONICLE is an ongoing, noninterventional study of U.S. adults with SA treated by allergists/immunologists or pulmonologists. Eligible patients are receiving biologics and/or mSCS or are uncontrolled on high-dosage inhaled corticosteroids with additional controllers (HD ICS+). Biologic and mSCS use patterns and patient characteristics were summarized for patients enrolled between February 2018 and February 2019. Results Among protocol-eligible patients, 58% and 12% were receiving biologics and mSCS respectively, with 7% receiving both. Among 796 enrolled, most were female (67%), non-Hispanic white (71%), of suburban residence (50%), and had elevated body mass index (median 31). Respiratory and nonrespiratory comorbidities were highly prevalent. With biologics (n=557), 51% were anti-IgE and 48% were anti–IL5/IL-5Rα; from May 2018, 76% of initiations were anti–IL-5/IL-5Rα. In patients receiving mSCS, median prednisone-equivalent daily dose was 10 mg. Multivariate logistic regression demonstrated patients of hospital clinics, sites with fewer nonphysician staff, and with a recorded concurrent chronic obstructive pulmonary disease diagnosis were less likely to receive biologics and more likely to receive mSCS. Conclusion In this real-world sample of U.S., subspecialist-treated patients with SA not controlled by HD ICS+, mSCS use was infrequent and biologic use was common, with similar prevalence of anti-IgE and anti–IL-5/IL-5Rα biologics. Treatment differences associated with patient and site characteristics should be investigated to ensure equitable access to biologics and minimize mSCS use.

Biologic and maintenance systemic corticosteroid therapy among US subspecialist-treated patients with severe asthma

BackgroundSevere asthma (SA) often requires subspecialist management and treatment with biologic therapies or maintenance systemic corticosteroids (mSCS). ObjectiveTo describe contemporary, real-world biologic and mSCS use among US subspecialist-treated patients with SA. MethodsCHRONICLE is an ongoing, noninterventional study of US adults with SA treated by allergists/immunologists or pulmonologists. Eligible patients are receiving biologics or mSCS or are uncontrolled on high-dosage inhaled corticosteroids with additional controllers. Biologic and mSCS use patterns and patient characteristics were summarized for patients enrolled between February 2018 and February 2019. ResultsAmong protocol-eligible patients, 58% and 12% were receiving biologics and mSCS, respectively, with 7% receiving both. Among 796 enrolled, most were women (67%), non-Hispanic white (71%), of suburban residence (50%), and had elevated body mass index (median: 31). Respiratory and nonrespiratory comorbidities were highly prevalent. With biologics (n = 557), 51% were anti–immunoglobulin E and 48% were anti–interleukin (IL)-5/IL-5Rα; from May 2018, 76% of initiations were anti–IL-5/IL-5Rα. In patients receiving mSCS, median prednisone-equivalent daily dose was 10 mg. Multivariate logistic regression found that patients of hospital clinics, sites with fewer nonphysician staff, and with a recorded concurrent chronic obstructive pulmonary disease diagnosis were less likely to receive biologics and more likely to receive mSCS. ConclusionIn this real-world sample of US subspecialist-treated patients with SA not controlled by high-dosage inhaled corticosteroids with additional controllers, mSCS use was infrequent and biologic use was common, with similar prevalence of anti–immunoglobulin E and anti–IL-5/IL-5Rα biologics. Treatment differences associated with patient and site characteristics should be investigated to ensure equitable access to biologics and minimize mSCS use. Trial RegistrationClinicalTrials.gov Identifier: NCT03373045.

The Effect of Metabolic Syndrome Status on Lung Function and Patient-reported Outcomes in Patients with COPD Receiving Nebulized Glycopyrrolate.

Concurrent chronic obstructive pulmonary disease (COPD) and metabolic syndrome (MetS) represent an important clinical phenotype with overlapping symptomology. The effect of MetS in COPD patients was assessed following treatment with nebulized glycopyrrolate (GLY; administered via eFlow® Closed System Nebulizer). Posthoc analyses were performed on pooled lung function, patient-reported outcome (PRO) and safety data by MetS status from patients treated with placebo, GLY 25 and 50 mcg twice daily in two 12-week studies (GOLDEN 3 and 4; N=1293). Patients with MetS were characterized as having ≥ 3 of hypertension, hyperlipidemia, diabetes, body mass index (BMI) > 30 kg/m2 risk factors. The results are presented for the Food and Drug Administration-approved GLY 25 mcg dose. A total of25% of patients met MetS criteria.At baseline, the MetS subgroup had higher BMIs, more ex-smokers, greater incidences of cardiovascular risk factors, and MetS-specific risk factors were 2-14 times higher than non-MetS. At 12 weeks, GLY produced significant, clinically important improvements (MetS: 0.121 L; non-MetS: 0.083 L) in trough forced expiratory volume in 1 second. In the non-MetS group, significant improvements occurred in the St George's Respiratory Questionnaire (MetS: -2.28, p=0.157; non-MetS: -3.71) and Evaluating Respiratory Symptoms in COPD tool (MetS: 0.42, p=0.574; non-MetS: -1.61) total scores. Incidence of adverse events was similar with GLY versus placebo regardless of MetS status. GLY was well-tolerated and significantly improved lung function regardless of MetS status, while significant PRO improvements occurred in non-MetS patients. These results highlight the importance of comorbidities on bronchodilator responses and patient symptoms in COPD patients.

Effectiveness and Safety of Inhaled Corticosteroids in Older Individuals with Chronic Obstructive Pulmonary Disease and/or Asthma. A Population Study.

Rationale: Inhaled corticosteroids (ICS) are established medications for the management of both asthma and chronic obstructive pulmonary disease (COPD), two common chronic airway diseases. However, there is still uncertainty with respect to their use in some cases, specifically in older adults with asthma, people with concurrent asthma and COPD, and some people with COPD (given the association of ICS with pneumonia).Objectives: To compare the effectiveness and safety of ICS in older adults with asthma, COPD, or features of both in a real-word setting.Methods: In this retrospective longitudinal population cohort study, individuals 66 years of age or older in Ontario, Canada, who met a validated case definition of physician-diagnosed COPD and/or asthma between 2003 and 2014 were followed until March 2015 through provincial health administrative data. Overlap in COPD and asthma diagnoses was permitted and stratified for in subgroup analyses. The exposure was new receipt of ICS. The primary effectiveness and safety outcomes were hospitalizations for obstructive lung disease (OLD) and hospitalizations for pneumonia, respectively. Propensity scores were used to adjust for confounders.Results: The study included 87,690 individuals with asthma (27% with concurrent COPD) and 150,593 individuals with COPD (25% with concurrent asthma). In terms of effectiveness, controlling for confounders, ICS was associated with fewer hospitalizations for OLD (hazard ratio [HR], 0.84; 95% confidence interval [CI], 0.79-0.88) in subjects with asthma alone, with concurrent COPD attenuating the benefit. A similar association was seen in subjects with COPD and concurrent asthma (HR, 0.88; 95% CI, 0.84-0.92), but not in those with COPD alone, where ICS receipt had little impact on hospitalizations. In terms of safety, ICS receipt was associated with a marginally increased risk of pneumonia hospitalizations in people with COPD and no asthma (HR, 1.03; 95% CI, 1.00-1.06), but not in the other groups.Conclusions: ICS was associated with fewer hospitalizations for OLD in older adults with asthma and concurrent asthma and COPD, but had little impact on OLD and pneumonia hospitalizations in those with COPD alone.

2209Oxygen therapy in suspected acute myocardial infarction and concurrent chronic obstructive pulmonary disease: a prespecified subgroup analysis from the DETO2X-AMI trial

Abstract Background The DETermination of the role of Oxygen in suspected Acute Myocardial Infarction (DETO2X-AMI) trial did not find any benefit of oxygen therapy compared to ambient air in normoxemic patients with suspected acute myocardial infarction (AMI). Patients with chronic obstructive pulmonary disease (COPD) may both benefit and be harmed by supplemental oxygen. Thus, we evaluated the effect of routine oxygen therapy compared to ambient air in normoxemic COPD patients with suspected AMI. Methods and results A total of 6629 patients with suspected AMI were randomized in the DETO2X-AMI trial to oxygen or ambient air. In the oxygen group (n=3311) and the ambient air group (n=3318), 155 and 141 patients, respectively, had COPD (prevalence of 4.5%). Patients with COPD were older, had more comorbid conditions and experienced a two-fold higher risk of death at one year (COPD: 32/296 [10.8%] vs. non-COPD 302/6333 [4.8%]). Oxygen therapy compared to ambient air was not associated with improved outcomes at 365 days (COPD: all-cause mortality HR 0.99 [95% CI 0.50–1.99, interaction-p=0.96]; cardiovascular death HR 0.80 [0.32–2.04, interaction-p=0.59]; rehospitalization with AMI or death HR 1.27 [0.71–2.28, interaction-p=0.46]; hospitalization for heart failure or death HR 1.08 [0.61–1.91, interaction-p=0.77]); there were no significant treatment-by-COPD interactions. Outcome Conclusions Although COPD patients had twice the mortality rate compared to non-COPD patients, this prespecified subgroup analysis from the DETO2X-AMI trial on oxygen therapy versus ambient air in normoxemic COPD patients with suspected AMI revealed no evidence for benefit of routine oxygen therapy consistent with the main trial's findings.

In-Hospital Mortality in Patients with Idiopathic Pulmonary Fibrosis: A US Cohort Study

PurposeIn patients with idiopathic pulmonary fibrosis (IPF), hospitalizations are associated with high mortality. We sought to determine in-hospital mortality rates and factors associated with in-hospital mortality in patients with IPF.MethodsPatients with IPF were identified from the Premier Healthcare Database, a representative administrative dataset that includes > 20% of hospital discharges in the US, using an algorithm based on diagnostic codes and billing data. We used logistic regression to analyze associations between patient-, hospital-, and treatment-related characteristics and a composite primary outcome of death during the index visit, lung transplant during the index visit and > 1 day after admission, or death during a readmission within 90 days.ResultsThe cohort comprised 6665 patients with IPF hospitalized between October 2011 and October 2014. A total of 963 (14.4%) met the primary outcome. Factors significantly associated with a higher risk of the primary outcome included mechanical ventilation [odds ratio 4.65 (95% CI 3.73, 5.80)], admission to the intensive care unit [1.83 (1.52, 2.21)], treatment with opioids (3.06 [2.57, 3.65]), and a diagnosis of pneumonia [1.44 (1.21, 1.71)]. Factors significantly associated with a lower risk included concurrent chronic obstructive pulmonary disease [0.65 (0.55, 0.77)] and female sex [0.67 (0.57, 0.79)].ConclusionsPatients with IPF, particularly those receiving mechanical ventilation or intensive care, are at substantial risk of death or lung transplant during hospitalization or death during a readmission within 90 days.

Beta-blocker choice and exchangeability in patients with heart failure and chronic obstructive pulmonary disease: an Italian register-based cohort study

Clinical guidelines suggest that for patients with heart failure and concurrent chronic obstructive pulmonary disease (COPD), metoprolol/bisoprolol/nebivolol should be preferred over carvedilol. However, studies suggest a high proportion of carvedilol usage that remains unexplained. Therefore, we aimed to investigate the predictors of carvedilol choice in patients with heart failure and COPD that were naïve to carvedilol or metoprolol/bisoprolol/nebivolol. Caserta Local Health Unit databases (Italy) were used as data sources. Age, sex, chronic/acute comorbidities, and co-medications were included in a logistic regression model to assess predictors of carvedilol choice. Chronic comorbidities include those defined in the Elixhauser comorbidity index and all hospitalizations within two years prior to the first beta-blocker prescription. Comedications include all redeemed prescriptions within one year prior to the beta-blocker prescription. Kernel density estimations were used to assess the overlap in propensity and preference scores distributions for receiving carvedilol and thereby potential beta-blocker exchangeability. Totally, 10091 patients composed the study population; 2011 were exposed to carvedilol. The overlapping of propensity scores distributions was 57%. Accordingly, the exchangeability was not reached. Atrioventricular block (Odds Ratio, OR 8.20; 95% Confidence Interval, 95% CI 1.30–51.80), cerebrovascular thrombosis (OR 7.06; 95% CI 1.14–43.68), chronic kidney disease (OR 4.32; 95% CI 1.16–16.02), and acute heart failure (OR 1.97; 95% CI 1.28–3.03) hospitalizations were statistically significantly associated with carvedilol choice. Analogously, human insulin (OR 3.00; 95% CI 1.24–7.24), fondaparinux (OR 2.47; 95% CI 1.17–5.21) or strontium ranelate (OR 2.03; 95% CI 1.06–3.90) redeemed prescriptions. In conclusion, this study suggests the absence of beta-blockers exchangeability and a preferential choice of carvedilol in patients with heart failure, COPD and concurrent chronic kidney disease, atrioventricular block, cerebrovascular thrombosis, acute heart failure or redeeming human insulin, fondaparinux or strontium ranelate prescriptions. Therefore, it suggests that choice of prescribing carvedilol over metoprolol/bisoprolol/nebivolol is driven by differences in comorbidities and co-treatments.

Are respiratory disorders risk factors for troublesome low-back pain? A study of a general population cohort in Sweden

PurposeA multi-morbidity perspective of troublesome low back pain (LBP) has been highlighted for example in relation to respiratory disorders. Our purpose was to investigate whether respiratory disorders are risk factors for reporting troublesome LBP in people with no or occasional LBP at baseline.MethodsThis prospective cohort study was based on the Stockholm Public Health Cohort 2006/2010. We included adults reporting no or occasional LBP the last 6 months at baseline (n = 17,177). Exposures were self-reported asthma and/or Chronic Obstructive Pulmonary Disease (COPD). Outcome was troublesome LBP defined as reporting LBP a couple of days per week or more often that restricted work capacity or hindered daily activities to some or to a high degree, the last 6 months. Binomial regression models were used to calculate risk ratios (RR) with 95% confidence intervals (95% CI).ResultsAdjusted results indicate that those suffering from asthma had a risk of troublesome LBP at follow-up (RR 1.29, 95% CI 0.92–1.81) as do those suffering from COPD (RR 2.0, 95% CI 1.13–3.56). If suffering from asthma and concurrent COPD the RR was 3.55 (95% CI 1.58–7.98).ConclusionOur findings indicate that suffering from asthma and/or COPD increases the risk of developing troublesome LBP, which highlights the importance to consider the overall health of people at risk of troublesome LBP and to take the multi-morbidity perspective into consideration. Future longitudinal studies are needed to confirm our findings.Graphic abstractThese slides can be retrieved under Electronic Supplementary Material.

Prevalence of COPD among workers with work-related asthma

Objective: Concurrent asthma and chronic obstructive pulmonary disease (COPD) diagnoses occur in 15%–20% of patients, and have been associated with worse health outcomes than asthma or COPD alone. Work-related asthma (WRA), asthma that is caused or made worse by exposures in the workplace, is characterized by poorly controlled asthma. The objective of this study was to assess the proportion of ever-employed adults (≥18 years) with current asthma who have been diagnosed with COPD, by WRA status.Methods: Data from 23 137 respondents to the 2012–2014 Behavioral Risk Factor Surveillance System Asthma Call-back Survey from 31 states and the District of Columbia were examined. Logistic regression was used to calculate adjusted prevalence ratios (PRs), examining six disjoint categories of WRA-COPD overlap with non-WRA/no COPD as the referent category.Results: An estimated 51.9% of adults with WRA and 25.6% of adults with non-WRA had ever been diagnosed with COPD. Adults with WRA/COPD were more likely than those with non-WRA/no COPD to have an asthma attack (PR = 1.77), urgent treatment for worsening asthma (PR = 2.85), an asthma-related emergency room visit (PR = 4.21), overnight stay in a hospital because of asthma (PR = 6.57), an activity limitation on 1–13 days (PR = 2.01) or ≥14 days (PR = 5.02), and very poorly controlled asthma (PR = 3.22).Conclusions: COPD was more frequently diagnosed among adults with WRA than those with non-WRA, and adults diagnosed with both WRA and COPD appear to have more severe adverse asthma outcomes than those with non-WRA and no COPD.

ВЛИЯНИЕ ХРОНИЧЕСКОЙ ОБСТРУКТИВНОЙ БОЛЕЗНИ ЛЕГКИХ НА УРОВЕНЬ ГОМОЦИСТЕИНЕМИИ И СОСТОЯНИЕ КОРОНАРНЫХ СОСУДОВ У БОЛЬНЫХ ИНФАРКТОМ МИОКАРДА

Objective : to study and compare the level of homocysteine with the results of coronary angiography in patients with myocardial infarction (MI) and concurrent chronic obstructive pulmonary disease (COPD). Subjects and methods . 246 patients with MI were examined. In 137 (55.7%) people, MI developed on the background of COPD, while in 109 (44.3%) patients MI was a single condition. Comparison groups consisted of 55 somatically healthy individuals and 50 patients with COPD. Enzyme immunoassay was used for testing homocysteine levels in plasma samples. Results . Stenoses of only one coronary artery (CA) with hyperhomocysteinemia were rare in patients in both groups (3.5% in patients with myocardial infarction and 3% in patients with myocardial infarction and concurrent COPD), multivessel diseases of CA statistically significantly prevailed. Lesions of 3 vessels or more were detected statistically significantly more often in patients with hyperhomocysteinemia with myocardial infarction and concurrent COPD. Among patients with myocardial infarction with hyperhomocysteinemia, patients with CA narrowing by 50-75% prevailed, and among patients with myocardial infarction with COPD and hyperhomocysteinemia, patients with CA narrowing by 75-99% and complete occlusion were statistically significantly more frequent. That is, in patients with myocardial infarction, concurrent COPD and hyperhomocysteinemia, more pronounced lesion of CA was observed, which was manifested by multivascular lesions, greater severity of occlusion and higher frequency of complete stenosis of CA.

A mini review of inhaled beta 2 agonists in acute decompensated heart failure requiring respiratory support.

Acute decompensated heart failure (HF) results in over one million hospital admissions per year, many requiring invasive or noninvasive mechanical ventilation for respiratory/cardiovascular support. Inhaled beta-2 adrenergic receptor agonists have been shown to be effective at clearance of extravascular lung water in HF patients. However, studies done in the late 1990s and early 2000s, prior to standardization and wide adoption of guideline directed medical therapy for HF, suggested that inhaled beta-2 agonist use increased admissions for HF exacerbations as well as in-hospital mortality. One study even attempted to utilize intravenous Beta-2 agonists in Acute Respiratory Distress Syndrome patients, however the study was stopped prematurely due to an 11% increased mortality in the treatment group. More recently however, studies examining patients who have concurrent diagnoses of chronic obstructive pulmonary disease (COPD) and HF showed that beta-2 agonist therapy resulted in similar or better outcomes compared to controls. Likewise, in-vitro studies, animal models, and studies utilizing chronic heart failure patients treated with nebulized beta-2 agonists with no concurrent respiratory diagnosis had a therapeutic effect of treatment over controls. These studies have the advantage of being performed with the standardization of guideline directed HF medical therapy. In conclusion, while we continue to recommend the use of Beta-2 agonist therapy in patients with concurrent COPD and HF requiring respiratory support, further studies, preferably single or double blinded prospective trials, will need to be performed to determine whether Beta-2 agonist therapy offers morbidity and mortality benefits in patients with strictly acute decompensated heart failure requiring respiratory support.

Concomitant diagnosis of asthma and COPD: a quantitative study in UK primary care.

BackgroundAsthma and chronic obstructive pulmonary disease (COPD) share many characteristics and symptoms, and the differential diagnosis between the two diseases can be difficult in primary care. This study explored potential overlap between both diseases in a primary care environment.AimTo quantify how commonly patients with COPD have a concomitant diagnosis of asthma, and how commonly patients with asthma have a concomitant diagnosis of COPD in UK primary care. Additionally, the study aimed to determine the extent of possible misdiagnosis and missed opportunities for diagnosis.Design and settingPatients with validated asthma and patients with validated COPD in primary care were identified from the UK Clinical Practice Research Datalink (CPRD) in separate validation studies, and the diseases were confirmed by review of GP questionnaires.MethodThe prevalence of concurrent asthma and COPD in validated cases of either disease was examined based on CPRD coding, GP questionnaires, and requested additional information.ResultsIn total, 400 patients with COPD and 351 patients with asthma in primary care were identified. Of the patients with validated asthma, 15% (n = 52) had previously received a diagnostic COPD Read code, although COPD was only likely in 14.8% (95% confidence interval [CI] = 11.3 to 19.0) of patients with validated asthma. More than half (52.5%, n = 210) of patients with validated COPD had previously received a diagnostic asthma Read code. However, when considering additional evidence to support a diagnosis of asthma, concurrent asthma was only likely in 14.5% (95% CI = 11.2 to 18.3) of patients with validated COPD.ConclusionA concurrent asthma and COPD diagnosis appears to affect a relative minority of patients with COPD (14.5%) or asthma (14.8%). Asthma diagnosis may be over-recorded in people with COPD.

Long-Term Outcomes in Patients with Incident Chronic Obstructive Pulmonary Disease after Acute Kidney Injury: A Competing-Risk Analysis of a Nationwide Cohort.

Both acute kidney injury (AKI) and chronic obstructive pulmonary disease (COPD) are associated with increased morbidity and mortality. However, the incidence of de novo COPD in patients with AKI, and the impact of concurrent COPD on the outcome during post-AKI care is unclear. Patients who recovered from dialysis-requiring AKI (AKI-D) during index hospitalizations between 1998 and 2010 were identified from nationwide administrative registries. A competing risk analysis was conducted to predict the incidence of adverse cardiovascular events and mortality. Among the 14,871 patients who recovered from temporary dialysis, 1535 (10.7%) were identified as having COPD (COPD group) one year after index discharge and matched with 1473 patients without COPD (non-COPD group) using propensity scores. Patients with acute kidney disease superimposed withs COPD were associated with a higher risk of incident ischemic stroke (subdistribution hazard ratio (sHR), 1.52; 95% confidence interval (95% CI), 1.17 to 1.97; p = 0.002) and congestive heart failure (CHF; sHR, 1.61; (95% CI), 1.39 to 1.86; p < 0.001). The risks of incident hemorrhagic stroke, myocardial infarction, end-stage renal disease, and mortality were not statistically different between the COPD and non-COPD groups. This observation adds another dimension to accumulating evidence regarding pulmo-renal consequences after AKI.

Mechanisms of Exercise Intolerance in Heart Failure with Reduced Ejection Fraction: Influence of COPD

IntroductionExercise intolerance is a hallmark of heart failure with reduced ejection fraction (HFrEF) resulting from a variety of factors including comprised oxygen delivery. A common comorbidity of HFrEF is chronic obstructive pulmonary disease (COPD), which is independently associated with reduced exercise tolerance and cardiac output (Q) as well as peripheral dysfunction similar to HFrEF. It is currently unknown if HFrEF and coexisting COPD (HFrEF+COPD) exhibit worsened exercise tolerance and whether the mechanisms thereof are similar to HFrEF alone. We hypothesized that patients with HFrEF+COPD demonstrate further reductions in peak VO2 and workload subsequent to a lower peak Q and arterio‐mixed venous O2 content difference (C(a‐v)O2) compared to HFrEF alone.MethodsHFrEF+COPD (n=16) and HFrEF (n=17) (age: 57±7 vs 54±6 yrs; EF%: 20±5 vs 21±5; height: 173±7 vs 174±7 cm; weight: 88±14 vs 86±17 kg; all p&gt;0.18) underwent peak exercise testing during right heart catheterization. At rest and peak exercise, invasive hemodynamic, cardiac pressures, and arterial pressures were performed. Heart rate and oxygen uptake (VO2) were measured at rest and peak exercise via 12‐lead ECG and metabolic measurement system, respectively. Convective oxygen delivery was calculated as Q multiplied by CaO2.ResultsPeak exercise VO2 and workload were lower in HFrEF+COPD compared to HFrEF (7.0±1.9 vs. 9.9±2.7 mL/min/kg; 34±7 vs. 45±12 watts; both p&lt;0.01). At peak exercise, Q and stroke volume were lower in HFrEF+COPD than HFrEF (4.8±1.3 vs. 7.0±3.0 L/min; 52±16 vs. 75±28 mL; both p&lt;0.01). Significant relationships existed between delta VO2 and Q (peak exercise minus resting) in HFrEF+COPD and HFrEF (r=0.84 and r=0.89; both p&lt;0.01); however, HFrEF+COPD had a significantly lower slope (p=0.02). Peak exercise C(a‐v)O2 was not different between HFrEF+COPD and HFrEF (12.9±2.3 vs. 12.8±2.6 mL/dL; p=0.89). No differences were present in heart rate or hemoglobin at peak exercise (p&gt;0.73). Delta VO2 and C(a‐v)O2 was significantly related for HFrEF+COPD (r=0.68; p&lt;0.01), but not HFrEF (r=0.14, p=0.57). At peak exercise, HFrEF+COPD had lower convective oxygen delivery (845±239 vs. 1230±517 mL/min; p&lt;0.01).ConclusionsPatients with HFrEF and concurrent COPD demonstrate worsened exercise tolerance compared to HFrEF resulting from reduced oxygen delivery. These data suggest HFrEF with COPD exhibit more severe central and peripheral abnormalities than HFrEF alone.Support or Funding InformationNHLBI RO1 HL126638This abstract is from the Experimental Biology 2018 Meeting. There is no full text article associated with this abstract published in The FASEB Journal.

Relationship between heart failure, concurrent chronic obstructive pulmonary disease and beta-blocker use: A Danish nationwide cohort study

Aims To compare the hazard of all-cause, chronic obstructive pulmonary disease (COPD) and heart failure (HF) hospitalization in carvedilol vs. metoprolol/bisoprolol/nebivolol users with COPD and concurrent HF from 2009 to 2012, and to evaluate the use and persistence in treatment of these β-blockers, their impact on the risk of COPD-related hospitalization, and the factors important for their selection. Methods and results Cox and logistic regression were used for both unadjusted and adjusted analyses. Carvedilol users had a higher hazard of being hospitalized for HF compared with metoprolol/bisoprolol/nebivolol users in both the unadjusted [hazard ratio (HR) 1.74; 95% confidence interval (CI) 1.65-1.83] and adjusted (HR 1.61; 95% CI 1.52-1.70) analyses. No significant differences were found for all-cause and COPD hospitalization between the two groups. Carvedilol users had a significant lower restricted mean persistence time than metoprolol/bisoprolol/nebivolol users. Patients exposed to carvedilol had an odds ratio (OR) of 1.38 (95% CI 1.23-1.56) for being hospitalized due to COPD within 60 days after redeeming the first carvedilol prescription, which was similar to that observed in metoprolol/bisoprolol/nebivolol users (OR 1.37; 95% CI 1.27-1.48). Patients with concurrent chronic kidney disease had a higher probability of receiving carvedilol (OR 1.16; 95% CI 1.04-1.29). Conclusion Carvedilol prescription carried an increased hazard of HF hospitalization and lower restricted mean persistence time among patients with COPD and concurrent HF. Additionally, we found a widespread phenomenon of carvedilol prescription at variance with the European Society of Cardiology guidelines and potential for improving the proportion of patients treated with β-blockers.

Relationship between heart failure, concurrent chronic obstructive pulmonary disease and beta-blocker use: a Danish nationwide cohort study.

To compare the hazard of all-cause, chronic obstructive pulmonary disease (COPD) and heart failure (HF) hospitalization in carvedilol vs. metoprolol/bisoprolol/nebivolol users with COPD and concurrent HF from 2009 to 2012, and to evaluate the use and persistence in treatment of these β-blockers, their impact on the risk of COPD-related hospitalization, and the factors important for their selection. Cox and logistic regression were used for both unadjusted and adjusted analyses. Carvedilol users had a higher hazard of being hospitalized for HF compared with metoprolol/bisoprolol/nebivolol users in both the unadjusted [hazard ratio (HR) 1.74; 95% confidence interval (CI) 1.65-1.83] and adjusted (HR 1.61; 95% CI 1.52-1.70) analyses. No significant differences were found for all-cause and COPD hospitalization between the two groups. Carvedilol users had a significant lower restricted mean persistence time than metoprolol/bisoprolol/nebivolol users. Patients exposed to carvedilol had an odds ratio (OR) of 1.38 (95% CI 1.23-1.56) for being hospitalized due to COPD within 60 days after redeeming the first carvedilol prescription, which was similar to that observed in metoprolol/bisoprolol/nebivolol users (OR 1.37; 95% CI 1.27-1.48). Patients with concurrent chronic kidney disease had a higher probability of receiving carvedilol (OR 1.16; 95% CI 1.04-1.29). Carvedilol prescription carried an increased hazard of HF hospitalization and lower restricted mean persistence time among patients with COPD and concurrent HF. Additionally, we found a widespread phenomenon of carvedilol prescription at variance with the European Society of Cardiology guidelines and potential for improving the proportion of patients treated with β-blockers.

Predictors of Early Readmission in Hospitalized Patients with Inflammatory Bowel Disease

Readmissions are being increasingly used as an indicator of quality of care. We sought to identify risk factors for 30-day readmission in hospitalized patients with inflammatory bowel disease. Patients with inflammatory bowel disease hospitalized between 2004 and 2013 at the University of Maryland were identified. Demographic and clinical information were extracted from the medical record for each admission. Multivariate logistic regression was performed to determine the association between these variables and readmission. One thousand two hundred thirteen admissions were identified in 498 patients; 232 (19.1%) index admissions were followed by a 30-day readmission. Mean age was 39.4 ± 14.5 years. Approximately 70% of the population was white, 60% were women, and 67.5% had Crohn's disease. Concurrent congestive heart failure and chronic obstructive pulmonary disease, history of steroid use, diverting ileostomy, subtotal colectomy, or a thromboembolic event during index admission, and IV antibiotics or restricted diet at discharge were associated with readmission. After adjustment, patients with congestive heart failure or chronic obstructive pulmonary disease were more likely to be readmitted (aOR 4.06 and 2.86, respectively). Underweight or obese patients were nearly twice as likely to be readmitted (aOR 1.81 and 1.72, respectively). Those with past steroid use, new ileostomy, or those who were discharged on hyperalimentation were twice as likely to be readmitted (aOR 1.90, 2.04, and aOR 1.97, respectively). Nineteen percentage of patients with inflammatory bowel disease treated at a referral center are readmitted within 30 days. Our results suggest that patients with comorbid medical conditions, malnutrition or obesity, a new ileostomy, past steroid use, or those discharged on hyperalimentation are at increased risk for readmission. Research is needed to determine if targeted interventions for high-risk patients decreases readmissions.

Concurrent physician-diagnosed asthma and chronic obstructive pulmonary disease: A population study of prevalence, incidence and mortality.

ObjectiveWe conducted a population-based cohort study to estimate trends in prevalence, incidence, and mortality of concurrent physician-diagnosed asthma and chronic obstructive pulmonary disease (COPD).Study design and settingTwo validated health administrative case definitions were used to identify asthma and COPD among all individuals aged 35 years and older living in Ontario, Canada. Annual asthma, COPD, and concurrent asthma and COPD prevalence, incidence, and mortality, standardized for age and sex, were estimated, and compared from 2002 to 2012, using generalized linear models.ResultsStandardized prevalence of concurrent asthma and COPD increased by 10.5%, from 2.9% in 2002 to 3.2% in 2012 overall, but more prominently in women compared to men. Overall, standardized incidence decreased by16%, from 2.5 to 2.1 per 1000 individuals, but increased significantly in young adults. All-cause mortality among patients with concurrent asthma and COPD decreased by 11.2%, from 2.6% to 2.2%. Being diagnosed with both diseases was significantly associated with higher all-cause mortality compared to asthma (OR = 1.56, 95% CI: 1.50–1.58), but not compared to COPD (OR = 0.97, 0.96–0.98), except in young adults aged 35 to 49 years where people with asthma and COPD had higher mortality (OR = 1.21, 1.15–1.27).ConclusionsIn a large North American population, the burden of concurrent physician-diagnosed asthma and COPD is increasing, particularly in women and young adults.

Chronic obstructive pulmonary disease and long-term mortality in elderly subjects with chronic heart failure.

Chronic heart failure (CHF) and chronic obstructive pulmonary disease (COPD) are associated with high rates of mortality in elderly subjects. Concurrent CHF and COPD frequently occur, especially in with advancing age. This study examines long-term mortality in community-dwelling elderly subjects affected by CHF alone, COPD alone, and coexistent CHF and COPD. The study evaluated 12-years mortality in 1288 subjects stratified for the presence or absence of CHF or COPD alone, and for coexistence of CHF and COPD. Mortality, at 12year follow-up, was 46.7% overall, 68.6% in the presence of CHF alone (p < 0.001), 56.9% in the presence of COPD alone (p < 0.01); mortality was 86.2% where CHF and COPD coexisted (p < 0.001) and was significantly higher than in CHF or COPD alone (p < 0.05). Multivariate analysis indicates that CHF (Hazard risk = 1.67, 95% confidence interval 1.15-3.27, p < 0.031) and COPD (Hazard risk = 1.27, 95% confidence interval = 1.08-1.85, p < 0.042) were predictive of long-term mortality. When CHF and COPD simultaneously occurred, the risk dramatically increased up to 3.73 (95% confidence interval = 1.19-6.93, p < 0.001). Long-term follow-up showed higher mortality among elderly subjects affected by CHF or COPD. Simultaneous presence of CHF and COPD significantly increased the risk of death. Therefore, the presence of COPD in CHF patients should be considered a relevant factor in predicting high risk of mortality.