Global Initiative For Chronic Obstructive Lung Disease Classification Research Articles

Multi-component assessment of chronic obstructive pulmonary disease: an evaluation of the ADO and DOSE indices and the global obstructive lung disease categories in international primary care data sets.

Suitable tools for assessing the severity of chronic obstructive pulmonary disease (COPD) include multi-component indices and the global initiative for chronic obstructive lung disease (GOLD) categories. The aim of this study was to evaluate the dyspnoea, obstruction, smoking, exacerbation (DOSE) and the age, dyspnoea, obstruction (ADO) indices and GOLD categories as measures of current health status and future outcomes in COPD patients. This was an observational cohort study comprising 5,114 primary care COPD patients across three databases from UK, Sweden and Holland. The associations of DOSE and ADO indices with (i) health status using the Clinical COPD Questionnaire (CCQ) and St George’s Respiratory Questionnaire (SGRQ) and COPD Assessment test (CAT) and with (ii) current and future exacerbations, admissions and mortality were assessed in GOLD categories and DOSE and ADO indices. DOSE and ADO indices were significant predictors of future exacerbations: incident rate ratio was 1.52 (95% confidence intervals 1.46–1.57) for DOSE, 1.16 (1.12–1.20) for ADO index and 1.50 (1.33–1.68) and 1.23 (1.10–1.39), respectively, for hospitalisations. Negative binomial regression showed that the DOSE index was a better predictor of future admissions than were its component items. The hazard ratios for mortality were generally higher for ADO index groups than for DOSE index groups. The GOLD categories produced widely differing assessments for future exacerbation risk or for hospitalisation depending on the methods used to calculate them. None of the assessment systems were excellent at predicting future risk in COPD; the DOSE index appears better than the ADO index for predicting many outcomes, but not mortality. The GOLD categories predict future risk inconsistently. The DOSE index and the GOLD categories using exacerbation frequency may be used to identify those at high risk for exacerbations and admissions.

Sputum inflammatory cells in COPD patients classified according to GOLD 2011 guidelines

Recently the definition of chronic obstructive pulmonary disease (COPD) severity, stated in 2001 by Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines and based on forced expiratory volume in 1 s (FEV1) evaluation, has been considered inadequate to recognise all the multifaceted aspects of the disease. To overcome this limitation, 2011 GOLD recommendations suggested a new approach, which stratified COPD patients in four groups of severity (A, B, C, D) according to the level of symptoms (as assessed by either the modified Medical Research Council (mMRC) score or the COPD Assessment Test), the degree of airflow limitation (expressed as percentage of predicted forced expiratory volume in 1 s (FEV1) value) and the number of exacerbations in the previous year [1]. It is still matter of debate if this new classification helps to better understand the disease and improve COPD treatment and prognosis. Studies on the existing database have been published comparing the old with the new GOLD classifications, showing that GOLD 2011 classification adds new details on the phenotyping and on the prognosis of COPD [2–5]. Despite the many post hoc analyses performed on the large databases of the most important recent observational studies (ECLIPSE, CCLS, COPDgene), the demonstration that these different groups of GOLD 2011 classification are different for physiological and biological features is controversial. The A, B, C and D groups of the new GOLD classification are at least partly related to different COPD phenotypes

Cardiac function of patients with chronic obstructive pulmonary disease evaluated by echocardiography

Objective To evaluate the cardiac function in patients with chronic obstructive pulmonary disease (COPD) by using echocardiography. Methods Three hundred and twenty eight COPD patients and 60 age and gender-matched healthy subjects (control group) were enrolled in the study. According to Global Initiative for Chronic Obstructive Lung Disease (GOLD) criteria, patients were as classified as mild (n=102), moderate (n=85), severe (n=80) and very severe (61). All participants underwent conventional echocardiography and two dimensional-speckle tracking echocardiography (2D-STE) to assess cardiac function. Results The LVEF was reduced significantly, while the PASP was increased in severe and very severe COPD patients [(60.9±2.0)% and (59.4±2.8)%, t value: 3.358, 4.859 to normal controls, 5.247, 6.641 to mild, 3.280, 4.863 to moderate, respectively, all P<0.001]. The LA size was dilated in very severe COPD patients [(3.9±0.5)cm, t value:-2.407,-2.625,-2.071,-2.186, P<0.05], and the RVEF was significantly less than those of the other patients [(42.8±7.3)%, t value: 6.357, 6.832, 5.581, 4.639, P<0.05]. The right ventricular FAC of moderate or severe COPD patients and the segmental and global LS of left and right ventricular in COPD patients were significantly lower than those in the normal controls, and which were gradually decreased as GOLD classification rising [RVFAC, moderate: (37.7±2.0)%, severe: (35.5±3.2) %, very severe: (34.0±3.1) %, t value:-4.616,-5.982,-7.195, respectively; LSLVg, moderate: (-18.62±1.76) %, severe: (-17.15±0.73) %, very severe: (-16.51±0.89) %, t value: -9.389,-15.494,-16.873, respectively; LSRVg, moderate: (-20.52±2.27) %, severe: (-18.84±1.38) %, very severe: (-16.82±1.10) %, t value: -8.555,-13.595,-18.499, respectively, all P<0.001]. Besides, the FAC of COPD patients was positively correlated with the RVEF (r=0.676, P<0.05), while the RVLSg was negatively correlated with the FAC and RVEF (r=-0.677,-0.591, all P<0.05). Conclusions There were left and right ventricular dysfunction in COPD patients, which decreased as GOLD classification upgraded. The FAC and 2D-STE can effectively detect the subtle abnormalities of regional and global ventricular function. Key words: Pulmonary disease, chronic obstructive; Ventricular function; Echocardiography

Biobehavioral Prognostic Factors in Chronic Obstructive Pulmonary Disease: Results From the INSPIRE-II Trial.

To examine the prognostic value of select biobehavioral factors in patients with chronic obstructive pulmonary disease (COPD) in a secondary analysis of participants from the INSPIRE-II trial. Three hundred twenty-six outpatients with COPD underwent assessments of pulmonary function, physical activity, body mass index, inflammation, pulmonary symptoms, depression, and pulmonary quality of life and were followed up for up to 5.4 years for subsequent clinical events. The prognostic value of each biobehavioral factor, considered individually and combined, also was examined in the context of existing Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2011 risk stratification. Sixty-nine individuals experienced a hospitalization or died over a mean follow-up period of 2.4 (interquartile range = 1.6) years. GOLD classification was associated with an increased risk of clinical events (hazard ratio [HR] = 2.72 [95% confidence interval = 1.63-4.54], per stage); 6-minute walk (HR = 0.50 [0.34-0.73] per 500 ft), total steps (HR = 0.82 [0.71-0.94] per 1000 steps), high-sensitivity C-reactive protein (HR = 1.44 [1.01-2.06] per 4.5 mg/l), depression (HR = 1.12 [1.01-1.25] per 4 points), and pulmonary quality of life (HR = 1.73 [1.14-2.63] per 25 points) were each predictive over and above the GOLD assessment. However, only GOLD group and 6-minute walk were predictive of all-cause mortality and COPD hospitalization when all biobehavioral variables were included together in a multivariable model. Biobehavioral factors provide added prognostic information over and above measures of COPD severity in predicting adverse events in patients with COPD.

Categorization of COPD patients in Turkey via GOLD 2013 strategy document: ALPHABET study.

ObjectiveTo determine distribution of COPD assessment categories and physicians’ adherence to Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2013 strategy in Turkish COPD patients.MethodsA total of 1,610 COPD patients (mean [standard deviation] age: 62.6 [9.9] years, 85.7% were males) were included in this multicenter, non-interventional, cross-sectional study. Patients were categorized via GOLD 2013 strategy document. Consistency between reported and re-classified GOLD categories, and measures used for symptom evaluation and exacerbation was analyzed.ResultsOverall, 41.1% of patients were assigned to GOLD A, while 13.2% were assigned to GOLD C categories. Long-acting beta-2 agonist + long-acting muscarinic antagonist + inhaled corticosteroid regimen was the most common treatment (62.0%). Over-treatment was noted in >70% of GOLD A, B, and C patients. A high consistency between measures of symptom evaluation (Kappa coefficient =0.993, P<0.0001) and a low-moderate consistency between exacerbation risk measures (Kappa coefficient =0.237, P<0.0001) were noted.ConclusionOur findings revealed GOLD A as the most prevalent category in Turkish cohort of COPD patients. Group assignment was altered depending on the chosen measure for symptom and risk assessment. Physician non-adherence to treatment recommendations in GOLD 2013 document leading to over-treatment in patients assigned to GOLD A, B, and C categories was also detected.

Epidemiology, severity, and treatment of chronic obstructive pulmonary disease in the United Kingdom by GOLD 2013.

ObjectivesIn 2013, the Global Initiative for Chronic Obstructive Lung Disease (GOLD) updated the management strategy on COPD based on severity using a combined assessment of symptoms, degree of airflow limitation, and number of exacerbations. This study quantified prevalence and incidence of COPD in the United Kingdom and estimated disease severity by GOLD 2013 categories A/B (low risk) and C/D (high risk).MethodsThe Clinical Practice Research Datalink was used to identify COPD patients ≥40 years. Patient characteristics were described, and prevalence was calculated on December 31, 2013. Five-year incidence (2009–2013) was estimated, with rates standardized using 2011 UK population age and sex. To classify patients by GOLD categories, spirometry results, the modified British Medical Research Council grade, and history of exacerbations were used.ResultsThe prevalent cohort comprised 49,286 patients with COPD with mean age 70 years; 51.0% were male. Overall prevalence was 33.3 per 1,000 persons (95% confidence interval [CI]: 33.1–33.6); 66.4% were classified as GOLD A/B and 33.6% as C/D. The standardized prevalence of GOLD A/B was 21.9 per 1,000 persons (95% CI: 21.7–22.1) and of C/D was 11.1 (95% CI: 10.9–11.2). A total of 27,224 newly diagnosed COPD patients were identified with mean age 67 years at diagnosis; 53.0% were male. Incidence was 2.2 per 1,000 person-years (95% CI: 2.2–2.3); 68.7% were classified in categories A/B and 31.3% in C/D, of which 17.2% did not receive COPD maintenance medication.ConclusionA third of COPD patients in the UK are considered high risk (GOLD 2013 categories C/D), and a third of patients are diagnosed for the first time at these severe stages. Given the progressive nature of the disease, results suggest that closer attention to respiratory symptoms for early detection, diagnosis, and appropriate treatment of COPD in the UK is warranted.

Present status of medical treatment for patients with chronic obstructive pulmonary disease based upon different severity classifications

To survey the present status of medical treatment for Chinese outpatients with chronic obstructive pulmonary disease (COPD) based upon the guidelines for diagnosing and treating COPD (2007 Revised Edition and 2013 Revised Edition) and explore the impact of new guideline on treatment regimens. A retrospective study was conducted at 11 participating hospitals. Stable COPD patients were consecutively recruited from outpatient clinics in China between September 2007 and December 2008 and categorized into the Global Initiative for Chronic Obstructive Lung Disease (GOLD) I-IV classification and A-D groups according to the Chinese guidelines for diagnosing and treating COPD (2007 Revised Edition and 2013 Revised Edition). The authors compared the present status of medical treatment of two guidelines and analyze the impact of new guideline on treatment regimens. Among a total of 749 patients, 79.2% (593/749) patients received medical treatment. The distribution of classification GOLD I-IV was 34 (4.5%), 211 (28.2%), 309 (41.3%) and 195 (26.0%). According to the guideline 2007, the patients on medical under-treatment based upon the guidelines in GOLD I-IV classification were 32.4% (11/34), 53.6% (113/211), 57.6% (178/309) and 55.4% (108/195); those on medical treatment: 23.5% (8/34), 3.8% (8/211), 28.8% (89/309) and 33.3% (65/195); those on medical over-treatment: 44.1% (15/34), 42.7% (90/211), 13.6% (42/309), 11.3% (22/195). The distribution of categories A-D was 93 (12.4%), 45 (6.0%), 196 (26.2%), and 415 (55.4%). According to guideline 2013, the patients on medical under-treatment were 34.4% (32/93), 62.2% (28/45), 67.9% (133/196) and 60.7% (252/415); those on medical treatment: 24.7% (23/93), 4.4% (2/45), 32.1% (63 /196) and 39.3% (163/415); those on medical over-treatment: 40.9% (38/93), 33.3% (15/45), 0 and 0. The concordance analysis comparing the judgments of treatment regimens by these two guideline yielded a weighted Kappa coefficient of 0.534 (P < 0.001), indicating that there was a moderate degree of judgments between two guidelines. Medical treatment regimens recommended by new guideline was different from old guideline in 143 COPD patients. Among them, 24 patients (16.8%) required a step-down therapy while 119 patients (83.2%) a step-up therapy. There are more outpatients with COPD on medical treatment, but few of them have received standardized treatment. Compared with the old GOLD classification, more patients are recommended for a step-up therapy by new stratification.

Six-minute-walk distance and accelerometry predict outcomes in chronic obstructive pulmonary disease independent of Global Initiative for Chronic Obstructive Lung Disease 2011 Group.

The 2011 combined Global Initiative for Chronic Obstructive Lung Disease (GOLD) assessment incorporates symptoms, exacerbation history, and spirometry in discriminating risk of exacerbations in patients with chronic obstructive pulmonary disease (COPD). Six-minute-walk distance (6MWD) and accelerometry also have been used to assess disease severity in COPD. The association between these measures and the risks of hospitalization and mortality in the context of GOLD 2011 is unknown. To describe changes in exercise tolerance and physical activity over time in patients with COPD and to test the hypothesis that lower baseline 6MWD or accelerometry step count is associated with increased risk of COPD-related hospitalization or all-cause mortality, independent of GOLD 2011 group. Physical function and medical outcomes were prospectively assessed in 326 patients with moderate to severe COPD in INSPIRE-II, a randomized controlled trial of a coping skills training intervention. Cox models were used to determine if GOLD 2011 group, 6MWD, or accelerometry steps were associated with risk of COPD-related hospitalization or all-cause mortality. Physical function declined over time in GOLD group D but remained stable in groups A, B, and C. GOLD classification was associated with time to death or first COPD-related hospitalization. Baseline 6MWD was more strongly associated with time to death or first COPD-related hospitalization (hazard ratio, 0.50 [95% confidence interval, 0.34, 0.73] per 150 m, P=0.0003) than GOLD 2011 classification. A similar relationship was observed for accelerometry steps (hazard ratio, 0.80 [95% confidence interval, 0.70, 0.92] per 1,000 steps, P=0.002). Exercise tolerance and daily physical activity are important predictors of hospitalization and mortality in COPD, independent of GOLD 2011 classification. Physical function may represent a modifiable risk factor that warrants increased attention as a target for interventions to improve clinically meaningful outcomes in COPD.

Validation of the GOLD 2013 classification in predicting exacerbations and mortality in Taiwanese patients with chronic obstructive pulmonary disease.

Evidence for the effectiveness of the new multidimensional GOLD (Global Initiative for Chronic Obstructive Lung Disease) classification is currently limited. The new classification has been validated in the United States and Europe, but validation in Asian patients is still lacking. We examined the abilities of the GOLD 2013 classification to predict clinical outcomes in Taiwanese patients with chronic obstructive pulmonary disease (COPD). Patients with COPD were recruited from January 2006 to December 2012 and followed up for exacerbation and mortality. The predictive abilities of various assessments were compared through logistic regression analysis using receiver operating curve (ROC) estimations and area under the curve (AUC). A total of 471 patients with COPD were analyzed. The GOLD 2013 groups at high risk of exacerbation (C and D) experienced a higher average number of exacerbations per year (2.1±3.1 vs. 0.3±1.0, p<0.001) than the low risk groups (A and B). The mortality rates were 10.1% in GOLD 2013 Group A, 14.1% in Group B, 4.0% in Group C, and 30.5% in Group D. The AUC values for GOLD 2013 and GOLD 2007 were 0.78 versus 0.67 (p<0.001) for exacerbation, and 0.66 versus 0.61 (p=0.15) for mortality. The GOLD 2013 classification has powerful ability to predict exacerbation, but poor ability to predict mortality. The prognostic validity of the GOLD 2013 classification to predict exacerbations was better than the GOLD 2007 classification.

Czech multicenter research database of severe COPD.

PurposeChronic obstructive pulmonary disease (COPD) has been recognized as a heterogeneous, multiple organ system-affecting disorder. The Global Initiative for Chronic Obstructive Lung Disease (GOLD) places emphasis on symptom and exacerbation management. The aim of this study is examine the course of COPD and its impact on morbidity and all-cause mortality of patients, with respect to individual phenotypes and GOLD categories. This study will also evaluate COPD real-life patient care in the Czech Republic.Patients and methodsThe Czech Multicentre Research Database of COPD is projected to last for 5 years, with the aim of enrolling 1,000 patients. This is a multicenter, observational, and prospective study of patients with severe COPD (post-bronchodilator forced expiratory volume in 1 second ≤60%). Every consecutive patient, who fulfils the inclusion criteria, is asked to participate in the study. Patient recruitment is done on the basis of signed informed consent. The study was approved by the Multicentre Ethical Committee in Brno, Czech Republic.ResultsThe objective of this paper was to outline the methodology of this study.ConclusionThe establishment of the database is a useful step in improving care for COPD subjects. Additionally, it will serve as a source of data elucidating the natural course of COPD, comorbidities, and overall impact on the patients. Moreover, it will provide information on the diverse course of the COPD syndrome in the Czech Republic.

Utility of the combination of serum highly-sensitive C-reactive protein level at discharge and a risk index in predicting readmission for acute exacerbation of COPD.

OBJECTIVE: Frequent readmissions for acute exacerbations of COPD (AECOPD) are an independent risk factor for increased mortality and use of health-care resources. Disease severity and C-reactive protein (CRP) level are validated predictors of long-term prognosis in such patients. This study investigated the utility of combining serum CRP level with the Global Initiative for Chronic Obstructive Lung Disease (GOLD) exacerbation risk classification for predicting readmission for AECOPD. METHODS: This was a prospective observational study of consecutive patients hospitalized for AECOPD at Peking University Third Hospital, in Beijing, China. We assessed patient age; gender; smoking status and history (pack-years); lung function; AECOPD frequency during the last year; quality of life; GOLD risk category (A-D; D indicating the greatest risk); and serum level of high-sensitivity CRP at discharge (hsCRP-D). RESULTS: The final sample comprised 135 patients. Of those, 71 (52.6%) were readmitted at least once during the 12-month follow-up period. The median (interquartile) time to readmission was 78 days (42-178 days). Multivariate analysis revealed that serum hsCRP-D ≥ 3 mg/L and GOLD category D were independent predictors of readmission (hazard ratio = 3.486; 95% CI: 1.968-6.175; p < 0.001 and hazard ratio = 2.201; 95% CI: 1.342-3.610; p = 0.002, respectively). The ordering of the factor combinations by cumulative readmission risk, from highest to lowest, was as follows: hsCRP-D ≥ 3 mg/L and GOLD category D; hsCRP-D ≥ 3 mg/L and GOLD categories A-C; hsCRP-D < 3 mg/L and GOLD category D; hsCRP-D < 3 mg/L and GOLD categories A-C. CONCLUSIONS: Serum hsCRP-D and GOLD classification are independent predictors of readmission for AECOPD, and their predictive value increases when they are used in combination.

New disease severity classification of patients with stable chronic obstructive pulmonary disease in Shanghai

Background The Global Initiative for Chronic Obstructive Lung Disease (GOLD) presented a new ABCD group classification of chronic obstructive pulmonary disease (COPD). We aimed to examine the association of spirometric classification and the new GOLD classification with exacerbations, and to compare symptoms in different ways. Methods We investigated 848 patients with stable COPD from 24 hospitals. The annual frequencies of acute exacerbation and hospitalization were compared between the old and new classification. The symptom level was assessed using COPD assessment test (CAT) and modified British Medical Research Council (mMRC) questionnaire. Results A total of 848 patients were included in this study. According to spirometric classification, there were 32 patients of grade I (3.8%), 315 of grade II (37.1%), 366 of grade III (43.2%), and 135 of grade IV (15.9%). According to GOLD 2011 classification, there were 59 patients of group A (7.0%), 172 of group B (20.3%), 55 of group C (6.5%), and 562 of group D (66.3%). In spirometric classification, the annual frequencies of acute exacerbation and associated hospitalization were respectively 1 (0–3) and 0 (0–2) for grade I; 1 (0–5) and 0 (0–2) for grade II; 2 (0–6) and 1 (0–3) for grade III, and 3 (0–6) and 2 (0–3) for grade IV. In GOLD 2011, respectively 0 (0–3) and 0 (0–1) (group A), 1 (0–4) and 0 (0–3) (group B), 1 (0–5) and 0 (0–3) (group C), and 3 (0–6) and 1 (0–3) (group D). There were no significant difference between group B and C (Z= -1.347, P=0.178; Z= -0.772, P=0.440, respectively). The coincidence rate using mMRC=1 and CAT=10 as cutoff points was 86.6% (734/848, κ=0.706), compared with 77.9% (661/848, κ=0.60) using mMRC=2 and CAT=10. Conclusions Lung function test may be a better predictor of acute exacerbation and associated hospitalization of COPD. It is more appropriate to use mMRC=1 as cutoff point for assessing COPD symptoms.

Relationship of the 2011 Global Initiative for Chronic Obstructive Lung Disease strategy to clinically relevant outcomes in individuals with α1-antitrypsin deficiency.

It is not known how the 2011 Global Initiative for Chronic Obstructive Lung Disease (GOLD) strategy predicts clinical course of α1-antitrypsin deficiency (AATD). To determine how the new strategy relates to outcomes (i.e., mortality, lung function decline, and exacerbations) in patients with AATD. All PiZZ patients (patients with ZZ genotype causing severe AATD) on the AATD registry with a physiological diagnosis of chronic obstructive pulmonary disease were grouped into four GOLD categories (A, B, C, and D) on the basis of their combined risk. We then compared mortality and lung function decline in these categories and also assessed the predictive ability of exacerbation history in the patients. Mortality (GOLD categories A: 6 [5.8%]; B: 7 [5.93%]; C: 11 [9.32%]; D: 94 [79.66%]) was greatest in high-symptom, high-risk category D (P = 0.0001), which also showed a faster decline in Kco (mmol/min/kPa/L/yr, mean [SD], A: -0.021 [0.03]; B: -0.022 [0.03]; C: -0.032 [0.03]; D: -0.031 [0.03]) (P = 0.012). The fastest mean decline in FEV1 (ml/yr, mean [SD], A: -66.59 [61.39]; B: -53.00 [47.09]; C: -56.96 [48.87]; D: -41.25 [62.09]) was observed in category A and least in category D (P = 0.002). Multivariate analysis showed that GOLD category was significant for all outcomes (P < 0.05). The new strategy performs well in identifying patients with increased risk of poorer outcomes in AATD. This has therapeutic implications enabling more aggressive therapy to be directed to those in the highest-risk group. Further studies to identify subgroups of patients most likely to benefit from augmentation therapy are indicated.

Prevalence of night-time dyspnoea in COPD and its implications for prognosis

The information on night-time symptoms in chronic obstructive pulmonary disease (COPD) is sparse. We investigated the prevalence of night-time dyspnoea in 6616 individuals with COPD recruited from the general population in the Copenhagen area, Denmark, and described characteristics and prognosis of subjects with this symptom. The prevalence of night-time dyspnoea was 4.3%: 2.1% in Global Initiative for Chronic Obstructive Lung Disease (GOLD) group A, 12.9% in GOLD B, 2.6% in GOLD C and 16.3% in GOLD D. Compared with individuals without night-time dyspnoea, those with night time dyspnoea had lower forced expiratory volume in 1 s, higher daytime dyspnoea scores (modified Medical Research Council scale) and more wheezing, more often had chronic mucus hypersecretion, ischaemic heart disease and atrial fibrillation, and more often reported stress, nervousness and tiredness. After adjustment for age and sex, the presence of night-time dyspnoea was associated with future COPD exacerbations (hazard ratio (HR) 2.3, 95% CI 1.7-3.0), hospital admissions due to COPD (HR 3.2, 95% CI 2.3-4.4) and mortality (HR 1.7, 95% CI 1.2-2.3). Prevalence of night-time dyspnoea in COPD increases with disease severity according to both spirometric and clinical GOLD classification, and is associated with presence of daytime respiratory symptoms and cardiac comorbidities. Night-time dyspnoea is a significant predictor of poor prognosis in individuals with COPD.

The Clinical Chronic Obstructive Pulmonary Disease Questionnaire: Cut Point for GOLD 2013 Classification

The Clinical Chronic Obstructive Pulmonary Disease Questionnaire: Cut Point for GOLD 2013 Classification

The distribution of COPD in UK general practice using the new GOLD classification

The new Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2011 document recommends a combined assessment of chronic obstructive pulmonary disease (COPD) based on current symptoms and future risk. A large database of primary-care COPD patients across the UK was used to determine COPD distribution and characteristics according to the new GOLD classification. 80 general practices provided patients with a Read code diagnosis of COPD. Electronic and hand searches of patient medical records were undertaken, optimising data capture. Data for 9219 COPD patients were collected. For the 6283 patients with both forced expiratory volume in 1 s (FEV1) and modified Medical Research Council scores (mean±sd age 69.2±10.6 years, body mass index 27.3±6.2 kg·m(-2)), GOLD 2011 group distributions were: A (low risk and fewer symptoms) 36.1%, B (low risk and more symptoms) 19.1%, C (high risk and fewer symptoms) 19.6% and D (high risk and more symptoms) 25.3%. This is in contrast with GOLD 2007 stage classification: I (mild) 17.1%, II (moderate) 52.2%, III (severe) 25.5% and IV (very severe) 5.2%. 20% of patients with FEV1 ≥50% predicted had more than two exacerbations in the previous 12 months. 70% of patients with FEV1 <50% pred had fewer than two exacerbations in the previous 12 months. This database, representative of UK primary-care COPD patients, identified greater proportions of patients in the mildest and most severe categories upon comparing 2011 versus 2007 GOLD classifications. Discordance between airflow limitation severity and exacerbation risk was observed.

Reanalysis of the Japanese experience using the combined COPD assessment of the 2011 GOLD classification

The Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2011 consensus report proposed a new classification system, incorporating symptoms with future risk, in subjects with chronic obstructive pulmonary disease (COPD). We hypothesized it could be applied to Japanese COPD patients. We previously analyzed clinical factors related to 5-year mortality in 150 male outpatients with COPD. We reviewed the data and reanalyzed the relationships between the new GOLD classification and various outcomes including mortality. There were 51 (34.0%), 12 (8.0%), 57 (38.0%), and 30 (20.0%) patients in GOLD A (forced expiratory volume in 1s [FEV1] ≥ 50% predicted and modified Medical Research Council [mMRC] 0-1), GOLD B (FEV1 ≥ 50% predicted and mMRC ≥ 2), GOLD C (FEV1<50% predicted and mMRC 0-1), and GOLD D (FEV1 <50% predicted and mMRC ≥ 2), respectively. The GOLD 2011 classification correlated significantly with exercise capacity and multi-dimensional disease staging. Cox proportional hazards analysis revealed that, among several methods categorizing symptoms, the GOLD A-D classification was significantly associated with mortality (p=0.0055). Although the relative number of patients in each category of the combined COPD assessment classification depended on the choice of symptom measures, the categories defined by the mMRC scale (score 0-1 versus ≥ 2) were most useful for future risk assessed as mortality. GOLD A had the lowest mortality, followed by GOLD B and C, and D had the highest mortality. Exercise capacity was also stratified by the new GOLD classification.

Impact of symptoms of anxiety and depression on COPD Assessment Test scores

Anxiety and depression are common comorbidities in patients with chronic obstructive pulmonary disease (COPD) and affect patients’ health status [1, 2]. Health status in COPD patients is frequently assessed by the St George’s Respiratory Questionnaire (SGRQ), which is a validated disease-specific questionnaire widely used in clinical trials [3], but complex and time-consuming to complete and score. Consequently, the COPD Assessment Test (CAT) has been developed [4]. This is a disease-specific health status questionnaire containing eight items with good sensitivity, reliability and responsiveness [4]. CAT scores are strongly positively correlated with SGRQ scores in patients with COPD [4]. Therefore, it is reasonable to hypothesise that those COPD patients with symptoms of anxiety and/or depression will report higher CAT scores (equalling worse health status) compared to those without symptoms. The latest version of the Global Initiative for Chronic Obstructive Lung Disease (GOLD) document [5] recommends the CAT as a tool to assess the impact of COPD on the individual patient beyond airflow limitation. Although it was known that clinically relevant symptoms of anxiety and depression are more common in patients in GOLD stage IV compared to patients in GOLD stages I and II [1], the frequency distribution of patients with symptoms of anxiety and depression across the updated GOLD classification remains unknown. Recently, Sillen et al. [6] reported a prevalence of symptoms of anxiety and depression of 38% and 32%, respectively, in COPD patients with GOLD group D. We aimed to assess …

Global Initiative for Chronic Obstructive Lung Disease 2011 Symptom/Risk Assessment in α1-Antitrypsin Deficiency

The new GOLD (Global Initiative for Chronic Obstructive Lung Disease) strategy recommends use of the COPD Assessment Test (CAT) or modified Medical Research Council (mMRC) scale to assess symptoms in COPD against "risk" as assessed by spirometry or exacerbation frequency. We aimed to determine the concordance between CAT and mMRC scale in assessing risk in patients with α1-antitrypsin deficiency (AATD) and the CAT threshold for risk assessment at which similar proportions of patients are assigned into the risk categories. Distribution of 309 patients (protease inhibitor Z phenotype) in four GOLD categories (A, B, C, and D) was compared. Using CAT for symptoms, we compared patient distribution using scores between 10 and 15 to ascertain the CAT threshold at which the distribution of patients in each group is proportional. Using CAT 10 and spirometry for risk assessment, 6.1% of patients were in group A (low symptoms/low risk), 39.2% in B (high symptoms/low risk), 2.3% in C (low symptoms/high risk), and 52.4% in D (high symptoms/high risk). Using mMRC scale and spirometry for risk produced a significantly different distribution from that using CAT (P &lt; .0001). Using CAT 13 as a symptom threshold and spirometry for risk resulted in a more proportional distribution of patients, which was similar using CAT and exacerbation history (P &gt; .0001) and mMRC scale and spirometry and/or exacerbation history for risk (P &gt; .0001). In patients with AATD, using either the mMRC scale 0 to 1 or CAT 10 scores to determine symptoms results in a significant difference in patient distribution. However, CAT 13 as the threshold for assessing symptoms results in a similar proportion of patients being categorized into the risk categories.

Relationship between chronic obstructive pulmonary disease and subclinical coronary artery disease in long-term smokers

Cardiovascular conditions are reported to be the most frequent cause of death in patients with chronic obstructive pulmonary disease (COPD). However, it remains unsettled whether severity of COPD per se is associated with coronary artery disease (CAD) independent of traditional cardiovascular risk factors. The aim of this study was to examine the relationship between the presence and severity of COPD and the amount of coronary artery calcium deposit, an indicator of CAD and cardiac risk, in a large population of current and former long-term smokers. In this cross-sectional study, long-term smokers without clinically manifested CAD were recruited from the Danish Lung Cancer Screening Trial and classified according to lung function by the Global Initiative for Chronic Obstructive Lung Disease (GOLD) criteria. Coronary artery calcium deposit as a measure of subclinical CAD and cardiac risk was evaluated with multi detector computed tomography and the Agatston coronary artery calcium score (CACS). Participants were categorized into five CACS risk classification groups according to the CACS. The population (n = 1535) consisted of 41% participants without COPD, 28% with mild, and 31% with moderate-to-severe COPD (n = 46 with severe COPD). In addition to age, male gender, hypertension, hypercholesterolaemia, and continued smoking, COPD according to GOLD classification were independent predictors of a higher CACS risk classification group in multivariable analysis [odds ratio (OR): 1.28 (1.01-1.63) and OR: 1.32 (1.05-1.67), for mild and moderate-to-severe COPD, respectively, compared with no COPD]. COPD in long-term smokers is independently correlated with the CACS, while COPD severity per se does not show a dose-response relationship.