Practice Update: Cardiology

ATS 2017 11

Providers should be particularly aware of the risk of a cardiovascular disease event in patients seeking acute medical care following an exacerbation of COPD.

COPD was increased significantly, par- ticularly during the first 30 days following an acute exacerbation of COPD (hazard ratio 3.8; 95% confidence interval 2.7, 5.5), though it remained increased between 30 days to 1 year (hazard ratio 1.8; 95% confi- dence interval 1.5, 2.3); and was no longer significant beyond 1 year following an acute exacerbation of COPD (hazard ratio 1.1; 95% confidence interval 0.8, 1.6). When analyses were restricted to the individual treatment arms in SUMMIT, the same general pattern was observed in each, with an increased risk for cardiovas- cular disease events early after an acute exacerbation of COPD and no significant increase >1 year after the acute exacerba- tion of COPD. Their findings led Dr Kunisaki and his team to consider evaluating interventions follow- ing an exacerbation of COPD in patients with cardiovascular disease. Dr Kunisaki said, “One approach might be to study currently used cardiac medica- tions, such as antiplatelet agents, statins and/or beta-blockers immediately following exacerbations of COPD. Another might be to use experimental drugs that specifically reduce inflammation.” “Until effective interventions are identified,” he added, “patients who have experienced a recent COPD exacerbation should pay attention to and seek immediate care for symptoms of myocardial infarction.” He added, “Providers should be particu- larly aware of the risk of a cardiovascular disease event in patients seeking acute medical care following an exacerbation of COPD.” Study limitations included the fact that all participants had a history of cardiovascular disease or multiple risk factors for cardio- vascular disease. Whether exacerbations of COPD pose the same risk of cardiovascular disease in patients with no or lower cardiovascular disease risk is not known. Another study of COPD reported at ATS assessed the incidence of in-hospital COPD mortality from 2005–2014. The number of hospitalizations for COPD in

the US fluctuated within a narrow range between 2005 and 2014. In-hospital deaths decreased substantially during that same time. Khushboo Goel, MD, of the University of Arizona, Tucson, and colleagues, set out to examine trends in COPD hospitaliza- tions and in-hospital mortality in a nationally representative sample and to evaluate potential differences by sex and race. She and her team analyzed data from the Healthcare Cost and Utilization Project Nationwide Inpatient Sample, which cap- tures 95% of all hospital discharges in the US. They reported 8,575,820 hospitaliza- tions for COPD-related health problems between 2005–2014. During that time, those who died in the hospital declined from 24,226 to 9090, a 62% decrease. Dr Goel said, “This was certainly an encour- aging trend. We expected to see a decline because of improvements in caring for con- ditions such as pneumonia, sepsis, septic shock, and thromboembolic diseases asso- ciated with COPD exacerbations, but the magnitude of the decline in mortality was surprising.” She noted that the decreasing mortality trend applied to white, black, and Hispanic patients. Most striking was that each year, women accounted for most of the hospitalizations and in-hospital deaths. Women made up 57–58% of hospitalizations and 51–55% of in-hospital deaths. Dr Goel said, “Possible explanations for the higher COPD burden in US women include the growing number of women who smoke, the increased severity of symp- toms they may experience, and longer life expectancy.” The study also found that from 2005 to 2014, the average age of those hospital- ized remained nearly constant at 67 years. The number of COPD patients treated at teaching hospitals increased from 212,346 to 371,215 and the average length of a hos- pital stay decreased from 5.2 to 4.2 days.

cardiovascular disease or multiple risk fac- tors for cardiovascular disease and whose forced expiratory volume in 1 s (FEV1) was 50–70% of predicted and whose FEV1/ forced vital capacity (total volume of exha- lation) was ≤70%. A Cox model was used with a time- dependent covariate for acute exacerbation of COPD events (defined as symptomatic deterioration requiring treatment with antibiotics or systemic corticosteroids). The team controlled for other risk factors and analyzed the hazard of cardiovascular disease events at 1–30 days, 31 days–1 year, and >1 year following acute exacerbation of COPD events. The primary analysis included data from all four SUMMIT arms (placebo, fluticasone furoate, vilanterol, fluticasone furoate + vilanterol), but additional sensitivity analy- ses restricted the model to individual study arms. The hazard of cardiovascular disease events following acute exacerbations of

PracticeUpdate Editorial Team

VOL. 2 • NO. 1 • 2017