COPD and Cardiovascular Disease.

COPD is one of the major public health problems in people aged 40 years or above. It is currently the 4th leading cause of death in the world and projected to be the 3rd leading cause of death by 2020. COPD and cardiac comorbidities are frequently associated. They share common risk factors, pathophysiological processes, signs and symptoms, and act synergistically as negative prognostic factors. Cardiac disease includes a broad spectrum of entities with distinct pathophysiology, treatment and prognosis. From an epidemiological point of view, patients with COPD are particularly vulnerable to cardiac disease. Indeed, mortality due to cardiac disease in patients with moderate COPD is higher than mortality related to respiratory failure. Guidelines reinforce that the control of comorbidities in COPD has a clear benefit over the potential risk associated with the majority of the drugs utilized. On the other hand, the true survival benefits of aggressive treatment of cardiac disease and COPD in patients with both conditions have still not been clarified. Given their relevance in terms of prevalence and prognosis, we will focus in this paper on the management of COPD patients with ischemic coronary disease, heart failure and dysrhythmia.

Understanding COPD: A vision on phenotypes, comorbidities and treatment approach.

Chronic Obstructive Pulmonary Disease (COPD) phenotypes have become increasingly recognized as important for grouping patients with similar presentation and/or behavior, within the heterogeneity of the disease. The primary aim of identifying phenotypes is to provide patients with the best health care possible, tailoring the therapeutic approach to each patient. However, the identification of specific phenotypes has been hindered by several factors such as which specific attributes are relevant, which discriminant features should be used for assigning patients to specific phenotypes, and how relevant are they to the therapeutic approach, prognostic and clinical outcome. Moreover, the definition of phenotype is still not consensual. Comorbidities, risk factors, modifiable risk factors and disease severity, although not phenotypes, have impact across all COPD phenotypes. Although there are some identified phenotypes that are fairly consensual, many others have been proposed, but currently lack validation. The on-going debate about which instruments and tests should be used in the identification and definition of phenotypes has contributed to this uncertainty. In this paper, the authors review present knowledge regarding COPD phenotyping, discuss the role of phenotypes and comorbidities on the severity of COPD, propose new phenotypes and suggest a phenotype-based pharmacological therapeutic approach. The authors conclude that a patient-tailored treatment approach, which takes into account each patient's specific attributes and specificities, should be pursued.

Co-morbidities in patients with gold stage 4 chronic obstructive pulmonary disease.

INTRODUCTION: Chronic Obstructive Pulmonary Disease (COPD) is associated with several co-morbidities, however their prevalence varies from one study to another. AIM: To determine the prevalence of several co-morbidities in patients with COPD severity score GOLD 4 (The Global Initiative for Chronic Obstructive Lung Disease, 2010) followed in ambulatory care, in a University Hospital. METHODS: A questionnaire was designed and carried out in order to characterize COPD and its co-morbidities. Clinical files were consulted in order to complete the data. RESULTS: 89 patients (87% male) with a mean age of 68 years old, of which 79% were ex-smokers, were included. The average value of FEV1 (forced expiratory volume in one second) was 38% of the expected values and all the patients presented chronic respiratory failure. Thirty-five patients (39%) were frequent exacerbators. Thirty-seven patients (42%) had been hospitalized at least once due to exacerbation of their respiratory disease in the previous year, and 66 patients (74%) hospitalized in the previous five years. Most of the patients (97%) presented at least one comorbidity, with an average of 4 co-morbidities per patient and an average Charlson index of 2. The most frequent co-morbidities were cardiovascular diseases (69%), osteoarticular pathology (51%), erectile dysfunction (48%), sleep apnoea syndrome (43%) dyslipidaemia (35%), cataracts (31%), gastroesophageal reflux (29%) and diabetes (20%). Frequent exacerbators presented an increased risk of having two or more co-morbidities (Odds Ratio of 5), as well as a higher prevalence of gastroesophageal reflux (p=0.0006) and more hospitalizations in the last year and in the previous 5 years (p <0.001). CONCLUSION: This study confirmed the high prevalence and the association of co-morbidities in patients with COPD severity score GOLD 4, thus justifying the need for a comprehensive and integrating therapeutic approach.

Evolution of functional capacity and health status two years after a pulmonary rehabilitation programme.

BACKGROUND: Pulmonary rehabilitation programs (PRP) have been shown to improve exercise capacity and health status and to reduce dyspnoea and use of healthcare resources, in patients with chronic lung disease. These benefits usually wane after the programs conclusion. AIM: Evaluate functional capacity and health status 2 years after the end of a PRP. METHODS: Retrospective study of patients who took part in PRP. After PRP, patients who reported a physically active lifestyle were included in the active group (AG). The other patients were considered as the control group (CG). Functional capacity was evaluated with 6minute walk distance (6MWD) and health status with St George's Respiratory Questionnaire (SGRQ). RESULTS: Thirty-two patients were included, 24 in the AG and 8 in the CG. Immediately after PRP, there was a significant improvement in the 6MWD and SGRQ global score, for both groups. After completing PRP, in the AG, there was a decline in the mean 6MWD when evaluated at 6 months, 1 and 2 years and also in health status. However, after 2 years, the AG continued to show an average improvement of 32 m (p=0.03) in the 6MWD and at least 4 points in SGRQ compared to pre-PRP, while in the CG, there was a clinically significant decline in 6MWD (-34 m) and SGRQ score (13 points worse). CONCLUSION: Despite the progressive decline of benefits gained after completing PRP, in the AG these are still significantly positive after 2 years. An active lifestyle seems to help maintain the benefits of the Rehabilitation Program.

Sleep apnea-hypopnea syndrome and acute coronary syndrome - an association not to forget.

AIM: To evaluate the prevalence of Sleep Apnea-Hypopnea Syndrome (SAHS) in patients who were admitted with Acute Coronary Syndrome (ACS) to the Coronary Care Unit (CCU) and the clinical predictors of SAHS in patients with ACS and to compare the results of the simple sleep test (SST) with polysomnography (PSG). METHODS: This was a prospective study that included patients who were admitted to the CCU with ACS, which was confirmed by coronary angiography. Demographic and anthropometric data, cardiovascular risk factors and measures on the Epworth Sleepiness Scale were collected. The SST was conducted with the ApneaLink(TM) device during hospitalization or after discharge. Patients with an apnea-hypopnea index (AHI) ≥ 10/h were invited to participate in PSG. RESULTS: Ninety-one patients with ACS were consecutively included over 4 months. Of the fifty-eight patients who completed the study 43 (74.1%) were male. The mean age was 61.7±12.2 years, and the mean body mass index was 27.4±3.5 kg/m(2). The median time for SST performance was 17.5 days. This study was compatible with SAHS in 25 cases (43.1%). Patients who had an AHI ≥ 10/h in the SST were submitted to PSG and SST simultaneously. The median interval between the ACS and the execution of PSG was 30 days. PSG confirmed that all of the cases that were detected by SST were positive. CONCLUSION: In our study, we found a high prevalence of SAHS in patients who were admitted to the CCU with ACS (43.1%). These results support the need for SAHS screening in patients who are hospitalized with ACS. The SST may have a role in the screening of SAHS in this population.