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Multicenter Study
. 2019 Sep 20:14:2163-2172.
doi: 10.2147/COPD.S209343. eCollection 2019.

Prevalence of cardiac comorbidities, and their underdetection and contribution to exertional symptoms in COPD: results from the COSYCONET cohort

Peter Alter  1 , Barbara A Mayerhofer  2 , Kathrin Kahnert  3 , Henrik Watz  4 , Benjamin Waschki  5   6 , Stefan Andreas  7   8 , Frank Biertz  9 , Robert Bals  10 , Claus F Vogelmeier  1 , Rudolf A Jörres  2
Affiliations
Multicenter Study

Prevalence of cardiac comorbidities, and their underdetection and contribution to exertional symptoms in COPD: results from the COSYCONET cohort

Peter Alter et al. Int J Chron Obstruct Pulmon Dis. .

Abstract

Background: A substantial prevalence of cardiovascular disease is known for COPD, but detection of its presence, relationship to functional findings and contribution to symptoms remains challenging. The present analysis focusses on the cardiovascular contribution to COPD symptoms and their relationship to the patients' diagnostic status, medication and echocardiographic findings.

Methods: Patients from the COPD cohort COSYCONET with data on lung function, including FEV1, residual volume/total lung capacity (RV/TLC) ratio, diffusing capacity TLCO, and echocardiographic data on left ventricular ejection fraction (LVEF) and end-diastolic diameter (LVEDD), medical history, medication, modified British Medical Research Council dyspnea scale (mMRC) and Saint Georges Respiratory Questionnaire (SGRQ) were analyzed.

Results: A total of 1591 patients (GOLD 0-4: n=230/126/614/498/123) fulfilled the inclusion criteria. Ischemic heart disease, myocardial infarction or heart failure were reported in 289 patients (18.2%); 860 patients (54%) received at least one cardiovascular medication, with more than one in many patients. LVEF<50% or LVEDD>56 mm was found in 204 patients (12.8%), of whom 74 (36.3%) had neither a cardiovascular history nor medication. Among 948 patients (59.6%) without isolated hypertension, there were 21/55 (38.2%) patients with LVEF<50% and 47/88 (53.4%) with LVEDD>56 mm, who lacked both a cardiac diagnosis and medication. LVEDD and LVEF were linked to medical history; LVEDD was dependent on RV/TLC and LVEF on FEV1. Exertional COPD symptoms were best described by mMRC and the SGRQ activity score. Beyond lung function, an independent link from LVEDD on symptoms was revealed.

Conclusion: A remarkable proportion of patients with suspicious echocardiographic findings were undiagnosed and untreated, implying an increased risk for an unfavorable prognosis. Cardiac size and function were dependent on lung function and only partially linked to cardiovascular history. Although the contribution of LV size to COPD symptoms was small compared to lung function, it was detectable irrespective of all other influencing factors. However, only the mMRC and SGRQ activity component were found to be suitable for this purpose.

Keywords: COPD; dyspnea; echocardiography; heart failure; medication; symptoms.

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Conflict of interest statement

Peter Alter, Barbara A Mayerhofer, Kathrin Kahnert, Henrik Watz, Benjamin Waschki, Frank Biertz, and Rudolf A Jörres report no conflicts of interest in this work. Stefan Andreas report grants and personal fees from Boehringer Ing and Pfizer, and personal fees from Novartis, Astra Zeneca, GSK, Chiesi, and Merini, outside the submitted work. Robert Bals report grants from German Federal Ministry of Education and Research (BMBF) Competence Network Asthma and COPD (ASCONET), during the conduct of the study, and grants and personal fees from AstraZeneca, Novartis, and Boehringer Ingelheim, and personal fees from GlaxoSmithKline, Grifols, and CSL Behring, outside the submitted work. Claus F Vogelmeier report grants and personal fees from AstraZeneca, Boehringer Ingelheim, GlaxoSmithKline, Grifols, and Novartis, personal fees from CSL Behring, Chiesi, Menarini, Mundipharma, Teva, and Cipla, and grants from Bayer Schering Pharma AG, MSD, and Pfizer, outside the submitted work. The authors report no other conflicts of interest regarding this work.

Figures

Figure 1
Figure 1
(A) Histogram showing the prevalence of ischemic heart disease, remote myocardial infarction and heart failure as reported, in addition a combined history, if any of the previous diagnoses was reported. Moreover, the prevalence of patients with echocardiographic impairments is shown. For this purpose, left ventricular dilatation with an end-diastolic diameter (LVEDD) >56 is defined, moreover a reduced ejection fraction (LVEF) <50% as well as <40%. (B) Euler diagram showing the proportion of and overlap between patients with a combined history, LVEF < 50% and LVEDD >56 mm. Percentages are referred to the total cohort (n=1591). Abbreviations: LVEF, left ventricular ejection fraction; LVEDD, left ventricular end-diastolic diameter.
Figure 2
Figure 2
(A) Histogram showing the prevalence of cardiovascular medication as reported. The combined score is positive, if at least one of the compounds was present. ACE inhibitor/ARB=angiotensin-converting enzyme inhibitor or angiotensin receptor blocker; MRA=mineralocorticoid receptor antagonist. (B) Euler diagram showing the proportion of and overlap between patients with a positive medication score, LVEF <50%, and LVEDD >56 mm. Percentages are referred to the total cohort (n= 1591). Abbreviations: LVEF, left ventricular ejection fraction; LVEDD, left ventricular end-diastolic diameter.
Figure 3
Figure 3
(A) Euler diagrams showing the proportion of and overlap between patients with a positive medication score, combined history and LVEF <50% in the total cohort (n =1591); percentages are referred to this. (B) In patients without isolated hypertension as defined in the methods section for LVEF <50% and (C) in patients without isolated hypertension for LVEDD >56 mm (n = 948); percentages are referred to this. Abbreviations: LVEF, left ventricular ejection fraction; LVEDD, left ventricular end-diastolic diameter.
Figure 4
Figure 4
Structural equation model (SEM) describing the relationships between indices of lung function including the FEV1% predicted, the ratio of residual volume to total lung capacity (RV/TLC) and carbon monoxide diffusing capacity (0% predicted), echocardiographic measures including the left ventricular end-diastolic diameter (LVEDD, mm) and left ventricular ejection fraction (LVEF, %), the combined medication score, the combined history score, the modified British Medical Research Council dyspnea scale (mMRC) and the activity component of the Saint George's Respiratory Questionnaire (SGRQ). All measured (manifest) variables are indicated by rectangles. A latent variable (indicated by an oval) named “Exertional COPD Symptoms” with indicator variables mMRC and the SGRQ activity component was defined to summarize symptoms. The lines with one arrow describe unidirectional effects, and standardized regression coefficients are given at these arrows. Correlations between a number of variables were introduced to improve the fit. Lung function parameters were correlated with each other, moreover history and medication, furthermore, the error terms of LVEDD and LVEF. These correlations, which were not relevant for the validity of the structure, and the error terms needed for mathematical reasons for all dependent variables have been omitted for the sake of clarity. The numerical values of the respective unstandardized regression coefficients as well as measures of statistical significance are given in Table S1.
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