A Research Agenda to Improve Outcomes in Patients with Chronic Obstructive Pulmonary Disease and Cardiovascular Disease: An Official American Thoracic Society Research Statement

Abstract

Background: Individuals with chronic obstructive pulmonary disease (COPD) are often at risk for or have comorbid cardiovascular disease and are likely to die of cardiovascular-related causes. Objectives: To prioritize a list of research topics related to the diagnosis and management of patients with COPD and comorbid cardiovascular diseases (heart failure, atherosclerotic vascular disease, and atrial fibrillation) by summarizing existing evidence and using consensus-based methods. Methods: A literature search was performed. References were reviewed by committee co-chairs. An international, multidisciplinary committee, including a patient advocate, met virtually to review evidence and identify research topics. A modified Delphi approach was used to prioritize topics in real time on the basis of their potential for advancing the field. Results: Gaps spanned the translational science spectrum from basic science to implementation: 1) disease mechanisms; 2) epidemiology; 3) subphenotyping; 4) diagnosis and management; 5) clinical trials; 6) care delivery; 7) medication access, adherence, and side effects; 8) risk factor mitigation; 9) cardiac and pulmonary rehabilitation; and 10) health equity. Seventeen experts participated, and quorum was achieved for all votes (>80%). Of 17 topics, ≥70% agreement was achieved for 12 topics after two rounds of voting. The range of summative Likert scores was -15 to 25. The highest priority was "Conduct pragmatic clinical trials with patient-centered outcomes that collect both pulmonary and cardiac data elements." Health equity was identified as an important topic that should be embedded within all research. Conclusions: We propose a prioritized research agenda with the purpose of stimulating high-impact research that will hopefully improve outcomes among people with COPD and cardiovascular disease.

Keywords: cardiovascular disease; chronic obstructive pulmonary disease; research priorities.

Figure 1.

Span of domains across the translational science spectrum. We used the NHLBI’s translational science spectrum as a framework to generate the list of 10 domains between Days 1 and 2. The domains range from basic science about the mechanisms of disease to the implementation of evidence-based treatments into everyday practice.

Figure 2.

Word cloud from transcript of Day 1 committee meeting. This word cloud was generated by feeding the transcript from Day 1 of the committee meeting into an online large language model that examined the frequency of words and their proximity to one another and generated this figure in the shape of the lungs. The words that are larger in size were said more frequently during the committee meeting on Day 1.

Figure 3.

Breakdown of responses for prioritization of the research topics in final Delphi round across the five-point Likert scale. If a color/percentage is missing along a row, that means that the value was zero, such as strongly disagree for priority 1. The text of each of the 17 prioritized topics is listed in Table 3. Briefly, they are 1) pragmatic trials with patient-centered outcomes, 2) cost-effectiveness of cardiac and respiratory tests, 3) phenotyping, 4) cardiac and pulmonary rehabilitation, 5) knowledge translation about COPD as a risk-enhancing diagnosis, 6) epidemiology of subgroups, 7) leverage lung cancer screening computed tomography scans, 8) simplified inhaler regimens that are accessible, 9) mechanisms of disease, 10) clinician awareness about evidence-based risks of cardiovascular treatments on lung function, 11) optimal roles of clinicians that prioritizes patients’ needs, 12) leverage technology, 13) longitudinal studies following stable and exacerbated patients with cardiac rhythm monitors, 14) risks and benefits of conservative medication management versus advanced cardiac testing/catheterization in patients with COPD with troponin leak, 15) impact of using active language to describe COPD exacerbation, 16) environmental triggers, and 17) performing spirometry in hospitalized patients. COPD = chronic obstructive pulmonary disease.