Impact of Chronic Obstructive Pulmonary Disease on Acute-Phase Outcome of Myocardial Infarction

doi:10.1016/j.amjcard.2010.03.026

The American Journal of Cardiology

Volume 106, Issue 3, 1 August 2010, Pages 305-309

https://doi.org/10.1016/j.amjcard.2010.03.026 Get rights and content

Several reports have alluded to the adverse effect of chronic obstructive pulmonary disease (COPD) on long-term prognosis of patients with myocardial infarction (MI). Little information is available, however, regarding the effects of a decrease in cardiopulmonary reserve imposed by COPD on in-hospital outcome of acute MI. This study aimed to evaluate the impact of COPD on acute-phase outcome of patients with acute MI. From a cohort of 3,249 consecutive patients with ST-elevation MI who underwent primary or rescue percutaneous coronary intervention, 365 patients were identified as having coexistent COPD. Their clinical presentation and in-hospital outcome were compared to those of 2,884 patients without COPD. The primary end point was a composite of in-hospital death or cardiogenic shock on presentation. Patients with COPD were older (p <0.001), more often women (p <0.001), and smokers (p <0.001). They had higher prevalence of chronic renal insufficiency (p <0.001), systemic hypertension (p = 0.001), and diabetes mellitus (p = 0.01). Patients with COPD had higher rates of the composite end point of death or cardiogenic shock (p <0.0001). After multivariate analysis, COPD remained a strong independent predictor of the composite end point of death or cardiogenic shock (p = 0.008). In conclusion, COPD is a very strong predictor of hemodynamic compromise resulting in death or cardiogenic shock in patients presenting with ST-elevation MI. This observation suggests that hemodynamic and pulmonary consequences of COPD decrease the capacity of the circulatory system to adjust to the effects of acute MI. Recognition of the potential for combined therapy is vital.

Section snippets

Methods

A prospective registry of patients undergoing percutaneous coronary intervention at our institution is maintained. From this registry, 3,249 consecutive patients with ST-elevation MI (STEMI) who underwent primary or rescue percutaneous coronary intervention from April 1999 to June 2008 were selected for study. All gave written informed consent for the percutaneous coronary intervention procedure. This analysis was conducted with the approval of the institutional review board. In this registry,

Results

Baseline clinical characteristics are listed in Table 1. Patients with COPD were older (p <0.001) and more often women (p <0.001). Further, they more often had chronic renal insufficiency (p <0.001), systemic hypertension (p = 0.001), diabetes mellitus (p = 0.01), and had ever been smokers (p <0.001). They more often reported previous coronary artery bypass graft surgery (p = 0.002) and percutaneous coronary intervention (p <0.001). Table 2 lists baseline angiographic and procedural

Discussion

The present study found COPD to be present in 11% of our STEMI population. In patients with STEMI, COPD imposes a significant, independent, and important increase in risk of cardiogenic shock or mortality. Risk-adjusted likelihood of these events was increased by 83%. As a consequence, presence of COPD prolonged length of stay and increased the incidence of periprocedural nephropathy, major bleeding, and transfusion. Several possible reasons for this finding should be considered. The National

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2023, American Journal of Cardiology
Data on mortality trends in patients with acute myocardial infarction (AMI) with cardiogenic shock (CS) are scant. This study aimed to assess the trends in CS-AMI-related mortality in United States (US) subjects over the latest 21 years. Mortality data of US subjects with AMI listed as the underlying cause of death and CS as contributing cause were obtained from the Centers for Disease Control and Prevention WONDER (Wide-Ranging Online Data for Epidemiologic Research) dataset from January 1999 to December 2019. CS-AMI-related age-adjusted mortality rates (AAMRs) per 100,000 US population were stratified by gender, race and ethnicity, geographic areas, and urbanicity. Nationwide annual trends were assessed as annual percent change (APC) and average APC with relative 95% confidence intervals (CIs). Between 1999 and 2019, CS-AMI was listed as the underlying cause of death in 209,642 patients, (AAMR of 3.01 per 100,000 people [95% CI 2.99 to 3.02]). AAMR from CS-AMI remained stable from 1999 to 2007 (APC −0.2%, [95% CI −2.0 to 0.5], p = 0.22) and then significantly increased (APC 3.1% [95% CI 2.6 to 3.6], p <0.0001), especially in male patients. Starting in 2009, the AAMR increase was more pronounced in those <65 years, Black Americans, and residents of rural areas. The higher AAMRs were clustered in the South (average APC 4.5%, [95% CI 4.4 to 4.6]) of the country. In conclusion, CS-AMI-related mortality in US patients increased from 2009 to 2019. Targeted health policy measures are needed to address the rising burden of CS-AMI in US subjects.
Detecting time-evolving phenotypic topics via tensor factorization on electronic health records: Cardiovascular disease case study
2019, Journal of Biomedical Informatics
Discovering subphenotypes of complex diseases can help characterize disease cohorts for investigative studies aimed at developing better diagnoses and treatments. Recent advances in unsupervised machine learning on electronic health record (EHR) data have enabled researchers to discover phenotypes without input from domain experts. However, most existing studies have ignored time and modeled diseases as discrete events. Uncovering the evolution of phenotypes – how they emerge, evolve and contribute to health outcomes – is essential to define more precise phenotypes and refine the understanding of disease progression. Our objective was to assess the benefits of an unsupervised approach that incorporates time to model diseases as dynamic processes in phenotype discovery.
In this study, we applied a constrained non-negative tensor-factorization approach to characterize the complexity of cardiovascular disease (CVD) patient cohort based on longitudinal EHR data. Through tensor-factorization, we identified a set of phenotypic topics (i.e., subphenotypes) that these patients established over the 10 years prior to the diagnosis of CVD, and showed the progress pattern. For each identified subphenotype, we examined its association with the risk for adverse cardiovascular outcomes estimated by the American College of Cardiology/American Heart Association Pooled Cohort Risk Equations, a conventional CVD-risk assessment tool frequently used in clinical practice. Furthermore, we compared the subsequent myocardial infarction (MI) rates among the six most prevalent subphenotypes using survival analysis.
From a cohort of 12,380 adult CVD individuals with 1068 unique PheCodes, we successfully identified 14 subphenotypes. Through the association analysis with estimated CVD risk for each subtype, we found some phenotypic topics such as Vitamin D deficiency and depression, Urinary infections cannot be explained by the conventional risk factors. Through a survival analysis, we found markedly different risks of subsequent MI following the diagnosis of CVD among the six most prevalent topics (p < 0.0001), indicating these topics may capture clinically meaningful subphenotypes of CVD.
This study demonstrates the potential benefits of using tensor-decomposition to model diseases as dynamic processes from longitudinal EHR data. Our results suggest that this data-driven approach may potentially help researchers identify complex and chronic disease subphenotypes in precision medicine research.
Inhaled corticosteroid/long-acting bronchodilator treatment mitigates STEMI clinical presentation in COPD patients
2018, European Journal of Internal Medicine
Citation Excerpt :
It is possible that using a clinical definition of COPD, rather than pulmonary function testing, may have led to some misclassification, especially in the small proportion of COPD patients who did not perform a lung function testing or respiratory consultation. However, this methodological approach has been previously adopted and validated not only in our cohort of COPD patients but also in similar registries [6,7,21,41]. In addition, this is an observational study and therefore prone to the inherent weakness of this type of study.
Patients with myocardial infarction and concomitant COPD are at increased risk of poor clinical outcomes, including death, as compared to patients without COPD.
To investigate and compare the severity of the clinical presentation of ST-segment elevation myocardial infarction (STEMI) and of the short-(7 days) and long-term-(end of follow up) mortality in COPD patients treated with inhaled corticosteroids (ICS)/long-acting bronchodilator (LABD) - either long-acting beta2 agonist (LABA) or long-acting muscarinic antagonist (LAMA) - vs. any other inhaled treatments.
Data from the REAL (Registro Angioplastiche dell'Emilia-Romagna) Registry were obtained from a large prospective study population of 11,118 patients admitted to hospital for STEMI.
From January 2003 to June 2009 we identified 2032 COPD patients admitted to hospital for STEMI. Eight hundred and twenty (40%) COPD patients were on ICS/LABD treatment (of which 55% on ICS/LABA) prior to admission. After adjustment for potential confounding factors, ICS/LABD treatment before STEMI was an independent predictor of reduced risk of pulmonary oedema and cardiogenic shock (OR 0.5, 95%CI 0.3–0.72, p < 0.01; OR 0.7, 95%CI 0.4–0.9, p = 0.03, respectively). ICS/LABD treatment was associated to reduced 7-days mortality (OR 0.54, 95%CI 0.29–0.98, p = 0.045) compared to other inhaled regimens. ICS/LABD-treated did not affect long-term (median 4 years) mortality. After hospital discharge, the proportion of ICS/LABD treated patients decreased significantly at 6 months and afterwards after the STEMI episode.
Our data provide preliminary evidence that in COPD patients ICS/LABD treatment reduces the severity of STEMI acute-phase clinical manifestations compared to other inhaled treatments.
Impact of chronic obstructive pulmonary disease on in-hospital morbidity and mortality in patients with ST-segment elevation myocardial infarction treated by primary percutaneous coronary intervention
2017, International Journal of Cardiology
Patients with chronic obstructive pulmonary disease (COPD) presenting with ST-segment elevation myocardial infarction (STEMI) are less likely to beneficiate of primary percutaneous coronary intervention (pPCI), and have poorer prognosis. We aimed to evaluate the impact of COPD on the in-hospital outcomes of pPCI-treated STEMI patients.
Data were collected from 418 STEMI patients treated by pPCI. Inotropics and diuretics usage, cardiogenic shock, asystole, kidney dysfunction, and left ventricular ejection fraction were used as markers of hemodynamic complications. Atrial and ventricular fibrillation, conduction disorders, and antiarrhythmics usage were used as markers of arrhythmic complications. In-hospital mortality was evaluated. The associations between these parameters and COPD were assessed.
COPD was present in 7.42% of STEMI patients. COPD patients were older (p = 0.02) and less likely to receive beta-blockers (OR 0.29; 95%CI 0.13–0.64; p < 0.01). They had higher Killip class on admission (p < 0.001), received more often inotropics (p < 0.001) and diuretics (p < 0.01), and presented more often atrial (p = 0.01) and ventricular fibrillation (p = 0.02). Unadjusted in-hospital mortality was higher in COPD patients (OR 4.18, 95%CI 1.55–11.30, p < 0.01). After adjustment for potentially confounding factors except beta-blockers, COPD remained an independent predictor of in-hospital mortality (p = 0.02). After further adjustment with beta-blocker therapy, no excess mortality was noted in COPD patients.
Despite being treated by pPCI, COPD patients with STEMI are more likely to develop hemodynamic and arrhythmic complications, and have higher in-hospital mortality. This appears to be due to lower beta-blockers usage in COPD patients. Increasing beta-blockers usage in COPD patients with STEMI may improve survival.
Comparison of Left Ventricular Function and Myocardial Infarct Size Determined by 2-Dimensional Speckle Tracking Echocardiography in Patients With and Without Chronic Obstructive Pulmonary Disease After ST-Segment Elevation Myocardial Infarction
2017, American Journal of Cardiology
Citation Excerpt :
Creatine kinase and troponin levels and imaging modalities, including echocardiography, nuclear imaging techniques, and late gadolinium contrast-enhanced cardiac magnetic resonance, are well-established methods to estimate the infarct size.21 Whether the presence of COPD has influence on infarct size has not been extensively evaluated.22,23 In 818 patients with STEMI (8.6% with COPD), Lazzeri et al showed no significant differences in peak troponin I in patients with and without COPD (54.1 [28.7 to 212] vs 92.2 [44.1 to 186.0] ng/ml, p = 0.084, respectively).22
Patients with chronic obstructive pulmonary disease (COPD) have a high risk of mortality after acute ST-segment elevation myocardial infarction (STEMI). We compared STEMI patients with versus without COPD in terms of infarct size and left ventricular (LV) systolic function using advanced 2-dimensional speckle tracking echocardiography. Of 1,750 patients with STEMI (mean age 61 ± 12 years, 76% male), 133 (7.6%) had COPD. With transthoracic echocardiography, left ventricular ejection fraction (LVEF) and wall motion score index were measured. Infarct size was assessed using biomarkers (creatine kinase and troponin T). LV global longitudinal strain (GLS), reflecting active LV myocardial deformation, was measured with 2-dimensional speckle tracking echocardiography to estimate LV systolic function and infarct size. STEMI patients with COPD were significantly older, more likely to be former smokers, and had worse renal function compared with patients without COPD. There were no differences in infarct size based on peak levels of creatine kinase (1315 [613 to 2181] vs 1477 [682 to 3047] U/l, p = 0.106) and troponin T (3.3 [1.4 to 7.3] vs 3.9 [1.5 to 7.8] µg/l, p = 0.489). Left ventricular ejection fraction (46% vs 47%, p = 0.591) and wall motion score index (1.38 [1.25 to 1.66] vs 1.38 [1.19 to 1.69], p = 0.690) were comparable. In contrast, LV GLS was significantly more impaired in patients with COPD compared with patients without COPD (−13.9 ± 3.0% vs −14.7 ± 3.9%, p = 0.034). In conclusion, despite comparable myocardial infarct size and LV systolic function as assessed with biomarkers and conventional echocardiography, patients with COPD exhibit more impaired LV GLS on advanced echocardiography than patients without COPD, suggesting a greater functional impairment at an early stage after STEMI.
Effect of Chronic Obstructive Pulmonary Disease on In-Hospital Mortality and Clinical Outcomes After ST-Segment Elevation Myocardial Infarction
2017, American Journal of Cardiology
There is controversy regarding in-hospital mortality, revascularization, and other adverse outcomes in patients with ST-segment elevation (STEMI) and chronic obstructive pulmonary disease (COPD). We queried the 2003 to 2011 Nationwide Inpatient Sample databases to identify patients aged ≥18 years with a primary diagnosis of STEMI. Univariate and multivariate analyses were performed to evaluate the association of COPD with in-hospital clinical outcomes. Patients with COPD comprised 13.2% of 2,120,005 patients with STEMI. COPD was associated with older age, Medicare insurance, greater co-morbidities, and lower socioeconomic status. Compared with non-COPD patients, patients with COPD had higher inpatient mortality even after adjustment for multiple potential other factors (12.5% vs 8.6%, adjusted odds ratio [AOR] 1.13, 95% CI 1.11 to 1.15, p <0.001). Patients with COPD were more likely to develop new-onset heart failure (AOR 2.01, 95% CI 1.99 to 2.03), cardiogenic shock (AOR 1.24, 95% CI 1.22 to 1.26), and acute respiratory failure (AOR 2.46, 95% CI 2.43 to 2.50) during their hospital stay. Patients with COPD were less likely to undergo diagnostic angiographies and any revascularization procedures. The mean length of stay (6.0 vs 4.6 days; p <0.001) was greater in patients with COPD, as were hospital average hospital charges ($63,956 vs $58,536; p <0.001). In conclusion, among patients with STEMI, COPD is associated with a greater risk of in-hospital mortality, new-onset heart failure, acute respiratory failure, and cardiogenic shock.

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Coronary artery diseaseImpact of Chronic Obstructive Pulmonary Disease on Acute-Phase Outcome of Myocardial Infarction

Section snippets

Methods

Results

Discussion

Chest

Am J Cardiol

Am J Med

Am J Cardiol

Chest

Am J Cardiol

Ann Thorac Surg

Am J Cardiol

Chronic obstructive pulmonary disease is an independent predictor of death but not atherosclerotic events in patients with myocardial infarction

Eur J Heart Fail

Coronary artery disease
Impact of Chronic Obstructive Pulmonary Disease on Acute-Phase Outcome of Myocardial Infarction