December 31, 2018
3 min read

COPD severity associated with mortality, hospitalization rates

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Increased severity of chronic obstructive pulmonary disease was associated with increased risk for hospitalization and mortality among patients with HF, according to findings published in JAMA Network Open.

Researchers sought to determine which patients with newly diagnosed HF and chronic obstructive pulmonary disease (COPD) were at highest risk for hospitalization and death based on two measures of COPD severity — prescription medication intensity and measured airflow limitation.

GOLD guidelines

“These studies were mostly conducted in small HF cohorts in specialist care populations or following discharge from hospital, with some evidence suggesting the risk of COPD-associated death in HF might differ according to COPD severity,” Claire A. Lawson, Wellcome Trust fellow and lecturer at University of Leicester in England, and colleagues wrote. “However, there is limited evidence on the impact of COPD on hospitalizations or on patients with HF in the community setting.”

The nested case-control study focused on a UK-based population using statistics from the Clinical Practice Research Datalink between Jan. 1, 2002 and Jan. 1, 2014, including participants aged 40 years and older with a new HF diagnosis. The primary outcome was first all-cause admission or all-cause death.

Researchers identified 50,114 participants (median age, 79 years; 46% women) with incident HF. Those with COPD (n = 18,478) were identified by a clinical code and at least one related medication based on Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines. Researchers wrote that GOLD guidelines recommended the use of forced expiratory volume in 1 second (FEV1) to measure the severity of airflow limitation in COPD.

Over a median follow-up of 2.6 years (interquartile range, 0.8-5), researchers observed significant associations between COPD and increased mortality (adjusted odds ratio [aOR] = 1.31; 95% CI, 1.26-1.36) and hospitalization (aOR = 1.33; 95% CI, 1.26-13.9) among patients with HF. The three most intense COPD medication regimens were associated with significantly increased risk for mortality — full inhaler therapy (aOR = 1.17; 95% CI, 1.06-1.29), oral corticosteroids (aOR = 1.69; 95% CI, 1.57-1.81) and oxygen therapy (aOR = 2.82; 95% CI, 2.42-3.28) — as well as hospitalization: full inhaler therapy (aOR = 1.17; 95% CI, 1.03-1.33), oral corticosteroids (aOR =1.75; 95% CI, 1.59-1.92) and oxygen therapy (aOR = 2.84; 95% CI, 1.22-3.63).

Increasing airflow limitation also was associated with increased risk for mortality, including FEV1 80% or more (aOR = 1.63, 95% CI, 1.42-1.87); FEV1 50% to 79% (aOR = 1.69, 95% CI, 1.56-1.83); FEV1 30% to 49% (aOR = 2.21; 95% CI, 2.01-2.42); and FEV1 less than 30% (aOR = 2.93; 95% CI, 2.49-3.43). Researchers noted similarly strong associations between FEV1 and hospitalization, from FEV1 80% or more (aOR = 1.48; 95% CI, 1.31-1.68) to FEV1 less than 30% (aOR = 1.73; 95% CI, 1.4-2.12).


Identifying severity

Routine measures of COPD severity in the community population with HF could serve as important prognostic tools for risk stratification, according to the researchers.

“The results generate the hypothesis that some of the adverse outcomes in the HF population with COPD could be improved by targeting better diagnosis of both, optimizing drug treatment for both and identifying patients with the greatest severity of HF and COPD for early aggressive treatment or close monitoring,” Lawson and colleagues wrote.

In a related editorial, Frans H. Rutten, MD, PhD, and Berna D.L. Broekhuizen, MD, PhD, both of the University Medical Center Utrecht in the Netherlands, wrote: “The findings that short-acting inhaled [beta-mimetics] may be deleterious in patients with HF is a crucial finding and in line with literature, and should urge clinicians to refrain from prescribing these drugs that are not obligatory in COPD, but instead use long-acting [beta-mimetics] and muscarin antagonists. In addition, we need valid diagnoses of both COPD and HF, and notably the diagnosis in the presence of the other is a challenge, even when a patient receives all noninvasive test available for such cases.” – by Earl Holland Jr.

Disclosures: Lawson reports grants from the NIH Research and Wellcome Trust during the study. Rutten and Broekhuizen report no relevant financial disclosures. Please see the study for all other authors’ relevant financial disclosures.