Abstract
Background
Patients with COPD are at high risk of major adverse cardiovascular events (MACEs) developing. Existing clinical tools for risk stratification in these patients have underperformed in predicting the outcomes.
Research Question
Does a combination of cardiovascular risk score (CVRS) and coronary artery calcium score (CACS) improve risk assessment of MACEs in patients with COPD?
Study Design and Methods
This was an observational cohort of patients with COPD (n = 529). They underwent a chest CT scan, and clinical, functional, and laboratory data were recorded. The CACS and CVRS (Systematic Coronary Risk Evaluation [SCORE] 2, SCORE2-Older People [OP], SCORE2-Diabetes, and Secondary Manifestations of Arterial Disease [SMART] risk scores) were calculated. Using a threshold of CVRS of ≥ 10% or CACS score of > 3, patients were divided into 4 groups—group I, CVRS < 10% and CACS ≤ 3; group II, CVRS ≥ 10% and CACS ≤ 3; group III, CVRS < 10% and CACS > 3; and group IV, CVRS ≥ 10% and CACS > 3—who were followed up for a median of 98 months. Regression analysis and Kaplan Meier curves were used to compare the risks among groups. Receiver operating characteristic (ROC) curve analysis determined the performance of CACS and CVRS and their combination to predict MACEs.
Results
Most patients were male (80%) with moderate COPD. Over time, 131 patients (24%) experienced a MACE. Compared with group I, the hazard ratios for MACEs were: group IV, 7.6 (95% CI, 4.9-11.9; P < .001); group III, 3.1 (95% CI, 1.8-8.5; P < .001); and group II, 2.6 (95% CI, 1.6-4.2; P < .001). The areas under the ROC curve for predicting MACEs were 0.72 (P < .01) for CACS plus CVRS compared with 0.69 for CVRS and 0.66 for CACS.
Conclusions
The combination of cardiovascular risk and coronary artery calcification scores were shown to provide a complementary role in MACE risk stratification in patients with COPD.
Key Words: cardiovascular risk, COPD, coronary artery calcium, MACE
Take-Home Points.
Research Question: Does a combination of cardiovascular risk score (CVRS) and coronary artery calcium score (CACS) improve risk assessment of a major adverse cardiovascular event (MACE) in patients with COPD?
Results: The discriminative power of CACS plus CVRS for MACEs in this cohort of patients with COPD was superior (area under the receiver operating characteristic curve [AUC], 0.72; P < .05) to that of CVRS (AUC, 0.69) or CACS (AUC, 0.66).
Interpretation: This study demonstrated that using 2 well-stablished noninvasive tools to determine cardiovascular risk in patients with COPD has a complementary role in risk stratification.
Patients with COPD are at high risk of cardiovascular disease (CVD) developing,1 a leading cause of death, particularly for those with mild to moderate airway obstruction.2,3 The Global Initiative for Obstructive Lung Disease (GOLD) recommends that patients with COPD be evaluated for the presence of CVD and managed according to current guidelines.4 However, the GOLD does not provide specific guidance on screening methods, likely because of a lack of solid evidence supporting this recommendation in patients with COPD. Consequently, many patients with COPD seen by health care providers are missing a unique opportunity to receive a diagnosis for potentially treatable causes of death.5
In clinical practice, different cardiovascular risk scores (CVRSs) are used to estimate the risk of future major adverse cardiovascular events (MACEs).6, 7, 8 However, studies have shown these CVRSs perform relatively poorly in patients with COPD.9 Importantly, these tools need to be adjusted based on each patient’s characteristics and regional health data (cardiovascular risk area), age, presence of diabetes mellitus (DM), or history of previous events.
In contrast, coronary artery calcium now can be assessed easily and reliably using low-dose CT (LDCT) imaging of the chest, with validated visual scores.10 In the large Evaluation of COPD Longitudinally to Identify Predictive Surrogate Endpoints cohort, Williams and coworkers11 documented that patients with COPD frequently demonstrated calcifications in the coronary arteries, which were associated with an increased risk of death, particularly resulting from cardiovascular events. Subsequent studies, including our own, have confirmed that a higher coronary artery calcium score (CACS) is associated with increased probability of cardiovascular events in patients with COPD.12,13 A recent cross-sectional study extended those findings by reporting that 50 patients with COPD showed more moderate and severe CACS coronary involvement than patients without COPD who had any history of smoking, and that the CACS was more sensitive and specific than 4 different cardiac risk scores in detecting severe coronary artery disease.14 However, this study did not explore if these differences were predictive of MACE occurrence because of a lack of follow-up. In an accompanying editorial, Fawzy and Vogelmeier15 concluded that determination of CACS should be considered in the clinical evaluation of certain individuals with COPD for cardiovascular risk stratification, given the poor performance of validated cardiovascular risk scores in this patient population. Lung cancer screening programs offer a unique opportunity to diagnose CACS using LDCT imaging, providing a reliable assessment of MACE risk.4
We hypothesized that combining the CVRS with CACS could improve the risk evaluation for cardiovascular events in stable patients with COPD. To test this hypothesis, we completed a multicenter study to explore the potential complementary role of both tools in daily clinical practice within the large BMI, obstructive airflow, dyspnea, and exertion (BODE) cohort of patients with COPD with > 8 years of observation.
Study Design and Methods
This was an analysis of the observational cohort of patients with COPD recruited between 2000 and 2011 in 4 pulmonary clinics at university hospitals in Spain as part of the well-established BODE cohort.16 All patients who had undergone chest CT scan evaluation at the time of enrollment were included in the analysis. Briefly, patients were recruited prospectively in the outpatient setting and then followed up annually. COPD was defined according to the GOLD guidelines by the presence of symptoms compatible with the disease, a smoking history of ≥ 10 pack-years, and an FEV1 to FVC ratio of < 0.7 after 400 μg of inhaled salbutamol.17 To participate in the study, patients had to be stable at baseline for at least 8 weeks and receiving optimal medical therapy according to current guidelines.5 Patients with other clinically significant respiratory diseases or malignancy, those receiving immunosuppressive therapy, or those unable to undergo a LDCT imaging were excluded. The Comité de Etica de la Investigación (Identifier: 258/2009) approved this project. All participants signed the informed consent approved by the ethics committees (Comité de Etica de la Investigación, Hospital Universitario la Candelaria, Tenerife; 258/2009).
Variables Determined at Baseline
Variables determined at baseline included age, sex, BMI in kilograms per square meter, smoking history (pack-years and smoking status), and spirometric values following the European Respiratory Society and American Thoracic Society recommendations with mean predicted values and z scores derived from prediction equations from the Global Lung Initiative.18 A 6-minute walking distance test was performed as recommended by American Thoracic Society.19 The BMI, obstructive airflow, dyspnea, and exertion index score was calculated as previously reported.16 Comorbidities were scored using the Charlson Comorbidity Index.20 Survival status was determined by direct follow-up with participants, review of death certificates, or contacting their family members if needed, as reported previously.16
Chest CT Scan Protocol and CT Scan-Assessed Comorbidities
All patients underwent a chest LDCT imaging examination using multidetector-row (16-detector or 64-detector) CT scans at baseline. The examinations were acquired at end-inspiration in a range extending from the thoracic inlet to the upper abdomen with the patient in supine position. The following parameters were used: 120 kV, 40 mAs, 32 × 0.6-mm detector collimation, and pitch of 1. Images were reconstructed with 5-mm and 1-mm slice thickness using soft tissue (B31f) and high-resolution (B60f) reconstruction algorithms to evaluate the mediastinum and lung parenchyma, respectively. CT scans were evaluated by 2 chest radiologists (A. E. and G. B.) masked to clinical data.
Coronary Artery Calcium Scores
Coronary artery calcification, a marker of coronary artery disease, was determined using the ordinal CACS, as previously described.21 The calcification of each of the 4 coronary arteries was scored ranging from 0 to 12. Figure 1 shows how the CACS is calculated and examples of patients with low-risk and high-risk CACSs. For purposes of this analysis, we divided the CACS in 2 categories, low (0-3) or moderate to severe (4-12), because a CACS of > 3 has been associated with a high incidence of MACEs.22
Figure 1.
Images demonstrating the ordinal scale for coronary calcium quantification. This semiquantitative method, based on visual assessment, scores the presence and extent of calcification in the major coronary arteries using a 0 to 3 scale per artery (total score range, 0-12): left main, left anterior descendent, circumflex, and right coronary arteries. A, Low-risk patient (score of 0-3) with no visible coronary artery calcification. B, High-risk patient with extensive calcification detected in all coronary arteries (arrows), based on ordinal scoring.
Definition of MACE
In this study, a MACE was defined as a composite of cardiovascular death, nonfatal myocardial infarction, nonfatal stroke, and hospitalization for unstable angina—the so-called 4-point MACE.23
Cardiovascular Risk Scores
Following the recommendations of the European Society of Cardiology,24 we used an individualized calculation for a 10-year risk of MACEs, selecting the correct European risk region (low risk for Spain) and taking into account patient age (< 70 years vs ≥ 70 years), history of DM, or history of a previous cardiovascular event. The Systematic Coronary Risk Evaluation (SCORE) 2, SCORE2-Older People (OP), SCORE2-Diabetes, and SMART risk scores were calculated for each patient.6, 7, 8, 9 For purposes of this analysis, we divided the CVRS into 2 categories: those with < 10% risk at 10 years and those with ≥ 10% risk. According to the European Society of Cardiology, those with a risk of ≥ 10% are at moderate to high risk.25 Therefore, 4 potential groups were formed: group I, CVRS < 10% and CACS ≤ 3; group II, CVRS ≥ 10% and CACS ≤ 3; group III, CVRS < 10% and CACS > 3; and group IV, CVRS ≥ 10% and CACS > 3.
Statistical Analysis
Statistical analysis was based on complete case. To explore the normality of the data distribution of the evaluated parameters, we used the Kolmogorov-Smirnov test. Data were summarized as relative frequencies for categorical variables and mean (SD) for normally distributed variables (only normally distributed variables were found). Comparison of percentage was carried out by the χ2 test. A proportional Cox survival analysis determined the independent association of risk for each category with MACE occurrence. Kaplan-Meier curves were used to represent probability of MACEs in each category risk. The log-rank test compared the survival curves. Time-dependent receiver operating characteristic curves were used to determine the performance of CACS, CVRS, and CACS plus CVRS at the mean follow-up time (98 months). Significance level was established as a 2-tailed P value of ≤ .05. For the statistical analyses we used SPSS version 26.0 software (SPSS, Inc.) and MedCalc (MedCalc Software Ltd).
Results
Patients’ Characteristics
The Consolidated Standards of Reporting Trials flow diagram of the patients participating in this analysis is shown in Figure 2. Initially, 622 patients were recruited in the BODE study. Of these, 549 patients had the clinical findings, laboratory findings, and low-dose CT scans available to calculate each patient’s CVRS and CACS, and therefore were included in this analysis. The clinical and physiologic characteristics of the participants are shown in Table 1. They were mostly middle-aged male individuals who were slightly overweight, and almost one-half of them actively smoked. Most patients had spirometric GOLD stages 1 or 2 airflow obstruction; a low BMI, obstructive airflow, dyspnea, and exertion index and Charlson Comorbidity Index; normal 6-minute walking distance; a low prevalence of DM; a high prevalence of hypertension; and an important prevalence of CACS of > 3 and CVRS of ≥ 10%. During the 8 years of follow-up, 24% of the patients experienced a MACE and 28% died. Of those patients with low CVRS (< 10%) at baseline (n = 341), 58 patients (17%) experienced a MACE during the follow-up time and 74 patients (22%) demonstrated a high CACS (> 3) at baseline.
Figure 2.
Consolidated Standards of Reporting Trials flow diagram showing the patients who participated in this analysis.
Table 1.
Clinical and Physiologic Characteristics of Patients (N = 549)
| Variable | Data |
|---|---|
| Age, y | 63 (9) |
| Female sex | 20% |
| Follow-up, mo | 98 (62) |
| BMI, kg/m2 | 27 (4) |
| Smoking history, pack-years | 51 (28) |
| Active smoking | 45% |
| FEV1 % predicted | 72 (24) |
| FVC % predicted | 97 (21) |
| FEV1 to FVC ratio | 57 (13) |
| GOLD stage | |
| 1 | 34% |
| 2 | 41% |
| 3 | 20% |
| 4 | 5% |
| BODE index | 1.57 (1.96) |
| Charlson Comorbidity Index | 1.52 (1.79) |
| 6MWD, m | 467 (110) |
| Systolic BP, mm Hg | 128 (17) |
| Total cholesterol, mg/dL | 200 (42) |
| HDL cholesterol, mg/dL | 53 (15) |
| DM | 17% |
| Hypertension | 38% |
| CACS | 2.67 (2.51) |
| CACS > 3% | 34 |
| CVRS risk | 11.28 (11.37) |
| CVRS risk at 10 y > 10% | 40% |
| MACE | 131 (24%) |
| MACE by GOLD stage | |
| 1 | 27% |
| 2 | 23% |
| 3 | 17% |
| 4 | 15% |
| Mortality | 156 (28%) |
Data are presented as No. (%), percentage, or mean (SD). 6MWD = 6-minute walking distance; BODE = BMI, obstructive airflow, dyspnea, and exertion; CACS = coronary artery calcium score; CVRS = cardiovascular risk score; DM = diabetes mellitus; GOLD = Global Initiative for Obstructive Lung Disease; HDL = high-density lipoprotein; MACE = major cardiovascular event.
Risk Scores by GOLD Spirometric Severity
The proportion of patients at each GOLD spirometric stage with a CVRS of ≥ 10% or CACS of > 3 is shown in Figure 3. The CVRSs are relatively constant in all spirometric groups, whereas the CACSs increased with the severity of airflow obstruction. Importantly, patients in GOLD stages 1 and 2 showed a higher proportion of MACEs that was underestimated by either the CVRS or the CACS.
Figure 3.
Bar graph showing the percentage of patients with COPD grouped by spirometric GOLD stage who had a CVRS of ≥ 10% at baseline, who had a CACS of > 3 at baseline, and the proportion of patients who experienced a MACE over the follow-up period. CACS = coronary artery calcium score; CVRS = cardiovascular risk score; GOLD = Global Initiative for Obstructive Lung Disease; MACE = major adverse cardiovascular event.
Incidence of MACEs by Risk Scores Classification
Table 2 shows patients characteristics according to risk categories. The clinical and physiologic characteristics in the 4 groups were different. The 101 patients in group IV (both scores were abnormal) were older and included a lower proportion of female individuals and a higher percentage of those with active smoking. They also had worse lung function; higher BMI, obstructive airflow, dyspnea, and exertion score and Charlson Comorbidity Index score; lower 6-minute walking distance; and higher prevalence of DM and hypertension than the other groups, particularly when compared with the 270 patients in group I (normal scores). Patients in groups II (n = 103) and III (n=75) had intermediate values in most variables compared with patients in groups I and IV. Their incidence of MACEs and death was lower than that in patients in group IV and higher than that in patients in group I.
Table 2.
Clinical and Physiologic Characteristics of Patients in Each of the 4 Groups Defined by the CVRS and CACS Thresholds
| Variable | Group I (CACS ≤ 3 and CVRS < 10%; n = 270) | Group II (CACS ≤ 3 and CVRS ≥ 10%; n = 103) | Group III (CACS > 3 and CVRS < 10%; n = 75) | Group IV (CACS > 3 and CVRS ≥ 10%; n = 101) |
|---|---|---|---|---|
| Age, y | 57 (8) | 68 (8) | 64 (7) | 71 (7) |
| Female sex | 29 | 10 | 17 | 8 |
| Follow-up, mo | 110 (64) | 98 (59) | 100 (60) | 66 (51) |
| BMI, kg/m2 | 27 (5) | 27 (4) | 28 (4) | 27 (4) |
| Smoking history, pack-years | 46 (26) | 56 (27) | 55 (24) | 58 (31) |
| Active smoking | 51 | 60 | 33 | 35 |
| FEV1 % predicted | 77 (24) | 72 (21) | 67 (20) | 63 (24) |
| FVC % predicted | 101 (20) | 98 (20) | 95 (19) | 89 (23) |
| FEV1 to FVC ratio | 60 (13) | 56 (11) | 54 (11) | 52 (13) |
| GOLD | ||||
| 1 | 50 | 36 | 27 | 29 |
| 2 | 31 | 46 | 51 | 39 |
| 3 | 17 | 16 | 17 | 22 |
| 4 | 2 | 2 | 6 | 10 |
| BODE index | 1.3 (1.74) | 1.47 (1.98) | 1.41 (1.84) | 3.57 (2.12) |
| Charlson Comorbidity Index | 1.22 (1.53) | 2 (2.25) | 1.44 (1.53) | 1.97 (1.93) |
| 6MWD, m | 506 (95) | 448 (119) | 471 (95) | 397 (105) |
| Systolic BP, mm Hg | 123 (16) | 137 (17) | 127 (15) | 135 (7) |
| Total cholesterol, mg/dL | 205 (40) | 197 (45) | 192 (39) | 166 (47) |
| HDL cholesterol, mg/dL | 56 (16) | 48 (13) | 55 (15) | 80 (10) |
| DM | 7 | 18 | 13 | 38 |
| Hypertension | 29 | 55 | 40 | 50 |
| MACE | 12 | 29 | 35 | 50 |
| Mortality | 19 | 35 | 35 | 48 |
Data are presented as percentage or mean (SD). 6MWD = 6-minute walking distance; BODE = BMI, obstructive airflow, dyspnea, and exertion; CACS = coronary artery calcium score; CVRS = cardiovascular risk score; DM = diabetes mellitus; GOLD = Global Initiative for Obstructive Lung Disease; HDL = high-density lipoprotein; MACE = major cardiovascular event.
Figure 4 shows the Kaplan-Meier curves of MACE incidence for each risk group. Group IV had a 50% risk of a MACE event, > 4 times higher than the 12% in group I at a mean follow-up time of 98 months. Interestingly, those in group II (CVRS ≥ 10% but CACS ≤ 3) showed a similar MACE risk as patients categorized as group III (CVRS < 10% but CACS > 3). The difference among the groups was significant by log-rank testing (P ≤ .01).
Figure 4.
Kaplan-Meier curves showing the probability of MACEs in patients with COPD who had: CVRS of < 10% and CACS of ≤ 3 (orange), CVRS of ≥ 10% and CACS of ≤ 3 (gray), CVRS of < 10% and CACS of > 3 (blue), and CVRS of ≥ 10% and CACS of > 3 (red). P ≤ .01 (log-rank test). CACS = coronary artery calcium score; CVRS = cardiovascular risk score; MACE = major adverse cardiovascular event.
The area under the curve from the time-dependent receiver operating characteristic analysis at 98 months showed that CVRS and CACS had an acceptable performance with no significant difference in the predictive power of a MACE (difference between areas, 0.034; SE, 0.031; 95% CI, –0.028 to 0.096; P = .283). In contrast, the area under the curve obtained by combining both risk scores (CVRS plus CACS) significantly improved the discrimination compared with each individual score; a P value of .026 compared with CACS alone and a P value of .015 compared with CVRS.
Table 3 shows the hazard ratio of having a MACE for each of the risk groups. Patients in group IV had the highest risk compared with those with both scores less than the abnormal threshold (hazard ratio, 7.7; 95% CI, 4.9-11.9; P < .001). Patients in groups II and III also showed a statistically significant higher hazard ratio of MACEs compared with the reference group (group IV), but a lower hazard ratio than patients with abnormal CVRS and CACS.
Table 3.
Hazard Ratio and 95% CI of the Risk of a MACE in the 4 Groups
| Group | β | Hazard Ratio | 95% CI | P Value |
|---|---|---|---|---|
| IV (CACS > 3 and CVRS ≥ 10%) | 2.04 | 7.7 | 4.9-11.9 | < .01 |
| III (CACS > 3 and CVRS < 10%) | 1.13 | 3.1 | 1.8-5.1 | < .01 |
| II (CACS ≤ 3 and CVRS ≥ 10%) | 0.95 | 2.6 | 1.6-4.2 | < .01 |
| I (CACS ≤ 3 and CVRS < 10%) | Reference | |||
CACS = coronary artery calcium score; CVRS = cardiovascular risk score; MACE = major adverse cardiovascular event.
Discussion
In this multicenter study of patients with COPD attending specialty clinics, we found that combining a clinical CVRS with the CACS significantly improved risk stratification for MACEs during follow-up, making this approach potentially useful in routine clinical practice. Primary cardiovascular events prevention is based on quantitative risk prediction using tools that combine clinical variables. In Europe, the SCORE, which includes traditional cardiovascular risk factors like age, sex, BP, serum lipid profile, and smoking status, is the most widely used risk assessment tool.6 It is recommended by the European Society of Cardiology.24 For individuals 40 to 69 years of age, the SCORE2 is used,6 whereas for those with diabetes, the SCORE2-Diabetes7 is recommended. The SCORE-OP8 is preferred for patients ≥ 70 years of age, and the SMART9 is preferred for those with a previous cardiovascular event. These scores are subdivided by cardiovascular event incidence into low, moderate, high, and very high risk. The absolute probability (in percentage) of a MACE is calculated over the next 10 years.
Our group previously reported on cardiovascular risk scores in patients with COPD. In that study, Zagaceta et al12 used the US-validated Framingham score for the first time in patients with COPD, reporting a high risk (27%) of a MACE developing over 10 years of follow-up, whereas the European SCORE underperformed in this setting. Similarly, the QRISK3, a very comprehensive tool that includes up to 21 variables, when applied to a COPD population, significantly underestimated the risk of MACEs especially in young patients.25 More recently, a new algorithm named the QR426 outperformed the atherosclerotic CVD27 and SCORE26 risk estimators to predict 10-year risk of CVD in a large population database from the United Kingdom. However, this new algorithm has not been investigated in patients with COPD. Unfortunately, because of a lack of some of the variables, we could not evaluate its performance in the present cohort.
In the current study, we adjusted the SCORE by geographic risk area (Spain = low risk), age (40-69 years and ≥ 70 years), diabetes diagnosis, and previous history of MACEs. The tool predicted a 10% risk of a MACE over the next 10 years. However, the actual occurrence of a MACE during the 8 years of follow-up was 24%, highlighting the high-risk profile of patients with COPD and the poor performance of this tool. Although CVRSs were similar across different spirometric GOLD stages (Fig 2), the incidence of MACEs was higher in GOLD groups 1 and 2, as previously shown. Our findings align with those of Amegadzie et al,25 who reported that cardiovascular risk assessment tools underestimate cardiovascular event risk in patients with COPD.
The evaluation of coronary artery calcium using visual vs automatically generated scores has shown a good correlation between both methods.13 The visual method is favored because of its competitive predictive performance and simplicity of use in routine clinical practice. We and others have shown that the CACS has an acceptable discriminative power to assess risk of incident cardiovascular events11,12 and is excellent at detecting moderate to severe coronary disease in patients with COPD. Indeed, these patients have a higher incidence of more severe calcification scores than people without COPD who smoke.15 In our study, the performance of CACS was similar to conventional cardiovascular risk scores with an area under the receiver operating characteristic curve that was 0.66 (95% CI, 0.61-0.71). However, when combined with CVRS using accepted abnormal thresholds for both methods (CVRS of 10 and CACS of 3), patients can be classified in 4 different risk groups (Table 2, Fig 2). Close to one-half of the current patients (group I) with a CVRS of < 10% and a CACS of ≤ 3 had a low incidence of MACE during the 8 years of follow-up. Patients in group IV (18%) had a CVRS of ≥ 10% and a CACS of > 3 and a high-risk profile, with 49% of them experiencing a MACE during the study period. These patients could benefit from preventive therapy. Those in groups II or III, where either the CVRS or CACS was abnormal, showed an intermediate risk. They also merit close attention because almost 30% of them experienced a MACE during follow-up. Patients with a positive CVRS and a low-risk CACS (group II) also deserve special attention. Initially, they had a low-risk profile (Fig 2), similar to group I, but over the subsequent 5 years, the incidence of MACEs increased, matching the risk profile of group III. This finding raises the question of whether these patients should have a repeat CACS at a 2- to 3-year interval to evaluate progression of disease better.
Our study has some limitations. First, the cohort included primarily male patients, and although > 100 female individuals were included, the findings should be replicated in female individuals with COPD with a wide range of airway obstruction. Second, although the study had a multicenter design, all sites were located in Spain, a country with a low risk of MACE incidence. Importantly, CVRSs were calculated in each patient as recommended by the European Society of Cardiology,24 the gold standard of cardiovascular risk assessment. Validation of these findings should be carried out prospectively in female and non-European populations. Third, because this was an observational study, we cannot infer causality, only an association and prediction of CVRS and CACS of MACEs, nevertheless potentially important tools to identify high-risk patients with COPD. Finally, we did not record systematically the occurrence of exacerbations or use of medications that also could have had an impact on MACE occurrence. This study was initiated before the evidence became clear that a close association existed between COPD and exacerbations and the incidence of cardiovascular events.28
Interpretation
This study demonstrated that using 2 well-established noninvasive tools to determine cardiovascular risk in patients with COPD has a complementary role in risk stratification. These scores could be implemented in routine clinical practice (especially now with the implementation of lung cancer screening with chest CT imaging in patients with COPD) to identify patients who might benefit from invasive testing or more intensive primary preventive measures.
Funding/Support
The authors have reported to CHEST that no funding was received for this study.
Financial/Nonfinancial Disclosures
None declared.
Acknowledgments
Author contributions: J. P. d. T. and B. R. C. planned the study. J. P. d. T., C. Casanova, J. Z., J. M. M., C. Cabrera, A. E., A. C., A. B. A., L. S., G. B., V. P.-P., M. D., and B. R. C. conducted the study. J. P. d. T., C. Casanova, J. Z., J. M. M., C. Cabrera, A. E., A. C., A. B. A., L. S., G. B., V. P.-P., M. D., and B. R. C. reported the findings. .J. P. d. T. is the guarantor of the study, taking responsibility for the integrity of the work as a whole, from inception to published article.
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