Abstract
Background:
There are limited data describing contemporary trends in the management and outcomes of patients with COPD who develop acute myocardial infarction (AMI).
Methods:
The study population consisted of patients hospitalized with AMI at all greater Worcester, Massachusetts, medical centers between 1997 and 2007.
Results:
Of the 6,290 patients hospitalized with AMI, 17% had a history of COPD. Patients with COPD were less likely to be treated with β-blockers or lipid-lowering therapy or to have undergone interventional procedures during their index hospitalization than patients without COPD. Patients with COPD were at higher risk for dying during hospitalization (13.5% vs 10.1%) and at 30 days after discharge (18.7% vs 13.2%), and their outcomes did not improve during the decade-long period under study. After multivariable adjustment, the adverse effects of COPD remained on both in-hospital (OR, 1.25; 95% CI, 0.99-1.50) and 30-day all-cause mortality (OR, 1.31; 95% CI, 1.10-1.58). The use of evidence-based therapies for all patients with AMI increased between 1997 and 2007, with a particularly marked increase for patients with COPD.
Conclusions:
Our results suggest that the gap in medical care between patients with and without COPD hospitalized with AMI narrowed substantially between 1997 and 2007. Patients with COPD, however, remain less aggressively treated and are at increased risk for hospital adverse outcomes than patients without COPD in the setting of AMI. Careful consideration is necessary to ensure that these high-risk complex patients are not denied the benefits of effective cardiac therapies.
COPD affects > 24 million American adults and results in 600,000 hospitalizations annually.1,2 Cardiovascular disease is an important cause of hospitalization in patients with COPD and is the leading cause of mortality in these high-risk patients.3,4 In addition to smoking, patients with COPD have other risk factors for cardiovascular disease due, in part, to their advanced age and reduced levels of physical activity.
Despite the magnitude of and mortality associated with COPD, there is limited information available about the characteristics, management practices, and hospital outcomes of patients with COPD with acute myocardial infarction (AMI). Although prior research has shown that β-blockers and other effective cardiac therapies are underused in patients with AMI with COPD,5‐8 it is less clear to what extent the overall management of AMI differs between patients with and without COPD and how their acute treatment and outcomes may have changed during recent periods. The purpose of this large observational study was to examine differences in the clinical characteristics, hospital outcomes, and use of different treatment approaches in patients with and without COPD hospitalized with AMI over the period of 1997 to 2007.
Materials and Methods
The Worcester (Massachusetts) Heart Attack Study is an ongoing population-based investigation examining long-term trends in the incidence and death rates of greater Worcester (2000 census: 478,000) residents hospitalized with AMI at all metropolitan Worcester medical centers. The methods used in this study have been previously described in detail.9‐11 Data have been collected on a biennial basis since 1975; a total of 6,290 patients hospitalized with independently validated AMI during the 6 study years of 1997, 1999, 2001, 2003, 2005, and 2007 comprised the population for this report, because information about COPD was only collected from 1997 on. In brief, patients with AMI were identified through standardized review of computerized hospital databases by trained study physicians and nurses according to preestablished criteria. At least two of the following three criteria needed to be satisfied for study inclusion: prolonged chest pain not relieved by rest or use of nitrates, biomarkers in excess of the upper limit of normal at each participating hospital, and serial ECG tracings showing changes in the ST segment and Q waves typical of AMI. Abstracted data included demographics, presenting symptoms, medical history, AMI characteristics, laboratory measurements, length of hospital stay, and hospital discharge status. Use of cardiac medications, cardiac catheterization, coronary reperfusion therapies used as primary revascularization (percutaneous coronary intervention [PCI] and coronary artery bypass surgery [CABG]), and development of important complications during hospitalization were determined. COPD was considered to be present if a patient was described in his/her medical record as having clinical or radiographic evidence of COPD. Pulmonary function testing results were not available to confirm the diagnosis or to assess the severity of COPD.
Data Analysis
Differences in the demographic and clinical characteristics as well as in the receipt of various treatment practices among patients with AMI with and without a history of COPD were examined using χ2 tests for discrete variables and Student t test for continuous variables. We examined the association between COPD and in-hospital and 30-day mortality as well as between COPD and significant hospital complications using multivariable logistic regression analyses to control for the influence of potentially confounding prognostic factors. The variables included in the logistic regression models were age, sex, year of hospitalization, history of cardiovascular disease, history of renal failure, ST-elevation MI, and hospital length of stay. In a secondary analysis we also adjusted for current smoking status, in addition to previously mentioned variables. We report the analysis for the 10-year period and for three aggregated periods of time for ease of analysis and interpretation: 1997/1999, 2001/2003, and 2005/2007. To examine changes over the period under study with regard to the use of various hospital treatments and short-term outcomes of patients with AMI with and without COPD, we used χ2 tests for trends.
All analyses were performed using SAS 9.2 (SAS Institute Inc). This study was approved by the institutional review board at the University of Massachusetts Medical School, Worcester, approval number H-458.
Results
Study Population Characteristics
Of the 6,290 patients hospitalized with AMI within the 10-year period of the study, 17% had COPD. Overall, the average age of this population was 71 years, and 56% were men. Compared with patients without COPD, patients with COPD were, on average, 4 years older and more likely to be current smokers and to have had angina, heart failure (HF), hypertension, diabetes, renal disease, and stroke previously diagnosed. Patients with COPD were more likely to have presented with a non-ST-segment elevation AMI and were less likely to present with chest pain but more likely to present with dyspnea. In comparison with all study patients, patients hospitalized during the 2 most recent years under investigation were older and had a higher prevalence of selected comorbidities (Table 1).
Table 1.
—Baseline Characteristics of Patients Hospitalized With AMI According to a History of COPD
| Total Study Population |
2005/2007 Cohort |
|||
| Characteristics | COPD Present (n = 1,080) | COPD Absent (n = 5,210) | COPD Present (n = 300) | COPD Absent (n = 1,512) |
| Demographics | ||||
| Age, mean, y | 74 | 70a | 73.5 | 69.8a |
| Age | ||||
| < 65 | 19.4 | 34.3 | 19.0 | 34.9 |
| 65-74 | 27.1 | 20.1 | 27.0 | 16.8 |
| 75-84 | 35.1 | 27.6 | 32.7 | 27.5 |
| > 85 | 18.4 | 18.0 | 21.3 | 20.9 |
| Male sex | 52.4 | 57.1b | 50.8 | 56.1 |
| Medical history | ||||
| Hypertension | 72.7 | 68.8b | 81.1 | 74.9b |
| Diabetes mellitus | 37.0 | 32.3b | 45.2 | 33.8c |
| Angina | 22.3 | 19.2b | 15.0 | 11.8 |
| Heart failure | 38.6 | 21.0a | 42.9 | 22.5c |
| Stroke | 15.0 | 11.0a | 15.3 | 11.0b |
| Renal disease | 22.3 | 15.6a | 32.9 | 21.6c |
| DNR | 34.4 | 22.1a | 35.2 | 24.6c |
| Current smoking | 27.3 | 20.4c | 29.6 | 20.8c |
| Symptoms | ||||
| Chest pain | 52.9 | 67.7c | 52.2 | 68.6c |
| Dyspnea | 61.5 | 47.0c | 62.9 | 48.0c |
| Initial heart rate | 94.4 | 84.9c | 93.0 | 84.4c |
| AMI type | ||||
| ST elevation MI | 26.7 | 39.6a | 24.3 | 32.9a |
Data are given as % unless otherwise indicated. AMI = acute myocardial infarction; DNR = do not resuscitate status; MI = myocardial infarction.
P < .01 patients with COPD compared with patients without COPD in each cohort.
P < .05 patients with COPD compared with patients without COPD in each cohort.
P < .001 patients with COPD compared with patients without COPD in each cohort.
Hospital Treatment Practices
Patients with COPD were less likely to have been treated with anticoagulants, aspirin, thrombolytics, lipid-lowering medication, or β-blockers or to have undergone primary cardiac revascularization procedures, but were more likely to have received calcium channel blockers, during their index hospitalization than patients without COPD (Table 2).
Table 2.
—Hospital Treatment Practices and Outcomes of Patients Hospitalized With AMI According to a History of COPD and Period of Hospitalization
| 1997/1999 |
2005/2007 |
|||
| Therapies/Outcomes | COPD Present | COPD Absent | COPD Present | COPD Absent |
| ACE inhibitors | 50.5 | 50.1 | 71.4 | 64.9a |
| Anticoagulants | 48.3 | 57.5a | 81.7 | 80.2 |
| Aspirin | 89.0 | 92.2 | 92 | 95.6a |
| β-Blockers | 64.6 | 84.6b | 93.4 | 95 |
| Calcim channel blockers | 42.3 | 25.2b | 24.3 | 20.8 |
| Lipid lowering | 25.0 | 32.4c | 76.0 | 79.0 |
| Cardiac catheterization | 28.6 | 44.0b | 53.2 | 69.3b |
| PCI | 11.0 | 20.3b | 36.5 | 51.8b |
| CABG | 3.8 | 5.8 | 5.7 | 5.6 |
| Atrial fibrillation | 17.6 | 13.6 | 28.2 | 20.7c |
| Heart failure | 46.4 | 32.2b | 55.2 | 36.9b |
| In-hospital mortality | 11 | 12 | 14.4 | 8.7c |
| 30-d mortality | 15 | 14.7 | 18.7 | 12.3c |
ACE = angiotensin-converting enzyme; CABG = coronary artery bypass surgery; PCI = percutaneous coronary intervention. See Table 1 legend for expansion of other abbreviation.
P < .05 patients with COPD compared with patients without COPD in each cohort.
P < .001 patients with COPD compared with patients without COPD in each cohort.
P < .01 patients with COPD compared with patients without COPD in each cohort.
After controlling for a number of potentially confounding factors that may have affected the prescribing of these treatment approaches, patients with COPD had a 56% lower odds to have been treated with β-blockers, 30% for lipid-lowering medication, and 44% lower odds to have undergone cardiac catheterization. They were also less likely to have undergone a PCI (OR, 0.64; 95% CI, 0.54-0.77) and CABG (OR, 0.46; 95% CI, 0.32-0.66) during their index hospitalization, but were more likely to have been prescribed calcium channel blockers, than patients without COPD (Table 3).
Table 3.
—Outcomes of Patients Hospitalized With AMI According to a History of COPD
| Total Study Population |
|||
| Therapies/Outcomes | COPD Present, % | COPD Absent, % | OR (95% CI) |
| Outcomes | |||
| Atrial fibrillation | 24.3 | 18.2a | 1.14 (0.97-1.34) |
| Heart failure | 52.5 | 34.8b | 1.59 (1.37-1.83) |
| Cardiogenic shock | 5.7 | 6.0 | 0.88 (0.66-1.18) |
| Stroke | 1.7 | 1.7 | 0.83 (0.49-1.40) |
| In-hospital death | 13.5 | 10.1b | 1.25 (0.99-1.50) |
| 30-d mortality | 18.7 | 13.2a | 1.31 (1.10-1.58) |
| Therapies | |||
| β-Blockers | 78.2 | 89.6a | 0.44 (0.35-0.50) |
| Anticoagulants | 69.7 | 73.1 | 0.81 (0.69-0.95) |
| Lipid-lowering agents | 52.9 | 59.2a | 0.70 (0.60-0.82) |
| Calcium channel blocker | 32.9 | 23.8a | 1.31 (1.13-1.52) |
| Cardiac catheterization | 39.0 | 56.0a | 0.56 (0.48-0.65) |
| PCI | 23.0 | 36.0a | 0.64 (0.54-0.77) |
| CABG | 4.0 | 6.4c | 0.46 (0.32-0.66) |
Variables included in the model: COPD, age, sex, year of hospitalization, cardiovascular disease history (coronary artery disease, stroke, heart failure, diabetes, hypertension), renal failure, length of stay, ST-elevation MI. See Table 1 and 2 legends for expansion of abbreviations.
P < .001.
P < .01.
P = .051.
In terms of changing treatment trends during the decade-long period under study, there was a marked increase in the use of β-blockers (64% in 1997, 93% in 2007), anticoagulants (48% in 1997, 93% in 2007), and lipid-lowering therapy (25% in 1997, 76% in 2007), and decrease in the use of calcium channel blockers (42% in 1997, 24% in 2007) in patients with COPD (Fig 1, Table 2). The use of cardiac catheterization (28% to 53% and 44% to 69%) and PCI (11% to 36% and 20% to 52%) increased significantly in patients with and without COPD, respectively, between 1997 and 2007, whereas the use of CABG remained relatively steady in both groups over time (4% to 6% in both groups).
Figure 1.
Hospital treatment practices of patients hospitalized with acute myocardial infarction (AMI) according to a history of COPD, 1997-2007. A, Use of cardiac medications according to a history of COPD and to time period of hospitalization. B, Use of cardiac procedures and coronary reperfusion therapy according to a history of COPD and to time period of hospitalization.
Outcomes
In comparison with patients without COPD, patients with COPD were more likely to have died during their acute hospitalization (13.5% vs 10.1%) and during the 30-day period after (18.7% vs 13.2%). The occurrence of atrial fibrillation (24.3% vs 18.2%) and heart failure (52.5% vs 34.8%) were significantly higher in patients with COPD (Table 3) Median hospital length of stay was 5 days for patients with COPD and 4 days for patients without COPD.
After adjusting for potential confounding factors of prognostic importance, patients with COPD had a 25% increased risk for dying in the hospital and a 31% higher risk of dying at 30 days after discharge (Table 3). Patients with COPD had a 59% increased risk for developing HF during hospitalization even after controlling for multiple potentially confounding variables.
Although in-hospital mortality rates steadily declined during the years under study for patients with AMI without COPD, there was no improvement over time in hospital and 30-day survival for patients with COPD. In both patient groups, the risk of atrial fibrillation and HF increased, whereas the risk of cardiogenic shock and stroke decreased, during the years under study. (Fig 2, Table 2) In a sensitivity analysis, we adjusted for current smoking status, but our main results did not change meaningfully.
Figure 2.
Outcomes of patients hospitalized with AMI according to a history of COPD and to time period of hospitalization. See Figure 1 legend for expansion of abbreviation.
Discussion
The results of this large observational study among residents of central Massachusetts hospitalized with AMI between 1997 and 2007 demonstrate significant differences among patients with and without COPD with regard to clinical presentation, treatments received, and hospital outcomes. Patients with COPD were more likely to have an atypical clinical presentation, were less likely to have been prescribed evidence-based cardiac therapies and interventional procedures during their hospitalization for AMI, and were more likely to have experienced complications. During the decade-long period under study, there was an overall improvement in the use of effective cardiac therapies in patients with and without COPD, with a particularly marked increase in the use of β-blockers and cardiac catheterization in patients with COPD. Although short-term mortality decreased for patients with AMI without COPD, there was no improvement over time in the survival of patients with COPD.
In the present study, approximately one in every six patients hospitalized with AMI had a history of COPD. Prior studies have reported considerable variation in the prevalence of COPD in patients with acute coronary syndromes, ranging from as low as 5%8 to as high as 20%.7,12,13 These wide variations in COPD prevalence likely reflect differences in the characteristics of patients studied and working definitions of COPD. Our observation that patients with COPD were older and had a worse cardiovascular profile than patients without COPD is consistent with the results of other investigations.8,14‐16 Patients with COPD were more likely to have presented with dyspnea than with chest pain (62% vs 47%). Shortness of breath is a common symptom of COPD, and it may be interpreted as part of an acute exacerbation; as such, the diagnosis of an AMI can be missed. These findings support the results of a study of 900 patients admitted with an exacerbation of COPD, which showed a high percentage of undiagnosed myocardial infarction.17
The results of the current study suggest that patients with a history of COPD were less likely to receive therapies of proven benefit for patients with AMI. As expected, the use of all evidence-based therapies for patients with AMI increased between 1997 and 2007, but more significantly so for patients with COPD. As a result of these changing trends, differences in the hospital use of several effective cardiac therapies between patients with and without COPD were relatively modest in the most recent years of our study (2005-2007). During the earlier years of this population-based study, patients with COPD were less likely to have been prescribed β-blocker therapy than patients without COPD, a finding that is consistent with the results of several previous studies.5,7,8,18 Physicians may be reluctant to use β-blockers in patients with COPD because of concerns with aggravating bronchospastic symptoms, but current evidence suggests that cardioselective β-blockers are generally well tolerated.19,20 In our analysis, the use of β-blockers was higher than has been reported in previously published studies. The increase in β-blocker prescribing over time was greater for patients with COPD, and by 2007 the gap between patients with and without COPD had narrowed considerably. This marked increase in the use of β-blockers between 1997 and 2007 is very encouraging and suggests that the results of systematic reviews and clinical trials have been increasingly incorporated into the care of patients with AMI and COPD.
In the current study, the rates of cardiac catheterization were only 39% in patients with COPD, lower than current national estimates.21 The use of PCI and CABG was also lower in patients with AMI and COPD than in patients without COPD, which suggests that clinicians are less likely to perform interventional procedures in this group of patients. There are conflicting findings in the published literature with regard to the outcomes of patients with AMI and COPD after undergoing PCI and CABG, with one study reporting a higher in-hospital death22 and another study not finding any differences in in-hospital death and major adverse outcomes between patients with COPD and without COPD.15
The older age, higher number of comorbidities, and overlap between the respiratory and cardiac symptoms in patients with AMI and associated COPD have important implications for the management of these complex patients. Physicians may consider patients with COPD at high risk for complications and they may be hesitant to recommend cardiac catheterization and PCI, although these patients may equally benefit from the receipt of these more aggressive but evidence-based interventions.
In our study, patients with AMI and COPD had a 59% increased risk for developing HF during their index hospitalization compared with those without COPD. The use of medications that stimulate the cardiovascular system, including sympathomimetic and anticholinergic drugs, together with persistent right ventricle strain, may predispose patients with COPD to develop HF post MI.
In the present study, patients with COPD and AMI had substantially higher hospital and 30-day mortality than patients without COPD, and the association between COPD and mortality remained significant after controlling for a variety of potentially confounding prognostic factors. The current results are in contrast with the findings from the Gulf Registry of Acute Coronary Events (Gulf RACE) study in Middle Eastern residents, which concluded that patients with AMI and COPD are at greater risk for developing HF but not at increased risk for dying during hospitalization.8 However, our results confirm and extend the findings from two other studies done in the United States that assessed long-term mortality post MI and showed that patients with COPD have approximate twofold greater 1-year mortality than patients without COPD.12,23
Despite significant improvements in the overall quality of care for patients hospitalized with AMI and COPD, their clinical outcomes did not improve significantly between 1997 and 2007. Sustained improvement and refinement in the appropriate use of novel treatment strategies in this increasingly prevalent and unique subgroup of patients may be necessary to achieve better survival and lower their risk of AMI-associated complications. Educational efforts for both specialists and general internists may improve the outcomes of these patients if, at the time of diagnosis of COPD, health-care professionals assess patients’ cardiovascular risk and aggressively target their risk factors. Further studies exploring their optimal management will contribute to additional improvement in their hospital and long-term outcomes.
Study Strengths and Limitations
The Worcester Heart Attack Study is a large population-based investigation that reflects community practice patterns and short-term outcomes of patients with and without COPD in a large Massachusetts population. A limitation of our study was that we did not have information about pulmonary function testing. However, previous studies of the interaction between COPD and AMI have used similar criteria to define COPD,8,12 and our results should be generalizable to patients who report a history of COPD.
Conclusions
In summary, patients with AMI and COPD were less likely to receive evidence-based therapies during hospitalization, and they had a higher risk of dying during hospitalization and at 30 days after discharge. Although the use of therapies recommended per current guidelines increased in all patients hospitalized with AMI during the 10 years under study, and the gap in care quality between patients with and without COPD closed substantially, differences in treatment persist, and the outcomes of patients with AMI and underlying COPD did not improve. Therefore, it is essential to educate providers to consider cardiovascular comorbidities in patients with COPD and not focus on the pulmonary disease in isolation. Careful consideration is necessary to treat established cardiovascular risk factors and optimize cardiac therapies in patients with COPD.
Acknowledgments
Author contributions: Dr Stefan: contributed to study conception and design, data analysis and interpretation, and drafting the manuscript for important intellectual content.
Dr Bannuru: contributed to study conception and design, data analysis and interpretation, and drafting the manuscript for important intellectual content.
Ms Lessard: contributed to data analysis and interpretation and drafting and revising the manuscript.
Dr Gore: contributed to drafting the manuscript for important intellectual content.
Dr Lindenauer: contributed to data analysis and interpretation and drafting the manuscript for important intellectual content.
Dr Goldberg: contributed to study conception and design, data analysis and interpretation, and drafting the manuscript for important intellectual content.
Financial/nonfinancial disclosures: The authors have reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.
Role of sponsors: The sponsors had no role in the design of the study, the collection and analysis of the data, or in the preparation of the manuscript. The content of this publication is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health, the National Center for Research Resources, the Agency for Healthcare Research and Quality, or the National Cancer Institute.
Other contributions: This research was made possible by the cooperation of participating hospitals in the Worcester, MA, metropolitan area.
Abbreviations
- AMI
acute myocardial infarction
- CABG
coronary artery bypass surgery
- HF
heart failure
- PCI
percutaneous coronary intervention
Footnotes
Funding/Support: This study was funded by the National Institutes of Health [Grant RO1 HL35434]. Dr Stefan is supported by the National Cancer Institute [Grant KM1 CA156726]. Dr Bannuru is supported by the Agency for Healthcare Research and Quality [Grant T32 HS000060]. Drs Bannuru and Stefan are supported by the National Center for Research Resources [Grant UL1 RR025752].
Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.
References
- 1.NHLBI morbidity and mortality chartbook. National Heart, Lung and Blood Institutes website. http://www.nhlbi.nih.gov/resources/docs/cht-book.htm. Accessed June 1, 2011.
- 2.National Center for Health StatisticsNational Health and Nutrition Examination Survey data US Centers for Disease Control website. http://www.cdc.gov/nchs/nhanes.htm. Accessed June 1, 2011.
- 3.Anthonisen NR, Connett JE, Enright PL, Manfreda J. Lung Health Study Research Group Hospitalizations and mortality in the Lung Health Study. Am J Respir Crit Care Med. 2002;166(3):333–339. doi: 10.1164/rccm.2110093. [DOI] [PubMed] [Google Scholar]
- 4.Zielinski J, MacNee W, Wedzicha J, et al. Causes of death in patients with COPD and chronic respiratory failure. Monaldi Arch Chest Dis. 1997;52(1):43–47. [PubMed] [Google Scholar]
- 5.Albouaini K, Andron M, Alahmar A, Egred M. Beta-blockers use in patients with chronic obstructive pulmonary disease and concomitant cardiovascular conditions. Int J Chron Obstruct Pulmon Dis. 2007;2(4):535–540. [PMC free article] [PubMed] [Google Scholar]
- 6.Andrus MR, Loyed JV. Use of beta-adrenoceptor antagonists in older patients with chronic obstructive pulmonary disease and cardiovascular co-morbidity: safety issues. Drugs Aging. 2008;25(2):131–144. doi: 10.2165/00002512-200825020-00005. [DOI] [PubMed] [Google Scholar]
- 7.Chen J, Radford MJ, Wang Y, Marciniak TA, Krumholz HM. Effectiveness of beta-blocker therapy after acute myocardial infarction in elderly patients with chronic obstructive pulmonary disease or asthma. J Am Coll Cardiol. 2001;37(7):1950–1956. doi: 10.1016/s0735-1097(01)01225-6. [DOI] [PubMed] [Google Scholar]
- 8.Hadi HA, Zubaid M, Al Mahmeed W, et al. Prevalence and prognosis of chronic obstructive pulmonary disease among 8167 Middle Eastern patients with acute coronary syndrome. Clin Cardiol. 2010;33(4):228–235. doi: 10.1002/clc.20751. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9.Goldberg RJ, Spencer FA, Gore JM, Lessard D, Yarzebski J. Thirty-year trends (1975 to 2005) in the magnitude of, management of, and hospital death rates associated with cardiogenic shock in patients with acute myocardial infarction: a population-based perspective. Circulation. 2009;119(9):1211–1219. doi: 10.1161/CIRCULATIONAHA.108.814947. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 10.Goldberg RJ, Yarzebski J, Lessard D, Gore JM. A two-decades (1975 to 1995) long experience in the incidence, in-hospital and long-term case-fatality rates of acute myocardial infarction: a community-wide perspective. J Am Coll Cardiol. 1999;33(6):1533–1539. doi: 10.1016/s0735-1097(99)00040-6. [DOI] [PubMed] [Google Scholar]
- 11.Gottlieb SS, McCarter RJ, Vogel RA. Effect of beta-blockade on mortality among high-risk and low-risk patients after myocardial infarction. N Engl J Med. 1998;339(8):489–497. doi: 10.1056/NEJM199808203390801. [DOI] [PubMed] [Google Scholar]
- 12.Salisbury AC, Reid KJ, Spertus JA. Impact of chronic obstructive pulmonary disease on post-myocardial infarction outcomes. Am J Cardiol. 2007;99(5):636–641. doi: 10.1016/j.amjcard.2006.09.112. [DOI] [PubMed] [Google Scholar]
- 13.Wakabayashi K, Gonzalez MA, Delhaye C, et al. Impact of chronic obstructive pulmonary disease on acute-phase outcome of myocardial infarction. Am J Cardiol. 2010;106(3):305–309. doi: 10.1016/j.amjcard.2010.03.026. [DOI] [PubMed] [Google Scholar]
- 14.Behar S, Panosh A, Reicher-Reiss H, Zion M, Schlesinger Z, Goldbourt U. SPRINT Study Group Prevalence and prognosis of chronic obstructive pulmonary disease among 5,839 consecutive patients with acute myocardial infarction. Am J Med. 1992;93(6):637–641. doi: 10.1016/0002-9343(92)90196-i. [DOI] [PubMed] [Google Scholar]
- 15.Berger JS, Sanborn TA, Sherman W, Brown DL. Effect of chronic obstructive pulmonary disease on survival of patients with coronary heart disease having percutaneous coronary intervention. Am J Cardiol. 2004;94(5):649–651. doi: 10.1016/j.amjcard.2004.05.034. [DOI] [PubMed] [Google Scholar]
- 16.Manganas H, Lacasse Y, Bourgeois S, Perron J, Dagenais F, Maltais F. Postoperative outcome after coronary artery bypass grafting in chronic obstructive pulmonary disease. Can Respir J. 2007;14(1):19–24. doi: 10.1155/2007/378963. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 17.Brekke PH, Omland T, Smith P, Søyseth V. Underdiagnosis of myocardial infarction in COPD-Cardiac Infarction Injury Score (CIIS) in patients hospitalised for COPD exacerbation. Respir Med. 2008;102(9):1243–1247. doi: 10.1016/j.rmed.2008.04.010. [DOI] [PubMed] [Google Scholar]
- 18.Egred M, Shaw S, Mohammad B, Waitt P, Rodrigues E. Under-use of beta-blockers in patients with ischaemic heart disease and concomitant chronic obstructive pulmonary disease. QJM. 2005;98(7):493–497. doi: 10.1093/qjmed/hci080. [DOI] [PubMed] [Google Scholar]
- 19.Salpeter S, Ormiston T, Salpeter E. Cardioselective beta-blockers for chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2005;(4):CD003566. doi: 10.1002/14651858.CD003566.pub2. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 20.Salpeter SR, Ormiston TM, Salpeter EE, Poole PJ, Cates CJ. Cardioselective beta-blockers for chronic obstructive pulmonary disease: a meta-analysis. Respir Med. 2003;97(10):1094–1101. doi: 10.1016/s0954-6111(03)00168-9. [DOI] [PubMed] [Google Scholar]
- 21.Bhatt DL, Roe MT, Peterson ED, et al. CRUSADE Investigators Utilization of early invasive management strategies for high-risk patients with non-ST-segment elevation acute coronary syndromes: results from the CRUSADE Quality Improvement Initiative. JAMA. 2004;292(17):2096–2104. doi: 10.1001/jama.292.17.2096. [DOI] [PubMed] [Google Scholar]
- 22.Selvaraj CL, Gurm HS, Gupta R, Ellis SG, Bhatt DL. Chronic obstructive pulmonary disease as a predictor of mortality in patients undergoing percutaneous coronary intervention. Am J Cardiol. 2005;96(6):756–759. doi: 10.1016/j.amjcard.2005.05.016. [DOI] [PubMed] [Google Scholar]
- 23.Hawkins NM, Huang Z, Pieper KS, et al. Valsartan in Acute Myocardial Infarction Trial Investigators Chronic obstructive pulmonary disease is an independent predictor of death but not atherosclerotic events in patients with myocardial infarction: analysis of the Valsartan in Acute Myocardial Infarction Trial (VALIANT) Eur J Heart Fail. 2009;11(3):292–298. doi: 10.1093/eurjhf/hfp001. [DOI] [PMC free article] [PubMed] [Google Scholar]