Abstract
Acute exacerbations of COPD (AECOPD) or “COPD crises” [1], are crucial events in the natural course of COPD. Although they can occur at any severity stage, their impact increases as patients develop more severe airflow limitation.
Acute exacerbations of COPD (AECOPD) or “COPD crises” [1], are crucial events in the natural course of COPD. Although they can occur at any severity stage, their impact increases as patients develop more severe airflow limitation.
Several studies have demonstrated that the occurrence of COPD exacerbations increases the risk of myocardial infarction and stroke [2], all cause [3, 4] and cardiovascular mortality [5], in the post exacerbation period, particularly in AECOPD with associated pneumonia [6]. This was best demonstrated by Kunisaki et al. in a pre-specified analysis of the data from the SUMMIT trial of over 16 thousand patients with moderate COPD and heightened cardiovascular risk [7]. The authors found that the hazard ratio (HR) for cardiovascular events was increased, particularly in the first 30 days after the exacerbations (HR, 3.8; 95% CI, 2.7–5.5). The risk increased more than twofold if the exacerbations lead to a hospitalisation; where the HR reached 9.9 (95% CI, 6.6–14.9). This study was important because all deaths were analysed by a clinical end-point committee. There was an unusually high number of cardiovascular events occurring after the exacerbations suggesting some vascular dysfunction leading to myocardial infarction, stroke and pulmonary embolism.
This scenario appears to be similar to that reported to occur following hospitalised pneumonias, particularly in the elderly [8–10].
The current pandemia of COVID-19 affects primarily adults and particularly those affected by one or more chronic diseases [11]. Because most of the severe COVID-19 are due to pneumonia associated with respiratory failure [11, 12], it is likely that similarly to patients with exacerbations of COPD and/or community acquired pneumonia, the survivors of COVID will be at high risk of cardiovascular events and mortality following the acute phase of the disease. We would like to call attention to this vulnerable period, and recommend that patients be closely followed with a management plan that pays special attention to the prompt recognition of cardiovascular complications, especially in the 30 days following the resolution of the acute phase of the event. It would be a pity that those survivors of COVID-19 pneumonia, would then succumb from a relatively preventable consequence.
Footnotes
Conflict of interest: Dr. Celli reports personal fees and other from Astra Zeneca, personal fees from GlaxoSmithKline, personal fees from Boehringer Ingelheim, personal fees from Novartis, personal fees from Sanofi Aventis and personal fess form Menarini other from outside the submitted work.
Conflict of interest: Dr. Fabbri reports personal fees and non-financial support from AstraZeneca, personal fees and non-financial support from Chiesi, personal fees and non-financial support from GSK, personal fees and non-financial support from Novartis, personal fees and non-financial support from Boehringer Ingelheim, personal fees and non-financial support from Zambon, personal fees from Lusofarmaco, outside the submitted work.
References
- 1.Bafadhel M, Criner G, Dransfield MT, et al. . Exacerbations of chronic obstructive pulmonary disease: time to rename. Lancet Respir Med 2020; 8: 133–135. doi: 10.1016/S2213-2600(19)30414-X [DOI] [PubMed] [Google Scholar]
- 2.Donaldson GC, Hurst JR, Smith CJ, et al. . Increased risk of myocardial infarction and stroke following exacerbation of COPD. Chest 2010; 137: 1091–1097. doi: 10.1378/chest.09-2029 [DOI] [PubMed] [Google Scholar]
- 3.Mullerova H, Maselli DJ, Locantore N, et al. . Hospitalized exacerbations of COPD: risk factors and outcomes in the ECLIPSE cohort. Chest 2015; 147: 999–1007. doi: 10.1378/chest.14-0655 [DOI] [PubMed] [Google Scholar]
- 4.Hartl S, Lopez-Campos JL, Pozo-Rodriguez F, et al. . Risk of death and readmission of hospital-admitted COPD exacerbations: European COPD Audit. Eur Respir J 2016; 47: 113–121. doi: 10.1183/13993003.01391-2014 [DOI] [PubMed] [Google Scholar]
- 5.Wang M, Pei-Ying Lin E, Huang L, et al. . Mortality of cardiovascular events in COPD patients with preceding hospitalized acute exacerbation. Chest 2020. Published online March 14, 2020. [DOI] [PubMed] [Google Scholar]
- 6.Shin B, Kim SH, Yong SJ, et al. . Early readmission and mortality in acute exacerbation of chronic obstructive pulmonary disease with community-acquired pneumonia. Chron Respir Dis 2019; 16: 1479972318809480. doi: 10.1177/1479972318809480 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7.Kunisaki KM, Dransfield MT, Anderson JA, et al. . Exacerbations of Chronic Obstructive Pulmonary Disease and Cardiac Events. A Post Hoc Cohort Analysis from the SUMMIT Randomized Clinical Trial. Am J Respir Crit Care Med 2018; 198: 51–57. doi: 10.1164/rccm.201711-2239OC [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8.Cilloniz C, Ferrer M, Liapikou A, et al. . Acute respiratory distress syndrome in mechanically ventilated patients with community-acquired pneumonia. EurRespir J 2018; 51: 1702215. doi: 10.1183/13993003.02215-2017 [DOI] [PubMed] [Google Scholar]
- 9.Jain S, Self WH, Wunderink RG, et al. . Community-Acquired Pneumonia Requiring Hospitalization among U. S. Adults. N EnglJ Med 2015; 373: 415–427. doi: 10.1056/NEJMoa1500245 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 10.Yousufuddin M, Shultz J, Doyle T, et al. . Incremental risk of long-term mortality with increased burden of comorbidity in hospitalized patients with pneumonia. Eur J Intern Med 2018; 55: 23–27. doi: 10.1016/j.ejim.2018.05.003 [DOI] [PubMed] [Google Scholar]
- 11.Wang D, Hu B, Hu C, et al. . Clinical Characteristics of 138 Hospitalized Patients With 2019 Novel Coronavirus-Infected Pneumonia in Wuhan, China. JAMA 2020. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 12.Wu C, Chen X, Cai Y, et al. . Risk Factors Associated With Acute Respiratory Distress Syndrome and Death in Patients With Coronavirus Disease 2019 Pneumonia in Wuhan, China. JAMA Intern Med 2020. [DOI] [PMC free article] [PubMed] [Google Scholar]