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Editorials |

Is COPD Really a Cardiovascular Disease?

Don D. Sin, MD, FCCP
Author and Funding Information

Don D. Sin, MD, FCCP, James Hogg iCAPTURE Center for Cardiovascular and Pulmonary Research, St. Paul's Hospital, Room 368A, 1081 Burrard St, Vancouver, BC, Canada V6Z 1Y6; e-mail: dsin@mrl.ubc.ca

Dr. Sin is Associate Professor of Medicine, Canada Research Chair in COPD, University of British Columbia, and a Michael Smith Foundation for Health Research Senior Scholar.


The author has reported to the ACCP that no significant conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (www.chestjournal.org/site/misc/reprints.xhtml).


© 2009 American College of Chest Physicians


Chest. 2009;136(2):329-330. doi:10.1378/chest.09-0808
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Extract

It is now well established that COPD is a chronic inflammatory condition with significant extrapulmonary manifestations.1 In patients with mild-to-moderate COPD, the leading cause of morbidity and mortality is cardiovascular disease. In the Lung Health Study,2 which examined nearly 6,000 smokers whose FEV1 was between 55% and 90% predicted, cardiovascular diseases were the leading cause of hospitalization, accounting for nearly 50% of all hospital admissions, and the second leading cause of mortality, accounting for a quarter of all deaths. Subsequent studies3 have confirmed that, on average, patients with COPD have two to three times the risk of hospitalization for cardiovascular conditions (including ischemic heart disease, stroke, and heart failure) compared to those patients without COPD. However, in more severe stages of disease (Global Initiative for Chronic Obstructive Lung Disease [GOLD] stages 3 and 4), the clinical relevance of cardiovascular disease is less certain. The conventional wisdom is that in these groups of patients “lung failure” is the predominant driver of morbidity and mortality, and that other “comorbidities,” including cardiovascular disease, play less important roles. This notion is supported by large-scale COPD studies such as that by Celli et al,4 which reported that 61% of patients with predominantly GOLD 3 and 4 stage disease died from respiratory failure; whereas, only 14% died from myocardial ischemia.4 In a more recent study, the Towards a Revolution in COPD Health (or TORCH) investigators5 demonstrated that 35% of predominantly GOLD 3 and 4 patients died from respiratory failure; whereas only 10% died of a clear cut cardiovascular event such as myocardial ischemia, heart failure, or stroke. Although the Towards a Revolution in COPD Health study5 and other studies2,4,6 went to extreme measures to ensure the accuracy of the reporting of the underlying causes of death, there were nevertheless some important limitations. In most cases, investigators relied on death certificates or medical records of events that led to the patient's demise for attributing causality. However, even with detailed documentation, assigning a cause of mortality based on these sources can be problematic and fraught with significant misclassification errors.7 Autopsies, on the other hand, are less susceptible to this type of error and are a more accurate means of attributing causality. However, previous autopsy studies8 of patients dying with COPD have produced heterogeneous results owing largely to selection bias of cases included in each of the series. This is not surprising given that only a very select (and biased) sample of cases go on to autopsies.8

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