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Overlooking Cardiovascular Risk in Patients With COPDOverlooking Cardiovascular Risk in COPD FREE TO VIEW

Richard D. Turner, MBChB; Charles M. Gwavava, MBChB; Stephen M. Bianchi, PhD
Author and Funding Information

From the Department of Respiratory Medicine, Sheffield Teaching Hospitals NHS Trust.

Correspondence to: Richard D. Turner, MBChB, Sheffield Teaching Hospitals NHS Trust, Department of Respiratory Medicine, Herries Rd, Sheffield, S5 7AU, England; e-mail: richturner77@yahoo.com


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.

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


© 2011 American College of Chest Physicians


Chest. 2011;140(5):1385-1386. doi:10.1378/chest.11-0887
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To the Editor:

In their excellent overview of the systemic effects of COPD in a recent issue of CHEST (January 2011), Nussbaumer-Ochsner and Rabe1 state that patients with COPD should be carefully evaluated for more general disorders associated with chronic systemic inflammation, such as cardiovascular disease (CVD). We present evidence that cardiovascular (CV) risk assessment is overlooked in this group.

We conducted a retrospective analysis of 117 patients with acute exacerbations of COPD consecutively admitted to two English district general hospitals over a period of 2 months in 2008. Evidence of preexisting CVD (a history of stroke, transient cerebral ischemia, myocardial infarction, angina, or peripheral vascular disease) was noted. For those with no previous CV events, we estimated the 10- and 20-year event risk in each case using a model from the Framingham data set based on gender, age, smoking status, BP, presence or absence of diabetes, and lipid profile.2 We also recorded prescriptions of statins and antiplatelet agents, drug classes both recommended for individuals at high risk of CV events.2,3

Thirty-two of the 117 patients had preexisting CVD; 22 of this group were prescribed an antiplatelet agent and 17 a statin. A further 58 patients (50% of the cohort) had an estimated 10-year CV risk > 10%; 32 of these patients had a risk of > 20%. Less than 60% of this primary prevention group was taking antiplatelet drugs, and less than one-third of them had been prescribed a statin (Table 1).

Table Graphic Jump Location
Table 1 —Patients With COPD in Each Cardiovascular Risk Category Prescribed an Antiplatelet Drug, Statin, or Other Anticoagulant

Data presented as No. (%). CV = cardiovascular; CVD = cardiovascular disease.

Low prescription rates of aspirin for secondary CVD prevention may be explained by concerns of increased bleeding risk from concurrent coumarin anticoagulation; warfarin was prescribed in eight of the 10 patients with established CVD who were not taking antiplatelet agents (no patient in our cohort was prescribed warfarin in addition to an antiplatelet agent). For primary cardiovascular prevention, levels of antiplatelet use perhaps reflect an unresolved conflict between current guidance supporting their use2,3 and increasing evidence of net harm from bleeding events.4 The evidence for the benefit of statins for both secondary and primary prevention is more robust, however, particularly where the risk of cardiovascular events exceeds 2% per year.5 Statins were underused in this cohort, particularly in the highest cardiovascular risk category, even in those patients with measured total cholesterol > 5 mmol/L.

Low rates of statin and aspirin prescribing in patients with both COPD and increased cardiovascular risk imply that CVD is considered too infrequently in this group. Because COPD itself may well be an additional risk factor for CVD, it follows that statin therapy, along with other interventions to modify cardiovascular risk, is especially important in this complex group.1

Nussbaumer-Ochsner Y, Rabe KF. Systemic manifestations of COPD. Chest. 2011;1391:165-173 [CrossRef] [PubMed]
 
British Cardiac SocietyBritish Cardiac Society British Hypertension Society British Hypertension Society Diabetes UK Diabetes UK HEART UK HEART UK Primary Care Cardiovascular Society Primary Care Cardiovascular Society Stroke Association Stroke Association JBS 2: Joint British Societies’ guidelines on prevention of cardiovascular disease in clinical practice. Heart. 2005;91suppl 5:v1-v52 [CrossRef] [PubMed]
 
Pearson TA, Blair SN, Daniels SR, et al; American Heart Association Science Advisory and Coordinating Committee American Heart Association Science Advisory and Coordinating Committee AHA guidelines for primary prevention of cardiovascular disease and stroke: 2002 update: consensus panel guide to comprehensive risk reduction for adult patients without coronary or other atherosclerotic vascular diseases. Circulation. 2002;1063:388-391 [CrossRef] [PubMed]
 
Baigent C, Blackwell L, Collins R, et al; Antithrombotic Trialists’ (ATT) Collaboration Antithrombotic Trialists’ (ATT) Collaboration Aspirin in the primary and secondary prevention of vascular disease: collaborative meta-analysis of individual participant data from randomised trials. Lancet. 2009;3739678:1849-1860 [CrossRef] [PubMed]
 
Taylor F, Ward K, Moore TH, et al. Statins for the primary prevention of cardiovascular disease. Cochrane Database Syst Rev. 2011;1:CD004816
 

Figures

Tables

Table Graphic Jump Location
Table 1 —Patients With COPD in Each Cardiovascular Risk Category Prescribed an Antiplatelet Drug, Statin, or Other Anticoagulant

Data presented as No. (%). CV = cardiovascular; CVD = cardiovascular disease.

References

Nussbaumer-Ochsner Y, Rabe KF. Systemic manifestations of COPD. Chest. 2011;1391:165-173 [CrossRef] [PubMed]
 
British Cardiac SocietyBritish Cardiac Society British Hypertension Society British Hypertension Society Diabetes UK Diabetes UK HEART UK HEART UK Primary Care Cardiovascular Society Primary Care Cardiovascular Society Stroke Association Stroke Association JBS 2: Joint British Societies’ guidelines on prevention of cardiovascular disease in clinical practice. Heart. 2005;91suppl 5:v1-v52 [CrossRef] [PubMed]
 
Pearson TA, Blair SN, Daniels SR, et al; American Heart Association Science Advisory and Coordinating Committee American Heart Association Science Advisory and Coordinating Committee AHA guidelines for primary prevention of cardiovascular disease and stroke: 2002 update: consensus panel guide to comprehensive risk reduction for adult patients without coronary or other atherosclerotic vascular diseases. Circulation. 2002;1063:388-391 [CrossRef] [PubMed]
 
Baigent C, Blackwell L, Collins R, et al; Antithrombotic Trialists’ (ATT) Collaboration Antithrombotic Trialists’ (ATT) Collaboration Aspirin in the primary and secondary prevention of vascular disease: collaborative meta-analysis of individual participant data from randomised trials. Lancet. 2009;3739678:1849-1860 [CrossRef] [PubMed]
 
Taylor F, Ward K, Moore TH, et al. Statins for the primary prevention of cardiovascular disease. Cochrane Database Syst Rev. 2011;1:CD004816
 
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