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Jonathan R. Enriquez, MD; Elizabeth M. Holper, MD, MPH
Author and Funding Information

From the Division of Cardiology, University of Texas Southwestern Medical Center (Dr Enriquez); and the Division of Cardiology, Medical City Hospital (Dr Holper).

Correspondence to: Elizabeth M. Holper, MD, MPH, Division of Cardiology, Medical City Hospital, 7777 Forest Ln, Ste 339, Dallas, TX 75230; e-mail: eholper@gmail.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).


© 2012 American College of Chest Physicians


Chest. 2012;141(2):572-573. doi:10.1378/chest.11-2564
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To the Editor:

We appreciate the interest and comments from Almagro and coauthors regarding our recent article in CHEST.1 We agree that COPD could likely be underdiagnosed among the population of patients in our study who underwent percutaneous coronary intervention (PCI) in the National Heart, Lung and Blood Institute Dynamic Registry because pulmonary function testing was not routinely performed on all patients. Thus, it is likely that the patients represent a more severe pulmonary disease spectrum, which was known and evaluated prior to PCI. Furthermore, if an underdiagnosis of COPD is present, it is likely not limited to the subset of patients within our study, but also exists within the general population, as described by the 2009 National Heart, Lung and Blood Institute Chart Book, which estimates that there are approximately 24 million Americans with COPD, 12 million physician-diagnosed and 12 million undiagnosed.2 We also agree that the variation in prevalence of COPD in prior studies could be related to differences in study definitions of COPD but could also be related to differences in the populations sampled and the years of enrollment. Although COPD is frequently underdiagnosed in many populations, the results of our study highlight that after PCI, patients with documented COPD have a significantly increased risk of adverse events and are discharged on fewer guideline-recommended class 1 therapies when compared with those without COPD.

Almagro and coauthors assert that spirometry should be required in all patients referred for PCI. Although our findings illustrate a higher risk for adverse events and decreased use of medical therapy for coronary artery disease among COPD patients who undergo PCI, based on these results alone we are unable to extrapolate or speculate on the usefulness of potential screening interventions for the diagnosis or stratification of COPD. We acknowledge the controversial nature of this issue and defer to existing guideline recommendations,3,4 as were recently well summarized by Hanania and Marciniuk,5 which strongly recommend the use of spirometry for the early diagnosis of COPD for patients with respiratory symptoms, although the use of screening spirometry in those without respiratory symptoms is less well supported. Rather than supporting novel screening or treatment interventions, we believe that our results support the need for the provision of evidence-based therapies for COPD patients with coronary artery disease and the close observation and follow-up of this high-risk patient subgroup after PCI for the prevention and management of adverse events.

Enriquez JR, Parikh SV, Selzer F, et al. Increased adverse events after percutaneous coronary intervention in patients with COPD: insights from the National Heart, Lung and Blood Institute Dynamic Registry. Chest. 2011;1403:604-610 [PubMed] [CrossRef]
 
National Heart, Lung and Blood Institute. Morbidity & Mortality: 2009 Chart Book on Cardiovascular, Lung, and Blood Diseases. National Heart, Lung and Blood Institute Web site .http://www.nhlbi.nih.gov/resources/docs/2009_ChartBook.pdf. Accessed December 19, 2011.
 
Rabe KF, Hurd S, Anzueto A, et al. Global Initiative for Chronic Obstructive Lung Disease Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: GOLD executive summary. Am J Respir Crit Care Med. 2007;1766:532-555 [PubMed]
 
Qaseem A, Wilt TJ, Weinberger SE, et al; American College of Physicians American College of Physicians American College of Chest Physicians American Thoracic Society European Respiratory Society Diagnosis and management of stable chronic obstructive pulmonary disease: a clinical practice guideline update from the American College of Physicians, American College of Chest Physicians, American Thoracic Society, and European Respiratory Society. Ann Intern Med. 2011;1553:179-191 [PubMed]
 
Hanania NA, Marciniuk DD. A unified front against COPD: clinical practice guidelines from the American College of Physicians, the American College of Chest Physicians, the American Thoracic Society, and the European Respiratory Society. Chest. 2011;1403:565-566 [PubMed]
 

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References

Enriquez JR, Parikh SV, Selzer F, et al. Increased adverse events after percutaneous coronary intervention in patients with COPD: insights from the National Heart, Lung and Blood Institute Dynamic Registry. Chest. 2011;1403:604-610 [PubMed] [CrossRef]
 
National Heart, Lung and Blood Institute. Morbidity & Mortality: 2009 Chart Book on Cardiovascular, Lung, and Blood Diseases. National Heart, Lung and Blood Institute Web site .http://www.nhlbi.nih.gov/resources/docs/2009_ChartBook.pdf. Accessed December 19, 2011.
 
Rabe KF, Hurd S, Anzueto A, et al. Global Initiative for Chronic Obstructive Lung Disease Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: GOLD executive summary. Am J Respir Crit Care Med. 2007;1766:532-555 [PubMed]
 
Qaseem A, Wilt TJ, Weinberger SE, et al; American College of Physicians American College of Physicians American College of Chest Physicians American Thoracic Society European Respiratory Society Diagnosis and management of stable chronic obstructive pulmonary disease: a clinical practice guideline update from the American College of Physicians, American College of Chest Physicians, American Thoracic Society, and European Respiratory Society. Ann Intern Med. 2011;1553:179-191 [PubMed]
 
Hanania NA, Marciniuk DD. A unified front against COPD: clinical practice guidelines from the American College of Physicians, the American College of Chest Physicians, the American Thoracic Society, and the European Respiratory Society. Chest. 2011;1403:565-566 [PubMed]
 
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