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ORIGINAL ARTICLE
Systemic inflammation in patients with chronic obstructive pulmonary disease undergoing percutaneous coronary intervention XIAO LEI ZHANG,1* YONG HUI CHI,2* LE FENG WANG,2 HONG SHI WANG2 AND XIANG MIN LIN2 1
Pulmonary and Critical Care Department, Beijing Institute of Respiratory Medicine and 2Cardiology Department, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
ABSTRACT Background and objective: Systemic inflammation plays an important role in both chronic obstructive pulmonary disease (COPD) and coronary artery disease (CAD). The purpose of the present study was to assess the association of high-sensitivity C-reactive protein (hs-CRP), a biomarker of systemic inflammation, with in-hospital outcomes in patients with COPD undergoing percutaneous coronary intervention (PCI). Methods: A total of 378 patients with COPD who were treated with PCI from January 2007 through January 2012, were divided into two groups according to hs-CRP level at admission. Demographics, clinical, angiographic data and in-hospital outcomes were compared. Results: Patients with elevated hs-CRP (≥3 mg/L) were more likely to be female and current smokers, had more severe airflow limitation, more hypertension, diabetes and cardiac dysfunction and had increased incidence of three-vessel disease and more type C lesions. Subjects with elevated hs-CRP were also less likely to have been prescribed with statins and B-blockers, perhaps. Rate of in-hospital composite major adverse cardiovascular events (MACEs) was higher (15.5% vs 8.2%, P = 0.041) and hospital stay was longer (8.2 ± 2.0 vs 7.5 ± 1.7 days, P < 0. 001) in patients with elevated hs-CRP. A combined analysis of MACE on the basis of airflow limitation and hs-CRP showed an exaggerated hazard ratio in the presence of both severe airflow limitation and elevated hs-CRP. In a multivariate analysis, elevated periprocedural hs-CRP was independently related with MACEs and hospital stay. Conclusions: Elevated periprocedural hs-CRP is independently and additively related with increased incidence of in-hospital adverse outcomes in COPD patients undergoing PCI.
Correspondence: Xiao Lei Zhang, Pulmonary and Critical Care Department, Beijing Institute of Respiratory Medicine, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China. Email: [email protected] *These authors contributed equally to the study. Received 1 July 2013; invited to revise 23 September and 6 December 2013; revised 29 September and 7 December 2013; accepted 5 February 2014 (Associate Editor: Shu Hashimoto). © 2014 Asian Pacific Society of Respirology
SUMMARY AT A GLANCE This study demonstrates that systemic inflammation is independently and additively associated with the increased incidence of in-hospital adverse outcomes in COPD patients undergoing percutaneous coronary intervention.
Key words: chronic obstructive pulmonary disease, coronary artery disease, inflammation, percutaneous coronary intervention. Abbreviations: ACEI, angiotensin-converting enzyme inhibitor; ARB, angiotensin II receptor blocker; CAD, coronary artery disease; COPD, chronic obstructive pulmonary disease; CRP, C-reactive protein; ECG, electrocardiogram; FEV1, forced expiratory volume in 1 s; HR, hazard ratio; LVEF, left ventricular ejection fraction; MACEs, composite major adverse cardiovascular events; NHANES, National Health and Nutrition Examination Survey; NSTEMI, non-ST segmental elevated myocardial infarction; PCI, percutaneous coronary intervention; STEMI, ST segmental elevated myocardial infarction; UA, unstable angina.
INTRODUCTION Patients with chronic obstructive pulmonary disease (COPD) have an increased risk for cardiovascular morbidity and mortality.1 Accumulating evidence has shown a close association between COPD and cardiovascular disease, especially coronary artery disease (CAD).2,3 The causal connection between COPD and CAD has historically been cigarette smoking. However, recent epidemiologic studies show that systemic inflammation plays a significant role in both atherogenesis and COPD.4 Additionally, it has been shown that independent from the extent of airflow limitation, the cardiac injury detected by electrocardiogram is related with low-level inflammation in COPD patients.5 However, the association of systemic inflammation and the clinical characteristics, especially the angiographic severity of coronary artery lesions in patients with COPD is currently unclear. Respirology (2014) doi: 10.1111/resp.12295
2 Treatment of CAD in subjects with COPD still presents therapeutic challenges. Percutaneous coronary intervention (PCI) is the frequent option for most COPD patients requiring revascularization. Several studies have reported an elevated risk of adverse outcomes among COPD patients after PCI.6–8 Previous clinical observations have demonstrated that systemic inflammation is related to adverse clinical outcomes in CAD subjects treated with PCI.9,10 Although COPD is considered as a systemic inflammatory disease, little is known about the potential additative effect of systemic inflammation on the in-hospital outcomes for patients with COPD undergoing PCI. High-sensitivity C-reactive protein (hs-CRP), a marker of systemic inflammation, is related to disease severity and prognosis in COPD.11 Hs-CRP measurements have also been used as a biomarker of periprocedural inflammation in CAD to predict plaque vulnerability and subsequent cardiovascular events. However, for some of these studies, subjects with COPD were excluded12 and in most other studies, it is not clearly stated whether patients concomitant with COPD were included in the study population.9,10 Thus, the role of hs-CRP in clinical outcome for this homogenous group of patients with COPD and concomitant CAD has not been adequately defined. In this study, we aim to evaluate whether periprocedural hs-CRP is related with in-hospital major advanced cardiac events (MACEs) and the angiographic severity of coronary artery lesions in subjects with COPD undergoing PCI.
METHODS We retrospectively analyzed a total of 378 stable COPD patients complicated with stable angina, unstable angina, non-ST segmental elevated myocardial infarction (NSTEMI) or segmental elevated myocardial infarction (STEMI), who required PCI in our medical center from January 2007 through January 2012. COPD was defined as a post-bronchodilator forced expiratory volume in 1 s (FEV1)/forced vital capacity (FVC) ratio of
ORIGINAL ARTICLE
Systemic inflammation in patients with chronic obstructive pulmonary disease undergoing percutaneous coronary intervention XIAO LEI ZHANG,1* YONG HUI CHI,2* LE FENG WANG,2 HONG SHI WANG2 AND XIANG MIN LIN2 1
Pulmonary and Critical Care Department, Beijing Institute of Respiratory Medicine and 2Cardiology Department, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
ABSTRACT Background and objective: Systemic inflammation plays an important role in both chronic obstructive pulmonary disease (COPD) and coronary artery disease (CAD). The purpose of the present study was to assess the association of high-sensitivity C-reactive protein (hs-CRP), a biomarker of systemic inflammation, with in-hospital outcomes in patients with COPD undergoing percutaneous coronary intervention (PCI). Methods: A total of 378 patients with COPD who were treated with PCI from January 2007 through January 2012, were divided into two groups according to hs-CRP level at admission. Demographics, clinical, angiographic data and in-hospital outcomes were compared. Results: Patients with elevated hs-CRP (≥3 mg/L) were more likely to be female and current smokers, had more severe airflow limitation, more hypertension, diabetes and cardiac dysfunction and had increased incidence of three-vessel disease and more type C lesions. Subjects with elevated hs-CRP were also less likely to have been prescribed with statins and B-blockers, perhaps. Rate of in-hospital composite major adverse cardiovascular events (MACEs) was higher (15.5% vs 8.2%, P = 0.041) and hospital stay was longer (8.2 ± 2.0 vs 7.5 ± 1.7 days, P < 0. 001) in patients with elevated hs-CRP. A combined analysis of MACE on the basis of airflow limitation and hs-CRP showed an exaggerated hazard ratio in the presence of both severe airflow limitation and elevated hs-CRP. In a multivariate analysis, elevated periprocedural hs-CRP was independently related with MACEs and hospital stay. Conclusions: Elevated periprocedural hs-CRP is independently and additively related with increased incidence of in-hospital adverse outcomes in COPD patients undergoing PCI.
Correspondence: Xiao Lei Zhang, Pulmonary and Critical Care Department, Beijing Institute of Respiratory Medicine, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China. Email: [email protected] *These authors contributed equally to the study. Received 1 July 2013; invited to revise 23 September and 6 December 2013; revised 29 September and 7 December 2013; accepted 5 February 2014 (Associate Editor: Shu Hashimoto). © 2014 Asian Pacific Society of Respirology
SUMMARY AT A GLANCE This study demonstrates that systemic inflammation is independently and additively associated with the increased incidence of in-hospital adverse outcomes in COPD patients undergoing percutaneous coronary intervention.
Key words: chronic obstructive pulmonary disease, coronary artery disease, inflammation, percutaneous coronary intervention. Abbreviations: ACEI, angiotensin-converting enzyme inhibitor; ARB, angiotensin II receptor blocker; CAD, coronary artery disease; COPD, chronic obstructive pulmonary disease; CRP, C-reactive protein; ECG, electrocardiogram; FEV1, forced expiratory volume in 1 s; HR, hazard ratio; LVEF, left ventricular ejection fraction; MACEs, composite major adverse cardiovascular events; NHANES, National Health and Nutrition Examination Survey; NSTEMI, non-ST segmental elevated myocardial infarction; PCI, percutaneous coronary intervention; STEMI, ST segmental elevated myocardial infarction; UA, unstable angina.
INTRODUCTION Patients with chronic obstructive pulmonary disease (COPD) have an increased risk for cardiovascular morbidity and mortality.1 Accumulating evidence has shown a close association between COPD and cardiovascular disease, especially coronary artery disease (CAD).2,3 The causal connection between COPD and CAD has historically been cigarette smoking. However, recent epidemiologic studies show that systemic inflammation plays a significant role in both atherogenesis and COPD.4 Additionally, it has been shown that independent from the extent of airflow limitation, the cardiac injury detected by electrocardiogram is related with low-level inflammation in COPD patients.5 However, the association of systemic inflammation and the clinical characteristics, especially the angiographic severity of coronary artery lesions in patients with COPD is currently unclear. Respirology (2014) doi: 10.1111/resp.12295
2 Treatment of CAD in subjects with COPD still presents therapeutic challenges. Percutaneous coronary intervention (PCI) is the frequent option for most COPD patients requiring revascularization. Several studies have reported an elevated risk of adverse outcomes among COPD patients after PCI.6–8 Previous clinical observations have demonstrated that systemic inflammation is related to adverse clinical outcomes in CAD subjects treated with PCI.9,10 Although COPD is considered as a systemic inflammatory disease, little is known about the potential additative effect of systemic inflammation on the in-hospital outcomes for patients with COPD undergoing PCI. High-sensitivity C-reactive protein (hs-CRP), a marker of systemic inflammation, is related to disease severity and prognosis in COPD.11 Hs-CRP measurements have also been used as a biomarker of periprocedural inflammation in CAD to predict plaque vulnerability and subsequent cardiovascular events. However, for some of these studies, subjects with COPD were excluded12 and in most other studies, it is not clearly stated whether patients concomitant with COPD were included in the study population.9,10 Thus, the role of hs-CRP in clinical outcome for this homogenous group of patients with COPD and concomitant CAD has not been adequately defined. In this study, we aim to evaluate whether periprocedural hs-CRP is related with in-hospital major advanced cardiac events (MACEs) and the angiographic severity of coronary artery lesions in subjects with COPD undergoing PCI.
METHODS We retrospectively analyzed a total of 378 stable COPD patients complicated with stable angina, unstable angina, non-ST segmental elevated myocardial infarction (NSTEMI) or segmental elevated myocardial infarction (STEMI), who required PCI in our medical center from January 2007 through January 2012. COPD was defined as a post-bronchodilator forced expiratory volume in 1 s (FEV1)/forced vital capacity (FVC) ratio of
