Chronic obstructive pulmonary disease in acute coronary syndromes Andell, Pontus PDF
Preview Chronic obstructive pulmonary disease in acute coronary syndromes Andell, Pontus
Chronic obstructive pulmonary disease in acute coronary syndromes ANDELL, PONTUS 2016 Document Version: Publisher's PDF, also known as Version of record Link to publication Citation for published version (APA): ANDELL, PONTUS. (2016). Chronic obstructive pulmonary disease in acute coronary syndromes. [Doctoral Thesis (compilation), Cardiology]. Lund University: Faculty of Medicine. 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LUND UNIVERSITY PO Box 117 221 00 Lund +46 46-222 00 00 Prin Po ted b nt y Media-Tryck, Lun us Andell d U n iversity 20 Ch 16 r Nordic Ecolab onic obstru Cdihseraosnei ci no bacsturtuec ctoivreo npaurlym soynnadrryo mes el 3041 ctiv Pontus Andell Pontus Andell was born in Gothenburg, Sweden in 0903 e p dePArtment of CArdiology | CliniCAl sCienCes, lund | lund university 2016 u 1987. He studied medicine at Lund University and l m graduated in 2014. He is now currently doing his o n internship at Skåne University Hospital in Lund and a r aims to specialize in cardiology. The focus of this y d doctoral thesis was to describe and characterize i s patients with acute coronary syndromes and e a concomitant chronic obstructive pulmonary se disease, their management, and the impact of in chronic obstructive pulmonary disease on outcome. a c u t e c o r o n a r y s y n d r o m e s 9 5 2 3 Lund University, Faculty of Medicine 9 1 Doctoral Dissertation Series 2016:99 6 7 ISBN 978-91-7619-325-9 91 8 ISSN 1652-8220 7 99 9 Chronic obstructive pulmonary disease in acute coronary syndromes Pontus Andell DOCTORAL DISSERTATION by due permission of the Faculty of Medicine, Lund University, Sweden. To be defended at lecture hall F5, Skåne University Hospital, Lund 2016-09-16 at 09:00 Faculty opponent Professor Gunnar Gislason, MD, PhD Gentofte Hospital, University of Copenhagen 1 Organization Document name LUND UNIVERSITY DOCTORAL DISSERTATION Department of Cardiology Date of dissertation Clinical Sciences, Lund University September 16th, 2016 Author: Pontus Andell Sponsoring organization Title and subtitle Chronic obstructive pulmonary disease in acute coronary syndromes Abstract Acute coronary syndromes (ACS) and chronic obstructive pulmonary disease (COPD) are leading causes of death and disability worldwide. The aim of this thesis was to describe and characterize ACS patients with concomitant COPD, their management, and the impact of COPD on outcome. The thesis includes four papers. The first paper characterized the ACS population with concomitant COPD and ascertained the impact of COPD on long-term mortality and cardiovascular morbidity in a large contemporary study population utilizing national registries. The second paper investigated the effect of beta-blocker treatment as secondary prevention on long-term mortality when prescribed at discharge in ACS patients with COPD, also with the use of national registries. The third paper was a post-hoc subgroup study from a randomized clinical trial that explored if the new and more potent antiplatelet agent ticagrelor was more beneficial than clopidogrel in ACS patients with COPD. Finally, the fourth paper investigated the effect of COPD on in-hospital complications and long-term mortality following coronary artery bypass grafting (CABG), in a nationwide concurrent ACS population with severe coronary artery disease, again utilizing national registries. ACS patients with concomitant COPD were found to be a high-risk population, with a heavy burden of comorbidity and a doubled unadjusted overall mortality. At discharge, ACS patients with COPD were less often treated with guideline-recommended secondary prevention, especially beta-blockers. In this group, beta- blocker treatment at discharge was associated with lower long-term mortality. Ticagrelor reduced the risk of ischemic event in ACS patients with COPD, without an increase in overall major bleeding. ACS patients with COPD and severe coronary artery disease treated with CABG had higher long-term mortality and more in- hospital infections than patients without COPD. In conclusion, improved guideline-recommended secondary prevention may improve outcome in ACS patients with COPD. Beta-blocker treatment should not be routinely withheld from ACS patients with COPD and the benefit-risk profile supports the use of ticagrelor. After CABG in ACS patients with COPD, preventive measures including careful monitoring of infection signs and prompt antibiotic treatment should be considered. Key words: chronic obstructive pulmonary disease, acute coronary syndrome, myocardial infarction, epidemiology Supplementary bibliographical information Language: English ISSN and key title: 1652-8220 - COPD in ACS ISBN: 978-91-7619-325-9 Recipient’s notes Number of pages Price Security classification I, the undersigned, being the copyright owner of the abstract of the above-mentioned dissertation, hereby grant to all reference sources permission to publish and disseminate the abstract of the above-mentioned dissertation. Signature date: 2 Chronic obstructive pulmonary disease in acute coronary syndromes Pontus Andell 3 “Never memorize something that you can look up.” Albert Einstein (1879-1955) © Pontus Andell Department of Cardiology, Clinical Sciences, Lund, Faculty of Medicine, Lund University Lund, Sweden Lund University, Faculty of Medicine Doctoral Dissertation Series 2016:99 ISBN 978-91-7619-325-9 ISSN 1652-8220 Printed in Sweden by Media-Tryck, Lund University Lund 2016 4 To mom and dad 5 Contents List of papers ............................................................................................................ 9 Abstract .................................................................................................................. 11 Sammanfattning (in Swedish) ................................................................................ 13 Abbreviations ......................................................................................................... 15 Introduction ............................................................................................................ 17 Historical perspective ................................................................................... 17 Coronary artery disease ....................................................................... 17 Chronic obstructive pulmonary disease ............................................... 19 Epidemiology ............................................................................................... 21 Coronary artery disease ....................................................................... 22 Chronic obstructive pulmonary disease ............................................... 22 COPD in myocardial infarction ........................................................... 23 Definitions .................................................................................................... 24 Coronary artery disease ....................................................................... 24 Chronic obstructive pulmonary disease ............................................... 25 Pathophysiology ........................................................................................... 25 Acute coronary syndrome .................................................................... 25 Chronic obstructive pulmonary disease ............................................... 28 Mechanisms connecting COPD and ACS ........................................... 30 Certain treatment and management aspects in ACS .................................... 31 Reperfusion therapy ............................................................................. 31 Dual anti-platelet therapy .................................................................... 32 Beta-blockers ....................................................................................... 33 Aims ....................................................................................................................... 35 6 Methods .................................................................................................................. 37 Patient populations ....................................................................................... 37 National healthcare registries .............................................................. 37 Study samples ...................................................................................... 38 Endpoints...................................................................................................... 39 Medical interventions ................................................................................... 40 Paper II ................................................................................................ 40 Paper III ............................................................................................... 40 Statistical analyses ....................................................................................... 40 Results .................................................................................................................... 43 Paper I .......................................................................................................... 43 Paper II ......................................................................................................... 45 Paper III ........................................................................................................ 47 Paper IV ....................................................................................................... 49 Discussion .............................................................................................................. 53 The COPD phenotype in ACS ..................................................................... 53 Presentation ......................................................................................... 53 Management ........................................................................................ 54 Impact of COPD on outcome .............................................................. 55 Secondary prevention ................................................................................... 56 Beta-blockers ....................................................................................... 56 Ticagrelor ............................................................................................ 57 CABG in COPD patients.............................................................................. 59 Conclusions ............................................................................................................ 61 Perspectives ............................................................................................................ 63 Acknowledgements ................................................................................................ 65 References .............................................................................................................. 68 7
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