ROTTERDAM, THE NETHERLANDS – Older patients with chronic obstructive pulmonary disease are at increased risk for carotid artery plaque formation and for the presence of vulnerable plaques with a lipid core, according to a new study from researchers in the Netherlands.

“We know that chronic obstructive pulmonary disease is a risk factor for ischemic stroke, and that certain components of carotid artery plaques such as intraplaque hemorrhage and lipid core increase the risk of ischemic events, but plaque composition in patients with chronic obstructive pulmonary disease has not been examined,” said researcher Bruno H.C. Stricker, MD, PhD, professor of pharmaco-epidemiology at the Erasmus Medical Center in Rotterdam, the Netherlands. “In our study, carotid artery wall thickening was increased twofold in older chronic obstructive pulmonary disease patients compared with controls with normal lung function, and chronic obstructive pulmonary disease was an independent predictor of the presence of plaques with a lipid core, which are more prone to rupture.”

The findings were published online in the American Thoracic Society’s American Journal of Respiratory and Critical Care Medicine.

The cross-sectional study, part of the Rotterdam Study, an ongoing population-based cohort study examining the occurrence of and risk factors for chronic diseases in subjects aged 55 years and older, involved 253 chronic obstructive pulmonary disease patients and 920 controls. Chronic obstructive pulmonary disease was confirmed by spirometry. Subjects with carotid wall thickening (intima-media thickness ≥ 2.5 mm) on ultrasonography underwent high-resolution magnetic resonance imaging (MRI) to characterize carotid plaques.

Subjects with chronic obstructive pulmonary disease had a twofold increased risk (odds ratio 2.0, 95%CI 1.44-2.85, p < 0.0001) of carotid wall thickening on ultrasonography compared to controls, and this risk increased significantly with the severity of airflow limitation. On MRI, vulnerable lipid core plaques were significantly more frequent in subjects with chronic obstructive pulmonary disease compared with controls (odds ratio 2.1, 95%CI 1.25-3.69, p=0.0058).

“Clinicians should be aware that chronic obstructive pulmonary disease patients are at increased risk for asymptomatic carotid atherosclerosis and that chronic obstructive pulmonary disease might lead to vulnerable plaques by inducing or aggravating the presence of plaques with a lipid core,” said Dr. Stricker.

The study had a few limitations, including the study’s cross-sectional design, which doesn’t allow causal associations between chronic obstructive pulmonary disease and carotid plaques to be inferred, and the lack of computed tomography confirmation of emphysema

“The results of our study provide new insights into the relationship between chronic obstructive pulmonary disease and the increased risk for stroke seen in these patients,” concluded Dr. Stricker. “Understanding the underlying risk factors for stroke in chronic obstructive pulmonary disease patients can help identify those at high risk and lead to the development of more personalized preventive treatment strategies targeting this devastating complication.”

- MFP Wire Services
- 10-30-2012

HALIFAX, NOVA SCOTIA, CANADA – Patients with advanced chronic obstructive pulmonary disease and shortness of breath found that opioids provided relief and improved their quality of life, states an article in Canadian Medical Association Journal. However, physicians are reluctant to prescribe opioids for this condition, meaning many people will not benefit from this treatment.

The prevalence of chronic obstructive pulmonary disease in Canada is increasing, and shortness of breath (dyspnea) is a major symptom that is difficult to treat and can result in fear, anxiety and a decreased quality of life. Although opioids are often used to treat pain and dyspnea associated with malignant diseases, they are underused in chronic obstructive pulmonary disease treatment. The Canadian Thoracic Society released a clinical practice guideline recommending the use of opioids for shortness of breath in patients with advanced chronic obstructive pulmonary disease that doesn’t respond to conventional treatment.

Researchers sought to understand physician attitudes toward this treatment and to understand the perspective of patients and their caregivers about the use of opioids for severe shortness of breath, known clinically as refractory dyspnea, that cannot be alleviated through other treatments. They interviewed 8 patients, 12 caregivers and 28 physicians in Nova Scotia, Canada. Patients had shortness of breath so severe that they could not leave their homes, or were breathless dressing or undressing, were on recommended therapies for chronic obstructive pulmonary disease and long-term oxygen, and had been using opioids for dyspnea for five weeks to four years.

“All patients reported that opioids provided significant improvements to their quality of life, relief of dyspnea, or both, and cited this as their main reason to continue taking opioids over the longer term,” write Dr. Graeme Rocker, Dalhousie University, Halifax, Nova Scotia, with coauthors.

Caregivers reported improvements in their family members’ quality of life and stress levels for themselves as well.

“Many physicians indicated uncertainty and discomfort about prescribing opioids to patients with chronic obstructive pulmonary disease,” state the authors. “Lack of guidance, confidence and experience, a fear of respiratory suppression, and concern about censure were key factors limiting their willingness to prescribe opioids in this context. However, most acknowledged that dyspnea is difficult and frustrating to manage and thus were willing to consider opioids for this purpose.”

“Discrepancies between the positive experiences of patients and family caregivers and the reluctance of physicians to prescribe opioids for refractory dyspnea constitute an important gap in care,” write the authors. “Bridging this gap will likely require innovative educational initiatives to improve the uptake of guidelines and confidence in prescribing opioids for refractory dyspnea.”

“Evidence is accumulating to suggest that soon the appropriate question will no longer be if we should prescribe opioids to help palliate refractory dyspnea in patients living with advanced chronic obstructive pulmonary disease, but rather how to do this competently and when,” conclude the authors.

- MFP Wire Services
- 04-25-2012

VANCOUVER, BRITISH COLUMBIA, CANADA – A blood protein known as surfactant protein-D (SP-D), which is mainly synthesised in the lungs, has been described as “a good predictor” of cardiovascular disease following a large study in North America. Reporting the study online today in the European Heart Journal, the investigators said that circulating SP-D levels were clearly associated with cardiovascular disease and total mortality in patients with angiographically diagnosed coronary artery disease independent of other well established risk factors (such as age, smoking, cholesterol and C-reactive protein levels).

In the lungs SP-D has a role in the body’s defensive response tot the many microorganisms and antigens inhaled each day, by binding to their surface and promting their clearance from the body. Blood levels of SP-D increase when the lungs are inflamed and not working well – for example, when someone catches a cold, flu or other respiratory tract infection. Blood levels also increase in those who smoke or develop a chronic lung condition such as asthma, emphysema or obstructive pulmonary disease (COPD).

In healthy people with normal lung function blood levels of SP-D are low, but when lung function is impaired (as with infections, smoking or COPD), SP-D leaks from the lungs into the blood and then into the circulation, increasing the risk of atherosclerosis.

This study aimed to determine whether or not circulating SP-D is related to cardiovascular morbidity and mortality in two independent cohorts: first, a large cohort of patients having coronary angiography for suspected coronary artery disease; and second, a “replication” cohort of ex- and current smokers with mild airflow restriction but without a known history of cardiovascular disease.

“We’ve known for a long time that chronic lung inflammation is associated with an increased risk of cardiovascular and total mortality,” said investigator Dr Don Sin from the Providence Heart and Lung Institute at St Paul’s Hospital, and University of British Columbia, Vancouver, Canada. “However, apart from lung function tests, there are no universally accepted biomarkers that could clearly predict these events. Recent studies have identified SP-D as a promising biomarker of lung inflammation and injury – for example, circulating SP-D levels are nearly 40% higher in active smokers than in lifetime non-smokers, and rise further in subjects with impaired lung function. It was our hypothesis that in the systemic circulation SP-D may promote atherosclerosis.”

Plasma SP-D levels were measured in 806 patients having coronary angiography. These patients were derived from the Vancouver Coronary Angiography Cohort referred for angiography between 1992 and 1995. Coronary artery disease was defined as any lesion causing at least 20% stenosis (and severe coronary artery disease at least 50%). Follow-up continued until 2007, with primary outcome defined as cardiovascular disease mortality. The replication cohort was derived from the Lung Health Study and included subjects with mild or moderate COPD.

The angiography patients who died during follow-up (30% of the cohort) had significantly higher plasma SP-D levels than those who survived (median 85.4 vs. 64.8 ng/mL; P < 0.0001). Those in the highest quintile of SP-D had a 4.4-fold higher risk of cardiovascular disease mortality than those in the lowest quintile, independent of age, sex, and plasma lipid levels.

Eight per cent of the patients in this group had coronary artery disease (verified by angiography), 71% had severe coronary artery disease, and 29% had angiographic evidence of triple vessel disease. Cardiovascular disease accounted for 45% of the total deaths in this group.

In the group of current and ex-smokers serum SP-D levels were higher in those who died or were hospitalised for cardiovascular disease than in those who did not (median 99.8 vs. 90.6 ng/mL; P = 0.0001).

Dr Sin described the association between circulating SP-D levels and cardiovascular disease as “strong” but emphasised that the study was designed to determine causality. “Based on our data,” he said, “we cannot determine whether SP-D was intrinsically involved in the pathogenesis of cardiovascular events or an epiphenomenon of lung inflammation.”

However, he agreed that circulating SP-D levels were a strong predictor of future cardiovascular disease mortality, independent of other risk factors. “Our data certainly implicate lung inflammation in the pathogenesis of heart and blood vessel disease and raise the possibility of using this protein as a biomarker for risk stratification in cardiovascular disease patients above and beyond the traditional biomarkers of serum cholesterol and C-reactive protein. SP-D may provide a simple blood test to determine who has lung disease and is also at high risk of heart and blood vessel disease. Such patients could be targeted for interventions such as smoking cessation and drug therapy to lower their heart disease risk.”

- MFP Wire Services
- 06-10-2011