Coronary artery disease as an extrapulmonary manifestation of Chronic Obstructive Pulmonary Disease

Aggelos S. Aggelakas MD
Medical Department, St. Anargiroi General Hospital

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Cite as: Aggelakas AS. Coronary Artery Disease as an Extra-Pulmonary Manifestation of Chronic Obstructive Pulmonary Disease. Alveolus 2013; 1(1):13-15.

The occurrence of COPD and coronary artery disease(CAD) is evident worldwide. COPD was the sixth leading cause of death in 1990, has been the fourth since 2000 and is predicted to be the third by 2020[1,2]. It is believed that, by 2030, COPD will be the direct underlying cause of 7.8% of all deaths and 27% of deaths related to smoking[3]. As far as CAD is concerned, its mortality remains increased in Central and Eastern Europe, while it has been decreased in Western Europe since 1970. Furthermore, despite the fact that survival after acute myocardial infarction improves, the occurrence of CAD still increases.

Given that COPD and CAD share many risk factors, there is a high possibility that these two conditions may coexist and may interact. Several studies have determined COPD as a major risk factor for atherosclerosis and development of CAD, above and beyond well established risk factors, such as hypercholesterolemia and hypertension[4]. Large clinical studies have proved that in patients with COPD, the risk for cardiovascular mortality is two to three times greater than in patients without COPD[5-7] and the cardiovascular disease is the primary cause of death in about 50% of patients with COPD[8].

In a recent study, Feary et al.[9] identified and analyzed the 2.5% of patients who had COPD in the UK. These patients (n = 29.870) were five times more likely to have a cardiovascular disease compared with those without COPD (n = 1.174.240). Moreover, in the follow-up analyses, the incidence of MI was greater in COPD patients than in those without COPD. Furthermore, Agusti et al.[10] found that COPD patients present an increased prevalence of ischemic heart disease compared to smoking and non-smoking control subjects. Finally, Enriquez et al.[11] suggested that patients with COPD who undergo PCI have more comorbidities and a greater extent of coronary artery disease. They also demonstrated that COPD is associated with higher risk of mortality and increased risk of repeat revascularization within 1 year after PCI and came to the conclusion that these outcomes may be due to the lower rates of guideline class 1-recommended therapies (ex. b-blockers) prescribed at discharge.

As far as the pathophysiologic mechanisms is concerned, the increase of CAD prevalence in patients with COPD is independent of known and common risk factors[12]. The exact mechanism linking COPD to cardiovascular disease is not yet found, but systemic inflammation, oxidative stress and hypoxemia are the most likely protagonists of this connection. First of all, systemic inflammation is a usual underlying mechanism in patients with clinically stable COPD and in many other chronic conditions, including CAD[13]. Especially, in COPD, systemic inflammation dominates during the exacerbations of the disease and these are the periods in which, patients with COPD have the highest risk of a cardiovascular event[14]. Recently, Fuschillo et al.[15] suggested that COPD patients with airway bacterial colonization, as compared to patients without airway colonization, generally present more frequent exacerbations and higher levels of both airway and systemic inflammation.

Additionally to systemic inflammation, oxidative stress and chronic hypoxia are important factors in the pathophysiologic pathway of COPD, as well as in the atherosclerosis and CAD.  Recent studies confirmed that oxidative stress and inflammation in COPD are associated with the progression of atherosclerosis in patients with established CAD, possibly through unfavourable effects on endothelial function[16] and elastic arterial properties (arterial stiffness)[17]. Arterial stiffness, which can be measured by aortic pulse wave velocity, is an independent predictor of adverse cardiovascular events and all-cause mortality[18]. In patients with COPD, arterial stiffness is increased[19] and is higher in patients with severe to very severe COPD compared to those with mild to moderate disease[20]. This increase of arterial stiffness may represent the mechanistic link between COPD and the high risk for cardiovascular disease associated with this condition[17].

To conclude with, it is easily understood that the impact of COPD and CAD on general population’s health is huge and becomes even higher when these diseases coexist. It is necessary for patients with COPD to be treated and monitored very carefully, especially when the exacerbations of the disease are occurred. In these phases of the disease, clinicians should not underestimate symptoms and clinical signs which may be suspect for the appearance of an acute cardiovascular event.

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[19] Sabit R, Bolton CE, Edwards PH et al. Arterial stiffness and osteoporosis in chronic obstructive pulmonary disease. Am J Respir Crit Care Med 2007; 175: 1259e65.

[20] McAllister DA, Maclay JD, Mills NL et al. Arterial stiffness is independently associated with emphysema severity in patients with chronic obstructive pulmonary disease. Am J Respir Crit Care Med 2007; 176: 1208e14.

 

Conflicts of Interest: None