Copd-15-2
Chronic Obstructive Pulmonary DiseasesThe Association between Chronic Obstructive Pulmonary Disease (COPD)
and Atrial Fibrillation: A Review
Varun Shah1, Trishla Desai1 and Abhinav Agrawal2,*
1Department of Internal Medicine, University of Miami/JFK Medical Center Palm Beach Regional GME Consortium, Atlantis, Florida, USA
2Department of Internal Medicine, Monmouth Medical Center, Long Branch, New Jersey, USA
*Corresponding author: Agrawal A, Chief Resident, Department of Medicine, Monmouth Medical Center, Long Branch, NJ, USA, Tel:
Rec date: Dec 21, 2015; Acc date: Dec 30, 2015; Pub date: Jan 6, 2016
Copyright: 2016 Shah V, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which
permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
propafenone can be used in patients with obstructive lung disease who do not have bronchospasm.
COPD is one of the leading causes of Mortality & Keywords: Chronic obstructive pulmonary disease;
Morbidity in the US and is associated with a wide variety Atrial fibrillation of cardiovascular diseases especially arrhythmias, angina, myocardial infarction and congestive heart failure and is directly associated with the severity of COPD described in the GOLD initiative. COPD is an independent risk factor for AF/AFL. Smoking, hypoxia and inflammation all contribute Chronic obstructive pulmonary disease (COPD) is a major to AF in COPD patients mainly via atrial remodeling while global public health problem. COPD is a common preventable hypercapnia contributes to it via increasing refractoriness and treatable disease, which is characterized by persistent of the atrial musculature and a delay in the return of the airflow limitation that is usually progressive and associated refractoriness to normal after resolution of the with an enhanced chronic inflammatory response in the hypercapnia. The most common EKG abnormality found in airways and the lung to noxious particles or gases. In 2020, patients with COPD is P pulmonale and the PQ interval is COPD is projected to rank fifth worldwide in terms of burden the strongest predictor of developing AF. The P wave of disease and third in terms of mortality [1] though presently Dispersion (PwD) was also an independent risk factor for it is the 4th leading cause of Mortality and the 2nd leading the development of AF and was found to be more in the cause of Morbidity in the United States (US) [2].
acute phase than in the stable phase.
Extra-pulmonary manifestations of COPD include The BODE index, an important prognostic score among cardiovascular disease, skeletal muscle dysfunction, patients hospitalized with a COPD exacerbation has a osteoporosis, metabolic syndrome depression and lung cancer direct co relation with the prevalence of AF/AFL while the [1]. COPD is associated with specific electrocardiographic (EKG) DECAF score, which was found to be superior to the CURB abnormalities while an increased incidence of cardiac 65 score as a mortality predictor for hospitalized patients, arrhythmias has been reported which includes atrial fibrillation includes AF as one of the criteria. Chronic hypoxemia is (AF), atrial flutter (AFL), multifocal atrial tachycardia (MAT) and one of the main reasons for altered pulmonary vein non-sustained ventricular tachycardia (NSVT) [3]. It is anatomy and hence the presence of COPD was identified estimated that there were approximately 33.5 million people as an independent risk factor for the recurrence of atrial with AF in 2010 worldwide (20.9 million men [95% uncertainty tachyarrhythmias after catheter ablation in patients with interval (UI), 19.5-22.2 million] and 12.6 million women [95% COPD and the absence of COPD was also found to be an UI, 12.0-13.7 million]) [4] and it was also estimated that the independent predictor for a successful electro- burden of AF in the United States alone would increase to at- cardioversion. These patients were also found to have an least 5.6 million by 2050 [5].
increased incidence of non-PV foci for the arrhythmias.
Oral glucocorticoids were associated with an increased risk of developing AF especially high dose steroids. It is COPD and Cardiovascular Disease
recommended to correct the underlying respiratory decompensation while treating patients with AF as they Patients with diagnosed and/or undergoing treatment for render the treatment of AF ineffective. Non- COPD are at a substantially increased risk of hospitalizations dihydropyridine calcium channel blockers should be used and mortality due to heart diseases. In one retrospective as first line rate control agents for AF in patients with cohort study, the prevalence of cardiovascular diseases (CVD) concomitant COPD while the β-blockers, sotalol, was higher in the COPD group than the control group. After all the cardiovascular risk factors were adjusted for odds ratios of Copyright iMedPub Chronic Obstructive Pulmonary Diseases
prevalence were: arrhythmia 1.76 (confidence interval [CI]: 1(TGF-β1) and TGF-βRII at the protein level, and a 60-70% 1.64-1.89), angina 1.61 (CI: 1.47-1.76), acute myocardial decrease in the levels of miRNAs miR-133 and miR-590 was infarction 1.61 (CI: 1.43-1.81), congestive heart failure 3.84 (CI: critical in atrial remodeling in the canine atrium [16]. Smoking 3.56-4.14). There was also an increased risk of hospitalization was found to be an independent risk factor in the recurrence secondary to cardiovascular causes in the COPD group [6].
of AF/AFL after cardioversion in women while an increased risk The Forced Vital Capacity (FVC), defined as the maximal of mortality and not arrhythmia was found in men [11].
volume of air exhaled with maximally forced effort from a It has been shown consistently that there exists an inverse maximal inspiration, Expressed in liters and the Forced relationship between FEV1, FVC with AF. The Copenhagen City Expiratory Volume in one second (FEV1), defined as the Heart Study demonstrated that the Risk of new AF at re- maximal volume of air exhaled in the first second of a forced examination was 1.8-times higher for FEV1 between 60-80% of expiration from a position of full inspiration, expressed in liters predicted compared with a FEV1 of ≥80% after adjustment for are the major determinants of the severity of COPD [1,7]. The sex, age, smoking, blood pressure, diabetes and body mass Global Initiative for Chronic Obstructive Lung Diseases (GOLD) index. They also showed that the risk of AF hospitalization was classifies the severity of airflow limitation as determined by 1.3 times more with a FEV1 between 60-80% of predicted and spirometry into 4 grades (GOLD 1, mild, FEV1 ≥80% predicted; 1.8 times with a FEV1 of ≤60% compared with a FEV1 of ≥80%, GOLD 2, moderate, FEV1 ≥50% but <80% predicted; GOLD 3, proving that reduced lung function as an independent severe, FEV1 ≥30% but <50% predicted; and GOLD 4, very predictor of AF [17]. It is well documented that oxidative stress severe, FEV1 <30% predicted) using the fixed ratio, post- and inflammation are two of the major factors in the bronchodilator FEV1/FVC <0.7 [1]. An association was also pathophysiology of COPD and now postulations have also been established between the severity of airflow obstruction based made of its impact in atrial remodeling and thus causing and on the GOLD criteria and the prevalence of CVD which showed potentially worsening existing AF [12].
that prevalence of CVD was higher among subjects with GOLD 2 (OR 2.9, 95% CI 2.4 to 3.6) and GOLD 3 or 4 COPD (OR 3.0, Hypoxia, commonly seen in patients with COPD, causes an 95% CI 2.0 to 4.5), compared with normal subjects [8]. The upregulation of Vascular Endothelial Growth Factor (VEGF) Atherosclerosis Risk in Communities (ARIC) cohort study secondary to an increase in Hypoxia-induced transcription established an inverse co-relation between the FEV1 and rate factor-1α (HIF-1α). Matrix metalloproteinase 9 (MMP9) of incident AF which was independent of age, gender, BMI, expression is increased in the atrium in a patient with AF and smoking and blood pressure [9].
potentially causes atrial remodeling. It was shown via Immunofluorescence that there was excess production and co- A recent retrospective study showed that of COPD were localization of HIF-1α, VEGF and MMP-9 within the associated with an increased likelihood of AF/AFL (23.3% vs. endothelium of the atrial arteries in the AF group as compared 11.0%, respectively, p<0.0001), NSVT (13.0% vs. 5.9%, to patients without AF [13].
respectively, p<0.0001), and sustained ventricular tachycardia (SVT; 0.9% vs. 1.6%, respectively, p<0.0001) and that it Patients with COPD are prone to have acute exacerbations remained a significant predictor of AF/AFL and NSVT (p<0.0001 of the disease and common causes for this are usually viral and p<0.0001, respectively) after adjusting for age, gender, infections of the upper respiratory tract and infections of the tobacco use, obesity, hypertension, coronary artery disease, tracheobronchial tree [1]. Terzano et al. showed that heart failure, diabetes, anemia, cancer, chronic kidney disease, suboptimal pulmonary function, hypercapnia and high values and rate/rhythm control medications [10]. This article provides of pulmonary artery systolic pressure are independent a succinct overview of the association of COPD with AF, the predictors of incident AF [18]. In their experimental sheep arrythmogenic mechanisms and potential treatment model, Stevenson et al. showed the hypercapnia caused an increase in the atrial musculature refractoriness and the conduction time however, intriguingly, there was a delay in COPD and Atrial Fibrillation: Potential only the conduction time to return to normal after the
resolution of hypercapnia prompting the theory that this Causes of Arrhythmia and EKG differential recovery time may be the reason for an increased
incidence of AF observed in the phase of eucapnia [19].
P pulmonale (P wave ≥0.25 mV in the inferior leads) is There seem to be a wide variety of reasons for arrhythmias usually omnipresent on EKG's of patients with chronic lung to occur in COPD beginning from risk factors, its effect in diseases. Hayashi et al, in a digital analysis of EKG's in a 25 year altering cardiopulmonary physiology to the treatment of period showed P-wave duration and PQ interval were COPD. Smoking, airway inflammation, hypoxia, hypercapnia, significantly longer in the AF group than in the non-AF group pulmonary hypertension, β-adrenergic agonist and steroids all (115.4 ± 17.2 ms vs. 107.0 ± 17.2 ms, P=0.0003 and 166.3 ± contribute to ultimately causing or worsening AF [11-15].
23.9 ms vs. 153.2 ± 25.4 ms, P=0.0001, respectively). They concluded that the PQ interval is the strongest stratifier for AF Shan et al. attempted to postulate the reasoning for the development in patients with P pulmonale [20]. The P wave increased incidence of AF in smokers using a canine model. dispersion (PwD), which is the difference in the maximum and They concluded that the pro fibrotic response of nicotine in minimum duration of the P wave, was also found to be an upregulation of expression of Transforming Growth Factor Beta independent risk factor associated in the development of AF Chronic Obstructive Pulmonary Diseases
[21] and the PwD was found to be increased more in the acute COPD Treatment Causing AF
phase than in stable phase and is greater in patients with more frequent exacerbations suggesting that the PwD could be a Inhaled bronchodilator medications continue to remain the target for prediction, prevention and therapy of acute mainstay treatment for COPD patients. It includes beginning exacerbation of COPD [22].
therapy with a β-2 agonist, an anticholinergic or a combination The BODE index is a multidimensional 10-point scale which of the two. A meta-analysis of randomized placebo-controlled integrates body mass index, degree of airflow obstruction and trials of β-2-agonist treatment in patients with obstructive dyspnea and exercise capacity measured in 6-min walk test airway disease performed concluded that the initiation of and the score is directly proportional with mortality. It was treatment increases heart rate and reduces potassium shown that patient's with higher BODE index scores had a concentrations compared to placebo and it causes adverse significantly greater prevalence of arrythmias including AF/AFL cardiovascular events like CHF, AF, etc. likely through these and SVT [23]. The Dyspnea, Eosinopenia, Consolidation, mechanisms along with β-1 adrenergic stimulation [14]. At the Acidemia and atrial Fibrillation (DECAF) score was introduced same time the side effect profile of tiotropium was studied in by Steer et al, as a predictor of mortality in hospitalized the UPLIFT trial and found no difference in the incidence of AF patients with COPD exacerbations. The DECAF score includes in patients receiving tiotropium vs placebo [30]. Long term the 5 strongest predictors of mortality i.e. MRC Dyspnea Score, glucocorticoid use is well known to cause hypertension, eosinopenia, consolidation, acidemia, and atrial fibrillation and Diabetes Mellitus, Left atrial enlargement, HF and ischemic was found to be a stronger than the other predictors like the heart disease all of which can directly or indirectly cause AF. In CURB65 [24].
a population based, case control study current glucocorticoid use was associated with an increased risk of AF or AFL COPD and its Effect on Ablation compared with never use (adjusted OR, 1.92; 95% confidence
interval [CI], 1.79-2.06) while among new glucocorticoid users; strategies of AF
the adjusted OR was 3.62 (95% CI, 3.11-4.22) (15). In another case control study by van der Hooft et al, findings strongly COPD has a significant effect on cardiopulmonary physiology showed that patients receiving high-dose corticosteroid but also has an impact in altering the anatomy of the same therapy, not uncommon in the treatment of COPD, are at system because of which it affects outcomes of catheter increased risk of developing atrial fibrillation [31]. Huerta et al.
ablations for AF, its progression and mortality. COPD is showed that inhaled steroids were not associated with an associated with hypoxemia and acidosis, which leads to, increased risk of AF or arrhythmias while theophylline and oral increased pulmonary vascular resistance. This causes an steroids were associated with an increased risk of arrhythmias increased level of inflammatory markers that promotes fibrosis especially AF [32]. In a Meta-Analysis from 2013 on and thus causes structural remodeling of pulmonary vessels Roflumilast, an increased incidence of AF as compared to [25]. A subgroup analysis of the European Heart Survey (EHS) placebo was seen however the writers pointed out that this is on AF by de Vos et al, gave rise to the HATCH score while likely due to chance as most of the studies in the analysis had studying AF progression from paroxysmal to persistent. The excluded patients with major cardiovascular events [33].
HATCH score was an abbreviation for heart failure, age, previous episode of transient ischemic attack or stroke, COPD Treatment Strategies
and hypertension, which were all, found to be independent predictors of AF progression [26]. In their study, Roh et al.
Per the AHA/ACC/HRS (American Heart Association/ showed that significant alteration of pulmonary vein (PV) American College of Cardiology/ Heart Rhythm Society) anatomy was related to arrhythmogenicity. They also showed guidelines, optimizing therapy for the underlying lung disease that non-PV foci were more common in the chronic lung with correction of the hypoxia and acidosis in patients with disease group (26.7%) than in the control group (5.0%; COPD developing AF is the cornerstone for management as the P=0.025) and all the non-PV foci were located in the right antiarrhythmic drugs or cardioversion are likely to be atrium [27]. The impact of COPD on outcomes of catheter ineffective until the respiratory decompensation has been ablation in patients with AF in terms of recurrence was corrected. Bronchodilator agents like Theophylline and β evaluated in a prospective study by Gu et al, which showed agonists have the propensity to precipitate AF and hence that non-paroxysmal AF (P=0.013, OR=1.767, 95% CI: should be avoided in patients with AF. Non β-1 selective 1.129-2.765) as well as the presence of COPD (P=0.029, blockers, sotalol, propafenone and adenosine are OR=1.951, 95% CI: 1.070-3.557) were the independent contraindicated in patients with bronchospasm however the β predictors for higher atrial tachyarrhythmia recurrence [28]. blockers, sotalol and propafenone can be considered in Absence of COPD was found to be an independent predictor patients with obstructive lung disease who do not have for a successful electro-cardioversion in patients with AF while bronchospasm. They also recommend a non-dihydropyridine the absence of COPD was also an independent predictor of calcium channel blocker as the first line therapy for rate sinus rhythm at a 1 yr follows up [29].
control in these patients while Amiodarone and Digoxin can also be used, the latter in patients with preserved left ventricular ejection fraction. In hemodynamically unstable patients, direct cardioversion is recommended while AV nodal ablation or ventricular pacing may be needed to control the Copyright iMedPub Chronic Obstructive Pulmonary Diseases
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The authors report no conflict of interest.
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Active International Research into Cardiometabolic and Liver Effects of a Proprietary Calabrian Bergamot Citrus Extract By James Ehrlich, MD and Jay Williams, PhD A team of Italian physicians and food scientists are leading an aggressive international research agenda into the salutary cardiovascular, metabolic, and hepatic properties of a juice extract of the bergamot citrus fruit (Citrus bergamia, Rutaceae), endemic to Calabria, Italy. After developing one of Europe's top medical research facilities at the Interregional Research Center for Food Safety and Health at the University of Catanzaro, the group has recruited academic physicians from Rome, Australia, and the United States to study the properties of a highly concentrated juice extract called(Bergamot Polyphenol Fraction/BPF 38%). Over the past few years, the group has organized international symposia, published book chapters, and has authored numerous publications concentrating its efforts on three key areas affecting at least 30% of western civilization -- high cholesterol, metabolic syndrome, and fatty liver disease. Safe and effective management of dyslipidemia (elevated cholesterol) with a "natural statin" It is well known that statin cholesterol medications have a long list of adverse side effects, including muscle aches, memory loss, and an elevated risk for diabetes. Finding a natural and safe lipid-lowering alternative is a topic of increased interest among clinicians and proactive citizens. Bergamot polyphenolic fraction (BPF) has been shown to lower LDL- cholesterol , raise HDL-cholesterol and favorably improve the dangerous lipoprotein particle characteristics seen in most Americans who consume excessive carbohydrates. Dietary polyphenols (especially bioflavonoids) may prevent atherosclerosis due to their anti-oxidative and anti-inflammatory proprieties. Among the citrus family (Rutaceae), bergamot fruits contain a very high content of flavonoids, including "statin-like" bruteridin and melitidin, two polyphenols which contain the same HMG-CoA reductase enzymatic activity found in all pharmacologic statins.
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Che cos'è l'artrite giovanile L e malattie reumatologiche del bambino sono patologie infiammatorie di causa spesso sconosciuta che, pur prediligendo le articolazioni, possono interessare ogni organo ed apparato dell'organismo. Esse deri-vano da un'abnorme regolazione della risposta immunitaria, hanno co-munemente un andamento cronico e possono causare gravi conseguenzecome limitazioni articolari rilevanti, danni oculari, danni cardiaci, insuf-ficienza renale e riduzione della crescita. Nel loro complesso costitui-scono una delle maggiori cause di disabilità nel bambino.In questi ultimi anni, la ricerca scientifica ha fatto grandi progressi nellostudio della patogenesi di queste malattie attraverso l'identificazione del-le molecole che determinano l'infiammazione. Grazie a ciò sono oggi di-sponibili farmaci ad alta selettività d'azione ed ottima efficacia, pur coni limiti di una risposta clinica soggettiva. Un'adeguata assistenza ospe-daliera e ambulatoriale è necessaria per affrontare e risolvere i problemiche queste malattie possono creare nella vita quotidiana dei bambini edelle loro famiglie.Per tale ragione oltre 15 anni fa a Chieti è stato istituito un ServizioRegionale per la diagnosi e cura delle malattie reumatologiche del bam-bino. Il Centro di Chieti collabora direttamente con altri Centri nazionalied europei negli studi epidemiologici e sui nuovi farmaci in questo settore.L'esigenza di un Centro di Riferimento Regionale in Abruzzo è nata pervolere di alcuni genitori stanchi dei "viaggi della speranza". Dal 1993l'ARARA collabora con il Servizio Regionale di Reumatologia Pediatricanella realizzazione di congressi, meeting e manifestazioni culturali atti adivulgare la conoscenza di tali patologie e sostenere l'attività di ricerca.Molta strada è stata percorsa, ma tanta ne resta da fare.Questa pubblicazione è rivolta non solo ad un ristretto gruppo di clinicio di specialisti, ma soprattutto ai bambini con patologie reumatologiche,alle loro famiglie e a quanti vogliano collaborare per curare queste ma-lattie, migliorare la qualità di vita e dare nuove opportunità ai piccolipazienti e alle loro famiglie.