Chronic obstructive pulmonary disease in acute coronary syndromes Andell, Pontus

124 Pages·2017·6.28 MB·English

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.
Total number of authors:
1
General rights
Unless other specific re-use rights are stated the following general rights apply:
Copyright and moral rights for the publications made accessible in the public portal are retained by the authors
and/or other copyright owners and it is a condition of accessing publications that users recognise and abide by the
legal requirements associated with these rights.
• Users may download and print one copy of any publication from the public portal for the purpose of private study
or research.
• You may not further distribute the material or use it for any profit-making activity or commercial gain
• You may freely distribute the URL identifying the publication in the public portal
Read more about Creative commons licenses: https://creativecommons.org/licenses/
Take down policy
If you believe that this document breaches copyright please contact us providing details, and we will remove
access to the work immediately and investigate your claim.
LUND UNIVERSITY
PO Box 117
221 00 Lund
[phone]
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