Elsevier

International Journal of Cardiology

Volume 222, 1 November 2016, Pages 806-812
International Journal of Cardiology

Predischarge screening for chronic obstructive pulmonary disease in patients with acute coronary syndrome and smoking history

https://doi.org/10.1016/j.ijcard.2016.08.030Get rights and content

Highlights

  • Concomitant chronic obstructive pulmonary disease (COPD) is a well-established determinant of poor prognosis in patients with ischemic heart disease (IHD) COPD is frequently undiagnosed in patients with IHD.

  • In patients with acute coronary syndromes (ACS) we found undiagnosed COPD in the 29% of cases (95%CI 21%–36%).

  • Our study is the first one trying to validate a simple, reproducible, quick test to screen undiagnosed COPD in ACS patients.

  • The proposed screening is simple, safe, inexpensive and feasible just few days after the acute event.

  • This simple screening applied by cardiologists might be sufficient to identify those patients with a negligible risk of concomitant undiagnosed COPD.

Abstract

Background

Several studies suggested that chronic obstructive pulmonary disease (COPD) is largely underdiagnosed in patients with acute coronary syndrome (ACS) contributing to further affect clinical outcome. Our aim was to validate a screening procedure to identify, in ACS patients, those with negligible risk of undiagnosed COPD.

Methods

From December 2014 to August 2015, 169 ACS patients with smoking history underwent screening procedure. Screening procedure combined peak expiratory flow rate (PEFR, defined as positive if < 80% of predicted) and respiratory health status questionnaire (RHSQ, defined as positive if > 19.5 points). The screening was considered negative if both tests provided negative results, positive if both were positive, uncertain in presence of discrepancy. Spirometry was planned after 2 months to identify or not the presence of irreversible airflow obstruction (undiagnosed COPD). The primary endpoint was the negative predictive value of screening for undiagnosed COPD.

Results

Overall, 137 (81%) patients received spirometry (final study population). Screening was negative, uncertain and positive in 58 (42%), 46 (34%) and 33 (24%) patients, respectively. We found undiagnosed COPD in 39 (29%) patients. Only 3 patients with negative screening showed undiagnosed COPD. Negative screening showed the best ability to discriminate patients without COPD (negative predictive value 95%). Two-month health status in patients with undiagnosed COPD was significantly poor.

Conclusions

Undiagnosed COPD is relatively frequent in ACS patients with smoking history and a simple screening procedure including PEFR and RHSQ can be administered before hospital discharge to discriminate those at negligible risk of undiagnosed COPD (ClinicalTrials.gov, NCT02324660).

Introduction

Chronic obstructive pulmonary disease (COPD) is one of the leading causes of morbidity, mortality and resource use worldwide, involving until the 20% of the general population [1], [2]. COPD and ischemic heart disease (IHD) share cigarette smoking as common risk factor [1], [2], [3]. COPD prevalence ranges from 5% to 20% of IHD patients and exerts a synergistic negative effect on prognosis [1], [2], [3], [4], [5]. Several studies suggested that COPD is largely underdiagnosed in IHD patients and therefore it is not appropriately treated, contributing to further affect clinical outcome [6], [7]. Spirometry is the gold standard for COPD diagnosis. However, it cannot be applied systematically. This is particularly true early after acute coronary syndrome (ACS), mainly for safety, but also for cost concerns [1]. Thus, a simple, reliable and reproducible algorithm to screen patients at higher probability of undiagnosed COPD is desirable, especially for ACS patients. Peak expiratory flow rate (PEFR) and Respiratory Health Screening Questionnaire (RHSQ) are simple and reproducible tools that can be used as first approach to assess COPD [1].

We have hypothesized that a combination of PEFR measurement and RHSQ result could be a reliable screening for COPD in patients hospitalized for ACS and with smoking history. Hence, to test this hypothesis, we have designed and conducted the Screening for COPD in ACS Patients (SCAP) trial.

Section snippets

Study design

The SCAP study is a single-center, single-group, investigator-driven, prospective trial involving consecutive ACS patients with smoking history referred to our University Hospital between December 2014 and August 2015 (Fig. 1). The research protocol was approved by the corresponding Ethics Authority (Comitato Etico Unico della Provincia di Ferrara). All patients gave their written informed consent. The study was registered at www.clinicaltrials.gov with identifier NCT02324660.

Study population

Inclusion criteria

Results

Overall, we included 137 patients (Fig. 1, Table 1). Baseline, laboratory and angiographic characteristics of the study population are reported in Table 1. Median hospital stay was 4 days [3–6 days]. One-hundred thirty-three (97%) patients received percutaneous coronary intervention (PCI). Due to not significant or small vessel disease, 4 (3%) patients were medically managed. Of note, the 87% (n = 119) of our study population patients received beta-blockers at hospital discharge (metoprolol or

Discussion

At the best of our knowledge, this is the first study describing a prespecified, prospective screening tool to discriminate ACS patients at negligible risk of undiagnosed COPD. We found that undiagnosed COPD is relatively common in patients with smoking history admitted to hospital for ACS (29% of patients, 95%CI 21%–36%). We demonstrated that a simple screening applied by cardiologists might be sufficient to identify those patients with a low risk of concomitant undiagnosed COPD (42% of

Conclusions

In conclusion, our study shows that undiagnosed COPD is relatively common in ACS patients with smoking history and that the application of a simple screening including PEFR and RHSQ can be safely performed before hospital discharge. This screening allows the identification of patients with negligible risk of undiagnosed COPD.

Conflict of interest

The authors report no relationships that could be construed as a conflict of interest

Financial disclosures

No authors reported financial disclosures.

Funding/support

The study was an investigator driven clinical trial conducted by the University of Ferrara.

Acknowledgements

GC is the guarantor of the content of the manuscript, including the data and analysis.

GC, RP, SB, MC, CB: conception, design, analysis and interpretation of data.

SM, EM, FZ, LF, ET, FG: data analysis and interpretation, drafting of the manuscript and revising it critically for important intellectual content.

RF and AP: final approval of the manuscript submitted.

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