Kaiser Permanente experts contribute to American Thoracic Society research statement
Patients with both chronic obstructive pulmonary disease (COPD) and heart disease will benefit most from research studies and clinical trials that test interventions in real-world settings, include patient-centered outcomes, and address health disparities, an expert committee assembled by the American Thoracic Society determined.
The finding is at the core of a new American Thoracic Society research statement published August 13 in the American Journal of Respiratory and Critical Care Medicine.
“COPD and heart disease are common, and both will become even more common as the population ages,” said the report’s lead author Laura C. Myers, MD, MPH, a research scientist with the Kaiser Permanente Division of Research and pulmonary intensivist with The Permanente Medical Group. “They have a shared risk factor, which is smoking. In addition, because the lungs and heart are so intertwined in bringing oxygenated blood to the rest of the body, there are subtleties in how these diseases evolve that are underappreciated. Understanding these subtleties better could have important implications for clinical outcomes.”
A worldwide problem
About 479 million people worldwide have COPD, an inflammatory lung disease that makes it increasingly difficult for people to breathe. COPD intersects and overlaps with heart disease in multiple ways. For example, COPD and cardiovascular disease cause similar symptoms, like shortness of breath and fatigue, which can make it difficult for doctors to make an initial diagnosis and identify when one organ system is deteriorating.
These conditions impact and play off of one another and we can’t treat them in isolation.
— Sagar Shah, MD
After a COPD diagnosis is made, the physical connection between the lungs and the heart can continue to make it difficult to determine the precise cause of specific symptoms. This is one reason why people with COPD are 2.5 times more likely to develop heart disease. It’s also why 35% of people with COPD die from a cardiovascular condition such as heart failure, atherosclerotic vascular disease (plaque buildup in the arteries), and atrial fibrillation (an irregular, rapid heart rhythm).
COPD can exacerbate heart problems, and heart disease can exacerbate COPD. “These conditions impact and play off of one another and we can’t treat them in isolation,” said co-author Sagar Shah, MD, an internist with The Permanente Medical Group. “There are medications that can help improve one condition, but these medications can also worsen the other condition, and physicians must understand this interplay in order to provide the best care to an individual patient.”
Opportunities and challenges
The research statement draws attention to specific issues that need to be addressed to create a better research structure. Currently, clinical trials testing new treatments or treatment combinations for COPD often exclude patients with cardiovascular disease.
“We need trials that specifically include COPD patients with co-existing cardiovascular conditions so that we can extrapolate the results to the complex medical patients we see in the clinic and hospital every day,” said Myers.
The committee also addressed problems that arise from COPD not being included on a list of risk-enhancing factors for atherosclerotic cardiovascular disease, highlighting the need for studies that directly evaluate the risks and benefits of aggressive treatment of blood pressure and lipids in patients with COPD.
“The committee felt that not having COPD on the list of risk-enhancing factors is a missed opportunity, given the degree of inflammation throughout the body that occurs in COPD,” said Myers. “Aggressively treating their cardiac risk factors could drastically improve their long-term outcomes.”
A research agenda
The research statement was developed by an international, multidisciplinary committee of experts convened by the American Thoracic Society. The members represented internal medicine, pulmonology, cardiology, geriatrics, nursing, pharmacy, drug development, quality improvement and policy, learning health systems, patient experience, patient advocacy, urban and rural healthcare settings, academic and non-academic institutions, and professional societies.
The committee began its work by identifying gaps in 10 specific research areas: disease mechanisms, epidemiology, subphenotyping, diagnosis and management, clinical trials, care delivery, medication access, adherence and side effects, risk factor mitigation, cardiac and pulmonary rehabilitation, and health equity. Next, a method called Delphi was used to lead the committee through multiple rounds of analysis, discussion, and voting to reach consensus on research priorities. The highest priority research topic was pragmatic clinical trials with patient-centered outcomes that collect both pulmonary and cardiac data elements. Health equity was a priority topic the committee determined should be part of all research studies.
“This research statement is critical because right now we don’t have the research necessary to drive our treatment plans for our patients,” said Shah. “As physicians, we often have to rely on our clinical judgement. But there is no question that having objective evidence will make a difference in how we care for our patients with COPD and cardiovascular disease.”
The study was funded by the American Thoracic Society.
Co-authors include Jennifer K. Quint, MD, of Imperial College London; Nathaniel M Hawkins, MD, of the University of British Columbia; Nirupam Putcha, MD, of Johns Hopkins Medicine; Alan Hamilton, PhD, Caroline Gainer, and David M. Mannino, MD, of the COPD Foundation; Peter Lindenauer, MD, of Baystate Health; J. Michael Wells, MD, MSPH, Surya P. Bhatt, MD, MSPH, and Mark Dransfield, MD, of the University of Alabama; Leah J. Witt, MD, of the University of California, San Francisco; Todd Lee, PharmD, PhD, of the University of Illinois; Huong Nguyen, RN, PhD, of Kaiser Permanente Southern California; Allan Walkey, MD, of the University of Massachusetts; R. Graham Barr, MD, DrPH, of Columbia University; Richard Mularski, MD, Kaiser Permanente Northwest; Sadiya S. Khan, MD, MSc, of Northwestern; Andrea S. Gershon, MD, of University of Toronto; Miguel Divo, MD, of Harvard Medical School; and Valerie G. Press MD, MPH, of the University of Chicago on behalf of the American Thoracic Society Assembly on Behavioral Science and Health Services Research.
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About the Kaiser Permanente Division of Research
The Kaiser Permanente Division of Research conducts, publishes and disseminates epidemiologic and health services research to improve the health and medical care of Kaiser Permanente members and society at large. It seeks to understand the determinants of illness and well-being, and to improve the quality and cost-effectiveness of health care. Currently, DOR’s 600-plus staff is working on more than 450 epidemiological and health services research projects. For more information, visit divisionofresearch.kaiserpermanente.org or follow us @KPDOR.
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