Applying the Rome Proposal on Exacerbations of Chronic Obstructive Pulmonary Disease: Does Comorbid Chronic Heart Failure Matter?

Figures & data

Table 1 Descriptive Statistics. Mean ± 1 S.D. (Min-Max) if Not Otherwise Stated

Variables	COPD (All) (n = 43)				CHF (n = 41)	^bp	^cp
	All (n = 43)	COPD w/o CHF (n = 15)	COPD with CHF (n = 28)	^ap
Study participation (days) per patient; md (IQR)	323 (279)	362 (157)	201 (280)	0.228	358 (221)	0.140	0.374
Age (yrs)	76 ±6 (65–88)	73±5 (67–83)	78±6 (65–88)	0.015	84±7 (66–100)	<0.001	<0.001
Women; n (%)	25 (58)	10 (67)	15 (54)	0.4068	20 (49)	0.696	0.390
BMI (kg/m^2)	24±5 (13–41)	22±6 (13–41)	25±4 (17–34)	0.029	28±5 (21–43)	0.083	0.903
CCI; md (IQR)	3 (4)	2 (2)	3 (3)	0.007	4 (3)	0.387	0.048
Current smokers; n (%)	11 (26)	5 (33)	6 (21)	0.394	0 (0)	n.a.	n.a.
Ex smokers; n (%)	29 (67)	10 (67)	19 (68)	0.937	19 (46)	0.238	0.196
Never smokers; n (%)	3 (7)	0 (0)	3 (11)	n.a.	22 (54)	0.002	<0.001
SAT at base-line; md (IQR)	93 (5)	93 (3)	93 (6)	0.878	95 (4)	0.005	<0.001
FEV1 (% predicted)	39±15 (15–74)	32±10 (15–58)	43±15 (20–74)	0.020	n.a.	n.a	n.a.
GOLD stage 1; n (%)	0 (0)	0 (0)	0 (0)	n.a.	n.a.	n.a.	n.a.
GOLD stage 2; n (%)	9 (21)	1 (7)	8 (29)	n.a.	n.a	n.a	n.a.
GOLD stage 3; n (%)	21 (49)	9 (60)	12 (42)	0.284	n.a.	n.a.	n.a.
GOLD stage 4; n (%)	13 (30)	5 (33)	8 (29)	0.742	n.a.	n.a.	n.a.
GOLD group A; n (%)	0 (0)	0 (0)	0 (0)	n.a.	n.a.	n.a.	n.a.
GOLD group B; n (%)	2 (5)	0 (0)	2 (5)	n.a.	n.a.	n.a.	n.a.
GOLD group E; n (%)	41 (95)	15 (100)	26 (95)	0.289	n.a.	n.a.	n.a.
NYHA I; n (%)	0 (0)	n.a.	0 (0)	n.a.	0 (0)	n.a.	n.a.
NYHA II; n (%)	0 (0)	n.a.	0 (0)	n.a.	0 (0)	n.a.	n.a.
NYHA III; n (%)	22 (51)	n.a.	22 (79)	n.a.	31 (76)	0.041	n.a.
NYHA IV; n (%)	1 (2)	n.a.	1 (4)^§	n.a.	10 (24)	0.080	n.a.
LVEF, preserved; n (%)	6 (14)	n.a.	6 (21)	n.a.	7 (17)	0.757	n.a
LVEF, mid-range; n (%)	13 (30)	n.a.	13 (47)	n.a.	20 (49)	0.848	n.a.
LVEF, reduced; n (%)	9 (21)	n.a.	9 (32)	n.a.	14 (34)	0.862	n.a.
Number of exacerbations per patient; md (IQR)	2 (2)	3 (6)	1 (1)	<0.028	0 (1)	<0.001	<0.001
ECOPDs; n (%)	107 (95)	61 (100)	46 (90)	0.012	n.a.	n.a	n.a.
ECHFs; n (%)	5 (5)	n.a.	5 (10)	n.a.	18 (100)	n.a	<0.001

Notes: ^ap, p-value for the comparison COPD with CHF vs COPD w/o CHF. ^bp, p-value for the comparison COPD with CHF vs CHF. ^cp, p-value for the comparison COPD, all vs CHF. ^§Data on NYHA are missing for 5 subjects. p-values < 0.05 are indicated by bold figures.

Abbreviations: BMI, body mass index; CCI, Charlson Comorbidity Index; CHF, chronic heart failure; COPD, chronic obstructive pulmonary disease; ECHF, exacerbation of chronic heart failure; ECOPD, exacerbation of chronic obstructive pulmonary disease; LVEF, left ventricular ejection fraction; FEV₁ (% of predicted), forced expiratory volume in one second expressed as % of predicted; GOLD, global initiative for chronic obstructive lung disease; IQR, interquartile range; md, median; NYHA, New York Heart Association; SAT, blood oxygen saturation; S.D., standard deviation.

Table 2 ECOPD Severity Assessed by the Criteria of GOLD 2022 and GOLD 2023 (the Rome Proposal)

Severity	COPD w/o CHF, Exacerbations (n = 61)		COPD with CHF, Exacerbations (n = 46)		p-values
	GOLD ^a2022	GOLD ^a2023	GOLD ^b2022	GOLD ^b2023	^a2022 vs ^a2023	^b2022 vs ^b2023	^a2022 vs ^b2022	^a2023 vs ^b2023
Mild exacerbations; n (%)	0 (0)	25 (41)	0 (0)	21 (46)	<0.001	<0.001	n.a.	0.629
Moderate exacerbations; n (%)	41 (67)	30 (49)	27 (55)	21 (46)	0.080	0.345	0.365	0.718
Severe exacerbations; n (%)	20 (33)	2 (3)	19 (45)	2 (4)	<0.001	<0.001	0.365	n.a.
Exacerbations with undefined severity; n (%)	0 (0)	4 (6)	0 (0)	2 (4)	n.a.	n.a.	n.a.	n.a.

Notes: p-values < 0.05 are indicated by bold figures. ^a2022 ECOPD severity assessed by the criteria of GOLD 2022. Patient group COPD w/o CHF. ^a2023 ECOPD severity assessed by the criteria of GOLD 2023. Patient group COPD w/o CHF. ^b2022 ECOPD severity assessed by the criteria of GOLD 2022. Patient group COPD with CHF. ^b2023 ECOPD severity assessed by the criteria of GOLD 2023. Patient group COPD with CHF.

Abbreviations: CHF, chronic heart failure; COPD, chronic obstructive pulmonary disease; ECOPD, exacerbation of chronic obstructive pulmonary disease; GOLD, global initiative for chronic obstructive lung disease; n.a., not applicable.

Figure 1 BaR and BaPA at base-line study day 1 (at inclusion). The groups were all COPD patients (n = 43), two subgroups of COPD patients, that is those without comorbid CHF (n = 15) and those with comorbid CHF (n = 28), and CHF patients (n = 41). Mean values ±1 S.D. are indicated. *p ˂0.05.

Abbreviations: BaR, breathlessness at rest; BaPA, breathlessness at physical activity; CHF, chronic heart failure; COPD, chronic obstructive pulmonary disease; S.D., standard deviation.

Figure 2 BaR and BaPA at the peak of the exacerbations (day 15). The groups were the ECOPDs of all COPD patients (n = 107), two subgroups of ECOPDs, that is those without comorbid CHF (n = 61) and those with comorbid CHF (n = 46), and the ECHFs of CHF patients (n = 18). Mean values ±1 S.D. are indicated. *p ˂0.05; **p ˂0.01, ***p ˂0.001.

Abbreviations: BaR, breathlessness at rest; BaPA, breathlessness at physical activity; CHF, chronic heart failure; COPD, chronic obstructive pulmonary disease; S.D., standard deviation.

Figure 3 (A) Mean values day-by-day during the exacerbation. Day 15 is the day when the exacerbation was diagnosed by HBHC staff and treatment with steroids and/or antibiotics (the ECOPDs) or diuretics (the ECHFs) was started. BaR (filled symbols) and BaPA (open symbols) during exacerbations among patients with COPD (all; blue squares and blue lines; n = 107) and patients with CHF (red circles and red lines; n = 18). (B and C) show the mean values adjusted to a shared baseline for BaPA (B) and BaR (C).

Abbreviations: BaR, breathlessness at rest; BaPA, breathlessness at physical activity; CHF, chronic heart failure; COPD, chronic obstructive pulmonary disease; S.D., standard deviation.

Data Sharing Statement

The data upon which this analysis was based are available from Professor Hans Lennart Persson in anonymised form, upon receipt of a reasonable request. Contact details are Professor Hans Lennart Persson, Department of Respiratory Medicine in Linköping, Linköping University, SE-581 85 Linköping, Sweden. Email: [email protected].