Doença pulmonar obstrutiva crônica e desfechos clínicos em pacientes pré-diabéticos com alto risco cardiovascular
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Data
2015-09-15
Autores
Silva, Pedro Gabriel Melo de Barros e [UNIFESP]
Orientadores
Lopes, Renato Delascio [UNIFESP]
Tipo
Tese de doutorado
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Introdução: A doença pulmonar obstrutiva crônica se associa a importantes alterações sistêmicas que aumentam a morbimortalidade de pacientes portadores desta doença. Objetivos: Avaliar a frequência de pacientes com diagnóstico de doença pulmonar obstrutiva crônica numa população de pré-diabéticos com alto risco cardiovascular, as características destes pacientes e a associação entre esta pneumopatia e o risco de eventos clínicos. Métodos: Foram avaliados os dados de 9.306 pacientes com intolerância à glicose e doença cardiovascular estabelecida e/ou fatores de risco cardiovascular incluídos no ensaio clínico NAVIGATOR (Nateglinide and Valsartan in Impaired Glucose Tolerance Outcomes Research). Os seguintes desfechos foram analisados nos grupos com ou sem doença pulmonar obstrutiva crônica: morte por causa cardiovascular, infarto do miocárdio não fatal e acidente vascular encefálico não fatal (desfecho composto central); estes três desfechos em conjunto com hospitalização por insuficiência cardíaca, revascularização miocárdica ou por angina instável (desfecho composto estendido); hospitalização por insuficiência cardíaca isoladamente; e também foi analisado desenvolvimento de diabetes mellitus. Modelos de regressão de risco proporcional de Cox foram usados para se avaliar a relação entre pneumopatia obstrutiva crônica e os desfechos clínicos citados, ajustando-se para importantes características basais dos pacientes. Resultados: Da população inicial do estudo, 451 (4,8%) tinham o diagnóstico de doença pulmonar obstrutiva crônica. Em geral, esses pacientes tinham idade mais avançada e maior comorbidade do que aqueles sem pneumopatia. Durante cinco anos de seguimento, os pacientes com diagnóstico de pneumopatia obstrutiva, quando comparados ao grupo sem doença pulmonar, tiveram maiores taxas de ?desfecho cardiovascular estendido? (27,1% vs. 12,3%; P<0,0001), do ?desfecho composto central? (14,0% vs. 5,5%; P<0,0001), e também maiores taxas de hospitalização por insuficiência cardíaca (7,1% vs. 1,5%; P<0,0001). Após ajuste, os pacientes com doença pulmonar obstrutiva crônica permaneceram apresentando um risco significativamente maior para o desfecho cardiovascular estendido (HR 1,28, IC 95% 1,1-1,5; P=0,013), para eventos cardiovasculares maiores (HR 1,44, IC 95% 1,1-1,9; P=0,008); e também maiores taxas de hospitalização por insuficiência cardíaca (HR 2,1, IC 95% 1,4-3,1; P=0,0002). O desenvolvimento de diabetes mellitus foi similar em ambos os grupos (39,3% vs. 34,8%; P=0,09), mesmo após ajuste (HR ajustado 1,10, IC 95% 0,94-1,30; P=0,23). Conclusão: Em pacientes pré-diabéticos e sob alto risco cardiovascular, a presença de doença pulmonar obstrutiva crônica esteve associada de maneira independente a eventos cardiovasculares, mas não para o desenvolvimento de diabetes mellitus.
Background: Chronic obstructive pulmonary disease (COPD) is associated with important systemic consequences that affect morbidity and mortality of the patients. Objectives: To evaluate the frequency of patients diagnosed with chronic obstructive pulmonary disease in a population of pre-diabetic patients with high cardiovascular risk, the characteristics of these patients and the association between this lung disease and the risk of clinical events. Methods: The data from 9306 patients with impaired glucose tolerance and established cardiovascular disease and / or cardiovascular risk factors included in the clinical trial NAVIGATOR (Nateglinide and Valsartan in Impaired Glucose Tolerance Outcomes Research) were evaluated. The following outcomes were assessed in patients with or without COPD: death from cardiovascular causes, non-fatal myocardial infarction, non-fatal stroke (core composite outcome); these three outcomes along with hospitalization for heart failure, coronary revascularization, or unstable angina (extended composite outcome); hospitalization for heart failure alone; and development of diabetes mellitus. Cox proportional hazards regression models were used to evaluate the relationship between chronic obstructive pulmonary disease and the cited clinical outcomes making adjustments for important baseline characteristics of the patients. Results: Of 9306 patients in NAVIGATOR, 451 (4.8%) had a diagnosis of COPD at baseline. In general, these patients were older and had more comorbidities compared to those without chronic obstructive pulmonar disease. Patients with COPD versus those without COPD had higher rates of the core composite outcome (14.0% vs. 5.5%; P<0.0001) as the extended composite outcome (27.1% vs. 12.3%; P<0.0001); and also more hospitalization due to heart failure (7.1% vs. 1.5%; P<0.0001). After adjustment, patients with COPD were at significantly higher risk for death, myocardial infarction, and stroke (adjusted HR 1.44, 95% CI 1.1-1.9; P=0.008); death, myocardial infarction, stroke, hospitalization for heart failure, unstable angina, or arterial revascularization (adjusted HR 1.28, 95% CI 1.1-1.5; P=0.013); and hospitalization due to congestive heart failure (adjusted HR 2.1, 95% CI 1.4-3.1; P=0.0002). The development of diabetes was similar in both groups (39.3% vs. 34.8%; P=0.09), even after adjustment (adjusted hazard ratio [HR] 1.10, 95% confidence interval [CI] 0.94-1.30; P=0.23). Conclusions: In patients at high risk for developing diabetes and cardiovascular events, the presence of COPD was independently associated with cardiovascular outcomes, but not for the development of diabetes.
Background: Chronic obstructive pulmonary disease (COPD) is associated with important systemic consequences that affect morbidity and mortality of the patients. Objectives: To evaluate the frequency of patients diagnosed with chronic obstructive pulmonary disease in a population of pre-diabetic patients with high cardiovascular risk, the characteristics of these patients and the association between this lung disease and the risk of clinical events. Methods: The data from 9306 patients with impaired glucose tolerance and established cardiovascular disease and / or cardiovascular risk factors included in the clinical trial NAVIGATOR (Nateglinide and Valsartan in Impaired Glucose Tolerance Outcomes Research) were evaluated. The following outcomes were assessed in patients with or without COPD: death from cardiovascular causes, non-fatal myocardial infarction, non-fatal stroke (core composite outcome); these three outcomes along with hospitalization for heart failure, coronary revascularization, or unstable angina (extended composite outcome); hospitalization for heart failure alone; and development of diabetes mellitus. Cox proportional hazards regression models were used to evaluate the relationship between chronic obstructive pulmonary disease and the cited clinical outcomes making adjustments for important baseline characteristics of the patients. Results: Of 9306 patients in NAVIGATOR, 451 (4.8%) had a diagnosis of COPD at baseline. In general, these patients were older and had more comorbidities compared to those without chronic obstructive pulmonar disease. Patients with COPD versus those without COPD had higher rates of the core composite outcome (14.0% vs. 5.5%; P<0.0001) as the extended composite outcome (27.1% vs. 12.3%; P<0.0001); and also more hospitalization due to heart failure (7.1% vs. 1.5%; P<0.0001). After adjustment, patients with COPD were at significantly higher risk for death, myocardial infarction, and stroke (adjusted HR 1.44, 95% CI 1.1-1.9; P=0.008); death, myocardial infarction, stroke, hospitalization for heart failure, unstable angina, or arterial revascularization (adjusted HR 1.28, 95% CI 1.1-1.5; P=0.013); and hospitalization due to congestive heart failure (adjusted HR 2.1, 95% CI 1.4-3.1; P=0.0002). The development of diabetes was similar in both groups (39.3% vs. 34.8%; P=0.09), even after adjustment (adjusted hazard ratio [HR] 1.10, 95% confidence interval [CI] 0.94-1.30; P=0.23). Conclusions: In patients at high risk for developing diabetes and cardiovascular events, the presence of COPD was independently associated with cardiovascular outcomes, but not for the development of diabetes.
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Citação
BARROS E SILVA, Pedro Gabriel Melo de. Doença pulmonar obstrutiva crônica e desfechos clínicos em pacientes pré-diabéticos com alto risco cardiovascular. 2015. 100 f. Tese (Doutorado em Cardiologia) - Escola Paulista de Medicina, Universidade Federal de São Paulo (UNIFESP), São Paulo, 2015.