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"en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Relationship between the various cardiovascular comorbidities and 2017 GOLD groups.</p> <p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Abbreviations: AHT, arterial hypertension; CKD, chronic kidney disease; DM2, type 2 diabetes mellitus; GOLD, Global Initiative for Chronic Obstructive Lung Disease; HF, heart failure; IHD, ischemic heart disease; PAD, peripheral artery disease; SAHS, sleep apnea-hypopnea syndrome.</p> <p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">The size of every node is proportional to the prevalence of each represented comorbidity. The width of the nexuses is proportional to the square of the phi coefficient. Blue represents an increase in the likelihood of the joint onset of 2 comorbidities in a patient, while the red lines represent a reduction in the likelihood of the joint onset of the 2 comorbidities (RRij < 1). Only statistically significant associations between 2 diseases are represented.</p>"
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"textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">In recent decades, the study of the relationship between chronic obstructive pulmonary disease (COPD), cardiovascular risk (CVR) and cardiovascular disease (CVD) has revealed complex interactions that have been only partially unraveled.</p><p id="par0010" class="elsevierStylePara elsevierViewall">In the US, the presence of COPD has been related to a higher cardiovascular risk and the onset of coronary artery disease, both in the National Health and Nutrition Examination Survey III<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> and the follow-up to the Kaiser Permanente Program.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> The Atherosclerosis Risk in Communities cohort<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> showed that individuals with COPD have higher levels of the amino-terminal fragment of the brain natriuretic peptide and a higher incidence of heart failure. In Spain, studies conducted with outpatients<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> and hospitalized patients<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5,6</span></a> have shown that COPD is associated with arterial hypertension, diabetes mellitus, dyslipidemia, coronary artery disease and heart failure.</p><p id="par0015" class="elsevierStylePara elsevierViewall">The Evaluation of COPD Longitudinally to Identify Predictive Surrogate Endpoints (ECLIPSE) study showed that patients with COPD have a higher prevalence of heart failure and ischemic heart disease, regardless of the level of obstruction.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> Cardiovascular disease is also the cause of death for 20–25% of patients with COPD,<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> a finding that the Towards a Revolution in COPD Health (TORCH)<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> and Understanding Potential Long-term Impacts on Function with Tiotropium (UPLIFT)<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> trials reaffirmed, with an approximately 27% and 17% cardiovascular mortality rate, respectively.</p><p id="par0020" class="elsevierStylePara elsevierViewall">The extensive relationship between COPD and CVD observed in clinical studies does not have a single pathophysiological mechanism. Numerous metabolic disorders have been described as nexuses between COPD and CVD.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> Additionally, the inflammatory characteristic of COPD exacerbations could explain the increased likelihood of presenting a cardiovascular event associated with COPD.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">In the current issue of this journal, Figueira et al. delve into our understanding of this relationship using a new procedure. The authors employed a topographical approach to the human phenotypes described by Hidalgo et al.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> This method defines a network: the diseases are represented as nodes with a size proportional to their prevalence, and the association between these diseases is represented by a line joining the nodes, with a thickness proportional to the intensity of the relationship.</p><p id="par0030" class="elsevierStylePara elsevierViewall">The data were recorded in a cross-sectional study that included 454 patients with COPD, adequately diagnosed through spirometry. All of the patients lived in the Canary Islands. The study variables were extracted from electronic medical records, widely used in daily clinical practice.</p><p id="par0035" class="elsevierStylePara elsevierViewall">The authors reported that a considerable proportion of the patients (70%) had dyslipidemia and that this condition is related to the presence of cardiovascular disease, which agrees with our understanding of this disease. However, as pointed out by the authors, there are very few studies that have specifically investigated the mutual relationship or that have shown the presence of a specific lipid profile in patients with COPD.</p><p id="par0040" class="elsevierStylePara elsevierViewall">In the study population, dyslipidemia was also associated with peripheral arterial disease, which has an obvious negative impact on patients with COPD as it reduces their physical abilities, complicates the achievement of proper motor rehabilitation, worsens the quality of life and is a marker of particularly increased vascular risk. Both conclusions reinforce the relevance of dyslipidemia and its proper control in patients with COPD.</p><p id="par0045" class="elsevierStylePara elsevierViewall">It is worth noting the significant relationship between GOLD B group and the presence of CVD, which is not observed in the GOLD A and GOLD D groups. As the authors state, the explanation could lie in a survival bias. Only patients without CVD survive long enough to present more intense bronchial obstruction, while the patients with more severe CVD die due to complications before the obstruction becomes so prominent.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> Moreover, patients with GOLD A COPD show no increase in CVD. The explanation could be that the diagnosis was performed early, before the arteriosclerosis had its first clinical manifestation.</p><p id="par0050" class="elsevierStylePara elsevierViewall">Figueira et al. provide a new graphical representation that is intuitive and useful. The relationships between the various diseases can be quickly defined, and the phenotypes of association between the various COPD categories according to their GOLD stratification can be differentiated. The connections with other diseases are easy to follow and understand. In fact, a considerable amount of information can be extracted from this graphic. For example, we can observe the association between sleep apnea syndrome, obesity and GOLD D COPD and the weak link surrounding the node for GOLD A COPD.</p><p id="par0055" class="elsevierStylePara elsevierViewall">This study had a number of limitations, the most important is that it only offers information on a single population: those who present COPD in the Canary Islands, whose residents have an especially high vascular risk. Although the results of this article are consistent with current medical knowledge, conclusions beyond this population cannot be extracted. The other problem is the study design, given its cross-sectional nature that precludes determining causality, allowing only the demonstration of associations. Lastly, the GOLD C COPD group had few patients, which precludes creating an appropriate graph for this subgroup.</p><p id="par0060" class="elsevierStylePara elsevierViewall">In conclusion, this is an interesting clinical study with a large number of patients despite its single-center nature and provides a new graphic approach that facilitates visualizing the phenotypes and connections between diseases.</p><p id="par0065" class="elsevierStylePara elsevierViewall">Further work is needed to expand our understanding of the relationship between COPD and cardiovascular diseases. The approach provided by the authors in classifying patients with COPD and their comorbidities according to the GOLD stratification can provide us with innovative data that can help explain the close relationship between COPD and CVD. In the future, we might be able to report a new inflammatory phenotype, consistent with other already published data.<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4,14</span></a> The association between tobacco use, dyslipidemia, inflammation and cardiovascular disease is more than just a mere co-incidence. In the interest of patients’ health, a greater involvement is warranted by health professionals in detecting dyslipidemia and other cardiovascular risk factors in COPD and tobacco use consultations. Analogously, the presence of COPD could be considered a risk factor for cardiovascular events beyond the mere attention to tobacco use in the guidelines for assessing vascular risk.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a></p></span>"
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"nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Pena X, Guijarro C. EPOC y enfermedad cardiovascular: algo más que una co-incidencia. Rev Clin Esp. 2020;220:290–291.</p>"
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