Prevalence of COPD in Atrial Fibrillation

Sep 24, 2021
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Authors:
Romiti GF, Corica B, Pipitone E, et al., on behalf of the AF-COMET International Collaborative Group.
Citation:
Prevalence, Management and Impact of Chronic Obstructive Pulmonary Disease in Atrial Fibrillation: A Systematic Review and Meta-Analysis of 4,200,000 Patients. Eur Heart J 2021;42:3541-3554.
Summary By:
Sarah Kohnstamm, MD, FACC

Quick Takes

  • A large meta-analysis of 46 international studies with >4.2 million patients with AF estimated a 13% prevalence of COPD. Furthermore, COPD was associated with more comorbidities, greater age, and higher CHA2DS2-VASc scores.
  • COPD increased the risk of worse outcomes in AF patients, including a two-fold higher risk of all-cause mortality, increased risk of CV death, and major bleeding.
  • Beta-blockers were less frequently prescribed in patients with COPD and AF, but were not associated with increased risk of adverse outcomes in these patients.

Study Questions:

What is the prevalence of chronic obstructive pulmonary disease (COPD) in patients with atrial fibrillation (AF), what is its impact on clinical management and outcomes, and how does the use of beta-blockers (BBs) affect outcomes in these patients?

Methods:

A systematic review and meta-analysis were performed according to the Meta-analysis Of Observational Studies in Epidemiology (MOOSE) guidelines. The primary aim was to estimate the prevalence of COPD among AF patients, while secondary aims included: 1) determining the association of COPD status with other comorbidities in AF patients; 2) evaluating the use of BBs and oral anticoagulants (OACs) in AF patients with COPD; 3) estimating the impact of COPD status on all-cause mortality, cardiovascular (CV) death, ischemic stroke, and major bleeding; and 4) determining the impact of BB use on major outcomes in patients with AF and COPD.

Results:

A total of 5,316 studies were retrieved, of which 46 studies were included for a total of 4,232,784 AF patients in aggregate. Three studies were secondary analyses of randomized trials, while 16 were observational multicenter studies, eight were observational single-center studies, and 19 cohorts were derived from administrative databases. The studies were geographically diverse (seven studies in Asia, 11 in North America, 22 in Europe, and six in other regions).

Among the 46 studies, the pooled prevalence of COPD was 13% (95% confidence interval [CI], 10-16%). On subgroup analyses, prevalence of COPD was higher in North American (20.3%, 95% CI, 16.3-25.0%) compared to European (10.7%, 95% CI, 8.1-14.0) and Asian (7%, 95% CI, 3.8-21.4%) cohorts. In addition, studies using International Classification of Diseases (ICD)-9 or ICD-10 codes for COPD showed a higher prevalence (17.5%, 95% CI, 13.5-22.4%) compared to those relying on self-reported history (8%, 95% CI, 6.4-12.1%).

In patients with AF, COPD was associated with a number of other comorbidities, including diabetes mellitus, coronary artery disease, chronic heart failure, and stroke. Furthermore, AF patients with COPD were significantly older, more likely to be male, and had higher CHA2DS2-VASc scores than those without COPD (+0.49, 95% CI, 0.16-0.81). BBs were less likely to be prescribed to AF patients with COPD (odds ratio [OR], 0.77; 95% CI, 0.61-0.98), but no significant differences were seen in the use of OACs.

COPD was associated with an increased risk for all-cause mortality (OR, 2.22; 95% CI, 1.93-2.55), CV death (OR, 1.84; 95% CI, 1.39-2.43), and major bleeding (1.45, 95% CI, 1.17-1.8). Interestingly, use of BBs was not associated with adverse outcomes (all-cause mortality, CV death, stroke, or major bleeding) in patients with AF and COPD.

Conclusions:

  1. COPD is common in AF patients, with an estimated prevalence of 13%.
  2. COPD and AF are associated with more comorbidities, greater age, and higher CHA2DS2-VASc scores.
  3. COPD increases the risk of worse outcomes in AF patients, including a two-fold higher risk of all-cause mortality, increased risk of CV death, and major bleeding.
  4. BBs are less frequently prescribed in patients with COPD and AF, but are not associated with an increased risk of adverse outcomes in these patients.

Perspective:

COPD is one of the leading causes of death worldwide, accounting for nearly 3 million deaths each year. This meta-analysis yielded over 4.2 million AF patients, with an estimated pooled prevalence of COPD in 13% of these patients. There was, however, a high between-study variability of this prevalence, possibly due to the heterogeneous definition of the disease. The meta-analysis methodology was rigorously done and included assessment of bias and sensitivity analysis. The conclusions are not entirely surprising, and it is good to see data disproving the common belief that BBs are contraindicated in COPD. Interestingly, smoking status and pack-year history were not accounted for in any of these studies. It is very likely that smoking is a confounding and potentially causative variable in all-cause mortality, increased CV death, and stroke. It, therefore, remains crucial to focus on smoking cessation in all patients with AF.

Clinical Topics: Anticoagulation Management, Arrhythmias and Clinical EP, Heart Failure and Cardiomyopathies, Prevention, Anticoagulation Management and Atrial Fibrillation, Implantable Devices, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias, Acute Heart Failure, Smoking

Keywords: Adrenergic beta-Antagonists, Anticoagulants, Arrhythmias, Cardiac, Atrial Fibrillation, Brain Ischemia, Comorbidity, Diabetes Mellitus, Heart Failure, Hemorrhage, Ischemic Stroke, Primary Prevention, Pulmonary Disease, Chronic Obstructive, Smoking, Smoking Cessation, Social Media, Stroke, Vascular Diseases


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