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      Increased risk of peripheral arterial occlusive diseases in patients with chronic obstructive pulmonary disease: a nationwide study in Taiwan

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          Chronic obstructive pulmonary disease (COPD) is associated with atherosclerosis. Previous studies including limited sample sizes have shown the prevalence of peripheral arterial occlusive disease (PAOD) among COPD patients. We sought to investigate the incidence of PAOD among COPD patients in Taiwan using a national database.


          COPD patients were collected from the National Health Insurance Research Database of Taiwan from 1996 to 2010. The COPD cohort was propensity score matched according to age, sex, and comorbidities of atrial fibrillation, hypertension, diabetes, hyperlipidemia, cerebrovascular accidents, and chronic liver disease to patients without COPD (the control cohort). We evaluated the incidence of PAOD in COPD patients and the risk of PAOD associated with atrial fibrillation, hypertension, diabetes, hyperlipidemia, cerebrovascular accidents, and chronic liver disease.


          The study included 51,869 COPD patients and 51,869 control patients without COPD. The incidence of PAOD was 1.23-fold higher (95% confidence interval [CI]  =1.17–1.29) in the COPD group than in the non-COPD group. Moreover, COPD and atrial fibrillation alone (adjusted hazard ratio (aHR) 2.99; P=0.001), hypertension alone (aHR, 2.05; P<0.001), diabetes alone (aHR, 2.62; P<0.001) and cerebrovascular accidents alone (aHR 2.05; P<0.001), increased the risk of developing PAOD. The significant aHRs increased (from 3.7 to 4.9) when the number of comorbidities increased (from ≥1 to ≥3 comorbidities).


          COPD patients have a higher incidence and an independently higher risk of PAOD than patients without COPD. The risk of PAOD is markedly elevated in COPD patients with more comorbidities.

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          Most cited references 16

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          Peripheral Artery Disease and Its Clinical Relevance in Patients with Chronic Obstructive Pulmonary Disease in the COPD and Systemic Consequences-Comorbidities Network Study.

          Knowledge about the prevalence of objectively assessed peripheral artery disease (PAD) and its clinical relevance in patients with chronic obstructive pulmonary disease (COPD) is scarce.
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            Chronic obstructive pulmonary disease and ischemic heart disease comorbidity: overview of mechanisms and clinical management.

            In the last few years, many studies focused their attention on the relationship between chronic obstructive pulmonary disease (COPD) and ischemic heart disease (IHD), showing that these diseases are mutually influenced. Many different biological processes such as hypoxia, systemic inflammation, endothelial dysfunction, heightened platelet reactivity, arterial stiffness and right ventricle modification interact in the development of the COPD-IHD comorbidity, which therefore deserves special attention in early diagnosis and treatment. Patients with COPD-IHD comorbidity have a worst outcome, when compared to patients with only COPD or only IHD. These patients showed a significant increase on risk of adverse events and of hospital readmissions for recurrent myocardial infarction, heart failure, coronary revascularization, and acute exacerbation of COPD. Taken together, these complications determine a significant increase in mortality. In most cases death occurs for cardiovascular cause, soon after an acute exacerbation of COPD or a cardiovascular adverse event. Recent data regarding incidence, mechanisms and prognosis of this comorbidity, along with the development of new drugs and interventional approaches may improve the management and long-term outcome of COPD-IHD patients. The aim of this review is to describe the current knowledge on COPD-IHD comorbidity. Particularly, we focused our attention on underlying pathological mechanisms and on all treatment and strategies that may improve and optimize the clinical management of COPD-IHD patients.
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              "Obesity paradox" in chronic obstructive pulmonary disease.

              The "obesity paradox" is defined as an inverse association of good health, survival and obesity. Usually in healthy persons the more obese you are the more metabolic complications you have; however, thin patients with chronic obstructive pulmonary disease (COPD) have more cardiovascular complications and a higher mortality rate. To explore whether atherosclerosis and peripheral artery disease (PAD) contribute to the higher morbidity and mortality of patients with COPD. This prospective study included 87 patients with chronic COPD who were treated in the pulmonary outpatient clinic; all signed a consent form before enrollment. We documented their lung function (FEV1%), body mass index (BMI) and ankle brachial index (ABI). The primary endpoints were to find an association between atherosclerosis and BMI in patients with COPD, and between atherosclerosis and severity of lung disease. Average ABI was 1.01 +/- 0.20, BMI was 29.33 +/- 7.48 kg/m2, and the abdominal circumference was 107.34 +/- 18.87 cm. A positive correlation was found between BMI and ABI (P=0.001) and between abdominal circumference and ABI (P=0.000). Patients with peripheral artery disease were older (73.6 +/- 11.5 vs. 68.1 +/- 11.6 years old, P= 0.04), were thinner (average BMI 25.5 +/- 6.2 vs. 31.06 +/- 7.3, P= 0.001), and had a lower abdominal circumference (97.7 +/- 18.3 vs. 111.7 +/- 17.5 cm, P=0.001). No such difference was observed for years of smoking. Male PAD patients with COPD had a lower BMI (25.2 +/- 5.6 vs. 29.9 +/- 7.4, P = 0.016), and their abdominal circumference was smaller (96.1 +/- 18.0 vs. 110.2 +/- 16.5 cm, P=0.004). Female PAD patients with COPD had a lower BMI (26.3 +/- 8.2 vs. 33.1 +/- 7.0, P=0.045), but their abdominal circumference was not different from females without PAD (102.0 +/- 19.7 vs. 114.0 +/- 19.4 cm, P=0.162). Patients with PAD had a worse lung disease (FEV1% 34 +/- 8% vs. 45 +/- 16%, P=0.01). During the 1 year of follow-up five patients died: two PAD patients due to acute myocardial infarction and three non-PAD patients died from pulmonary insufficiency (two patients) and pulmonary emboli (one patient). We found that COPD patients with PAD were older and thinner and had a lower abdominal circumference and a more progressive lung disease. Extensive atherosclerosis in patients with COPD may partly explain the "obesity paradox" observed in patients with COPD.

                Author and article information

                Int J Chron Obstruct Pulmon Dis
                Int J Chron Obstruct Pulmon Dis
                International Journal of Chronic Obstructive Pulmonary Disease
                04 July 2019
                : 14
                : 1455-1464
                [1 ] Department of Internal Medicine, Chi Mei Medical Center , Chiali, Taiwan
                [2 ] Division of Neurosurgery, Department of Surgery, National Taiwan University Hospital , Taipei 100, Taiwan
                [3 ] Department of Industrial Engineering and Management, National Yunlin University of Science and Technology , Yunlin, Taiwan
                Author notes
                Correspondence: Hsueh-Yi LuDepartment of Industrial Engineering and Management, National, Yunlin University of Science and Technology , 123 University Road, Section 3, Douliou, Yunlin64002TaiwanTel +886 5 534 2601 ext. 5230Fax +886 05 531 2073Email hylu@
                © 2019 Liao et al.

                This work is published and licensed by Dove Medical Press Limited. The full terms of this license are available at and incorporate the Creative Commons Attribution – Non Commercial (unported, v3.0) License ( By accessing the work you hereby accept the Terms. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed. For permission for commercial use of this work, please see paragraphs 4.2 and 5 of our Terms (

                Page count
                Figures: 7, Tables: 3, References: 19, Pages: 10
                Original Research


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