Why is it that we have not seen the urgency in COPD management we would expect for a disease of this burden and scale? As a trained pulmonologist, and having dedicated my career to advancing respiratory science and medicine, I’m deeply concerned about what I see as a global respiratory health crisis.
Chronic obstructive pulmonary disease (COPD) is a serious chronic respiratory condition — more specifically, a group of conditions, including emphysema and chronic bronchitis — that affects hundreds of millions of people worldwide, often causing poor quality of life, hospitalizations, and even death.1,2 For too many patients, COPD exacerbations, which are the acute worsening of symptoms or flare-ups, are viewed as inevitable.3-5 At AstraZeneca, we believe that by following the science, we can prevent COPD exacerbations and reduce the rates of premature death in COPD.
The statistics are startling and require greater attention from those who can make a difference for patients. Globally, COPD continues to be the third leading cause of death, after stroke and heart disease6, and mortality rates have not substantially improved in the last 20 years.7,8 In the United States alone, more than 15 million people have been diagnosed with COPD, though many more may be undiagnosed, and the disease is responsible for 150,000 deaths per year — that’s equivalent to one death every four minutes.9,10
Despite this, I’m writing this article because I believe there has never been a more exciting time to be in respiratory medicine. There is incredible momentum building through growing consensus in the scientific community that encourages a more proactive mindset in COPD management to prevent exacerbations and target mortality reduction as a treatment goal. By uniting with the clinical community, and working in partnership with health systems and governments, we can change the trajectory in COPD and, in so doing, improve millions of lives.
It’s time for a different approach to COPD care
There are core biological mechanisms in COPD that elevate risks both in the lung and the heart, making the impact of COPD exacerbations — even moderate ones — far more urgent than how they’re often viewed today.11-14
COPD, through damage to the lungs, elevates patients’ risk both in and beyond the lung. 11-14 It is well established that people with COPD, even those without a recent flare-up of COPD, are at risk of a future lung exacerbation.15 What needs greater attention, is that COPD increases the risk of cardiovascular events. This is because up to 50% of COPD patients are also diagnosed with cardiovascular disease and up to 39% of deaths in COPD patients are due to cardiovascular causes.16,17 Additionally, the risk of a cardiovascular event is increased nearly 10 times within 30 days following a hospitalization for a severe COPD exacerbation.18
New data from AstraZeneca presented at the ATS 2023 International Conference, hosted by the American Thoracic Society, further highlight this “cardiopulmonary risk” of a COPD exacerbation. Results from the retrospective EXACOS-CV US study, funded by AstraZeneca, of more than 355,000 patients in the US demonstrate that the incidence of acute severe cardiovascular events — including heart attack, heart failure and stroke — was increased by 32 percent after a moderate or severe acute exacerbation of COPD, particularly in the first 90 days, and this risk stayed elevated for an entire year.19
The evidence is clear. We must keep the link between the lung and the heart top of mind in clinical practice, and prioritize earlier escalation of COPD management approaches to reduce the risk of cardiopulmonary events and prevent premature mortality.
Groundbreaking recent progress in COPD
To this end, it is promising to see the growing consensus in the scientific community that encourages approaching COPD as the health emergency it is. The traditional reactive approach to COPD management, where pharmacotherapy is not escalated until symptoms worsen20-22, is now evolving into a more preventative clinical approach that involves early identification of at-risk patients, enhanced appreciation for the magnitude and scope of risk of a COPD exacerbation, and mortality reduction as an achievable treatment goal.23,24
At AstraZeneca, we applaud the important step forward made with respect to these goals in the 2023 GOLD Report, generally considered to be the main evidence-based reference guide for the diagnosis, management and prevention of COPD, which included evidence supporting the use of pharmacological therapy for reduction in mortality as a treatment goal.23
The recent 2022 Lancet Commission on COPD of internationally renowned lung experts also support the need for changes in thinking about COPD management. The Commission points to the need for a “wholesale rethinking of COPD” and advocates for 1) broader understanding of risk factors, 2) preventative measures and disruptive approaches to diagnosis, and 3) a coordinated plan to combat COPD.22 Additionally, a recently published expert consensus perspective article known as the “Rome Proposal” has suggested the need for a new way of defining COPD exacerbations that reflects the potential severity of these events, and is based on clinical and physiological parameters, rather than on the therapy applied.25
The urgent need to prioritize COPD
In addition to following the science that tells us exacerbation prevention is essential in reducing cardiopulmonary risk and reducing mortality, we also need policies that support health services to achieve the same goals.
Much work remains to be done to change the trajectory around COPD mortality and increasing healthcare burden, but the growing consensus around the need for proactive management and identification of at-risk patients is a step in the right direction.
Quality Standards can play a key role in guiding policy change toward more proactive care. Recently a group of COPD experts published Global Quality Standards in COPD, a roadmap for effective COPD management, providing key principles of quality care that include: early and accurate diagnosis; improved disease education; improved follow-up care; and access to treatment following hospital discharge for an exacerbation.26
Important examples of policies that support a more preventative approach to COPD can be seen in the European Commission’s Healthier Together — EU Non-Communicable Diseases (NCDs) Initiative, giving policy guidance for member countries and highlighting the importance of holistic care, including the assessment of comorbidities.27 And, in Canada, Best Care is an innovative integrated disease management program for managing high-risk, exacerbation-prone patients with COPD in a primary care setting. Best Care has been shown to improve quality of life and exacerbation-related outcomes, and reduce costs.28,29
Greater awareness and recognition of the urgency is also needed, which is why at AstraZeneca, we are proud to be a founding partner of the Speak Up for COPD campaign alongside industry and advocacy partners from around the globe, collectively calling for further understanding and prioritization of COPD within healthcare systems worldwide.30
By prioritizing proactive COPD management, we can improve patient outcomes, reduce mortality, and create more resilient healthcare systems. This will require support from governments and healthcare practitioners alike, but the benefits will be worth the effort. By working together, we can make real progress in the fight against COPD and help millions of people worldwide live longer, healthier and fuller lives. I hope you’ll join us in this fight.
Veeva ID: Z4-53223
Date of preparation: May 2023
1. WHO. Fact Sheet: Chronic obstructive pulmonary disease (COPD). Available here: https://www.who.int/news-room/fact-sheets/detail/chronic-obstructive-pulmonary-disease-(copd) [last accessed May 2023]
2. Adeloye D, Song P, Zhu Y, et al. Global, regional, and national prevalence of, and risk factors for, chronic obstructive pulmonary disease (COPD) in 2019: a systematic review and modelling analysis. Lancet Respir Med. (2022) Vol 10(5); 447-458
3. Lareau et al. Exacerbation of COPD. Am J Respir Crit Care Med (2018) Vol. 198:21-22
4. V. Kim et al. What is a COPD Exacerbation: Current definitions, pitfalls, challenges and opportunities for improvement. European Respiratory Journal 2018 52: 1801261
5. Wilkinson TM, Donaldson GC, Hurst JR, et al. Early therapy improves outcomes of exacerbations of chronic obstructive pulmonary disease. Am J Respir 2004;169:1298-303
6. WHO Fact Sheet; The Top 10 Causes of Death https://www.who.int/news-room/fact-sheets/detail/the-top-10-causes-of-death [last accessed May 2023]
7. Shavelle et al. Life expectancy and years of life lost in chronic obstructive pulmonary disease: findings from the NHANES III Follow-up Study. Int J Chron Obstruct Pulmon Dis. 2009;4:137-48. https://pubmed.ncbi.nlm.nih.gov/19436692/
8. Centres for Disease Control and Prevention. Chronic Obstructive Pulmonary Disease (COPD): National Trends. (2022) Accessible at: https://www.cdc.gov/copd/data-and-statistics/national-trends.html [last accessed May 2023]
9. Centres for Disease Control and Prevention. Disease or Condition of the Week: COPD. (2022). Accessible at: https://bit.ly/3MzcvRv [last accessed May 2023]
10. Centres for Disease Control and Prevention. Basics about COPD. Accessible at: https://bit.ly/42KNDfi [last accessed May 2023]
11. Crisan L, Wong N, Sin DD, et al. Karma of cardiovascular disease risk factors for prevention and management of major cardiovascular events in the context of acute exacerbations of chronic obstructive pulmonary disease. Front Cardiovasc Med. 2019;6:79.
12. Rabe K, Hurst JR, Suissa S. Cardiovascular disease and COPD: dangerous liaisons? Eur Respir Rev. 2018; 27:180057.
13. Van Eeden S, Leipsic J, Man SFP, et al. The relationship between lung inflammation and cardiovascular disease. Am J Respir Crit Care Med. 2012;186:11-16.
14. Aisanov Z. Khaltaev N. Management of cardiovascular comorbidities in chronic obstructive pulmonary disease patients. J Thorac Dis. 2020; 12:2791-2802.
15. Whittaker H, Rubino A, Mullerova H, et al. Frequency and Severity of exacerbations of COPD Associated with Future Risk of Exacerbations and Mortality: A UK Routine Health Care Data Study. Int J Chron Obstruct Pulmon Dis. 2022;17:427-437
16. Finkelstein J, Cha E, Scharf SM. Chronic obstructive pulmonary disease as an independent risk factor for cardiovascular morbidity. Int J Chron Obstruct Pulmon Dis. 2009;4:337-349.
17. Berry CE, Wise RA. Mortality in COPD: causes, risk factors, and prevention. COPD. 2010; 7:375-382
18. Kunisaki KM, Dransfield MT, Anderson JA, et al. Exacerbations of chronic obstructive pulmonary disease and cardiac events. A post hoc cohort analysis from the SUMMIT randomized clinical trial. Am J Respir Crit Care Med. 2018;198:51-57.
19. Daniels, K, Tave, A., Neikirk, A., et al. Incidence of acute cardiovascular events following acute exacerbation of chronic obstructive pulmonary disease in a large US claims database [Thematic Poster Session]. Presented at the American Thoracic Society International Conference 2023 (19-24 May).
20. Wilkinson TM, Donaldson GC, Hurst JR, et al. Early therapy improves outcomes of exacerbations of chronic obstructive pulmonary disease. Am J Respir 2004;169:1298-303
21. Halpin DMG, Decramer M, Celli BR, et al. Effect of a single exacerbation on decline in lung function in COPD. Respiratory Medicine 2017; 128: 85-91.
22. Kerkhof M, Voorham J, Dorinsky P, et al. Association between COPD exacerbations and lung function decline during maintenance therapy. Thorax. 2020; 75 (9): 744-753.
23. GOLD. Global Strategy for the Diagnosis, Management and Prevention of COPD, Global Initiative for Chronic Obstructive Lung Disease (GOLD), 2023. [Online]. Available at: http://goldcopd.org. [Last accessed: May 2023]
24. Stolz, D., Mkorombindo, T., Schumann, D., Agusti, Alvar., Ash, Samuel, Bafadhel, M., et al. Towards the elimination of chronic obstructive pulmonary disease: a Lancet Commission. The Lancet Commissions. Vol.400 Issue 10356 (Sept. 2022); pp.921-972.
25. Celli B, Fabbri L, Aaron S, et al. An Updated Definition and Severity Classification of Chronic Obstructive Pulmonary Disease Exacerbations: The Rome Proposal. Am J Respir Crit Care Med (2021) Vol 204, 11:1251-1258
26. Bhutani et al. Quality Standards Position Statements for Healthy System Policy Changes in Diagnosis and Management of COPD: A Global Perspective, Advances in Therapy, 2022; 39:2302-2322
27. European Commission Directorate-General for Health and Food Safety, Healthier Together: EU Non-Communicable Diseases Initiative. June 2022. Accessible at: https://health.ec.europa.eu/system/files/2022-06/eu-ncd-initiative_publication_en_0.pdf [last accessed May 2023]
28. Hussey AJ, Wing K, Ferrone M, et al. Integrated Disease Management for Chronic Obstructive Pulmonary Disease in Primary Care, from the Controlled Trial to Clinical Program: A Cohort Study. Int J Chron Obstruct Pulmon Dis. 2021;16:3449-3464
29. Scarffe A, Licskai CJ, Ferrone M, et al. Cost-effectiveness of integrated disease management for high risk, exacerbation prone, patients with chronic obstructive pulmonary disease in a primary care setting. Cost Eff Resour Alloc 20, 39 (2022)
30. Winders T, Barratt J. 2022. ‘It is time to make COPD a public health priority’. POLITICO. https://www.politico.eu/sponsored-content/it-is-time-to-make-copd-a-public-health-priority/ [last accessed May 2023]