April 2, 2008
Extrapulmonary Effects of Chronic Obstructive Pulmonary Disease on Physical Activity: A Cross-Sectional Study
By Watz, Henrik Waschki, Benjamin; Boehme, Corinna; Claussen, Martin; Meyer, Thorsten; Magnussen, Helgo
Rationale: Physical activity is reduced in patients with chronic obstructive pulmonary disease (COPD). COPD has a systemic component that includes significant extrapulmonary effects that may contribute to its severity in individual patients. Objectives: To investigate the association of extrapulmonary effects of the disease and its comorbidities with reduced physical activity in patients with COPD.Methods: In a cross-sectional study, 170 outpatients with COPD (GOLD [Global Initiative for Chronic Obstructive Lung Disease] stages I-IV; BODE [body mass index, airway obstruction, dyspnea, and exercise capacity] score 0-10) underwent a series of tests. Physical activity was assessed over 5 to 6 consecutive days by using a multisensor accelerometer armband that records steps per day and the physical activity level (total daily energy expenditure divided by whole-night sleeping energy expenditure). Cardiovascular status was assessed by echocardiography, vascular Doppler sonography, and levels of N-terminal pro-B-type natriuretic peptide. Mental status, metabolic/muscular status, systemic inflammation, and anemia were assessed by Beck Depression Inventory, bioelectrical impedance analysis, handgrip strength, high-sensitivity C-reactive protein/ fibrinogen, and hemoglobin, respectively.
Measurements and Main Results: In a multivariate linear regression analysis using either steps per day or physical activity level as a dependent variable, the extrapulmonary parameters that were associated with reduced physical activity in patients with COPD independently of GOLD stages or BODE score were N-terminal pro- B- type natriuretic peptide levels, echocardiographically measured left ventricular diastolic function, and systemic inflammation.
Conclusions: Higher values of systemic inflammation and left cardiac dysfunction are associated with reduced physical activity in patients with COPD.
Keywords: pulmonary disease, chronic obstructive; ventricular function, left; acute phase reaction; activities of daily living
Physical activity is a parameter of increasing clinical interest. Lower levels of physical activity are associated with a higher risk for diseases such as cardiovascular disease (1), type 2 diabetes mellitus (2), mental disorders (3, 4), cancer (5), and chronic obstructive pulmonary disease (COPD) (6). In COPD, regular physical activity modifies smoking-related lung function decline and is associated with lower mortality (6, 7).
COPD has been defined as a preventable and treatable disease with significant extrapulmonary effects that may contribute to its severity in individual patients (8). Cardiovascular, mental, and musculoskeletal comorbidities, as well as elevated markers of systemic inflammation and anemia, can frequently be found in patients with COPD and have an impact on mortality in this population (9-12).
Physical activity has been shown to be reduced in patients with COPD (13, 14). We hypothesized that this reduction in physical activity may be explained by the extrapulmonary effects of COPD and its comorbidities. Thus, the rationale of our study was to assess the association of extrapulmonary effects and comorbidities in patients with COPD with reduced physical activity as measured by an accelerometer. We used multivariate linear regression analysis, the clinical stages of COPD according to the Global Initiative for Chronic Obstructive Lung Disease (GOLD) (8), and the BODE (body mass index, airway obstruction, dyspnea, and exercise capacity) index (15) to analyze the data. We previously presented the methodologic aspects of accelerometer measurement in abstract form in this journal (16).
One hundred seventy outpatients with stable COPD (128 male, 42 female) were studied between February and November 2006 at the Pulmonary Research Institute at Hospital Grosshansdorf, Schleswig Holstein, Germany. Patients were recruited from the institute's database that is used for clinical trials in COPD; it consists of 691 ambulatory patients with an established diagnosis of COPD (mean FEV^sub 1^, 54% predicted; mean age, 62 yr). Patients were contacted by a study nurse, and those who expressed their availability and interest in the study were enrolled. Exclusion criteria were an exacerbation of COPD within the past 2 months, clinical signs of acute heart failure, and severe pain syndromes that could interfere with physical activity. The study was approved by the local ethics committee of Schleswig Holstein, and participants gave their written, informed consent.
Clinical Stages of COPD
Patients were classified according to the GOLD staging system (8) and the criteria of the BODE index (15). The BODE index was designed to predict mortality in patients with COPD and has a range of 0 to 10 points, with higher scores indicating a greater risk of death (15).
Cardiovascular Status and Systemic Inflammation
Echocardiography was performed to measure systolic left heart function (left ventricular ejection fraction), diastolic left heart function (deceleration time of the early transmitral flow and ratio of the peak velocity of the early E-wave to atrial A-wave), and systolic pulmonary artery pressure. N-terminal pro-B-type natriuretic peptide (NT-pro BNP) was used as a systemic biomarker of heart failure (17). Vascular Doppler sonography was performed to assess the ankle brachial index, which is an accurate measurement of peripheral arterial disease (18). High-sensitivity C-reactive protein (hs-CRP) and fibrinogen served as markers of systemic inflammation.
The Beck Depression Inventory was used to assess depressive symptoms. Depression was defined as a Beck Depression Inventory score of 15 or greater (19).
Metabolic and Muscular Status
Body mass index (BMI; weight in kg/height in m^sup 2^) and fat- free mass index (fat-free mass in kg/height in m^sup 2^; measured by bioelectrical impedance analysis) were determined. Nutritional depletion was defined as a BMI of 21 kg/m^sup 2^ or less or a fat- free mass index of 16 kg/m^sup 2^ or less in men and 15 kg/m^sup 2^ or less in women (20). Peripheral muscle strength was measured with a handgrip dynamometer.
Hemoglobin levels were determined in tubes containing ethylenedia- minetetraacetic acid. Anemia was defined as a hemoglobin level below 13 g/dl (12).
Physical activity was measured over 5 to 6 consecutive days using a multisensor armband (SenseWear Pro Armband; BodyMedia, Inc., Pittsburgh, PA) that is worn on the upper right arm over the triceps muscle. It incorporates a biaxial accelerometer that records steps per day, and physiologic indicators of energy expenditure that enable the investigator to determine the physical activity level. We determined the physical activity level by dividing total daily energy expenditure by whole-night sleeping energy expenditure (21). A physical activity level of 1.70 or greater is defined as active, and a physical activity level greater than 1.78 is strongly associated with a lower risk of mortality in healthy older adults (22). A more detailed description of the applied clinical methods and the accelerometer measurement is contained in the online supplement.
Assessment of Potential Confounders of Physical Activity
Because of the potential interaction of lifestyle with physical activity (23-25), we also assessed alcohol consumption (drinks per week) and current smoking status. Educational status, which is positively correlated with leisure time physical activity (26), was also assessed. Patients quoting pain symptoms that interfered with general activity on the "interference with function scale" of the Brief Pain Inventory (27) were recorded. Because a history of diabetes mellitus has been shown to be a determinant of low physical activity in COPD (28), it was also recorded.
Differences between patients in different GOLD stages were analyzed by chi^sup 2^ test (categorical variables), Kruskal-Wallis test (ordinal or non-normal metric variables), and analysis of variance (normally distributed metric variables). Skewed data were log transformed to yield normal distributions.
Multivariate linear regression analyses were performed using either the physical activity level or steps per day as the dependent variable. It was the aim of this analysis to identify extrapulmonary factors that are associated with reduced physical activity independent of the clinical stages of COPD. Therefore, after controlling for possible confounders, a stepwise approach to model building was applied. In a first step, age, sex, obesity (BMI >/= 30 kg/m^sup 2^), and arterial hypertension were included in the model independent of statistical significance. The potential confounders (drinks per week, smoking status, educational status, pain symptoms, and history of diabetes mellitus) were included in the model if they were of statistical significance (P
Characteristics of patients, measurements of physical activity, and extrapulmonary parameters are given in Tables 1 to 3. A more detailed description of patients' characteristics can be found in the online supplement (Tables E1 and E2).
Twenty-two percent of the patients had a physical activity level of 1.70 or greater (Table 2). Results of the multivariate analysis for the physical activity level are given in Tables 4 and 5: The total explained variance of the physical activity level (total R^sup 2^) was 37% for the model that included GOLD stages plus extrapulmonary effects and 36% for the model that included BODE score plus extrapulmonary effects. GOLD stages or BODE score accounted for two-thirds of the explained variance of the physical activity level. The extrapulmonary factors that significantly contributed to the model independently of GOLD stage or BODE score were NT-pro-BNP, diastolic left ventricular function, and systemic inflammation. Together, they accounted for another third of the explained variance of the physical activity level. Deceleration time of the early trans-mitral flow had a stronger effect on the model than did the ratio of the peak velocity of the early E-wave to atrial A-wave (Tables 4 and 5). Fibrinogen had a stronger effect than hs-CRP (Tables 4 and 5). Similar results of the multivariate analysis for steps per day are given in Tables 6 and 7. Figures 1A- 1F depict the impact of the extrapulmonary effects that were significant in the multivariate analysis on steps per day according to the clinical stages provided by GOLD and BODE.
Arterial hypertension did not affect echocardiographic parameters of diastolic function of the left ventricle in our cohort (deceleration time of the early transmitral flow, P = 0.72 for hypertension vs. no hypertension; log ratio of the peak velocity of the early E-wave to atrial A-wave, P = 0.6 for hypertension vs. no hypertension).
A weak but significant correlation between NT-pro-BNP and measurements of echocardiography was for left atrial size and NT- pro-BNP (r = 0.36, P
The main finding of our study is that higher values of systemic inflammation and left cardiac dysfunction are associated with reduced physical activity in patients with COPD, independent of the clinical stages of COPD according to GOLD or the multidimensional BODE index.
Physical activity has previously been shown to be reduced in patients with moderate to severe COPD compared with healthy subjects (13, 14). Airway obstruction, however, correlates only weakly (14) to moderately (13, 29) with physical activity, which implies that there might be additional factors influencing physical activity in patients with COPD. Garcia-Aymerich and coworkers found further determinants of physical activity in a cohort of 346 patients with severe COPD (FEV^sub 1^, 35% predicted) (28). Using the Minnesota Leisure Time Physical Activity Questionnaire, they found that socioeconomic status, history of diabetes, health-related quality of life, and long-term oxygen therapy were independently associated with a low level of physical activity. Our study extended these observations by objectively quantifying systemic components of COPD (10) and their associations with reduced physical activity.
Left heart failure is present in 20% of elderly patients with COPD (30). In about 50% of these patients, left ventricular diastolic dysfunction causes the symptoms of heart failure (30). Even without symptoms of heart failure, diastolic dysfunction of the left ventricle in COPD is a frequently reported echocardiographic observation (31). Here we show for the first time that echocardiographic parameters indicating impaired diastolic filling processes of the left ventricle are associated with reduced physical activity in patients with COPD.
Twenty-three percent of our cohort-nearly 30% of the patients with GOLD stage IV disease-had NT-pro-BNP levels greater than 125 pg/ ml, which is an accepted threshold that indicates potential heart failure in patients with COPD (17). NT-pro-BNP values showed a weak correlation with left atrial size, which is known in patients with stable chronic left heart failure (32) and may reflect chronic left ventricular filling pressure (33). An increased left ventricular filling pressure leads to an increase in left ventricular wall stretch, which is the predominant pathophysiologic process underlying increased circulating levels of NT-pro-BNP (34). Higher levels of NT-pro BNP were associated with reduced physical activity in our patients.
We did not find a relationship between physical activity and systolic pulmonary artery pressure estimated by Doppler echocardiography. Doppler echocardiography, however, is of limited value in accurately assessing pulmonary hypertension in patients with advanced lung diseases (35). Furthermore, we could only measure systolic pulmonary artery pressure in 72% of our patients (see Table 3 and the online supplement).
The ankle brachial index is a noninvasive, reliable measure of peripheral arterial disease (18) and is a strong predictor for cardiovascular morbidity and mortality in the general population (36). Values less than 0.9 indicate peripheral arterial disease (18). In patients with values less than 0.5, physical activity is reduced, whereas mild to moderate peripheral arterial disease (ankle brachial index, 0.5-0.9) is not associated with reduced physical activity (18). On the basis of the values less than 0.9, we observed a frequency of peripheral arterial disease of 25% in our cohort- nearly 40% in patients with GOLD stage IV. Only 3% of our patients had values less than 0.5. The presence of peripheral arterial disease was not associated with reduced physical activity in our cohort.
Systemic inflammation is present in patients with COPD and has an impact on mortality in this population (37, 38). Furthermore, higher values of hs-CRP are associated with a reduced exercise capacity in patients with COPD (39, 40). It is known from epidemiologic studies that people who report less physical activity have higher values for markers of systemic inflammation (41). Here we confirm with accelerometer data the association between physical inactivity and systemic inflammation.
Depression is a frequent comorbidity in patients with COPD (19). We found depression to be prevalent in nearly 20% of our patients according to the Beck Depression Inventory-42% of patients with GOLD stage IV disease. Our prevalence data are similar to those from a previous study using the same test (19). Depression was not associated with reduced physical activity in our cohort.
The frequency of nutritional depletion in our cohort paralleled GOLD stages, with an overall prevalence of 21%. In a previous study, which included patients with GOLD stages II and III COPD, the prevalence of nutritional depletion was 27% (20). Nutritional depletion was not associated with reduced physical activity in our cohort.
Peripheral muscle weakness in COPD is considered to be related to loss of fat-free mass (20), muscle atrophy, and deconditioning (42). We found no relationship between physical activity and peripheral muscle strength. This result has to be discussed in the context of existing data concerning peripheral muscle weakness in COPD. Pitta and coworkers showed that both handgrip muscle strength and quadriceps muscle strength correlated moderately with physical activity in a bivariate model (14). We cannot confirm the association of handgrip muscle weakness with reduced physical activity in our multivariate model. In a landmark study investigating the effect of peripheral muscle weakness on exercise limitations, it was isometric quadriceps force, not handgrip force, that remained a significant predictor of exercise limitations in a stepwise multiple regression analysis (43). In a small study of 16 patients with COPD, impaired endurance time of the quadriceps muscle was shown to be related to physical inactivity (44). Therefore, it seems possible that physical activity may be affected by quadriceps muscle strength, which was not assessed in our study due to the lack of adequate equipment.
Preliminary evidence suggests that anemia in patients with COPD may be more prevalent than expected and may be related to systemic inflammation (45). Anemia is associated with reduced functional exercise capacity and a higher mortality rate in patients with COPD (12). The prevalence of anemia in our cohort was 5%, which is less than that reported in a cohort of patients with COPD (mean FEV1 , 43% predicted) attending a Veterans Administration clinic (12). The prevalence of 14% in our GOLD stage IV patients, however, was comparable to the reported data in patients with COPD receiving long- term oxygen therapy (46). The presence of anemia was not associated with reduced physical activity in our cohort.
Physical activity is defined as any bodily movement produced by skeletal muscles that results in energy expenditure beyond resting energy (1). The "gold standard" to assess total energy expenditure under free-living conditions is the doubly labeled water method (22). This methodology, however, is limited by cost and by its unavailability outside specialized centers. Simple accelerometers are inaccurate at estimating total daily energy expenditure from body movement counts only (47, 48). The SenseWear Pro Armband incorporates several other physiologic sensors that, in conjunction with the accelerometer recordings, give a more valid estimate of total daily energy expenditure (49). The physical activity level, which is defined as total daily energy expenditure divided by resting energy expenditure, is the equivalent of any physical activity performed during the day and has been shown to be a predictor of mortality in a healthy elderly population (22). At present, only limited data about the physical activity levels in COPD are available. Slinde and coworkers determined the physical activity levels in 10 underweight patients with COPD using the doubly labeled water method and indirect calorimetry (50). Physical activity levels ranged from 1.15 to 1.8, which are comparable to the range of physical activity levels found in our cohort. Of interest, only 22% of our patients had a physical activity level of 1.70 or greater, which suggests that most patients with COPD have a sedentary lifestyle. This observation confirms a previous finding that patients with COPD are markedly inactive in daily life (14). In our multivariate analysis, the explained variance of physical activity by the BODE index was similar to the explained variance by GOLD stages. Furthermore, extrapulmonary effects remained significant when added to the BODE index. This is a surprising result, as the BODE index incorporates functional exercise capacity and dyspnea, two parameters that are affected by pulmonary and cardiac function (51). A possible explanation could be the fact that our cohort had a median of only 2 BODE points. The BODE index is potentially superior to GOLD stages in predicting physical activity in a cohort of patients with more severe COPD and a higher BODE score. This possibility, however, is subject to further studies.
Our study has limitations that need to be addressed. Because it was a cross-sectional study, no causality or directionality of the findings can be inferred. Furthermore, a selection bias has to be considered, as we recruited our patients from an existing database of patients with COPD who were willing to participate in clinical projects. Therefore, the prevalence and magnitude of observed extrapulmonary effects, which clearly affected statistical analysis in our study, have to be seen in context with other studies and larger epidemiologic cohorts.
In summary, this study provides cross-sectional evidence that reduced physical activity in patients with COPD is associated not only with clinical stages of COPD severity but also with left heart dysfunction and systemic inflammation.
Conflict of Interest Statement: None of the authors has a financial relationship with a commercial entity that has an interest in the subject of this manuscript.
Acknowledgment: The authors thank Dr. Stephanie Bitter-Suermann, Dr. Christine Otten, Dr. Margret Jandl, Dr. Frank Kanniess, Ms. Ines Zimmermann, Ms. Jeanette Kotzur, and Ms. Diana Knut-Rehr for their help collecting patients' data. They thank Prof. Dr. Heiner Raspe for the academic discussions about the topic of the study, and Dr. Olaf Holz and Ms. Mary McKenney for the critical review of the manuscript.
AT A GLANCE COMMENTARY
Scientific Knowledge on the Subject
Physical activity is reduced in patients with moderate to severe chronic obstructive pulmonary disease compared with healthy subjects.
What This Study Adds to the Field
Higher values of systemic inflammation and left cardiac dysfunction are associated with reduced physical activity in patients with chronic obstructive pulmonary disease.
1. Thompson PD, Buchner D, Pina IL, Balady GJ, Williams MA, Marcus BH, Berra K, Blair SN, Costa F, Franklin B, et al. Exercise and physical activity in the prevention and treatment of atherosclerotic cardiovascular disease: a statement from the Council on Clinical Cardiology (Subcommittee on Exercise, Rehabilitation, and Prevention) and the Council on Nutrition, Physical Activity, and Metabolism (Subcommittee on Physical Activity). Circulation 2003;107:3109-3116.
2. Knowler WC, Barrett-Connor E, Fowler SE, Hamman RF, Lachin JM, Walker EA, Nathan DM. Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. N Engl J Med 2002;346:393- 403.
3. Strawbridge WJ, Deleger S, Roberts RE, Kaplan GA. Physical activity reduces the risk of subsequent depression for older adults. Am J Epidemiol 2002;156:328-334.
4. Rovio S, Kareholt I, Helkala EL, Viitanen M, Winblad B, Tuomilehto J, Soininen H, Nissinen A, Kivipelto M. Leisure-time physical activity at midlife and the risk of dementia and Alzheimer's disease. Lancet Neurol 2005;4:705-711.
5. Colditz GA, Sellers TA, Trapido E. Epidemiology: identifying the causes and preventability of cancer? Nat Rev Cancer 2006;6:75- 83.
6. Garcia-Aymerich J, Lange P, Benet M, Schnohr P, Anto JM. Regular physical activity modifies smoking-related lung function decline and reduces risk of chronic obstructive pulmonary disease: a population-based cohort study. Am J Respir Crit Care Med 2007;175:458-463.
7. Garcia-Aymerich J, Lange P, Benet M, Schnohr P, Anto JM. Regular physical activity reduces hospital admission and mortality in chronic obstructive pulmonary disease: a population based cohort study. Thorax 2006;61:772-778.
8. Rabe KF, Hurd S, Anzueto A, Barnes PJ, Buist SA, Calverley P, Fukuchi Y, Jenkins C, Rodriguez-Roisin R, van Weel C, et al. Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: GOLD executive summary. Am J Respir Crit Care Med 2007;176:532-555.
9. Sin DD, Anthonisen NR, Soriano JB, Agusti AG. Mortality in COPD: role of comorbidities. Eur Respir J 2006;28:1245-1257.
10. Agusti AG. Systemic effects of chronic obstructive pulmonary disease. Proc Am Thorac Soc 2005;2:367-370.
11. Ng TP, Niti M, Tan WC, Cao Z, Ong KC, Eng P. Depressive symptoms and chronic obstructive pulmonary disease: effect on mortality, hospital readmission, symptom burden, functional status, and quality of life. Arch Intern Med 2007;167:60-67.
12. Cote C, Zilberberg MD, Mody SH, Dordelly LJ, Celli B. Haemoglobin level and its clinical impact in a cohort of patients with COPD. Eur Respir J 2007;29:923-929.
13. Schonhofer B, Ardes P, Geibel M, Kohler D, Jones PW. Evaluation of a movement detector to measure daily activity in patients with chronic lung disease. Eur Respir J 1997;10:2814-2819.
14. Pitta F, Troosters T, Spruit MA, Probst VS, Decramer M, Gosselink R. Characteristics of physical activities in daily life in chronic obstructive pulmonary disease. Am J Respir Crit Care Med 2005;171: 972-977.
15. Celli BR, Cote CG, Marin JM, Casanova C, Montes de Oca M, Mendez RA, Pinto Plata V, Cabral HJ. The body-mass index, airflow obstruction, dyspnea, and exercise capacity index in chronic obstructive pulmonary disease. N Engl J Med 2004;350:1005-1012.
16. Watz H, Waschki B, Meyer T, Kanniess F, Magnussen H. Quantification of physical activity in daily life of patients with COPD: comparison of two devices and two parameters of activity measurement [abstract]. Am J Respir Crit Care Med 2007;175:A369.
17. Rutten FH, Cramer MJ, Zuithoff NP, Lammers JW, Verweij W, Grobbee DE, Hoes AW. Comparison of B-type natriuretic peptide assays for identifying heart failure in stable elderly patients with a clinical diagnosis of chronic obstructive pulmonary disease. Eur J Heart Fail 2007;9:651-659.
18. McDermott MM, Greenland P, Liu K, Guralnik JM, Celic L, Criqui MH, Chan C, Martin GJ, Schneider J, Pearce WH, et al. The ankle brachial index is associated with leg function and physical activity: the Walking and Leg Circulation Study. Ann Intern Med 2002;136: 873-883.
19. Wagena EJ, Arrindell WA, Wouters EF, van Schayck CP. Are patients with COPD psychologically distressed? Eur Respir J 2005;26:242-248.
20. Vermeeren MA, Creutzberg EC, Schols AM, Postma DS, Pieters WR, Roldaan AC, Wouters EF. Prevalence of nutritional depletion in a large out-patient population of patients with COPD. Respir Med 2006;100:1349-1355.
21. Hunter GR, Larson-Meyer DE, Sirikul B, Newcomer BR. Muscle metabolic function and free-living physical activity. J Appl Physiol 2006;101:1356-1361.
22. Manini TM, Everhart JE, Patel KV, Schoeller DA, Colbert LH, Visser M, Tylavsky F, Bauer DC, Goodpaster BH, Harris TB. Daily activity energy expenditure and mortality among older adults. JAMA 2006; 296:171-179.
23. Blair SN, Jacobs DR Jr, Powell KE. Relationships between exercise or physical activity and other health behaviors. Public Health Rep 1985; 100:172-180.
24. Bouchard C, Shephard RJ, Stephens C. Physical activity, fitness, and health. Champaign, IL: Human Kinetics Publishers; 1994.
25. Pate RR, Pratt M, Blair SN, Haskell WL, Macera CA, Bouchard C, Buchner D, Ettinger W, Heath GW, King AC, et al. Physical activity and public health: a recommendation from the Centers for Disease Control and Prevention and the American College of Sports Medicine. JAMA 1995;273:402-407.
26. Folsom AR, Cook TC, Sprafka JM, Burke GL, Norsted SW, Jacobs DR Jr. Differences in leisure-time physical activity levels between blacks and whites in population-based samples: the Minnesota Heart Survey. J Behav Med 1991;14:1-9.
27. Radbruch L, Loick G, Kiencke P, Lindena G, Sabatowski R, Grond S, Lehmann KA, Cleeland CS. Validation of the German version of the Brief Pain Inventory. J Pain Symptom Manage 1999;18:180-187.
28. Garcia-Aymerich J, Felez MA, Escarrabill J, Marrades RM, Morera J, Elosua R, Anto JM. Physical activity and its determinants in severe chronic obstructive pulmonary disease. Med Sci Sports Exerc 2004;36: 1667-1673. 29. Steele BG, Holt L, Belza B, Ferris S, Lakshminaryan S, Buchner DM. Quantitating physical activity in COPD using a triaxial accelerometer. Chest 2000;117:1359-1367.
30. Rutten FH, Cramer MJ, Grobbee DE, Sachs AP, Kirkels JH, Lammers JW, Hoes AW. Unrecognized heart failure in elderly patients with stable chronic obstructive pulmonary disease. Eur Heart J 2005;26: 1887-1894.
31. Boussuges A, Pinet C, Molenat F, Burnet H, Ambrosi P, Badier M, Sainty JM, Orehek J. Left atrial and ventricular filling in chronic obstructive pulmonary disease: an echocardiographic and Doppler study. Am J Respir Crit Care Med 2000;162:670-675.
32. Barclay JL, Kruszewski K, Croal BL, Cuthbertson BH, Oh JK, Hillis GS. Relation of left atrial volume to B-type natriuretic peptide levels in patients with stable chronic heart failure. Am J Cardiol 2006;98:98-101.
33. Abhayaratna WP, Seward JB, Appleton CP, Douglas PS, Oh JK, Tajik AJ, Tsang TS. Left atrial size: physiologic determinants and clinical applications. J Am Coll Cardiol 2006;47:2357-2363.
34. Kragelund C, Gronning B, Kober L, Hildebrandt P, Steffensen R. N-terminal pro-B-type natriuretic peptide and long-term mortality in stable coronary heart disease. N Engl J Med 2005;352:666-675.
35. Arcasoy SM, Christie JD, Ferrari VA, Sutton MS, Zisman DA, Blumenthal NP, Pochettino A, Kotloff RM. Echocardiographic assessment of pulmonary hypertension in patients with advanced lung disease. Am J Respir Crit Care Med 2003;167:735-740.
36. Criqui MH, Langer RD, Fronek A, Feigelson HS, Klauber MR, McCann TJ, Browner D. Mortality over a period of 10 years in patients with peripheral arterial disease. N Engl J Med 1992;326:381- 386.
37. Man SF, Connett JE, Anthonisen NR, Wise RA, Tashkin DP, Sin DD. C-reactive protein and mortality in mild to moderate chronic obstructive pulmonary disease. Thorax 2006;61:849-853.
38. Dahl M, Vestbo J, Lange P, Bojesen SE, Tybjaerg-Hansen A, Nordestgaard BG. C-reactive protein as a predictor of prognosis in chronic obstructive pulmonary disease. Am J Respir Crit Care Med 2007;175:250-255.
39. de Torres JP, Cordoba-Lanus E, Lopez-Aguilar C, Muros de Fuentes M, Montejo de Garcini A, Aguirre-Jaime A, Celli BR, Casanova C. C-reactive protein levels and clinically important predictive outcomes in stable COPD patients. Eur Respir J 2006;27:902-907.
40. Broekhuizen R, Wouters EF, Creutzberg EC, Schols AM. Raised CRP levels mark metabolic and functional impairment in advanced COPD. Thorax 2006;61:17-22.
41. Mora S, Lee IM, Buring JE, Ridker PM. Association of physical activity and body mass index with novel and traditional cardiovascular biomarkers in women. JAMA 2006;295:1412-1419.
42. Bernard S, Leblanc P, Whittom F, Carrier G, Jobin J, Belleau R, Maltais F. Peripheral muscle weakness in patients with chronic obstructive pulmonary disease. Am J Respir Crit Care Med 1998;158:629-634.
43. Gosselink R, Troosters T, Decramer M. Peripheral muscle weakness contributes to exercise limitation in COPD. Am J Respir Crit Care Med 1996;153:976-980.
44. Serres I, Gautier V, Varray A, Prefaut C. Impaired skeletal muscle endurance related to physical inactivity and altered lung function in COPD patients. Chest 1998;113:900-905.
45. Similowski T, Agusti A, Macnee W, Schonhofer B. The potential impact of anaemia of chronic disease in COPD. Eur Respir J 2006;27: 390-396.
46. Chambellan A, Chailleux E, Similowski T. Prognostic value of the hematocrit in patients with severe COPD receiving long-term oxygen therapy. Chest 2005;128:1201-1208.
47. Leenders NY, Sherman WM, Nagaraja HN, Kien CL. Evaluation of methods to assess physical activity in free-living conditions. Med Sci Sports Exerc 2001;33:1233-1240.
48. Leenders NY, Sherman WM, Nagaraja HN. Energy expenditure estimated by accelerometry and doubly labeled water: do they agree? Med Sci Sports Exerc 2006;38:2165-2172.
49. St.-Onge M, Mignault D, Allison DB, Rabasa-Lhoret R. Evaluation of a portable device to measure daily energy expenditure in free-living adults. Am J Clin Nutr 2007;85:742-749.
50. Slinde F, Ellegard L, Gronberg AM, Larsson S, Rossander- Hulthen L. Total energy expenditure in underweight patients with severe chronic obstructive pulmonary disease living at home. Clin Nutr 2003;22: 159-165.
51. American Thoracic Society/American College of Chest Physicians. ATS/ ACCP statement on cardiopulmonary exercise testing. Am J Respir Crit Care Med 2003;167:211-277.
Henrik Watz1, Benjamin Waschki1, Corinna Boehme1, Martin Claussen2, Thorsten Meyer3, and Helgo Magnussen1,2
1Pulmonary Research Institute, 2Center for Pneumology and Thoracic Surgery, Hospital Grosshansdorf, Grosshansdorf, Germany; and 3Institute of Social Medicine, Medical University Luebeck, Luebeck, Germany
(Received in original form July 10, 2007; accepted in final form November 29, 2007)
Supported by an unrestricted research grant from AstraZeneca. The funding source had no role in the study design, collection, analysis, and interpretation of the data or in the decision to submit the paper for publication.
Correspondence and requests for reprints should be addressed to Prof. Dr. Helgo Magnussen, M.D., Pulmonary Research Institute at Hospital Grosshansdorf, Center for Pneumology and Thoracic Surgery, Woehrendamm 80, D-22927 Grosshansdorf, Germany. E-mail: firstname.lastname@example.org
This article has an online supplement, which is accessible from this issue's table of contents at www.atsjournals.org
Am J Respir Crit Care Med Vol 177. pp 743-751, 2008
Originally Published in Press as DOI: 10.1164/rccm.200707-1011OC on November 29, 2007
Internet address: www.atsjournals.org
Copyright American Thoracic Society Apr 1, 2008
(c) 2008 American Journal of Respiratory and Critical Care Medicine. Provided by ProQuest Information and Learning. All rights Reserved.