Introduction Quantitative assessment of emphysema, gas trapping and airway wall thickness on CT correlates with chronic obstructive pulmonary disease (COPD) disease severity and exacerbation risk. In stable COPD, airway wall thickness is associated with prior myocardial infarction. Cardiac disease is often undiagnosed in COPD, and the risk of cardiac events following hospitalised exacerbations of COPD (ECOPD) is high. CT scans during hospitalised exacerbations may help clinicians identify patients with heart disease.Methods As part of the SCATECOPD study (IRAS 277817), patients with ECOPD underwent a detailed cardiac assessment encompassing an ECG, echocardiogram, CT coronary calcium score, and inspiratory and expiratory CT chest. Expiratory gas trapping (Exp%856), emphysema (Insp%950) and airway wall thickness (Pi10) were compared with clinical and cardiac data.Results 56 participants were recruited: 33 (58.9%) were female, with a mean (SD) age of 72.5 (6.5) years. The mean forced expiratory volume in 1 s was 50.6% predicted (SD 19.2), consistent with moderate-to-severe COPD.Cardiac assessment identified moderate–severe left ventricular systolic dysfunction (LVSD) in 10.7%, heart failure without moderate–severe LVSD in 25.0% and right heart failure in 17.9%; these were newly diagnosed in 8.9%, 23.2% and 14.3%, respectively. Severe coronary artery disease was found in 43.1%. Airway wall thickness was significantly negatively correlated with left ventricular ejection fraction. Emphysema and gas trapping correlated with spirometric airflow obstruction and showed weaker associations with cardiac dysfunction.Conclusion Quantitative CT performed during ECOPD may offer opportunistic insights into cardiac health, particularly through Pi10. Further research is warranted to evaluate its utility as a screening tool in COPD admissions.

Background/Objectives: Heart disease is common in COPD, yet it is underdiagnosed and undertreated. Heart failure (HF) is undiagnosed in up to 20% of hospital inpatients. Hospitalised exacerbations of COPD (ECOPD) confer high mortality and readmission rates, with an elevated temporal cardiac risk. We performed a pilot randomised controlled trial examining the feasibility and effect of inpatient structured cardiac assessment (SCA) to diagnose and prompt guideline-recommended treatment of heart disease. Methods: A total of 115 inpatients with ECOPD were randomised 1:1 to receive usual care (UC) or SCA, comprising transthoracic echocardiography, CT coronary artery calcium scoring, 24 h ECG, blood pressure, and diabetes assessment. Follow-up was for 12 months. The prevalence of underdiagnosis and undertreatment of heart disease were captured, and potential outcome measures for future trials assessed. Results: Among patients undergoing SCA, 42/57 (73.7%) received a new cardiac diagnosis and 32/57 (56.1%) received new cardiac treatment, compared with 11/58 (19.0%; p < 0.001) and 5/58 (8.6%; p < 0.001) in the UC group. More patients in the SCA group were newly diagnosed with HF (36.8% vs. 12.1%; p = 0.002). When heart disease was diagnosed, the proportion receiving optimal treatment at discharge was substantially higher in SCA (35/47 (74%) vs. 4/11 (34%); p = 0.029). The occurrence of a major adverse cardiovascular event (MACE) showed promise as an appropriate clinical outcome for a future definitive trial. MACEs occurred in 17.2% in usual care vs. 10.5% in SCA in one year, with a continued separation of survival curves during follow up, although statistical significance was not shown. Conclusions: A structured cardiac assessment during ECOPD substantially improved diagnosis and treatment of heart disease. HF and coronary artery disease were the most common new diagnoses. Future interventional trials in this population should consider MACEs as the primary outcome.

Objectives: To quantify medication burden among adults with cystic fibrosis (CF) prescribed CFTR modulators, using the "Living with Medicines Questionnaire" (LMQ-3), a validated measure of medication burden and to identify factors associated with high burden.

Exercise is associated with multiple benefits and considered integral to the management of Cystic Fibrosis (CF). The UK Standards of Care and Good Clinical Practice for the Physiotherapy Management of Cystic Fibrosis recommend there should be adequate staffing and appropriate skill mix to ensure hospitalized patients with CF have opportunity to exercise daily. Furthermore, suitable facilities should be available to permit this. To review inpatient exercise provision across CF centres in the UK and identify existing challenges faced when delivering the standard of care. Survey distributed to CF physiotherapists across the UK exploring inpatient exercise provision and facilities available at centres, and challenges faced when working towards standards of care. 31 responses, 11 adult and 7 paediatric centres. 13 did not differentiate. 11 centres offered exercise daily, 15 weekdays only, 3 offered three to five times weekly and 2 offered one to two times weekly. Exercise was delivered by qualified physiotherapists at 21 centres, physiotherapy assistants at 6 and at 4 centres exercise practitioners were utilised. 19 centres had a gym, 7 did not, 4 delivered exercises solely in patients' rooms and 1 virtually. All had access to equipment to be taken into patient rooms. Outdoor space was available at 19 centres. Barriers to exercise delivery included time(9), space(17), inadequate staffing(6), patient choice(13) and infection control(1). Inpatient exercise provision and facilities vary between CF centres across the UK. Barriers to exercise delivery should be addressed to improve overall provision of care to achieve the recommended standards of care.

Introduction: Stable state blood eosinophil counts (BEC) should be used to guide inhaled corticosteroid (ICS) treatment in COPD as BEC may drop during acute illness. Expedient treatment decisions are challenged by the availability and stability of BEC; a reliable surrogate would be helpful. Aims: The blood eosinophils in COPD (BECCOPD) study is assessing whether the highest of ≥3 BEC within 24 months (historical BEC) is a surrogate for stable state BEC. We investigated the variability between historical and stable state BEC, and two prospective stable state BECs. Methods: Patients were recruited from primary and secondary care. Stable state BEC were collected on study entry and after at least 3 months. We compared the agreement between study entry BEC, and historical and second stable state BEC. Results: 295 participants were recruited, 196 included in this analysis. Mean (SD) age 71 (7), mean FEV1% predicted 55 (23). 52% were male, median eMRCD 3 (3-4). Agreement between BEC samples is tabulated below. Conclusion: Historical BEC showed good agreement at the 0.1 threshold and is a reasonable surrogate when a stable state BEC is unavailable. Historical BEC offered reasonable performance at the 0.3 threshold but with greater variation. Acknowledgements: The BECCOPD study is funded by GSK via the supported studies program.

Introduction Blood eosinophil counts (BEC) are used to direct ICS therapy in COPD. BEC are variable and can move across treatment thresholds over time. Multiple factors can influence the stability of BEC. Identification and assessment of potential surrogate markers for stable state BEC over time would be helpful. Aims The blood eosinophils in COPD (BECCOPD) study is assessing whether the highest of ≥3 BEC within 24 months is a suitable surrogate for stable state BEC. We compared the stability of the highest and second highest BEC over 10 years. Methods Patients with spirometry confirmed COPD, stable at baseline, were recruited from primary and secondary care. BEC over the first and last 3 years within the previous 10 years were captured and converted to 1 decimal place for reporting consistency. Only patients with 3 or more BEC within both time periods were included. The highest and second highest BEC between both time frames were compared using a paired t-test. Results 145/235 (62%) of participants were included in this analysis. Mean age 71 (7), mean FEV1% predicted 57 (22), 58% female, median eMRCD 4 (3–4). When comparing the highest BEC between the two groups, 101/145 (69.66%) were in the same GOLD guideline threshold, 20/145 (13.79%) moved into a lower threshold and 24/145 (16.55%) into a higher threshold. The mean and SD values are shown in table 1. The intraclass correlation coefficient between the two groups for highest BEC was 0.555 and 0.670 for the second highest BEC indicating moderate reliability for both. Conclusion Blood eosinophil endotype varied over a ten-year period. The ICC for both measures of BEC showed a moderate correlation but was better when comparing the second highest BEC. This shows promise as a surrogate marker of eosinophil endotype. Acknowledgements The BECCOPD study is funded by GSK via the supported studies program.

Introduction COPD is a heterogenous condition with multiple endotypes including eosinophilic airway inflammation. Blood eosinophils have been identified as a treatable trait in COPD. There is increasing interest in the role of basophils and eosinophil/basophil ratio (EBR) in COPD.1 Aims The blood eosinophils in COPD (BECCOPD) study is assessing whether the highest of ≥3 BEC within 24 months is a suitable surrogate for stable state BEC. We assessed the association of stable state, BEC, basophils and EBR with exacerbation frequency in BECCOPD participants 12 months before and after recruitment. Methods Eligible patients, stable at baseline, were recruited to the BECCOPD study from both primary and secondary care. Stable state full blood count was collected at first study visit. Moderate and severe exacerbation frequency were collected from primary and secondary care health records. Participants were split into a low and high exacerbation frequency group. Mean BEC, basophils and EBR were compared between groups using a two tailed t-test. Results 188 participants were included in the prospective analysis, 192 in the retrospective analysis. Mean (SD) age70 (8), Mean (SD) FEV1% predicted 55 (22), 51% female, median eMRCD 3 (3–4). The mean and SD values are shown in table 1. Conclusion Increased BEC was seen in the higher exacerbation group consistent with other larger observational studies. A raised peripheral EBR was significantly associated with more exacerbations in both analyses driven by primarily higher BEC as well as low basophils. Acknowledgements The BECCOPD study is funded by GSK via the supported studies program. Reference Jogdand P, et al. Eosinophils, basophils, and type 2 immune microenvironments in COPD-affected lung tissue. Eur Respir J. 2020 May 7;55(5):1900110.

Background It is often stated that heart disease is underdiagnosed in COPD. Evidence for this statement comes from primary studies, but these have not been synthesised to provide a robust estimate of the burden of undiagnosed heart disease. Methods A systematic review of studies using active diagnostic techniques to establish the prevalence of undiagnosed major cardiac comorbidities in patients with COPD was carried out. MEDLINE, Embase, Scopus and Web of Science were searched for terms relating to heart failure (specifically, left ventricular systolic dysfunction (LVSD), coronary artery disease (CAD) and atrial fibrillation), relevant diagnostic techniques and COPD. Studies published since 1980, reporting diagnosis rates using recognised diagnostic criteria in representative COPD populations not known to have heart disease were included. Studies were classified by condition diagnosed, diagnostic threshold used and whether participants had stable or exacerbated COPD. Random-effects meta-analysis of prevalence was conducted where appropriate. Results In general, prevalence estimates for undiagnosed cardiac comorbidities in COPD had broad confidence intervals, with significant study heterogeneity. Most notably, a prevalence of undiagnosed LVSD of 15.8% (11.1-21.1%) was obtained when defined as left ventricular ejection fraction <50%. Undiagnosed CAD was found in 2.3-18.0% of COPD patients and atrial fibrillation in 1.4% (0.3-3.5%). Conclusion Further studies using recent diagnostic advances, and investigating therapeutic interventions for patients with COPD and heart disease are needed.

Introduction: COPD patients suffer recurrent admissions, which are difficult to prevent. We explored whether underdiagnosis or undertreatment of heart disease was related to hospital admissions. Methods: 115 patients admitted with COPD exacerbation (ECOPD) were categorised based on chart-recorded diagnoses ('clinical diagnoses'): Known heart disease (significant heart failure [HF] or coronary artery disease [CAD]); or None. Known patients were Treated optimally or Undertreated, based on NICE/ESC guidelines. 57 patients were randomly selected for structured cardiac assessment (SCA), including echocardiogram and CT coronary artery calcium score, and categorised likewise. Relationships with admission in the past year were tested (Chi-square, 2-sided). Results: By clinical diagnoses: 17% of 115 had CAD, 7% HF. 36% were undertreated. After SCA: 35% of 57 were newly diagnosed with CAD, 12% with HF. Heart disease was present in 65%, 62% were undertreated. After SCA, patients with heart disease were almost twice as likely to have been admitted for any cause in the past year. Patients with undertreated heart disease were twice as likely to have been admitted for ECOPD. Small numbers limit statistical power. Discussion: Underdiagnosis and undertreatment were rife. Readmission is commoner in those with heart disease and, intriguingly, ECOPD admission rates may be higher in those who are undertreated. A rigorous assessment for heart disease may help direct interventions to tackle recurrent admissions.

Introduction LV and RV dysfunction are common in patients with ECOPD, yet little is known about rates of resolution and associations with post-exacerbation outcomes. Methods Echocardiography was performed on patients hospitalised with ECOPD, and repeated at stability after 90 days. LV and RV function were measured, with data reviewed by a second, blinded clinician. 365-day outcomes were recorded, including days alive outside hospital (DAOH365). Results 55 patients were assessed. 3 died and 9 withdrew before 90 days; 43 had follow-up echocardiography. The tables show rates of (new) diagnosis, resolution and outcomes, according to different diagnostic classifications. Ventricular dysfunction was a new finding in a substantial majority of cases. Severe LV dysfunction was significantly associated with increased mortality; there was a trend towards fewer DAOH365 with worse LV function. In most patients, echocardiographic abnormalities resolved at 90 days. Right ventricular dysfunction during ECOPD was not associated with worse 1-year outcomes. Discussion Echocardiography at the time of ECOPD is worthwhile: ventricular dysfunction is highly prevalent and usually unknown. Severe LV dysfunction portended a dichotomous outcome: early death, or universal resolution in treated survivors. Those with the adverse outcome had markedly worse breathlessness and frailty scores, and many more recent admissions. The absence of a negative prognostic effect for RV dysfunction contrasts with previous echocardiography studies.1[SJ(N1] This is probably because our study was conducted mid-exacerbation: for survivors after 90 days, RV dysfunction was significantly associated with subsequent mortality (50% vs 11%, p=0.048). This suggests clinicians should be cautious about using inpatient echocardiography to diagnose cor pulmonale. The distributions of DAOH365 were heavily left-skewed, limiting straightforward methods to identify population differences. Nevertheless, DAOH365 may be a more expedient outcome measure in this population than time to readmission/death, given the insensitivity of the latter to repeated events, which occurred in over half this cohort. Reference Burgess MI, Mogulkoc N, Bright-Thomas RJ, Bishop P, Egan JJ, Ray SG. Comparison of echocardiographic markers of right ventricular function in determining prognosis in chronic pulmonary disease. J Am Soc Echocardiogr. 2002 Jun;15(6):633–9.

Physical activity (PA) and exercise are integral to the management of Cystic Fibrosis (CF). The James Lind Alliance identified exercise as a research priority in the UK for people with CF (PwCF) and professionals. PA levels in PwCF are similar to age-matched peers however during acute exacerbations are lower compared to stable patients. To explore attitudes and beliefs of hospitalized PwCF to identify motivation and barriers to exercise. A questionnaire was completed by PwCF following hospitalization exploring motivation, perceived benefits, attitudes, and barriers to inpatient exercise. 27 patients mean age 32 years (22–67), 16 male, average length of stay 11.3 days included. Motivating factors focused on health outcomes: improving pulmonary function(5), staying healthy(4), sputum clearance (2), preventing constipation(1) and stability for lung transplantation(1). Factors relating to quality of life: remaining active for dependants(4), achieving stability to attend events(3), independence with activities of daily living(1), external encouragement(3) and enjoyment of going outside (3). All patients identified benefits of PA: improved pulmonary function, sputum clearance, strength, pain management, improved mental health and sleep, and maintaining function. When ranking attitudes towards exercise from 1 to 10 (1 = fully disagree) all rated importance of exercise in CF care as >6, understanding of benefits >8, need for education surrounding exercise <5 and confidence to integrate exercise into routine >8. Barriers to exercise: fatigue(15), nausea(4), coughing(2), headache(2), pain(2) and preference to complete activity independently(2). PwCF have good self-reported awareness of the importance of exercise during admissions. There are a range of motivating factors, and an individualised approach should be adopted. Barriers to exercise should be addressed to support education, and activity modified appropriately to overcome them.

Background and Objectives: Chronic obstructive pulmonary disease (COPD) is a leading cause of death worldwide. Acute exacerbations (AECOPD) are common and often triggered by viral infection. During the COVID-19 pandemic social restrictions, including ‘shielding’ and ‘lockdowns’, were mandated. Multiple, worldwide studies report a reduction in AECOPD admissions during this period. This study aims to assess the effect of the pandemic and Lockdown on the rates of admission with AECOPD and severity of hospitalised exacerbations in the North-East of England. Materials and Methods: Data were extracted for patients presenting with a diagnosis of AECOPD or respiratory failure secondary to AECOPD during the ‘COVID-19 period’ (26/3/20–31/12/20) and a date-matched control period from the year previous. We present descriptive statistics and regression analysis of the effects of the COVID-19 period on the rates of hospital admission. Results: Compared to the matched control period, the COVID-19 period was associated with fewer AECOPD admissions (COVID-19 = 719, control = 1257; rate ratio 0.57, p < 0.001) and shorter length of stay (COVID-19 = 3.9 ± 0.2, control = 4.78 ± 0.2 days; p = 0.002), with similar in-hospital plus 30-day post-discharge mortality. Demographics were similar between periods. Only six patients had a positive COVID-19 PCR test. Conclusion: During the COVID-19 period there was a substantial reduction in AECOPD admissions, but no increase in overall severity of exacerbations or mortality. Rather than fear driving delayed hospital presentation, physical and behavioural measures taken during this period to limit transmission of COVID-19 are likely to have reduced transmission of other respiratory viruses. This has important implications for control of future AECOPD.

Introduction Stable-state blood eosinophil counts (BEC) are important in guiding inhaled corticosteroid (ICS) treatment in COPD. The Blood eosinophils in COPD (BECCOPD IRAS: 285200) study is an observational, cohort study assessing whether the highest of at least three BEC within the previous 24 months is a suitable surrogate for stable-state BEC. Stable state blood eosinophil counts show variability over time and multiple factors may influence BEC including bacterial load. In this sub-group analysis of the BECCOPD study participants, we investigated the association between azithromycin therapy and stable state blood eosinophils. Methods Patients, recruited into BECCOPD, who had received azithromycin therapy for at least six months, were identified. BEC over 10 years prior to, and 1 year after enrolment were reviewed. BEC during moderate or severe exacerbations, ascertained from hospital and GP records, were excluded. Mean BEC for each patient was calculated for up to two consecutive years before and after treatment initiation and for the total study period. Paired t tests were used to compare the mean BEC. Results 37/158 patients (23.4%) received azithromycin therapy for a minimum of nine months. Mean (SD) age 71 (6) years; mean FEV1 (SD) 48.9% (19.3); 54% male. 35 patients had BEC both before and after starting azithromycin therapy. 33/208 (15.9%) stable state BEC were <0.1 on azithromycin treatment, 35/237 (14.8%) off treatment. Discussion Patients who were on azithromycin therapy had a higher mean stable state blood counts compared to those who were not on therapy. However, in most cases this was unlikely to influence ICS treatment decisions. Further work on a larger sample size and modelling other factors influencing BEC would be of interest.

Introduction In COPD patients heart disease is often underdiagnosed and undertreated. The post-exacerbation period is hazardous, with adverse cardiac events common. A pilot randomised controlled trial of a structured cardiac assessment in patients hospitalised with COPD exacerbation (ECOPD) was undertaken. We report 90-day readmission rates according to whether heart disease was diagnosed and/or treated correctly. Methods 101 patients hospitalised with ECOPD were randomised 1:1 to receive usual care ± a structured cardiac assessment (SCA) including echocardiogram and CT coronary artery calcium score (CACS). Patients were categorised at the time of hospital discharge: 1) Known Treated heart disease, if any of myocardial infarction, coronary artery disease requiring intervention, left ventricular ejection fraction < 50% or CACS > 100 known and treated according to pre-specified guideline-informed criteria 2) Known Undertreated heart disease, if any of these conditions present but not treated appropriately 3) Known No heart disease, if no diagnosis made by SCA 4) No Known heart disease, if no diagnosis made but SCA not performed. Time to first all-cause readmission or death without readmission, censored at 90 days, was recorded. Results 100 patients survived to discharge. Mean age 72, median length of stay 5.5 days. Within 90 days, 7/100 patients died. 34/100 experienced readmission. Survival curves separate, showing a trend for patients with Known No heart disease and Known Treated heart disease to be more likely to remain event-free than patients with Known Undertreated heart disease and those whose heart disease status was not intensively investigated. (p=0.119, log-rank test). 27 patients had Known Treated heart disease, with 24 having undergone SCA. 14 (64%) of these achieved Known Treated status via SCA. Conclusions This pilot study is limited by small numbers but suggests that better diagnosis and appropriate treatment may preserve readmission-free survival at the same level as for patients known to be heart disease-free. A structured cardiac assessment shows promise as an intervention to reduce the burden of death and readmission following hospitalisation with ECOPD. Assessment of the effect of SCA on days alive outside hospital at one year is planned, to inform the design of a definitive randomised controlled trial.

Background: Heart disease is common in COPD and often underdiagnosed or undertreated. COPD exacerbation (ECOPD) is followed by high rates of adverse cardiac events. We aimed to report the diagnostic and therapeutic gap for heart disease in ECOPD. Methods: Consenting patients hospitalised with ECOPD were randomised (1:1) to structured cardiac assessment (SCA, including echocardiography, 24-hour ECG and CT coronary artery calcium score [CACS]) or usual care (UC). Diagnoses and treatment were based on current international guidance. Results: 94 patients were recruited: 38 (40%) male; mean (SD) age 71 (7) and FEV1% 49 (18); median (IQR) DECAF score 1 (0-2). Median length of stay (IQR) 6 days (3-8); 20% required acute NIV and 2 died in hospital. 32 (34%) patients had ≥1 known heart disease (Table 1). In known moderate to severe LVSD or previous MI, only 44% were being treated with beta blockers and 31% with ACEi or ARB. SCA found a new cardiac diagnosis in 35 (74%) patients, with LVSD in 26% and coronary artery disease (CAD) in 49%. SCA changed management (new or intensified drug therapy, or specialist follow-up) in 31 (66%) patients. Conclusion: In patients with ECOPD, known heart disease is common and often inadequately treated. A structured cardiac assessment found diagnoses leading to treatment change in 66%. Closing the diagnostic and treatment gap in COPD could yield major patient benefit.

Background: Patients surviving hospitalization for exacerbations of chronic obstructive pulmonary disease (ECOPD) are at heightened risk of cardiovascular events. Heart failure is often underdiagnosed and undertreated in COPD; better care could improve outcome. We aimed to capture contemporary investigation and management of heart failure (HF) in patients hospitalized with ECOPD. Methods: In two UK hospitals, patients admitted with ECOPD between 2017 and 2020 were retrospectively identified. Baseline characteristics between known, newly diagnosed and no HF were compared using analysis of variance and chi-squared test. Impact of HF on mortality was assessed by Kaplan-Meier analysis and Cox proportional-hazards regression. Sensitivity and specificity of NT-proBNP for diagnosing HF at recognized thresholds were reported. Results: On admission, 94/476 (19.7%) patients had known HF. Among remaining patients, 89/382 (23.3%) were investigated within 100 days of admission, confirming HF in 38. Of 33 patients with heart failure with reduced ejection fraction (HFrEF), 18 (54.5%) were prescribed ACE-inhibitor and B-blocker. 77/132 patients (58.3%) with HF and 108/344 patients (31.4%) without HF died (adjusted HR 2.03, 95% CI 1.46-2.82, p < 0.001) during follow up (median 11.7 months). At >= 400 pg/mL, NPV and PPV of NT-proBNP for the diagnosis of HF were 77.8% and 82.8%. Conclusions: A new diagnosis of HF was made in over 40% investigated. In patients with coexistent HF, under-treatment was common and 1-year mortality exceeded 50%. NT-proBNP may help identify patients who need cardiovascular functional imaging. Research to improve HF diagnosis and treatment in hospitalized ECOPD is urgently needed.