PHENOTYPE CHARACTERIZATION OF COPD€¦ · Web viewCHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD)...

ONLINE SUPPLEMENT

IDENTIFICATION AND PROSPECTIVE VALIDATION OF CLINICALLY RELEVANT

CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD) SUBTYPES

Judith Garcia-Aymerich, Federico P Gómez, Marta Benet, Eva Farrero, Xavier Basagaña, Àngel

Gayete, Carles Paré, Xavier Freixa, Jaume Ferrer, Antoni Ferrer, Josep Roca, Juan B Gáldiz, Jaume

Sauleda, Eduard Monsó, Joaquim Gea, Joan A Barberà, Àlvar Agustí, and Josep M Antó, on behalf

of the PAC-COPD Study Group.

This supplement includes:

- METHODS (COMPLETE VERSION)

- Table 1. Number of subjects in the total sample and subsamples.

- Table 2. Number of missing values for each variable.

- Figure 1. Flow chart of the PAC-COPD study.

- Table 3. Complete description (non-standardized values of variables) of the three COPD Groups

identified by cluster analysis, for each of the six cluster analyses (total sample and the five

subsamples ).

- Table 4. Influence of severity in the association between the three COPD Groups identified by

cluster analysis and longitudinal outcomes (Cox regression models).

- SUPPLEMENT REFERENCES

26

METHODS (COMPLETE VERSION)

Design

The present study includes a cross-sectional analysis to identify COPD groups and a 4-years

prospective assessment of their relationship with cause-specific admissions and all-cause mortality.

Subjects

We recruited all subjects hospitalized for the first time because of an exacerbation of COPD in nine

teaching hospitals in Spain between January 2004 and March 2006. Any hospital stay or time spent

in the emergency room for at least 18 hours, with a clinical diagnosis of COPD exacerbation was

considered as admission. A COPD exacerbation was defined as “a sustained worsening of the

patient's condition, from the stable state and beyond normal day-to-day variations, that is acute in

onset and necessitates a change in regular medication in a patient with underlying COPD”.[1] The

criteria for a first admission definition was established by means of a questionnaire, the patient’s

clinical record and a search of the hospital records. The exclusion criteria were: 1) patients under 45

years of age; 2) severe comorbidity, i.e. tuberculosis with residual lesion affecting more than 1/3 of

parenchyma, pneumectomy or diagnosed pneumoconiosis, advanced cancer, psychiatric disorder,

severe cardiovascular or neurological disease, and other; 3) mental incapacity; 4) frail or elderly

patients with any disability that would hinder participation in the study; 5) not living in the

healthcare area of that particular hospital; and 6) not understanding the language. The diagnosis of

COPD was confirmed by spirometry when the patient had reached clinical stability (at least three

months after discharge), according to the criteria of the American Thoracic Society (ATS) and the

European Respiratory Society (ERS) (postbronchodilator forced expiratory volume in one second to

forced vital capacity ratio ≤0.7).[2] The protocol was approved by the Ethics Committees of all the

participating hospitals, and written informed consent was obtained from all subjects. Detailed

information about recruitment methods has been previously published.[3]

27

Measurements

Detailed information about the methods used, sources of questionnaires and standardization of the

tests used in the study have been published elsewhere.[4] In brief, when patients were considered

clinically stable, at least three months after discharge, they underwent extensive characterization

that required from two to four visits, in separate days, to the hospital, and included the following:

(1) a computerized epidemiologic questionnaire, covering sociodemographic and environmental

exposure data, smoking habits and cumulative exposure, dietary habits, self-reported comorbidities,

previous treatments and diagnoses, respiratory symptoms, health-related quality of life (St George’s

Respiratory Questionnaire),[5] activities of daily living (Barthel index),[6] Epworth Sleepiness

Scale,[7] and the Hospital Anxiety and Depression Scale[8]; (2) detailed physical examination and

Charlson comorbidity index[9] obtained by a respiratory physician participating in the study; (3)

body composition determination by bioelectric impedance;[10] (4) complete lung function tests

including forced spirometry, bronchodilator test, body plethysmography, carbon monoxide

diffusing capacity, resting arterial blood gases, respiratory and peripheral muscle strength, and

night-time pulse oximetry;[11,12,13,14] (5) exercise capacity assessment by the 6-minute walk test

(6MWT);[15,16] (6) chest radiographs;[17] (7) skin prick tests; (8) induced sputum;[18] (9) routine

laboratory analyses in each of the participating hospitals, including peripheral blood cell counts,

cholesterol, triglycerides and total IgE; (10) measurements of serum inflammatory and oxidative

stress markers, to reflect systemic inflammation, centralized in a single laboratory; and, (11)

Doppler echocardiography evaluation[19,20] for centralized readings (after testing for reliability in a

random sample). All these previous measurements were done in the total sample of patients

(n=342). Additionally, due to their technical and logistical requirements, the following

measurements could be performed only in some of the participating hospitals: (12) lung density and

emphysema quantification from computed tomographies (CT)[21] by a centralized evaluation using

PulmoCT (Siemens, Munich, Germany) (Subsample 1: three hospitals, 102 subjects); (13)

28

semiquantitative evaluation of bronchial wall thickness[22] on CT scans by four trained radiologists

(Subsample 2: four hospitals, 148 subjects); (14) microbiological culture of sputum performed in

the microbiological laboratories of the hospitals (Subsample 3: 8 hospitals, 224 subjects); (15)

sputum samples processed following the selection plug method[Error: Reference source not found]

with centralized measurement of inflammatory markers and differential cell counts (Subsample 4: 7

hospitals, 181 subjects); and, (16) a cardiopulmonary incremental exercise test (CPET) with

cycloergometer[23,24] to measure exercise capacity (Subsample 5: 6 hospitals, 200 subjects). The

overlap between patients in Subsamples is shown in Table 1 of the Supplement.

Quality control consisted in centralized training sessions, rapid support and supervision of all

fieldworkers, recording and checking of questionnaires administration, double verification of case

report forms, and at least one visit to each of the participating centers during data collection. Further

details of quality control have also been previously published.[Error: Reference source not found]

Information on re-hospitalizations up to December 31st 2007 was obtained for all patients in the

cohort from the Minimum Basic Dataset (CMBD), a national administrative database. According to

the International Classification of Diseases, 9th revision, an admission for a COPD exacerbation

was defined as any admission with codes 466, 480-486, 490-496, or 518.81 as the main diagnosis.

Cardiovascular admissions were defined by codes 390 to 459. Survival status until December 31st

2008 was obtained from direct interview to the patients or their relatives. In case of death, both

hospital and primary care registries were checked to ensure exact date. At the stage of the current

analyses only all-cause mortality was available.

Statistical analysis

Sample size calculations

29

There are no sample size calculation formulas for cluster analysis. However, our study included a

sample size equivalent to or greater than previous studies that were able to identify heterogeneous

groups in COPD populations even when they used a much smaller set of variables.[25,26] The use of

clustering methods has become widespread in the context of high-dimension low-sample size data,

such as in microarray data analysis, where the ratio of number of subjects to number of variables is

often as low as 0.01.[27] In our study, the number of subjects was greater than the number of

variables with the exception of Subsamples 1 and 2. In addition, our a priori sample size

calculations, as published in the original protocol,[Error: Reference source not found] predicted that

with a recruitment of between 300 and 400 patients with COPD, readmission rates of 50% and 60%

after one and two years,[28] and mortality rates of 15% and 20% after one and two years,[Error:

Reference source not found] we would have a statistical power greater than 80% to detect relative

risks of 1.5 for readmission and 1.8 for mortality at the 0.05 significance level when comparing two

hypothetical groups (phenotypes) derived from the cluster analysis.

Variables selection and treatment of missing data

A total of 536 variables were obtained from the different tests and questionnaires. Among them, a

total of 224 were considered after excluding: (i) variables with additive relations (e.g., % fat free

mass was kept, instead of keeping both % fat mass and % fat free mass); and, (ii) those resulting

from categorizations (e.g., continuous FEV1 was kept, instead of keeping both continuous FEV1 and

COPD severity according to stratification of FEV1).

The complexity of data collection produced missing values in almost all variables (Supplement

Table 2). Most of them were found in a small proportion of subjects of the corresponding

(sub)sample (<20%). Assuming ignorability holds, they were considered either completely at

random or at random.[29] Thus, multiple imputation through chained equations was used, replacing

missing values by imputations drawn from the predictive distribution of each variable,[30] which

30

was obtained from a regression model (logistic, lineal, or politomous depending on the type of

variable), where all the remaining variables were used as covariates. To account for the additional

uncertainty produced by the fact that missing values are substituted by estimates,[31] we imputed

missing values 100 times. Multiple imputation process was done separately six times, both for the

total sample and for each of the five subsamples detailed in Measurements. Further steps of the

analysis were done with each of the different datasets (600, from 6 samples x 100 datasets), as

detailed further.

Cluster analysis

Partitioning cluster analysis to group subjects according to distribution of measured variables was

done by the k-means method, which constructs partitions so that the squared Euclidean distance

between the row vector for any object and the centroid vector of its respective cluster is at least as

4 Garcia-Aymerich J, Gómez FP, Antó JM. Phenotype characterisation and course of chronic

obstructive pulmonary disease (COPD) in the PAC-COPD Study: design and methods. Arch

Bronconeumol 2009;45:4-11.

5 Jones PW, Quirk FH, Baveystock CM. The St George's Respiratory Questionnaire. Respir Med

1991;85(Supl B):25-31.

6 Mahoney F, Barthel D. Functional Evaluation: The Barthel Index. Md State Med J 1965;14:61-5.

7 Johns MW. A new method for measuring daytime sleepiness: the Epworth sleepiness scale. Sleep

1991;14:540-5.

8 Zigmond AS, Snaith RP. The Hospital Anxiety and Depression Scale. Acta Psychiatr Scand

1983;67:361-70.

31

small as the distances to the centroids to the remaining clusters.[32] The number of clusters was

determined considering both clinical coherence and statistical appropriateness, using for the latter

the Calinski and Harabasz stopping rule. This index is a measure of inter-cluster (dis)similarity over

intra-cluster (dis)similarity, thus larger values indicate better clustering (a high between-cluster

difference and a low within-cluster difference).[33] Prior to clustering, all variables were

9 Charlson M, Szatrowski TP, Peterson J, et al. Validation of a combined comorbidity index. J Clin

Epidemiol 1994;47:1245-1251.

10 Baarends EM, van Marken Lichtenbelt WD, Wouters EF, et al. Body-water compartments

measured by bio-electrical impedance spectroscopy in patients with chronic obstructive pulmonary

disease. Clin Nutr 1998;17:15-22.

11 Manual SEPAR de Procedimientos. Módulo 3. Procedimientos de evaluación de la función

pulmonar. Madrid, Spain: Ediciones Luzán 5, S.A., 2002.

12 Manual SEPAR de Procedimientos. Módulo 4. Procedimientos de evaluación de la función

pulmonar-II. Barcelona, Spain: Publicaciones Permanyer, 2004.

13 Global Initiative for Chronic Obstructive Lung Disease. Global strategy for the diagnosis,

management, and prevention of chronic obstructive pulmonary disease (updated 2004). (Accessed

March 30, 2010, at htttp://www.goldcopd.org.)

14 Morales P, Sanchis J, Cordero PJ, et al. [Maximum static respiratory pressures in adults. The

reference values for a Mediterranean Caucasian population]. Arch Bronconeumol 1997;33:213-9.

32

standardized using Z-scores ((actual score-mean score)/standard deviation), “0” value

corresponding to the mean of each variable in each (sub)sample.

Six cluster analyses were built. The first one included all patients and all variables determined in the

different tests performed in all the participating hospitals; the remaining five ones were restricted to

each of the five subsamples previously defined in Measurements and included all variables from the

15 ATS Committee on Proficiency Standards for Clinical Pulmonary Function Laboratories. ATS

statement: guidelines for the six-minute walk test. Am J Respir Crit Care Med 2002,166:111-117.

16 Guyatt GH, Pugsley SO, Sullivan MJ, et al. Effect of encouragement on walking test

performance. Thorax 1984;39:818-822.

17 McLoud TC, ed. Thoracic Radiology. The Requisites. St. Louis, MO, USA: Mosby Inc., 1998.

18 Belda J, Leigh R, Parameswaran K, et al. Induced sputum cell counts in healthy adults. Am J

Respir Crit Care Med 2000;161:475-8.

19 Quiñones MA, Otto CM, Stoddard M, et al. Recommendations for quantification of Doppler

echocardiography: a report from the Doppler Quantification Task Force of the Nomenclature and

Standards Committee of the American Society of Echocardiography. J Am Soc Echocardiogr

2002;15:167-84.

20 Gardin JM, Adams DB, Douglas PS, et al. Recommendations for a standardized report for adult

transthoracic echocardiography: a report from the American Society of Echocardiography's

Nomenclature and Standards Committee and Task Force for a Standardized Echocardiography

Report. J Am Soc Echocardiogr 2002;15:275-90.

33

tests performed in all participating hospitals plus the specific variables for each subsample. The

number of subjects and variables for each specific cluster were as follows: total sample with

variables available for all subjects (n=342, 150 variables), subsample 1 with density CT scan data

(n=102, 178 (150+28) variables), subsample 2 with airway variables on CT scan (n=148, 162

(150+12) variables), subsample 3 with microbiology data (n=224, 159 (150+9) variables),

subsample 4 with sputum inflammation data (n=181, 162 (150+12) variables), and subsample 5

21 Webb WR, Müller NL, Naidich DP, eds. High-resolution CT of the lung. 3rd ed. Philadelphia,

PA, USA: Lippincott, Williams & Wilkins, 2001.

23 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.

24 Neder JA, Nery LE, Castelo A, et al. Prediction of metabolic and cardiopulmonary response to

maximum cycle ergometry: a randomised study. Eur Respir J 1999;14:1304-13.

25 Weatherall M, Travers J, Shirtcliffe PM, et al. Distinct clinical phenotypes of airways disease

defined by cluster analysis. Eur Respir J 2009;34:812-8.

26 Burgel PR, Paillasseur JL, Caillaud D, et al. Clinical COPD phenotypes: a novel approach using

principal component and cluster analyses. Eur Respir J 2010 Jan 14. [Epub ahead of print]

27 Wang Y, Miller DJ, Clarke R. Approaches to working in high-dimensional data spaces: gene

expression microarrays. Br J Cancer 2008;98:1023-8.

28 Garcia-Aymerich J, Farrero E, Félez MA, et al. Risk factors of readmission to hospital for a

COPD exacerbation: a prospective study. Thorax 2003;58:100-5.

34

with CPET data (n=200, 163 (150+13) variables). We compared the profile of the distribution of the

150 variables common to cluster analyses in the total sample and in each subsample across the three

groups identified separately in each of the six cluster analyses, and tested the individual agreement

in the assigned cluster group using Kappa statistic.

Because the multiple imputation strategy resulted in 100 different datasets for each of the six

described samples, a cluster analysis was performed for each of them. To assess the uncertainty

produced by the imputation method, we calculated the average probability of group membership

(i.e., whether each subject was always assigned to the same group)[Error: Reference source not

found], considering a mean of 70% as appropriate.[34] These calculations showed that after cluster

analyses of the 100 datasets resulting from the 100 imputations, 304 (89%) of the subjects had a

probability ≥ 70% of being included all the 100 times in the same cluster group. Finally, for

interpretation purposes, each subject was assigned to the group with its highest membership

probability.[Error: Reference source not found]

1 Rodríguez-Roisin R. Toward a consensus definition for COPD exacerbations. Chest

2000;117(Suppl 2):398-401.

2 Celli BR, MacNee W, ATS/ERS Task Force. Standards for the diagnosis and treatment of patients

with COPD: a summary of the ATS/ERS position paper. Eur Respir J 2004;23:932-946.

3 Balcells E, Antó JM, Gea J, et al. Characteristics of patients admitted for the first time for COPD

exacerbation. Respir Med 2009;103:1293-302.

22 Sheehan RE, Wells AU, Copley SJ, et al. A comparison of serial computed tomography and

functional change in bronchiectasis. Eur Respir J 2002;20:581-7.

35

Description of COPD groups identified by cluster analysis

For the graphical description of COPD groups identified by cluster analysis (Figure 1 in the main

text), we used abovementioned standardized values of all variables, keeping their sign or changing

it (multiplying by -1) for all values ranging from +1 (less impairment) to -1 (more impairment), and

plotted these values with a color intensity scale spanning from yellow to red, respectively.[35] As

examples, forced expiratory volumne in one second values of 63% and 41% would have a

stardandized value of 0.67and -0.72, respectively, without having changed their sign, while residual

volume values of 122% and 178% would have a stardandized value of 0.67 and -0.45, respectively,

after changing their sign. Nutritional variables whose level of impairment can theoretically follow a

J distribution were kept as continuous due to the lack of undernourished patients in our sample (e.g.,

body mass index values of 25 and 31 would have standardized values of 0.65 and –0.66,

respectively). To facilitate graphical comparisons, variables were grouped under several

dimensions, following previous publications[36]: respiratory symptoms and quality of life, lung

function, lung density and morphology (chest X-ray morphometry, lung density, and airway

morphology), systemic inflammation, bronchial colonization and inflammation, nutritional status,

muscle strength, exercise capacity (6MWT and CPET), cardiovascular measurements and disorders,

and other comorbidities and measurements.

To interpret the differences observed between the groups identified by the cluster analysis, we

compared the distribution of all variables across them. To present the relative relevance of each

variable to the separation in cluster groups, F values were computed as the ratio of the variance of

the group means (between-group variance) over the overall variance of the variable (higher values

meaning higher relevance), and was obtained by means of linear regression models using the

variable under study as the outcome and the cluster group as the exposure, taking into account the

variability imposed by the 100 imputed datasets.[37]

36

To assess the potential determinants of the groups obtained by the cluster analysis,

sociodemographic characteristics (gender, age, and socioeconomic status), lifestyle factors

(smoking history, physical activity, and dietary habits), and environmental exposures (childhood

wood/charcoal smoke exposure, air pollution exposure, and occupational exposures), were

compared according to cluster groups by means of Chi2, Fisher exact, ANOVA, or Kruskal-Wallis

tests, as appropriate.

Oucomes of COPD groups identified by cluster analysis

To validate the clinical relevance of the groups identified by cluster analysis, we compared their

pattern of admissions and mortality during the follow-up. Kaplan Meier curves of time to first event

(COPD admission, cardiovascular admission, and all-cause mortality) were plotted, and groups

were compared using log-rank tests. To assess the influence of COPD severity in the association

between cluster groups and longitudinal outcomes, Cox multivariate models of time to event were

built using as covariates the cluster groups and either American Thoracic Society/European

Respiratory Society (ATS/ERS) severity stages[Error: Reference source not found] (mild, moderate,

severe, and very severe) or U-BODE (updated body-mass index, airflow obstruction, dyspnoea, and

exercise capacity) score[38] categories (0-1, 2, and ≥3).

Sensitivity analyses

As sensitivity analyses, we repeated cluster analyses excluding subjects with pneumonia as their

cause of first COPD admission, as well as restricting it to males only (93% of the sample). We also

implemented a previously published variable selection procedure that allows dropping noisy, non-

informative, or redundant variables, thus keeping a smaller number of variables that were used to

reconduct the cluster analysis.[39] Analyses were performed with Stata release 10.0 (2008,

37

StataCorp LP, College Station, TX, USA), and R 2.6.2 (2008, R Foundation for Statistical

Computing, Vienna, Austria).

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Table 1. Number of subjects in the total sample and subsamples.

Total

sample

Subsample

1

Subsample

2

Subsample

3

Subsample

4

Subsample

5

Total sample 342

Subsample 1 102 102

Subsample 2 148 97 148

Subsample 3 224 86 120 224

Subsample 4 181 69 84 139 181

Subsample 5 200 73 103 135 103 200

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Table 2. Number of missing values for each variable.

Total sample

n=342

n (%) of missing values

Respiratory symptoms and quality of life

Wheezing 4 (1.2)

Chest tightness 4 (1.2)

Dyspnea attack at rest 4 (1.2)

Dyspnea attack after exercise 4 (1.2)

Dyspnea attack at night 4 (1.2)

Cough attack at night 4 (1.2)

Cough in the morning 4 (1.2)

Cough day or night 4 (1.2)

Sputum in the morning 4 (1.2)

Sputum day or night 5 (1.5)

Sneezing 4 (1.2)

Asthma (self-reported) 4 (1.2)

Dyspnea usually (visual analogue scale) 4 (1.2)

Dyspnea in exercise (visual analogue scale) 4 (1.2)

Dyspnea (modified Medical Research Council scale) 4 (1.2)

Previous COPD exacerbations 0 (0)

Saint-George Respiratory Questionnaire - Symptoms 4 (1.2)

Saint-George Respiratory Questionnaire - Activity 4 (1.2)

Saint-George Respiratory Questionnaire - Impacts 4 (1.2)

Anxiety (Hospital Anxiety and Depression scale) 5 (1.5)

Depression (Hospital Anxiety and Depression scale) 5 (1.5)

Activities of Daily Living (Barthel index) 9 (2.6)

Sleepiness (Epworth scale) 4 (1.2)

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Lung function

Prebronchodilator forced vital capacity (FVC) 8 (2.3)

Prebronchodilator forced expiratory volume in one second (FEV1) 8 (2.3)

Prebronchodilator FEV1/FVC ratio 8 (2.3)

Prebronchodilator forced expiratory flow during the middle half of FVC 56 (16.4)

Postbronchodilator FVC 0 (0)

Postbronchodilator FEV1 0 (0)

Postbronchodilator FEV1/FVC ratio 0 (0)

Postbronchodilator forced expiratory flow during the middle half of FVC 63 (18.4)

FVC bronchodilation change 14 (4.1)

FEV1 bronchodilation change 14 (4.1)

Prebronchodilator vital capacity 19 (5.6)

Prebronchodilator inspiratory capacity 19 (5.6)

Postbronchodilator inspiratory capacity 144 (42.1)

Prebronchodilator thoracic gas volume 24 (7.0)

Prebronchodilator residual volume 27 (7.9)

Prebronchodilator total lung capacity 27 (7.9)

Residual volume/total lung capacity 27 (7.9)

Inspiratory capacity/total lung capacity ratio 27 (7.9)

Prebronchodilator expiratory reserve volume 19 (5.6)

Carbon monoxide diffusing capacity 46 (13.5)

Alveolar volume 48 (14.0)

Carbon monoxide diffusing capacity/alveolar volume 48 (14.0)

Prebronchodilator airway resistance 77 (22.5)

Prebronchodilator specific airway conductance 111 (32.5)

Arterial oxygen partial pressure 11 (3.2)

Arterial carbon dioxide partial pressure 10 (2.9)

pH 10 (2.9)

Arterial oxygen saturation at rest 29 (8.5)

Carboxyhaemoglobin 18 (5.3)

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Oxygen alveolar-arterial partial pressure difference 11 (3.2)

Baseline arterial oxygen saturation when sleeping 48 (14.0)

Mean arterial oxygen saturation when sleeping 42 (12.3)

Minimum arterial oxygen saturation when sleeping 44 (13.9)

Time with arterial oxygen saturation <90% when sleeping 45 (13.2)

Dessaturations ≥4% arterial oxygen saturation when sleeping 49 (14.3)

Dessaturations ≥3% arterial oxygen saturation when sleeping 47 (13.7)

Baseline arterial oxygen saturation during six minutes walk test 33 (9.7)

Mean arterial oxygen saturation during six minutes walk test 36 (10.5)

Minimum arterial oxygen saturation during six minutes walk test 36 (10.5)

Chest X-ray morphometry

Right hemidiaphragm height in postero-anterior projection 56 (16.4)

Right hemidiaphragm height in lateral projection 66 (19.3)

Right hemithorax height 44 (12.9)

Costophrenic angle 83 (27.3)

Retrosternal space 76 (22.2)

Interlobar artery diameter 110 (32.2)

Systemic inflammation

C-reactive protein in serum 17 (5.0)

Fibrinogen in serum 13 (3.8)

Tumor necrosis factor in serum 12 (3.5)

Interleukin-8 in serum 14 (4.1)

Hepatocyte Growth Factor in serum 14 (4.1)



Carbonyls in serum 13 (3.8)

Nitrotyrosine in serum 13 (3.8)

42

Malondialdehyde in serum 13 (3.8)

Glutathione in serum 13 (3.8)

White blood cell count 7 (2.1)

Neutrophyl count 7 (2.1)

Lymphocyte count 7 (2.1)

Monocyte count 7 (2.1)

Eosinophil count 7 (2.1)

Basophil count 7 (2.1)

Erythrosedimentation 40 (14.6)

Antinuclear antibodies 14 (4.1)

Antitissue antibodies 17 (5.0)

Total IgE in serum 23 (6.7)

Skin prick test 5 (1.5)

Nutritional status

Fat free mass 13 (3.8)

Fat free mass index 13 (3.8)

Body weight 0 (0)

Height 0 (0)

Body mass index 0 (0)

Cholesterol in serum 10 (2.9)

Total proteins in serum 12 (3.5)

Albumine in serum 10 (2.9)

Triglicerides in serum 9 (2.6)

Albumine / Globuline ratio 64 (18.7)

Muscle strength

Maximal inspiratory pressure 43 (12.6)

43

Maximal expiratory pressure 47 (13.7)

Handgrip strength in non-dominant hand 13 (3.8)

Exercise capacity (six minutes walk test)

Baseline legs pain (Borg scale) 37 (10.8)

Final legs pain (Borg scale) 39 (11.4)

Number of stops 33 (9.7)

Total distance 33 (9.7)

Cardiovascular disorders and measurements

Heart rate 3 (0.9)

Systolic blood pressure 5 (1.5)

Diastolic blood pressure 5 (1.5)

Peripheric edema or increased iugular pressure 4 (1.2)

Myocardial infarction (doctor diagnosed) 3 (0.9)

Congestive heart failure (doctor diagnosed) 3 (0.9)

Peripheric or cerebrovascular disease (doctor diagnosed) 3 (0.9)

Vascular problems (self-reported) 5 (1.5)

Cardiac disorders (self-reported) 3 (0.9)

High blood pressure (self-reported) 1 (0.3)

Embolism (self-reported) 13 (3.8)

Varicose veins in legs (self-reported) 1 (0.3)

Right ventricle telediastolic diameter 108 (31.6)

Left ventricle telediastolic diameter 49 (14.3)

Left ventricle telesystolic diameter 49 (14.3)

Interventricular septum thickness 51 (14.9)

Posterior wall thickness 54 (15.8)

Left ventricle mass 54 (15.8)

Aortic root diameter 64 (18.7)

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Left atrium diameter 63 (18.4)

Ejection fraction 48 (14.0)

Aortic stenosis 91 (26.6)

Tricuspid insufficiency 87 (25.4)

Transtricuspid regurgitant velocity 163 (47.7)

Tricuspid early diastolic tissular velocity/late diastolic tissular velocity 127 (37.1)

Mitral early diastolic tissular velocity/late diastolic tissular velocity 119 (34.8)

Other comorbidities and measurements

Eczema (self-reported) 4 (1.2)

Allergy (self-reported) 5 (1.5)

Hemoglobine 6 (1.8)

Hematocrit 6 (1.8)

Diabetes (doctor diagnosed) 3 (0.9)

Stomach Ulcer (doctor diagnosed) 3 (0.9)

Tumour/cancer (doctor diagnosed) 3 (0.9)

Moderate to severe kidney disease (doctor diagnosed) 3 (0.9)

Arthrosis (self-reported) 4 (1.2)

Deafness (self-reported) 4 (1.2)

Migraine or headaches (self-reported) 0 (0)

Prostate disorders (self-reported) 20 (5.9)

Chronic back pain (self-reported) 1 (0.3)

Sinusitis (self-reported) 4 (1.2)

Hemorrhoids, fistula (self-reported) 1 (0.3)

Kidney stones (self-reported) 1 (0.3)

Cataracts (self-reported) 0 (0)

Lung density Subsample 1

n=102

45


Density in supracarinal right lung thick sections 0 (0)

Density in supracarinal left lung thick sections 0 (0)

Density in supracarinal both lungs thick sections 0 (0)

Density in carinal right lung thick sections 0 (0)

Density in carinal left lung thick sections 0 (0)

Density in carinal both lungs thick sections 0 (0)

Density in infracarinal right lung thick sections 0 (0)

Density in infracarinal left lung thick sections 0 (0)

Density in infracarinal both lungs thick sections 0 (0)

Density in right lung thick sections 0 (0)

Density in left lung thick sections 0 (0)

Density in both lungs thick sections 0 (0)

Density <-950 Hounsfield units in both lungs supracarinal thick sections 0 (0)

Density <-950 Hounsfield units in both lungs carinal thick sections 0 (0)

Density <-950 Hounsfield units in both lungs infracarinal thick sections 0 (0)

Density <-950 Hounsfield units in both lungs thick sections 0 (0)

Density in supracarinal right lung thin sections 2 (2)

Density in supracarinal left lung thin sections 2 (2)

Density in supracarinal both lungs thin sections 2 (2)

Density in carinal right lung thin sections 2 (2)

Density in carinal left lung thin sections 2 (2)

Density in carinal both lungs thin sections 2 (2)

Density in infracarinal right lung thin sections 2 (2)

Density in infracarinal left lung thin sections 2 (2)

Density in infracarinal both lungs thin sections 2 (2)

Density <-950 Hounsfield units in both lungs supracarinal thin sections 2 (2)

Density <-950 Hounsfield units in both lungs carinal thin sections 2 (2)

Density <-950 Hounsfield units in both lungs infracarinal thin sections 2 (2)

46

Airway morphology

Subsample 2

n=148


Bronchial wall thickness extension in right superior lobe 0 (0)

Bronchial wall thickness extension in left superior lobe 0 (0)

Bronchial wall thickness extension in right middle lobe 0 (0)

Bronchial wall thickness extension in lingula 0 (0)

Bronchial wall thickness extension in right inferior lobe 0 (0)

Bronchial wall thickness extension in left inferior lobe 0 (0)

Bronchial wall thickness severity in right superior lobe 0 (0)

Bronchial wall thickness severity in left superior lobe 0 (0)

Bronchial wall thickness severity in right middle lobe 0 (0)

Bronchial wall thickness severity in lingula 0 (0)

Bronchial wall thickness severity in right inferior lobe 0 (0)

Bronchial wall thickness severity in left inferior lobe 0 (0)

Bronchial colonization

Subsample 3

n=224


Potentially pathogenic microorganisms colonization 0 (0)

Haemophilus Influenza 0 (0)

Haemophilus Parainfluenza 0 (0)

Streptococcus Pneumonia 0 (0)

Moraxella Catarrhalis 0 (0)

Pseudomonas Aeruginosa 0 (0)

Enterobacteriaceae 0 (0)

Staphylococcus Aureus 0 (0)

Streptococcus Viridans 0 (0)

47

Bronchial inflammation

Subsample 4

n=181


Interleukin-12p70 in sputum supernatant 9 (5.0)

Tumor necrosis factor in sputum supernatant 10 (5.5)

Interleukin-6 in sputum supernatant 9 (5.0)

Interleukin-1 beta in sputum supernatant 9 (5.0)

Interleukin-8 in sputum supernatant 9 (5.0)

Total cell count in sputum 5 (2.8)

Bronchial cells count in sputum 12 (6.6)

Lymphocyte count in sputum 18 (9.9)

Macrophage count in sputum 17 (9.4)

Eosinophil count in sputum 17 (9.4)

Neutrophil count in sputum 17 (9.4)

Metachromatic cells count in sputum 18 (9.9)

Exercise capacity (cardiopulmonary incremental exercise test)

Subsample 5

n=200


Final dyspnea (Borg scale) 9 (4.5)

Final legs fatigue (Borg scale) 10 (5.0)

Final blood lactate 82 (41.0)

Workload peak 11 (5.5)

Maximal oxygen uptake at test peak by weight 10 (5.0)

Maximal oxygen uptake at test peak 9 (4.5)

Minute ventilation at test peak 11 (5.5)

Maximum respiratory rate 10 (5.0)

Arterial oxygen saturation by pulse oximetry at test peak 41 (20.5)

Arterial oxygen saturation by pulse oximetry difference (peak-baseline) 49 (24.5)

48

Heart rate at peak 14 (7.0)

Breathing reserve 19 (9.5)

Oxygen pulse at peak 20 (10.0)

49

Figure 1. Flow chart of the PAC-COPD study.

* Considering data obtained during hospitalization, there were no differences between participants and non-

participants in age, gender, marital status, Charlson comorbidity index, length of hospital stay, or forced

expiratory volume in one second. Non-participants were more likely to have never been smokers (3% vs 1%,

p=0.028) and to have a doctor diagnose of congestive heart failure (9% vs 5%, p=0.042).[Error: Reference

source not found]

Non participantsa

n=183Refusal (n=160)Discharge before the interview (n=23)

Participantsn=506

Eligiblen=470

Excludedd

n=413

Advanced cancer (n=63)Severe respiratory disease (n=35)Severe cardiovascular disease (n=36)Psyquiatric disorder (n=33)Other severe comorbidities (n=66)Mental incapacity (n=75)Frailty (n=95)Not living in the area (n=10)

Eligiblen=689

Subjects admitted for their first COPD exacerbation

n=1102

TOTAL EXCLUDEDd+e

n=449TOTAL ELIGIBLEa+b+c

n=604

TOTAL NON PARTICIPANTS TOTAL PARTICIPANTSn=262 (43%)* n=342 (57%)*

Participantsc

n=342Non participantsb

n=79Death (n=12)Refusal (n=53)Lost to follow-up (n=14)

Excludede

n=85Advanced cancer (n=11)Severe respiratory disease (n=3)Severe cardiovascular disease (n=3)Other severe comorbidities (n=8)Frailty (n=4)Not living in the area (n=7)Non COPD (FEV1/FVC > 0.70) (n=49)

Checking elegibility criteria during admission

Proposing study participation

Checking elegibility criteria in clinical stability

50

Table 3. Complete description (non-standardized values of variables) of the three COPD Groups identified by cluster analysis, for each of the six cluster

analyses (total sample and the five subsamples).

3a. Cluster in the total sample (n=342, 150 variables) Group 1 Group 2 Group 3

n=126 n=125 n=91 F*

Respiratory symptoms and quality of life

Wheezing, n (%) 94 (75) 82 (65) 70 (77) 2.09

Chest tightness, n (%) 40 (32) 36 (29) 33 (37) 0.78

Dyspnea attack at rest, n (%) 40 (32) 32 (26) 26 (29) 0.57

Dyspnea attack after exercise, n (%) 88 (70) 62 (49) 58 (64) 6.21

Dyspnea attack at night, n (%) 34 (28) 23 (19) 24 (27) 1.54

Cough attack at night, n (%) 71 (57) 61 (49) 46 (51) 0.82

Cough in the morning, n (%) 67 (54) 51 (41) 42 (46) 2.11

Cough day or night, n (%) 78 (62) 48 (38) 40 (44) 8.19

Sputum in the morning, n (%) 83 (66) 68 (54) 53 (59) 1.98

Sputum day or night, n (%) 79 (63) 57 (46) 46 (51) 4.05

Sneezing, n (%) 50 (40) 33 (27) 31 (34) 2.49

Asthma (self-reported), n (%) 13 (11) 10 (8) 8 (9) 0.22

Dyspnea usually (visual analogue scale, 0-10), m (SE) 4.19 (0.24) 1.68 (0.16) 2.87 (0.28) 34.44

Dyspnea in exercise (visual analogue scale, 0-10), m (SE) 6.26 (0.22) 3.93 (0.21) 5.30 (0.31) 26.58

Dyspnea (modified Medical Research Council scale, 0-5), m (SE) 3.17 (0.12) 1.90 (0.10) 2.82 (0.13) 33.53

51

Previous COPD exacerbations, n (%) 42 (33) 43 (34) 35 (38) 0.32

Saint-George Respiratory Questionnaire - Symptoms (0-100), m (SE) 54.13 (1.69) 43.82 (1.41) 47.25 (1.80) 11.35

Saint-George Respiratory Questionnaire - Activity (0-100), m (SE) 61.36 (2.10) 31.91 (1.69) 49.24 (2.22) 60.01

Saint-George Respiratory Questionnaire - Impacts (0-100), m (SE) 36.44 (1.74) 16.83 (1.14) 26.23 (1.84) 42.62

Anxiety (Hospital Anxiety and Depression scale, 0-21), m (SE) 6.13 (0.40) 4.67 (0.32) 5.30 (0.45) 4.02

Depression (Hospital Anxiety and Depression scale, 0-21), m (SE) 4.38 (0.34) 3.34 (0.28) 3.88 (0.37) 2.74

Activities of Daily Living (Barthel index, 0-100), m (SE) 97.74 (0.72) 99.60 (0.17) 99.05 (0.44) 3.72

Sleepiness (Epworth scale, 0-24), m (SE) 7.25 (0.43) 8.88 (0.36) 9.92 (0.50) 9.84

Lung function

Prebronchodilator forced vital capacity (FVC) (% predicted), m (SE) 60.65 (1.24) 76.56 (1.35) 68.32 (1.58) 36.78

Prebronchodilator forced expiratory volume in one second (FEV1) (%

predicted), m (SE)34.98 (0.79) 57.84 (1.23) 54.56 (1.21) 139.74

Prebronchodilator FEV1/FVC ratio, m (SE) 0.43 (0.01) 0.56 (0.01) 0.60 (0.0.01) 96.35

Prebronchodilator forced expiratory flow during the middle half of FVC (%

predicted), m (SE)16.47 (0.72) 31.75 (1.49) 30.49 (1.34) 55.30

Postbronchodilator FVC (% predicted), m (SE) 65.14 (1.33) 81.36 (1.31) 71.07 (1.53) 38.76

Postbronchodilator FEV1 (% predicted), m (SE) 38.10 (0.83) 62.54 (1.24) 58.39 (1.26) 148.99

Postbronchodilator FEV1/FVC ratio, m (SE) 0.44 (0.01) 0.57 (0.0.1) 0.61 (0.01) 101.49

Postbronchodilator forced expiratory flow during the middle half of FVC (% 19.23 (1.04) 41.33 (2.76) 38.26 (2.27) 36.46

52

predicted), m (SE)

FVC bronchodilation change (% of prebronchodilator FVC), m (SE) 8.45 (1.29) 7.39 (1.19) 4.92 (1.14) 1.94

FEV1 bronchodilation change (% of prebronchodilator FEV1), m (SE) 9.94 (1.19) 9.10 (1.09) 7.57 (0.97) 1.04

Prebronchodilator vital capacity (% predicted), m (SE) 61.39 (1.28) 77.48 (1.22) 69.03 (1.55) 40.28

Prebronchodilator inspiratory capacity (% predicted), m (SE) 50.27 (1.54) 69.60 (1.48) 69.79 (1.68) 53.59

Postbronchodilator inspiratory capacity (% predicted), m (SE) 59.45 (3.23) 73.94 (4.04) 76.28 (3.82) 8.54

Prebronchodilator thoracic gas volume (% predicted), m (SE) 161.03 (3.98) 129.05 (2.61) 113.99 (2.70) 52.98

Prebronchodilator residual volume (% predicted), m (SE) 185.68 (5.10) 140.40 (3.70) 133.94 (3.64) 43.34

Prebronchodilator total lung capacity (% predicted), m (SE) 107.27 (1.95) 100.45 (1.51) 92.10 (1.67) 17.52

Residual volume/total lung capacity (%), m (SE) 62.81 (0.80) 51.15 (0.80) 52.14 (0.91) 64.44

Inspiratory capacity/total lung capacity ratio, m (SE) 0.23 (0.01) 0.34 (0.01) 0.37 (0.01) 95.26

Prebronchodilator expiratory reserve volume (l), m (SE) 0.92 (0.05) 0.99 (0.04) 0.74 (0.05) 6.78

Carbon monoxide diffusing capacity (% predicted), m (SE) 54.03 (1.86) 72.84 (1.87) 70.01 (2.02) 30.09

Alveolar volume (% predicted), m (SE) 85.44 (1.70) 96.38 (1.39) 90.93 (1.69) 12.88

Carbon monoxide diffusing capacity/alveolar volume (%), m (SE) 62.12 (2.03) 74.33 (1.89) 75.39 (2.21) 13.67

Prebronchodilator airway resistance (cmH2O*s/l), m (SE) 8.05 (0.43) 5.71 (0.45) 5.35 (0.37) 13.12

Prebronchodilator specific airway conductance (l/cmH2O*s), m (SE) 0.04 (0.01) 0.08 (0.01) 0.08 (0.01) 7.74

Arterial oxygen partial pressure (mmHg), m (SE) 69.51 (0.77) 80.81 (0.94) 72.22 (0.98) 47.39

Arterial carbon dioxide partial pressure (mmHg), m (SE) 43.51 (0.54) 40.05 (0.42) 41.69 (0.54) 13.24

53

pH, m (SE) 7.41 (0.00) 7.41 (0.00) 7.41 (0.00) 3.51

Arterial oxygen saturation at rest (%), m (SE) 94.26 (0.23) 96.15 (0.15) 94.81 (0.23) 24.91

Carboxyhaemoglobin (%), m (SE) 1.95 (0.18) 1.20 (0.11) 1.68 (0.22) 5.54

Oxygen alveolar-arterial partial pressure difference (mmHg), m (SE) 36.52 (0.76) 28.72 (0.96) 35.60 (0.91) 24.80

Baseline arterial oxygen saturation when sleeping (%), m (SE) 92.92 (0.33) 95.19 (0.20) 93.30 (0.34) 18.38

Mean arterial oxygen saturation when sleeping (%), m (SE) 90.93 (0.35) 93.51 (0.19) 90.65 (0.40) 26.20

Minimum arterial oxygen saturation when sleeping (%), m (SE) 75.95 (1.20) 82.98 (0.81) 70.68 (1.55) 27.07

Time with arterial oxygen saturation <90% when sleeping (%), m (SE) 26.24 (2.89) 6.49 (1.21) 27.25 (3.12) 23.88

Dessaturations ≥4% arterial oxygen saturation when sleeping (number/hour),

m (SE)7.22 (1.06) 5.87 (0.84) 16.19 (1.74) 20.12

Dessaturations ≥3% arterial oxygen saturation when sleeping (number/hour),

m (SE)11.54 (1.29) 9.15 (1.05) 22.47 (1.96) 23.08

Baseline arterial oxygen saturation during six minutes walk test (%), m (SE) 93.64 (0.23) 95.76 (0.16) 94.18 (0.28) 27.60

Mean arterial oxygen saturation during six minutes walk test (%), m (SE) 88.83 (0.46) 93.78 (0.24) 91.50 (0.43) 45.78

Minimum arterial oxygen saturation during six minutes walk test (%), m (SE) 86.34 (0.62) 92.02 (0.37) 89.59 (0.54) 33.13

Chest X-ray morphometry

Right hemidiaphragm height in postero-anterior projection (cm), m (SE) 2.31 (0.11) 2.80 (0.11) 2.70 (0.12) 5.76

Right hemidiaphragm height in lateral projection (cm), m (SE) 2.31 (0.12) 2.77 (0.12) 2.77 (0.16) 4.26

Right hemithorax height (cm), m (SE) 24.37 (0.26) 23.40 (0.23) 23.07 (0.29) 6.94

54

Costophrenic angle (º), m (SE) 89.48 (1.93) 83.88 (1.78) 83.37 (2.71) 2.79

Retrosternal space (cm), m (SE) 3.76 (0.18) 3.22 (0.13) 3.29 (0.21) 3.28

Interlobar artery diameter (cm), m (SE) 1.41 (0.11) 1.32 (0.07) 1.41 (0.11) 0.34

Systemic inflammation

C-reactive protein in serum (mg/dl), m (SE) 0.99 (0.17) 0.36 (0.04) 1.37 (0.28) 8.46

Fibrinogen in serum (g/l), m (SE) 4.23 (0.11) 3.77 (0.09) 4.50 (0.13) 11.40

Tumor necrosis factor in serum (pg/ml), m (SE) 0.88 (0.14) 0.72 (0.09) 1.05 (0.18) 1.37

Interleukin-8 in serum (pg/ml), m (SE) 5.87 (0.43) 4.90 (0.32) 4.82 (0.38) 2.38

Hepatocyte Growth Factor in serum (pg/ml), m (SE) 992.29 (37.94) 887.14 (38.73) 1219.41 (63.15) 12.79



Carbonyls in serum (nM/ml), m (SE) 0.19 (0.01) 0.19 (0.01) 0.20 (0.01) 0.25

Nitrotyrosine in serum (nM/ml), m (SE) 6.75 (0.39) 6.58 (0.40) 7.21 (0.71) 0.41

Malondialdehyde in serum (µM/ml), m (SE) 9.25 (0.58) 8.06 (0.40) 11.22 (0.69) 7.69

Glutathione in serum (µM/ml), m (SE) 3.07 (0.06) 3.07 (0.07) 3.26 (0.06) 2.68

White blood cell count (n*106/ml), m (SE) 7.70 (0.18) 6.70 (0.16) 8.25 (0.21) 19.06

Neutrophyl count (n*106/ml), m (SE) 4.76 (0.15) 3.94 (0.10) 5.35 (0.18) 23.55

55

Lymphocyte count (n*106/ml), m (SE) 2.08 (0.07) 1.97 (0.09) 2.01 (0.07) 0.55

Monocyte count (n*106/ml), m (SE) 0.57 (0.02) 0.48 (0.01) 0.58 (0.03) 6.37

Eosinophil count (n*106/ml), m (SE) 0.21 (0.01) 0.21 (0.01) 0.21 (0.02) 0.00

Basophil count (n*106/ml), m (SE) 0.04 (0.00) 0.04 (0.00) 0.04 (0.00) 0.11

Erythrosedimentation (mm/h), m (SE) 21.82 (1.78) 16.58 (1.40) 23.43 (2.29) 4.03

Antinuclear antibodies (0-3 semiquantitative score), m (SE) 1.40 (0.07) 1.64 (0.08) 1.49 (0.09) 2.61

Antitissue antibodies (0-3 semiquantitative score), m (SE) 1.85 (0.12) 1.46 (0.09) 1.65 (0.13) 3.30

Total IgE in serum (U/ml), m (SE) 138.59 (42.27) 153.66 (27.38) 192.82 (32.19) 0.56

Skin prick test (number of positive allergens), m (SE) 0.13 (0.04) 0.18 (0.05) 0.25 (0.07) 1.53

Nutritional status

Fat free mass (%), m (SE) 72.02 (0.80) 71.39 (0.76) 66.98 (0.84) 10.26

Fat free mass index (kg/m2), m (SE) 18.58 (0.27) 19.32 (0.24) 21.57 (0.31) 29.53

Body weight (kg), m (SE) 68.64 (1.04) 73.59 (1.08) 89.90 (1.29) 87.04

Height (cm), m (SE) 1.62 (0.01) 1.64 (0.01) 1.66 (0.01) 11.24

Body mass index (kg/m2), m (SE) 26.03 (0.36) 27.24 (0.33) 32.44 (0.40) 78.30

Cholesterol in serum (mg/dl), m (SE) 209.97 (4.03) 211.74 (4.15) 206.55 (5.37) 0.32

Total proteins in serum (g/dl), m (SE) 7.26 (0.05) 7.13 (0.04) 7.28 (0.05) 2.93

Albumine in serum (g/dl), m (SE) 4.27 (0.04) 4.24 (0.03) 4.29 (0.03) 0.53

56

Triglicerides in serum (mg/dl), m (SE) 128.63 (7.01) 118.23 (4.96) 180.57 (21.10) 7.94

Albumine / Globuline ratio, m (SE) 1.37 (0.04) 1.47 (0.07) 1.39 (0.04) 1.16

Muscle strength

Maximal inspiratory pressure (% predicted), m (SE) -62.03 (2.65) -69.96 (2.36) -62.03 (2.83) 3.25

Maximal expiratory pressure (% predicted), m (SE) 65.70 (2.32) 70.22 (2.57) 65.77 (2.82) 1.09

Handgrip strength in non-dominant hand (% predicted), m (SE) 99.56 (2.33) 104.78 (2.48) 106.98 (3.07) 2.14

Exercise capacity (six minutes walk test)

Baseline legs pain (Borg scale, 0-10), m (SE) 1.06 (0.18) 0.75 (0.15) 1.28 (0.22) 2.20

Final legs pain (Borg scale, 0-10), m (SE) 2.75 (0.30) 1.87 (0.24) 3.90 (0.35) 11.29

Number of stops, m (SE) 0.27 (0.08) 0.04 (0.03) 0.22 (0.08) 3.98

Total distance (meters), m (SE) 414.02 (11.56) 465.54 (7.71) 417.09 (11.11) 8.52

Cardiovascular disorders and measurements

Heart rate (b/min), m (SE) 79.37 (1.37) 73.66 (1.03) 78.21 (1.28) 6.35

Systolic blood pressure (mmHg), m (SE) 135.17 (1.91) 137.42 (1.79) 140.13 (2.09) 1.54

Diastolic blood pressure (mmHg), m (SE) 77.38 (1.12) 77.11 (1.05) 78.63 (1.27) 0.45

Peripheric edema or increased iugular pressure, n (%) 20 (16) 9 (8) 32 (35) 14.51

Myocardial infarction (doctor diagnosed), n (%) 7 (6) 9 (7) 21 (23) 9.40

57

Congestive heart failure (doctor diagnosed), n (%) 6 (5) 1 (1) 15 (17) 11.14

Peripheric or cerebrovascular disease (doctor diagnosed), n (%) 10 (8) 14 (11) 24 (27) 8.29

Vascular problems (self-reported), n (%) 26 (21) 27 (22) 47 (52) 16.09

Cardiac disorders (self-reported), n (%) 21 (17) 27 (22) 33 (36) 5.70

High blood pressure (self-reported), n (%) 32 (25) 37 (29) 55 (60) 17.47

Embolism (self-reported), n (%) 2 (2) 6 (5) 5 (5) 1.37

Varicose veins in legs (self-reported), n (%) 24 (19) 24 (19) 37 (41) 8.72

Right ventricle telediastolic diameter (mm), m (SE) 31.08 (0.49) 30.98 (0.45) 32.95 (0.69) 4.22

Left ventricle telediastolic diameter (mm), m (SE) 49.63 (0.58) 50.12 (0.53) 52.34 (0.70) 5.34

Left ventricle telesystolic diameter (mm), m (SE) 32.30 (0.60) 32.25 (0.51) 34.40 (0.69) 3.90

Interventricular septum thickness (mm), m (SE) 10.60 (0.14) 10.50 (0.13) 11.38 (0.21) 8.30

Posterior wall thickness (mm), m (SE) 10.01 (0.13) 9.97 (0.12) 10.66 (0.17) 7.15

Left ventricle mass (mg), m (SE) 189,752 (4,816) 190,172 (4,369) 225,972 (6,512) 14.84

Aortic root diameter (mm), m (SE) 32.11 (0.42) 32.09 (0.38) 33.46 (0.49) 3.00

Left atrium diameter (mm), m (SE) 35.89 (0.67) 37.57 (0.71) 41.51 (0.92) 12.89

Ejection fraction (%), m (SE) 59.68 (1.00) 58.75 (0.84) 59.46 (1.28) 0.25

Aortic stenosis (mean gradient aortic valve≥20mmHg), n (%) 5 (4) 4 (3) 4 (4) 0.07

Tricuspid insufficiency, n (%) 82 (66) 76 (61) 39 (43) 4.63

Transtricuspid regurgitant velocity (cm/sec), m (SE) 2.36 (0.11) 2.24 (0.11) 2.36 (0.17) 0.38

58

Tricuspid early diastolic tissular velocity/late diastolic tissular velocity, m (SE) 0.80 (0.08) 0.87 (0.08) 1.00 (0.13) 1.05

Mitral early diastolic tissular velocity/late diastolic tissular velocity, m (SE) 0.92 (0.07) 0.91 (0.06) 0.94 (0.09) 0.07

Other comorbidities and measurements

Eczema (self-reported), n (%) 22 (18) 22 (18) 17 (18) 0.01

Allergy (self-reported), n (%) 17 (14) 21 (17) 12 (13) 0.42

Hemoglobine (g/dl), m (SE) 14.55 (0.15) 14.59 (0.13) 14.55 (0.17) 0.02

Hematocrit (%), m (SE) 43.68 (0.42) 43.64 (0.42) 43.75 (0.49) 0.02

Diabetes (doctor diagnosed), n (%) 19 (16) 18 (14) 29 (32) 6.11

Stomach Ulcer (doctor diagnosed), n (%) 16 (13) 16 (13) 9 (10) 0.35

Tumour/cancer (doctor diagnosed), n (%) 25 (20) 30 (24) 28 (31) 0.73

Moderate to severe kidney disease (doctor diagnosed), n (%) 15 (12) 16 (13) 13 (14) 0.08

Arthrosis (self-reported), n (%) 34 (28) 50 (40) 39 (43) 3.39

Deafness (self-reported), n (%) 21 (17) 31 (25) 25 (28) 2.10

Migraine or headaches (self-reported), n (%) 13 (10) 12 (10) 5 (5) 0.85

Prostate disorders (self-reported), n (%) 32 (25) 39 (31) 21 (23) 1.00

Chronic back pain (self-reported), n (%) 30 (24) 24 (19) 20 (21) 0.39

Sinusitis (self-reported), n (%) 8 (6) 13 (11) 6 (7) 0.86

Hemorrhoids, fistula (self-reported), n (%) 19 (15) 26 (21) 24 (26) 1.99

59

Kidney stones (self-reported), n (%) 14 (11) 14 (11) 7 (8) 0.45

Cataracts (self-reported), n (%) 34 (27) 35 (28) 27 (30) 0.09

3b. Cluster in Subsample 1 (n=102, 178 variables) Group 1 Group 2 Group 3

Agreement with cluster in the total sample: Kappa 0.55 n=19 n=44 n=39 F

Lung density

Density in supracarinal right lung thick sections (Hounsfield units), m (SE) -880,23 (8,69) -877,87 (3,11) -824,05 (4,63) 44.34

Density in supracarinal left lung thick sections (Hounsfield units), m (SE) -872,58 (8,24) -873,43 (2,83) -824,26 (5,27) 31.43

Density in supracarinal both lungs thick sections (Hounsfield units), m (SE) -876,47 (8,27) -876,00 (2,73) -824,16 (4,71) 41.59

Density in carinal right lung thick sections (Hounsfield units), m (SE) -873,59 (5,89) -865,41 (2,87) -823,18 (4,15) 41.54

Density in carinal left lung thick sections (Hounsfield units), m (SE) -880,18 (6,43) -869,88 (2,39) -826,85 (4,83) 44.10

Density in carinal both lungs thick sections (Hounsfield units), m (SE) -876,88 (5,61) -867,61 (2,29) -824,88 (4,09) 52.47

Density in infracarinal right lung thick sections (Hounsfield units), m (SE) -863,54 (8,39) -865,71 (2,79) -822,32 (4,86) 27.19

Density in infracarinal left lung thick sections (Hounsfield units), m (SE) -863,10 (4,74) -857,74 (3,88) -814,00 (5,40) 31.34

Density in infracarinal both lungs thick sections (Hounsfield units), m (SE) -863,63 (5,67) -862,26 (2,87) -819,25 (4,60) 37.16

Density in right lung thick sections (Hounsfield units), m (SE) -867,08 (4,55) -858,98 (2,98) -809,92 (7,46) 28.69

Density in left lung thick sections (Hounsfield units), m (SE) -863,59 (3,35) -856,14 (2,54) -807,93 (6,68) 33.47

Density in both lungs thick sections (Hounsfield units), m (SE) -864,72 (3,50) -857,61 (2,49) -809,35 (6,79) 33.58

60

Density <-950 Hounsfield units in both lungs supracarinal thick sections (%),

m (SE)

18,74 (3,78) 11,25 (1,39) 2,63 (0,74)42.77

Density <-950 Hounsfield units in both lungs carinal thick sections (%), m

(SE)

15,87 (2,88) 8,16 (0,87) 1,96 (0,36)72.48

Density <-950 Hounsfield units in both lungs infracarinal thick sections (%),

m (SE)

11,97 (2,27) 7,39 (0,75) 2,71 (0,53)61.22

Density <-950 Hounsfield units in both lungs thick sections (%), m (SE) 14,81 (1,87) 8,94 (0,72) 2,88 (0,49) 91.04

Density in supracarinal right lung thin sections (Hounsfield units), m (SE) -889,02 (6,64) -884,67 (3,41) -840,34 (4,38) 37.63

Density in supracarinal left lung thin sections (Hounsfield units), m (SE) -888,12 (6,34) -885,14 (2,84) -841,68 (5,14) 29.96

Density in supracarinal both lungs thin sections (Hounsfield units), m (SE) -888,55 (6,29) -884,84 (2,96) -841,02 (4,62) 35.34

Density in carinal right lung thin sections (Hounsfield units), m (SE) -880,73 (5,79) -875,95 (2,76) -838,21 (4,72) 34.35

Density in carinal left lung thin sections (Hounsfield units), m (SE) -885,84 (5,37) -877,25 (2,22) -845,03 (4,98) 26.09

Density in carinal both lungs thin sections (Hounsfield units), m (SE) -883,35 (5,13) -876,72 (2,17) -842,33 (4,61) 34.67

Density in infracarinal right lung thin sections (Hounsfield units), m (SE) -869,92 (8,51) -873,53 (3,22) -835,73 (5,04) 20.71

Density in infracarinal left lung thin sections (Hounsfield units), m (SE) -878,79 (5,86) -865,02 (4,17) -825,91 (5,93) 29.43

Density in infracarinal both lungs thin sections (Hounsfield units), m (SE) -874,03 (6,45) -869,84 (3,29) -832,21 (4,86) 29.83

Density <-950 Hounsfield units in both lungs supracarinal thin sections (%),

m (SE)

26,14 (3,88) 18,68 (1,68) 4,61 (0,90)31.89

Density <-950 Hounsfield units in both lungs carinal thin sections (%), m (SE) 24,65 (3,09) 16,15 (1,03) 4,92 (0,57) 51.92

61

Density <-950 Hounsfield units in both lungs infracarinal thin sections (%), m

(SE)

24,07 (2,97) 15,74 (0,94) 6,34 (0,75)34.03

Selection of 8 out of the 150 variables from the cluster in the total

sample









3c. Cluster in Subsample 2 (n=148, 162 variables) Group 1 Group 2 Group 3


Airway morphology

Bronchial wall thickness extension in right superior lobe (score, 0-3), m (SE) 2.02 (0.15) 0.61 (0.21) 0.49 (0.14) 38.53

Bronchial wall thickness extension in left superior lobe (score, 0-3), m (SE) 1.88 (0.17) 0.54 (0.21) 0.35 (0.12) 40.85

62

Bronchial wall thickness extension in right middle lobe (score, 0-3), m (SE) 2.26 (0.15) 0.79 (0.24) 0.42 (0.13) 57.05

Bronchial wall thickness extension in lingula (score, 0-3), m (SE) 2.08 (0.16) 0.61 (0.23) 0.42 (0.13) 56.06

Bronchial wall thickness extension in right inferior lobe (score, 0-3), m (SE) 2.74 (0.09) 1.50 (0.26) 1.09 (0.18) 47.26

Bronchial wall thickness extension in left inferior lobe (score, 0-3), m (SE) 2.66 (0.10) 1.46 (0.26) 1.15 (0.18) 37.40

Bronchial wall thickness severity in right superior lobe (score, 0-3), m (SE) 0.83 (0.06) 0.25 (0.08) 0.20 (0.05) 47.80

Bronchial wall thickness severity in left superior lobe (score, 0-3), m (SE) 0.77 (0.06) 0.21 (0.08) 0.16 (0.05) 45.35

Bronchial wall thickness severity in right middle lobe (score, 0-3), m (SE) 0.86 (0.06) 0.32 (0.09) 0.18 (0.05) 54.23

Bronchial wall thickness severity in lingula (score, 0-3), m (SE) 0.77 (0.05) 0.21 (0.08) 0.20 (0.05) 63.34

Bronchial wall thickness severity in right inferior lobe (score, 0-3), m (SE) 1.03 (0.05) 0.57 (0.10) 0.44 (0.07) 37.45

Bronchial wall thickness severity in left inferior lobe (score, 0-3), m (SE) 1.02 (0.05) 0.61 (0.11) 0.44 (0.07) 31.49


sample






63




3d. Cluster in Subsample 3 (n=224, 159 variables) Group 1 Group 2 Group 3


Bronchial colonization

Potentially pathogenic microorganisms colonization, n (%) 34 (36.17) 27 (35.07) 14 (26.42) 0.79

Haemophilus Influenza, n (%) 18 (19.15) 9 (11.69) 5 (9.43) 1.63

Haemophilus Parainfluenza, n (%) 8 (8.51) 6 (7.79) 2 (3.77) 0.61

Streptococcus Pneumonia, n (%) 3 (3.19) 6 (7.79) 1 (1.89) 1.59

Moraxella Catarrhalis, n (%) 4 (4.26) 4 (5.19) 2 (3.77) 0.08

Pseudomonas Aeruginosa, n (%) 6 (6.38) 3 (3.90) 3 (5.66) 0.26

Enterobacteriaceae, n (%) 3 (3.19) 2 (2.60) 2 (3.77) 0.07

Staphylococcus Aureus, n (%) 2 (2.13) 1 (1.30) 0 (0) 0.58

Streptococcus Viridans, n (%) 0 (0) 1 (1.30) 0 (0) 0.95


64

sample









3e. Cluster in Subsample 3 (n=181, 162 variables) Group 1 Group 2 Group 3


Bronchial inflammation

Interleukin-12p70 in sputum supernatant (pg/ml), m (SE) 3.23 (1.95) 6.12 (4.01) 2.95 (2.13) 0.43

Tumor necrosis factor in sputum supernatant (pg/ml), m (SE) 23.24 (5.38) 18.55 (6.78) 17.69 (5.98) 0.29

Interleukin-6 in sputum supernatant (pg/ml), m (SE) 324.80 (77.75) 249.25 (82.98) 220.75 (63.60) 0.60

Interleukin-1 beta in sputum supernatant (pg/ml), m (SE) 936.60 (274.04) 771.52 (387.91) 647.44 (228.78) 0.31

Interleukin-8 (*103) in sputum supernatant (pg/ml), m (SE) 11.90 (1.02) 8.54 (1.33) 8.98 (1.15) 2.72

65

Total cell count in sputum (n*106/ml), m (SE) 90 (86) 29 (86) 15 (43) 0.32

Bronchial cells count in sputum (n*106/ml), m (SE) 0.44 (0.13) 0.27 (0.09) 0.59 (0.22) 0.72

Lymphocyte count in sputum (n*106/ml), m (SE) 0.01 (0.01) 0.01 (0.01) 0.08 (0.40) 2.19

Macrophage count in sputum (n*106/ml), m (SE) 150 (67) 180 (100) 360 (100) 1.59

Eosinophil count in sputum (n*106/ml), m (SE) 5.70 (2.50) 6.60 (3.70) 13.00 (3.80) 1.58

Neutrophil count in sputum (n*106/ml), m (SE) 250 (110) 290 (160) 570 (170) 1.59

Metachromatic cells count in sputum (n*106/ml), m (SE) 1.45 (0.72) 0.13 (0.46) 0.22 (0.36) 1.62


sample









66

3f. Cluster in Subsample 3 (n=200, 163 variables) Group 1 Group 2 Group 3


Exercise capacity (cardiopulmonary incremental exercise test)

Final dyspnea (Borg, 0-10), m (SE) 5.72 (0.33) 3.55 (0.33) 5.11 (0.39) 11.36

Final legs fatigue (Borg, 0-10), m (SE) 5.22 (0.36) 4.40 (0.33) 5.57 (0.45) 2.34

Final blood lactate (mEq/l), m (SE) 10.47 (0.70) 9.98 (0.71) 7.83 (0.79) 3.08

Workload peak (watts), m (SE) 63.23 (2.82) 83.30 (3.85) 90.62 (3.89) 18.34

Maximal oxygen uptake at test peak by weight (l/min/kg), m (SE) 14.15 (0.43) 17.75 (0.59) 15.74 (0.58) 13.36

Maximal oxygen uptake at test peak (% predicted), m (SE) 52.65 (1.73) 69.11 (2.41) 68.29 (2.74) 19.93

Minute ventilation at test peak (l/min), m (SE) 35.77 (1.11) 47.80 (1.74) 50.69 (2.43) 24.88

Maximum respiratory rate, m (SE) 34.77 (0.82) 32.65 (0.95) 32.46 (1.03) 2.15

Arterial oxygen saturation by pulse oximetry at test peak (%), m (SE) 90.90 (1.09) 95.09 (0.50) 94.06 (0.56) 6.85

Arterial oxygen saturation by pulse oximetry difference (peak-baseline) (%),

m (SE)-3.76 (1.08) -1.26 (0.45) -2.31 (0.50) 2.34

Heart rate at peak (% predicted), m (SE) 75.63 (1.59) 87.46 (2.07) 79.97 (2.19) 10.99

Breathing reserve (%), m (SE) 11.17 (2.67) 25.86 (2.86) 32.70 (3.12) 12.08

Oxygen pulse at peak (ml/beat), m (SE) 8.76 (0.34) 9.67 (0.44) 11.52 (0.48) 10.73

67


sample









m (SE): mean (standard error).

* F values correspond to the ratio of the variance of the group means (between-group variance) over the overall variance of the variable (higher values meaning

higher relevance of the variable for separating cluster groups), and were obtained by means of linear regression models using each variable as the outcome, and the

cluster group as the exposure.

68

Table 4. Influence of severity in the association between the three COPD Groups identified by cluster analysis and longitudinal outcomes (Cox

regression models).

COPD admission

Unadjusted

Adjusted by American Thoracic

Society/European Respiratory

Society (ATS/ERS) severity stages

Adjusted by updated body-mass

index, airflow obstruction,

dyspnoea, and exercise capacity

(U-BODE) categories

HR (95% CI) p HR (95% CI) p HR (95% CI) p

Group 1 3.28 (2.09 - 5.15) <0.001 2.89 (1.59 - 5.25) <0.001 2.45 (1.44 - 4.18) 0.001

Group 2 (reference) 1.00 -- 1.00 -- 1.00 --

Group 3 1.65 (0.98 - 2.79) 0.062 1.54 (0.91 - 2.63) 0.111 1.69 (0.97 - 2.96) 0.064

ATS/ERS I- mild (reference) 1.00 --

ATS/ERS II – moderate 2.50 (0.60 - 10.45) 0.209

ATS/ERS III – severe 2.33 (0.53 - 10.25) 0.264

ATS/ERS IV – very severe 3.43 (0.72 - 16.30) 0.122

U-BODE 0-1 (reference) 1.00 --

U-BODE 2 1.04 (0.59 - 1.85) 0.888

69

U-BODE ≥3 1.48 (0.80 - 2.71) 0.209

70

Cardiovascular admission

UnadjustedAdjusted by

ATS/ERS severity stages

Adjusted by

U-BODE categories


Group 1 1.32 (0.53 - 3.29) 0.549 1.94 (0.60 - 6.31) 0.271 1.27 (0.43 - 3.72) 0.669

Group 2 (reference) 1.00 -- 1.00 -- 1.00 --

Group 3 2.87 (1.24 - 6.65) 0.014 2.88 (1.23 - 6.76) 0.015 2.27 (0.86 - 5.99) 0.100






U-BODE 2 0.85 (0.30 - 2.41) 0.763

U-BODE ≥3 1.34 (0.45 - 4.02) 0.604

71

Mortality

UnadjustedAdjusted by

ATS/ERS severity stages

Adjusted by

U-BODE categories


Group 1 2.36 (1.16 - 4.79) 0.018 2.01 (0.72 - 5.62) 0.183 1.41 (0.58 - 3.45) 0.449

Group 2 (reference) 1.00 -- 1.00 -- 1.00 --

Group 3 1.51 (0.67 - 3.42) 0.323 1.55 (0.67 - 3.58) 0.306 1.13 (0.45 - 2.84) 0.791






U-BODE 2 0.49 (0.18 - 1.28) 0.145

U-BODE ≥3 1.41 (0.55 - 3.60) 0.473

HR: hazard ratio; CI: confidence interval.

72

SUPPLEMENT REFERENCES

29 Rubin DB. Inference and missing data. Biometrika 1976;63;581-592.

30 van Buuren S, Boshuizen HC, Knook DL. Multiple imputation of missing blood pressure

covariates in survival analysis. Stat Med 1999;18:681-94.

31 Donders AR, van der Heijden GJ, Stijnen T, et al. Review: a gentle introduction to imputation of

missing values. J Clin Epidemiol 2006;59:1087-91.

32 Steinley D. K-means clustering: a half-century synthesis. Br J Math Stat Psychol 2006;59(Pt 1):1-

34.

33 Calinski, Harabasz. A dendrite method for cluster analysis. Communications in Statistics

1974;3:1-27.

34 Nagin DS, ed. Group-based Modeling of Development. Cambridge, MA, USA: Harvard

University Press, 2005.

35 Cohen J, ed. Statistical Power Analysis for the Behavioral Sciences. Hillsdale, NJ, USA:

Lawrence Erlbaum Associates Publishers, 1988.

73

36 Garcia-Aymerich J, Agustí A, Barberà JA, et al. Phenotypic heterogeneity of chronic obstructive

pulmonary disease. Arch Bronconeumol 2009;45:129-38.

37 Sterne JA, White IR, Carlin JB, et al. Multiple imputation for missing data in epidemiological and

clinical research: potential and pitfalls. BMJ 2009;338:b2393.

38 Puhan MA, Garcia-Aymerich J, Frey M, et al. Expansion of the prognostic assessment of patients

with chronic obstructive pulmonary disease: the updated BODE index and the ADO index. Lancet

2009;374:704-11.

39 Fraiman R, Justel A, Svarc M. Selection of variables for cluster analysis and classification rules. J

Am Stat Assoc 2008;103:1294-1303.

74

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