Exacerbations profoundly affect the cardiovascular system, and this might account for significant morbidity and mortality. Freixa et al. prospectively evaluated 342 moderate-to-severe COPD patients’ first admission with exacerbation. Transthoracic echocardiography was performed in clinically stable condition, at least 3 months after discharge. They revealed that cardiac abnormalities, such as right ventricular enlargement and pulmonary hypertension, are highly prevalent in COPD patients at the time of their first severe exacerbation, even in the absence of established cardiac disease or cardiovascular risk factors [54]. CT evaluation seems to be useful to evaluate the adverse effects on the cardiac system caused by exacerbation [18, 21]. Further investigations using novel markers such as the cross-sectional area of small pulmonary vessels are waited [55].

Exacerbations of COPD are associated with high in-hospital and post-discharge mortality. Reported mortality rates vary from 2.5 to 30 % depending upon patient characteristics and the design of the study. A recent investigation from the European Respiratory Society COPD audit that was designed as a prospective, observational, and noninterventional cohort trial found that 10.8 % of those admitted with exacerbated COPD died during the observational period, from admission to 90 days after discharge. In expired patients, 45.7 % died while still in hospital, whereas 54.3 % died during the 90-day post-discharge follow-up. The risk associated with mortality was higher age, the presence of acidotic respiratory failure, subsequent need for ventilator support, and the presence of comorbidity [56]. According to the long-term history and mortality after COPD exacerbations, Suissa et al. conducted an epidemiological study with a cohort of patients at first hospitalization for COPD using healthcare databases. The cohort included 73,106 patients, and during the 17-year follow-up period, 50,580 died with 50 and 75 % mortality at 3.6 and 7.7 years, respectively. They also reported a rapid decline in health status after the second severe exacerbation and high mortality in the weeks following every severe exacerbation. From these results, they stated the importance of delaying the second severe exacerbation and intensifying inpatient treatment of COPD exacerbation to prevent excessive early mortality [57].