Use of blockers and the risk of death in hospitalised patients with acute exacerbations of COPD

β-Blockers, heart disease and COPD: current controversies and uncertainties

Treating people with cardiovascular disease and COPD causes significant clinician anxiety. β-Blockers save lives in people with heart disease, specifically postinfarction and heart failure. COPD and heart disease frequently coexist and people with both disorders have particularly high cardiovascular mortality. There are concerns about giving β-blockers to people with concomitant COPD that include reduced basal lung function, diminished effectiveness of emergency β-agonist treatments, reduced benefit of long-acting β-agonist treatment and difficulty in discriminating between asthma and COPD. β-Blockers appear to reduce lung function in both the general population and those with COPD because they are poorly selective for cardiac β1-adrenoceptors over respiratory β2-adrenoceptors, and studies have shown that higher β-agonist doses are required to overcome the β-blockade. COPD and cardiovascular disease share similar environmental risks and both disease states have high adrenergic and inflammatory activation. β-Blockers may therefore be particularly helpful in reducing cardiovascular events in this high-risk group. They may reduce the background inflammatory state, and inhibit the tachycardia and hypertension associated with both the endogenous adrenaline and high-dose β-agonist treatment associated with acute exacerbations of COPD. Some studies have suggested no increased and, at times, reduced mortality in patients with COPD taking β-blockers for heart disease. However, these are all observational studies and there are no randomised controlled trials. Potential ways to improve this dilemma include the development of highly β1-selective β-blockers or the use of non-β-blocking heart rate reducing agents, such as ivabridine, if these are proven to be beneficial in randomised controlled trials.

Prevalence and burden of comorbidities in Chronic Obstructive Pulmonary Disease

The classical definition of Chronic Obstructive Pulmonary Disease (COPD) as a lung condition characterized by irreversible airway obstruction is outdated. The systemic involvement in patients with COPD, as well as the interactions between COPD and its comorbidities, justify the description of chronic systemic inflammatory syndrome. The pathogenesis of COPD is closely linked with aging, as well as with cardiovascular, endocrine, musculoskeletal, renal, and gastrointestinal pathologies, decreasing the quality of life of patients with COPD and, furthermore, complicating the management of the disease. The most frequently described comorbidities include skeletal muscle wasting, cachexia (loss of fat-free mass), lung cancer (small cell or non-small cell), pulmonary hypertension, ischemic heart disease, hyperlipidemia, congestive heart failure, normocytic anemia, diabetes, metabolic syndrome, osteoporosis, obstructive sleep apnea, depression, and arthritis. These complex interactions are based on chronic low-grade systemic inflammation, chronic hypoxia, and multiple common predisposing factors, and are currently under intense research. This review article is an overview of the comorbidities of COPD, as well as their interaction and influence on mutual disease progression, prognosis, and quality of life.

Challenges in the Management of Patients with Chronic Obstructive Pulmonary Disease and Heart Failure With Reduced Ejection Fraction

Chronic obstructive pulmonary disease (COPD) and heart failure with reduced ejection fraction (HFrEF) commonly coexist in clinical practice. The prevalence of COPD among HFrEF patients ranges from 20 to 32 %. On the other hand; HFrEF is prevalent in more than 20 % of COPD patients. With an aging population, the number of patients with coexisting COPD and HFrEF is on rise. Coexisting COPD and HFrEF presents a unique diagnostic and therapeutic clinical conundrum. Common symptoms shared by both conditions mask the early referral and detection of the other. Beta blockers (BB), angiotensin-converting enzyme inhibitors, and aldosterone antagonists have been shown to reduce hospitalizations, morbidity, and mortality in HFrEF while long-acting inhaled bronchodilators (beta-2-agonists and anticholinergics) and corticosteroids have been endorsed for COPD treatment. The opposing pharmacotherapy of BBs and beta-2-agonists highlight the conflict in prescribing BBs in COPD and beta-2-agonists in HFrEF. This has resulted in underutilization of evidence-based therapy for HFrEF in COPD patients owing to fear of adverse effects. This review aims to provide an update and current perspective on diagnostic and therapeutic management of patients with coexisting COPD and HFrEF.

Beta-blockers in COPD: time for reappraisal

The combined effects on the heart of smoking and hypoxaemia may contribute to an increased cardiovascular burden in chronic obstructive pulmonary disease (COPD). The use of beta-blockers in COPD has been proposed because of their known cardioprotective effects as well as reducing heart rate and improving systolic function. Despite the proven cardiac benefits of beta-blockers post-myocardial infarction and in heart failure they remain underused due to concerns regarding potential bronchoconstriction, even with cardioselective drugs. Initiating treatment with beta-blockers requires dose titration and monitoring over a period of weeks, and beta-blockers may be less well tolerated in older patients with COPD who have other comorbidities. Medium-term prospective placebo-controlled safety studies in COPD are warranted to reassure prescribers regarding the pulmonary and cardiac tolerability of beta-blockers as well as evaluating their potential interaction with concomitant inhaled long-acting bronchodilator therapy. Several retrospective observational studies have shown impressive reductions in mortality and exacerbations conferred by beta-blockers in COPD. However, this requires confirmation from long-term prospective placebo-controlled randomised controlled trials. The real challenge is to establish whether beta-blockers confer benefits on mortality and exacerbations in all patients with COPD, including those with silent cardiovascular disease where the situation is less clear.

Chronic Obstructive Pulmonary Disease

COPD is a common, preventable, and treatable disease characterized by persistent airflow obstruction associated with enhanced inflammation in the airways and the lung in response to noxious particles or gases. Clinical history and pulmonary function testing are necessary for accurate diagnosis. While exposure to tobacco smoke remains a common cause, other etiologies and underlying genetic predisposition play significant roles. Treatment options are numerous and should be individualized based on symptoms and exacerbation frequency.

Management of chronic obstructive pulmonary disease beyond the lungs

Chronic obstructive pulmonary disease (COPD) is an umbrella term that covers many clinical subtypes with clearly different pulmonary and extra-pulmonary characteristics, but with persistent airflow limitation in common. This insight has led to the development of a more personalised approach in bronchodilator therapy, prevention of exacerbations, and advanced treatments (such as non-invasive ventilation and lung volume reduction techniques). However, systemic manifestations and comorbidities of COPD also contribute to different clinical phenotypes and warrant an individualised approach as part of integrated disease management. Alterations in bodyweight and composition, from cachexia to obesity, demand specific management. Psychological symptoms are highly prevalent, and thorough diagnosis and treatment are necessary. Moreover, prevention of exacerbations requires interventions beyond the lungs, including treatment of gastro-oesophageal reflux disease, reduction of cardiovascular risks, and management of dyspnoea and anxiety. In this Review, we discuss the management of COPD beyond the respiratory system and propose treatment strategies on the basis of the latest research and best practices.

Carvedilol, Bisoprolol, and Metoprolol Use in Patients With Coexistent Heart Failure and Chronic Obstructive Pulmonary Disease

Beta (β)-blockers are under-prescribed in patients with heart failure (HF) and concurrent chronic obstructive pulmonary disease (COPD) due to concerns about adverse pulmonary effects and a poor understanding of the effects of these drugs. We aimed to evaluate the survival effects of β-blockers in patients with coexistent HF and COPD. Using the Taiwan National Health Insurance Research Database, we conducted a nationwide population-based study. Patients with coexistent HF and COPD diagnosed between 2000 and 2009 were enrolled. Doses of the 3 β-blockers proven to be beneficial to HF (carvedilol, bisoprolol, and metoprolol) during the study period were extracted. The primary endpoint was cumulative survival. Patients were followed until December 31, 2009. The study included 11,558 subjects, with a mean follow-up period of 4.07 years. After adjustment for age, sex, comorbidities, and severity of HF and COPD, bisoprolol use showed a dose-response survival benefit [low dose: adjusted hazard ratio (HR) = 0.76, 95% confidence interval (CI) = 0.59-0.97, P = 0.030; high dose: adjusted HR = 0.40, 95% CI = 0.26-0.63, P < 0.001] compared with nonusers, whereas no survival difference was observed for carvedilol or metoprolol. Compared with patients with HF alone, this special HF + COPD cohort received significantly fewer targeted β-blockers (108.8 vs 137.3 defined daily doses (DDDs)/person-year, P < 0.001) and bisoprolol (57.9 vs 70.8 DDDs/person-year, P < 0.001). In patients with coexisting HF and COPD, this study demonstrated a dose-response survival benefit of bisoprolol use, but not of carvedilol or metoprolol use.

Optimal treatment sequence in COPD: Can a consensus be found?

There is currently no consensus on the treatment sequence in chronic obstructive pulmonary disease (COPD), although it is recognized that early diagnosis is of paramount importance to start treatment in the early stages of the disease. Although it is fairly consensual that initial treatment should be with an inhaled short-acting beta agonist, a short-acting muscarinic antagonist, a long-acting beta-agonist or a long-acting muscarinic antagonist. As the disease progresses, several therapeutic options are available, and which to choose at each disease stage remains controversial. When and in which patients to use dual bronchodilation? When to use inhaled corticosteroids? And triple therapy? Are the existing non-inhaled therapies, such as mucolytic agents, antibiotics, phosphodiesterase-4 inhibitors, methylxanthines and immunostimulating agents, useful? If so, which patients would benefit? Should co-morbidities be taken into account when choosing COPD therapy for a patient? This paper reviews current guidelines and available evidence and proposes a therapeutic scheme for COPD patients. We also propose a treatment algorithm in the hope that it will help physicians to decide the best approach for their patients. The authors conclude that, at present, a full consensus on optimal treatment sequence in COPD cannot be found, mainly due to disease heterogeneity and lack of biomarkers to guide treatment. For the time being, and although some therapeutic approaches are consensual, treatment of COPD should be patient-oriented.

Effect of Perioperative β-Blockers on Pulmonary Complications among Patients with Chronic Obstructive Pulmonary Disease Undergoing Lung Resection Surgery

The aim of this study is to determine if COPD patients undergoing lung resection with perioperative β-blocker use are more likely to suffer postoperative COPD exacerbations than those that did not receive perioperative β-blockers. Methods. A historical cohort study of COPD patients, undergoing lung resection surgery at Memorial Sloan-Kettering Cancer Center between 2002 and 2006. Primary outcomes were the rate of postoperative COPD exacerbations, defined as any initiation or increase of glucocorticoids for documented bronchospasm. Results. 520 patients with COPD were identified who underwent lung resection. Of these, 205 (39%) received perioperative β-blockers and 315 (61%) did not. COPD was mild among 361 patients (69% of all patients), moderate in 117 patients (23%), and severe in 42 patients (8%). COPD exacerbations occurred among 11 (5.4%) patients who received perioperative β-blockers and among 20 (6.3%) patients who did not. Secondary outcomes, which included respiratory failure, 30-day mortality, and the presence or absence of any cardiovascular complication, ICU transfer, cardiovascular complication, or readmission within 30 days, did not differ in prevalence between the two groups. Conclusions. This study implies that perioperative β-blockers use among COPD patients undergoing lung resection surgery does not impact the rate of exacerbations.

Systemic manifestations of chronic obstructive pulmonary disease

Chronic obstructive pulmonary disease is a complex multisystem disease with comorbidities and systemic manifestations that affect respiratory symptoms, exacerbation frequency and mortality. This article gives an overview of these systemic manifestations and their importance, and offers strategies for managing them.

β-Blockers are associated with a reduction in COPD exacerbations

BACKGROUND

While some retrospective studies have suggested that β-blocker use in patients with COPD is associated with a reduction in the frequency of acute exacerbations and lower mortality, there is concern that their use in patients with severe COPD on home oxygen may be harmful.

METHODS

Subjects with Global Initiative for Chronic Obstructive Lung Disease (GOLD) stage 2-4 COPD participating in a prospective follow-up of the COPDGene cohort, a multicentre observational cohort of current and former smokers were recruited. Total and severe exacerbation rates were compared between groups categorised by β-blocker use on longitudinal follow-up using negative binomial regression analyses, after adjustment for demographics, airflow obstruction, %emphysema on CT, respiratory medications, presence of coronary artery disease, congestive heart failure and coronary artery calcification, and after adjustment for propensity to prescribe β-blockers.

RESULTS

3464 subjects were included. During a median of 2.1 years of follow-up, β-blocker use was associated with a significantly lower rate of total (incidence risk ratio (IRR) 0.73, 95% CI 0.60 to 0.90; p=0.003) and severe exacerbations (IRR 0.67, 95% CI 0.48 to 0.93; p=0.016). In those with GOLD stage 3 and 4 and on home oxygen, use of β-blockers was again associated with a reduction in the rate of total (IRR 0.33, 95% CI 0.19 to 0.58; p<0.001) and severe exacerbations (IRR 0.35, 95% CI 0.16 to 0.76; p=0.008). Exacerbation reduction was greatest in GOLD stage B. There was no difference in all-cause mortality with β-blocker use.

CONCLUSIONS

β-Blockers are associated with a significant reduction in COPD exacerbations regardless of severity of airflow obstruction. The findings of this study should be tested in a randomised, placebo-controlled trial.

TRIAL REGISTRATION NUMBER

(ClinicalTrials.gov NCT00608764).

Prediction of short term re-exacerbation in patients with acute exacerbation of chronic obstructive pulmonary disease

Background

The objective of the study is to develop a scoring system for predicting a 90-day re-exacerbation in hospitalized patients with acute exacerbations of chronic obstructive pulmonary disease (AECOPD).

Methods

A total of 176 consecutive hospitalized patients with AECOPD were included. The sociodemographic characteristics, status before acute exacerbation (AE), presentations of and treatment for the current AE, and the re-exacerbation in 90 days after discharge from hospital were collected.

Results

The re-exacerbation rate in 90 days was 48.9% (86 out of 176). It was associated with the degree of lung function impairment (Global initiative for chronic Obstructive Lung Disease [GOLD] grades), frequency of AE in the previous year, and parameters of the current AE, including pleural effusion, use of accessory respiratory muscles, inhaled long-acting β-2-agonists, inhaled corticosteroids, controlled oxygen therapy, noninvasive mechanical ventilation, and length of hospital stay, but was not associated with body mass index, modified Medical Research Council scale, or chronic obstructive pulmonary disease assessment test. A subgroup of ten variables was selected and developed into the re-exacerbation index scoring system (age grades, GOLD grades, AE times in the previous year, pleural effusion, use of accessory respiratory muscles, noninvasive mechanical ventilation, controlled oxygen therapy, inhaled long-acting β-2-agonists and inhaled corticosteroids, and length of hospital stay). The re-exacerbation index showed good discrimination for re-exacerbation, with a C-statistic of 0.750 (P<0.001).

Conclusion

A comprehensive assessment integrating parameters of stable chronic obstructive pulmonary disease, clinical presentations at exacerbation, and treatment showed a strong predictive capacity for short-term outcome in patients with AECOPD. Further studies are required to verify these findings.

Impact of β-blocker selectivity on long-term outcomes in congestive heart failure patients with chronic obstructive pulmonary disease

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is present in approximately one-third of all congestive heart failure (CHF) patients, and is a key cause of underprescription and underdosing of β-blockers, largely owing to concerns about precipitating respiratory deterioration. For these reasons, the aim of this study was to evaluate the impact of β-blockers on the long-term outcomes in CHF patients with COPD. In addition, we compared the effects of two different β-blockers, carvedilol and bisoprolol.

METHODS

The study was a retrospective, non-randomized, single center trial. Acute decompensated HF patients with COPD were classified according to the oral drug used at discharge into β-blocker (n=86; carvedilol [n=52] or bisoprolol [n=34]) and non-β-blocker groups (n=46). The primary endpoint was all-cause mortality between the β-blocker and non-β-blocker groups during a mean clinical follow-up of 33.9 months. The secondary endpoints were the differences in all-cause mortality and the hospitalization rates for CHF and/or COPD exacerbation between patients receiving carvedilol and bisoprolol.

RESULTS

The mortality rate was higher in patients without β-blockers compared with those taking β-blockers (log-rank P=0.039), and univariate analyses revealed that the use of β-blockers was the only factor significantly correlated with the mortality rate (hazard ratio: 0.41; 95% confidence interval: 0.17-0.99; P=0.047). Moreover, the rate of CHF and/or COPD exacerbation was higher in patients treated with carvedilol compared with bisoprolol (log-rank P=0.033). In the multivariate analysis, only a past history of COPD exacerbation significantly increased the risk of re-hospitalization due to CHF and/or COPD exacerbation (adjusted hazard ratio: 3.11; 95% confidence interval: 1.47-6.61; P=0.003).

CONCLUSION

These findings support the recommendations to use β-blockers in HF patients with COPD. Importantly, bisoprolol reduced the incidence of CHF and/or COPD exacerbation compared with carvedilol.

[Medical therapy of heart and lung diseases. Effects on the respective other organ]

Many patients suffer from both heart and lung diseases. The choice of medical drugs should not only be driven by the clinical and prognostic effects on the target organ but should also be selected based on the effects on the respective other organ. Beta blockers and statins have both beneficial and harmful effects on the respiratory system. Angiotensin-converting enzyme (ACE) inhibitors and amiodarone can cause severe lung damage. Low-dose thiazides and calcium antagonists are first-line medications in hypertensive asthma patients but beta blockers should be avoided. Theophyline should be used with caution in patients with known cardiac disease. Glucocorticosteroids can cause cardiovascular symptoms while the phosphodiesterase inhibitor roflumilast appears to have no relevant cardiovascular side effects. Anticholinergic drugs have both favorable and unfavorable cardiovascular (side) effects. Short-acting beta-2 sympathomimetic drugs (SABA) and macrolides in particular can trigger arrhythmia and some SABAs are associated with a higher incidence of myocardial infarction. Detailed knowledge of the effects of drugs used for the treatment of lung and heart diseases on the respective other organ and the associated complications and long-term effects are essential in providing optimal medical care to the many patients who present with both respiratory and cardiovascular diseases.

The impact of exacerbation frequency on mortality following acute exacerbations of COPD: a registry-based cohort study

OBJECTIVE

To examine the association between exacerbation frequency and mortality following an acute exacerbation of chronic obstructive pulmonary disease (AECOPD).

DESIGN

Cohort study using medical databases.

SETTING

Northern Denmark.

PARTICIPANTS

On 1 January 2005, we identified all patients with prevalent hospital-diagnosed chronic obstructive pulmonary disease (COPD) who had at least one AECOPD during 1 January 2005 to 31 December 2009. We followed patients from the first AECOPD during this period until death, emigration or 31 December 2009, whichever came first. We flagged all AECOPD events during follow-up and characterised each by the exacerbation frequency (0, 1, 2 or 3+) in the prior 12-month period.

MAIN OUTCOMES AND MEASURES

Using Cox regression, we computed 0-30-day and 31-365-day age-adjusted, sex-adjusted, and comorbidity-adjusted mortality rate ratios (MRRs) with 95% CIs entering exacerbation frequency as a time-varying exposure.

RESULTS

We identified 16,647 eligible patients with prevalent COPD, of whom 6664 (40%) developed an AECOPD and were thus included in the study cohort. The 0-30-day MRRs were 0.97 (95% CI 0.80 to 1.18), 0.90 (95% CI 0.70 to 1.15) and 1.03 (95% CI 0.81 to 1.32) among patients with AECOPD with 1, 2 and 3+ AECOPDs versus no AECOPD within the past 12 months, respectively. The corresponding MRRs were 1.47 (95% CI 1.30 to 1.66), 1.89 (95% CI 1.59 to 2.25) and 1.59 (95% CI 1.23 to 2.05) for days 31-365.

CONCLUSION

Among patients with AECOPD, one or more exacerbations in the previous year were not associated with 30-day mortality but were associated with an increased 31-365-day mortality.

In-hospital and one-year mortality and their predictors in patients hospitalized for first-ever chronic obstructive pulmonary disease exacerbations: a nationwide population-based study

Introduction

Natural history of chronic obstructive pulmonary disease (COPD) is punctuated by exacerbations; however, little is known about prognosis of the first-ever COPD exacerbation and variables predicting its outcomes.

Materials and Methods

A population-based cohort study among COPD patients with their first-ever exacerbations requiring hospitalizations was conducted. Main outcomes were in-hospital mortality and one-year mortality after discharge. Demographics, comorbidities, medications and in-hospital events were obtained to explore outcome predictors.

Results

The cohort comprised 4204 hospitalized COPD patients, of whom 175 (4%) died during the hospitalization. In-hospital mortality was related to higher age (odds ratio [OR]: 1.05 per year; 95% confidence interval [CI]: 1.03–1.06) and Charlson comorbidity index score (OR: 1.08 per point; 95% CI: 1.01–1.15); angiotensin II receptor blockers (OR: 0.61; 95% CI: 0.38–0.98) and β blockers (OR: 0.63; 95% CI: 0.41–0.95) conferred a survival benefit. At one year after discharge, 22% (871/4029) of hospital survivors were dead. On multivariate Cox regression analysis, age and Charlson comorbidity index remained independent predictors of one-year mortality. Longer hospital stay (hazard ratio [HR] 1.01 per day; 95% CI: 1.01–1.01) and ICU admission (HR: 1.33; 95% CI: 1.03–1.73) during the hospitalization were associated with higher mortality risks. Prescription of β blockers (HR: 0.79; 95% CI: 0.67–0.93) and statins (HR: 0.66; 95% CI: 0.47–0.91) on hospital discharge were protective against one-year mortality.

Conclusions

Even the first-ever severe COPD exacerbation signifies poor prognosis in COPD patients. Comorbidities play a crucial role in determining outcomes and should be carefully assessed. Angiotensin II receptor blockers, β blockers and statins may, in theory, have dual cardiopulmonary protective properties and probably alter prognosis of COPD patients. Nevertheless, the limitations inherent to a claims database study, such as the diagnostic accuracy of COPD and its exacerbation, should be born in mind.

Beta-blockers reduced the risk of mortality and exacerbation in patients with COPD: a meta-analysis of observational studies

BACKGROUND

Cardiovascular disease is a primary cause of death in patients with chronic obstructive pulmonary disease (COPD). Beta-blockers have been proved to reduce morbidity and improve survival in patients with cardiac diseases. But the effects of beta-blockers on outcomes in patients with COPD remain controversial. The objective of this meta-analysis was to assess the effect of beta-blockers on mortality and exacerbation in patients with COPD.

METHODS

An extensive search of the EMBASE, MEDLINE and Cochrane was performed to retrieve the studies of beta-blockers treatment in patients with COPD. The random effects model meta-analysis was used to evaluate effect on overall mortality and exacerbation of COPD.

RESULTS

Fifteen original observational cohort studies with a follow-up time from 1 to 7.2 years were included. The results revealed that beta-blockers treatment significantly decreased the risk of overall mortality and exacerbation of COPD. The relative risk (RR) for overall mortality was 0.72 (0.63 to 0.83), and for exacerbation of COPD was 0.63 (0.57 to 0.71). In subgroup analysis of COPD patients with coronary heart disease or heart failure, the risk for overall mortality was 0.64 (0.54-0.76) and 0.74 (0.58-0.93), respectively.

CONCLUSION

The findings of this meta-analysis confirmed that beta-blocker use in patients with COPD may not only decrease the risk of overall mortality but also reduce the risk of exacerbation of COPD. Beta-blocker prescription for cardiovascular diseases needs to improve in COPD patients.

Effects of one month treatment with propranolol and metoprolol on the relaxant and contractile function of isolated trachea from rats exposed to cigarette smoke for four months

BACKGROUND AND OBJECTIVE

The effects of one-month treatment of β-adrenergic receptor (AR) blockers on the relaxant function of airway in chronic obstructive pulmonary disease (COPD) are unknown. A passive cigarette smoking rat model was used to investigate the effect of β-AR blockers.

METHODS

Thirty-six rats were randomly divided into six groups: control (C); propranolol (P); metoprolol (M); smoking (S); smoking + propranolol (SP); and smoking + metoprolol (SM). Histological analysis of the lungs was done and isolated tracheal segments were studied in vitro to assess the contractile and relaxant function of the smooth muscle. The level of norepinephrine (NE) was measured.

RESULTS

Airway inflammation was more severe in group S than group C (p < 0.001), and it was alleviated in group SP (p < 0.001) while had no change in group SM. After propranolol or metoprolol administration, the level of NE was significantly lower in both SP and SM groups (p < 0.01). The maximal contractile response to acetylcholine (Ach) in groups S and SM was increased compared to group C (p < 0.01). Propranolol significantly inhibited contractile response in group SP (p < 0.05), while metoprolol did not show the same effect. The curve of maximum relaxant rate to isoprenaline (Iso) shifted to the left in group SP (p < 0.01), while group SM showed no changes.

CONCLUSION

One-month treatment with propranolol increased the relaxant effect mediated by the β₂-AR and decreased the contractile response to Ach by reducing the level of NE.

Prevention of Exacerbations in Chronic Obstructive Pulmonary Disease: Knowns and Unknowns

The 2011 recommendations of the Global initiative for chronic Obstructive Lung Disease (GOLD) constituted a major paradigm shift in COPD management since they set 2 major goals for the assessment and management of patients: (1) the reduction of their current level of symptoms (i.e., treat the patient today); and (2) the reduction of their risk of exacerbations (i.e., prevent them tomorrow). Exacerbations are not only an important clinical endpoint in patients with COPD, but they are also a risk factor themselves for additional adverse outcomes since they have been shown to increase the risk for mortality, to accelerate the decline in pulmonary function, and to decrease health status and quality of life. Despite their importance, many unanswered questions related to exacerbations remain. The purpose of this review is to discuss: (1)knowns and unknowns in our current understanding of exacerbations, (2) what known factors increase their risk, and (3) how to best prevent them.

Predictors for mortality in hospitalized patients with chronic obstructive pulmonary disease

BACKGROUND

Chronic obstructive pulmonary disease (COPD) has been the only leading cause of death associated with a continuously increasing trend in the US over the past 30 years.

OBJECTIVES

The aim of this research was to identify predictors for all-cause in-hospital mortality for COPD patients.

METHODS

We conducted a cross-sectional study of patients with the discharge diagnosis of COPD, utilizing the 2007 Premier Perspective database. Inpatients aged 40 years and above were selected if they had a discharge with a primary diagnosis of COPD between January 1, 2007 and December 31, 2007. All data analyses were based on individual level. If a patient had multiple discharges, only the last discharge was included for mortality analysis. Predictors for mortality were identified by multiple logistic regressions. Bonferroni correction for multiple logistic regression models was adapted to control for family-wise errors.

RESULTS

The total of 57,224 patients was selected for data analysis in the study. All-cause in-hospital mortality for patients with COPD was 2.4%. Older age, insurance coverage, elective admission, intensive care unit admission, prolonged length of stay, increased Deyo-adapted Charlson Index (DCI) score and Elixhauser comorbidities of renal failure, metastatic cancer, solid tumor without metastasis, and weight loss were identified as independent predictors for all-cause in-hospital mortality. Antibiotics and β-blockers were predictors of lower all-cause in-hospital mortality risk after adjusting for other factors.

CONCLUSIONS

The nationwide discharge database provides useful information to identify predictors for all-cause in-hospital mortality of patients with COPD.

β₂-Adrenergic agonists augment air pollution-induced IL-6 release and thrombosis

Acute exposure to particulate matter (PM) air pollution causes thrombotic cardiovascular events, leading to increased mortality rates; however, the link between PM and cardiovascular dysfunction is not completely understood. We have previously shown that the release of IL-6 from alveolar macrophages is required for a prothrombotic state and acceleration of thrombosis following exposure to PM. Here, we determined that PM exposure results in the systemic release of catecholamines, which engage the β2-adrenergic receptor (β2AR) on murine alveolar macrophages and augment the release of IL-6. In mice, β2AR signaling promoted the development of a prothrombotic state that was sufficient to accelerate arterial thrombosis. In primary human alveolar macrophages, administration of a β2AR agonist augmented IL-6 release, while the addition of a beta blocker inhibited PM-induced IL-6 release. Genetic loss or pharmacologic inhibition of the β2AR on murine alveolar macrophages attenuated PM-induced IL-6 release and prothrombotic state. Furthermore, exogenous β2AR agonist therapy further augmented these responses in alveolar macrophages through generation of mitochondrial ROS and subsequent increase of adenylyl cyclase activity. Together, these results link the activation of the sympathetic nervous system by β2AR signaling with metabolism, lung inflammation, and an enhanced susceptibility to thrombotic cardiovascular events.

Multicentric study on the beta-blocker use and relation with exacerbations in COPD

Chronic obstructive pulmonary disease (COPD) is frequently associated with chronic heart failure (CHF) or coronary artery disease (CAD). In spite of the recommendation to use beta-blockers (BB) they are likely under-prescribed to patients with concurrent COPD and heart diseases. To find out the prevalence of use of BB, 256 COPD patients were consecutively recruited by pulmonary physicians from 14 hospitals in 7 regions of Spain in their outpatient offices if they had a diagnosis of COPD, were not on long-term oxygen therapy, had CHF or CAD, and met the criteria for BB treatment. In patients with indication 58% (95%CI, 52-64%) of the COPD patients and 97% of the non-COPD patients were on BB (p < 0.001). In patients with COPD, several factors were independently related to at least one visit to the emergency room in the previous year such as use of BB, adjusted OR = 0.27 (95% CI 0.15-0.50), GOLD stage D, OR = 2.52 (1.40-4.53), baseline heart rate >70, OR 2.19 (1.24-3.86) use of long-acting beta2-agonists OR = 2.18 (1.29-3.68), previous episodes of left ventricular failure OR 2.27 (1.19-4.33) and diabetes, OR = 1.82 (1.08-3.38). We conclude that, according to what is recommended by current guidelines, BB are still under-prescribed in COPD patients. COPD patients with CHF or CAD using BB suffer fewer exacerbations and visits to the ER. GOLD stage, use of long-acting beta2-agonists, baseline heart rate and comorbidities are also risk factors for exacerbations in this population.

The safety of beta-blocker use in chronic obstructive pulmonary disease patients with respiratory failure in the intensive care unit

Background

The safety of beta-blockers as a heart rate-limiting drug (HRLD) in patients with acute respiratory failure (ARF) due to chronic obstructive lung disease (COPD) has not been properly assessed in the intensive care unit (ICU) setting. This study aims to compare the use of beta-blocker drugs relative to non-beta-blocker ones in COPD patients with ARF due to heart rate-limiting with respect to length of ICU stay and mortality.

Methods

We performed a retrospective (January 2011-December 2012) case-control study in a level III ICU in a teaching hospital. It was carried out in a closed ICU by the same intensivists. All COPD patients with ARF who were treated with beta-blockers (case group) and non-beta-blocker HRLDs (control group) were included. Their demographics, reason for HRLD, cause of ARF, comorbidities, ICU data including acute physiology and chronic health evaluation (APACHE II) score, type of ventilation, heart rate, and lengths of ICU and hospital stays were collected. The mortality rates in the ICU, the hospital, and over 30 days were also recorded.

Results

We enrolled 188 patients (46 female, n = 74 and n = 114 for the case and control groups, respectively). Reasons for HRLD (case and control group, respectively) were atrial fibrillation (AF, 23% and 50%), and supraventricular tachycardia (SVT, 41.9% and 54.4%). Patients’ characteristics, APACHE II score, heart rate, duration and type of ventilation, and median length of ICU-hospital stay were similar between the groups. The mortality outcomes in the ICU, hospital, and 30 days after discharge in the case and control groups were 17.6% versus 15.8% (p > 0.75); 18.9% versus 19.3% (p > 0.95) and 20% versus 11% (p > 0.47), respectively.

Conclusions

Our results suggest that beta-blocker use for heart rate control in COPD patients with ARF is associated with similar ICU stay length and mortality compared with COPD patients treated with other HRLDs.

β-Blockers and chronic obstructive pulmonary disease: inappropriate avoidance?

Chronic obstructive pulmonary disease (COPD) is the third leading cause of death in the United States and is often accompanied by one or more comorbid conditions. While there are established morbidity and mortality benefits of β-blocker (BB) use for certain cardiovascular conditions, data suggest that clinicians are often reluctant to prescribe them in the presence of COPD because of concerns for bronchoconstriction, despite evidence that they are typically well-tolerated among these patients. Treatment guidelines for COPD are consistent with those for cardiovascular disease management and support the role of BBs in management of particular cardiovascular conditions, even in the presence of severe COPD. Adherence to these guidelines could result in significant decreases in morbidity and mortality among patients with COPD. Additionally, current treatments for COPD are often linked to increased cardiovascular disease events. Further study is needed to clarify and guide therapeutic management in patients with COPD.

Effect of β blockers on mortality after myocardial infarction in adults with COPD: population based cohort study of UK electronic healthcare records

OBJECTIVES

To investigate whether the use and timing of prescription of β blockers in patients with chronic obstructive pulmonary disease (COPD) having a first myocardial infarction was associated with survival and to identify factors related to their use.

DESIGN

Population based cohort study in England.

SETTING

UK national registry of myocardial infarction (Myocardial Ischaemia National Audit Project (MINAP)) linked to the General Practice Research Database (GPRD), 2003-11.

PARTICIPANTS

Patients with COPD with a first myocardial infarction in 1 January 2003 to 31 December 2008 as recorded in MINAP, who had no previous evidence of myocardial infarction in their GPRD or MINAP record. Data were provided by the Cardiovascular Disease Research using Linked Bespoke studies and Electronic Health Records (CALIBER) group at University College London.

MAIN OUTCOME MEASURE

Cox proportional hazards ratio for mortality after myocardial infarction in patients with COPD in those prescribed β blockers or not, corrected for covariates including age, sex, smoking status, drugs, comorbidities, type of myocardial infarction, and severity of infarct.

RESULTS

Among 1063 patients with COPD, treatment with β blockers started during the hospital admission for myocardial infarction was associated with substantial survival benefits (fully adjusted hazard ratio 0.50, 95% confidence interval 0.36 to 0.69; P<0.001; median follow-up time 2.9 years). Patients already taking a β blocker before their myocardial infarction also had a survival benefit (0.59, 0.44 to 0.79; P<0.001). Similar results were obtained with propensity scores as an alternative method to adjust for differences between those prescribed and not prescribed β blockers. With follow-up started from date of discharge from hospital, the effect size was slightly attenuated but there was a similar protective effect of treatment with β blockers started during hospital admission for myocardial infarction (0.64, 0.44 to 0.94; P=0.02).

CONCLUSIONS

The use of β blockers started either at the time of hospital admission for myocardial infarction or before a myocardial infarction is associated with improved survival after myocardial infarction in patients with COPD.

REGISTRATION

NCT01335672.

Predictors of mortality in hospitalized adults with acute exacerbation of chronic obstructive pulmonary disease

RATIONALE

There is a need to identify clinically meaningful predictors of mortality following hospitalized COPD exacerbation.

OBJECTIVES

The aim of this study was to systematically review the literature to identify clinically important factors that predict mortality after hospitalization for acute exacerbation of chronic obstructive pulmonary disease (COPD).

METHODS

Eligible studies considered adults admitted to hospital with COPD exacerbation. Two authors independently abstracted data. Odds ratios were then calculated by comparing the prevalence of each predictor in survivors versus nonsurvivors. For continuous variables, mean differences were pooled by the inverse of their variance, using a random effects model.

MEASUREMENTS AND MAIN RESULTS

There were 37 studies included (189,772 study subjects) with risk of death ranging from 3.6% for studies considering short-term mortality, 31.0% for long-term mortality (up to 2 yr after hospitalization), and 29.0% for studies that considered solely intensive care unit (ICU)-admitted study subjects. Twelve prognostic factors (age, male sex, low body mass index, cardiac failure, chronic renal failure, confusion, long-term oxygen therapy, lower limb edema, Global Initiative for Chronic Lung Disease criteria stage 4, cor pulmonale, acidemia, and elevated plasma troponin level) were significantly associated with increased short-term mortality. Nine prognostic factors (age, low body mass index, cardiac failure, diabetes mellitus, ischemic heart disease, malignancy, FEV1, long-term oxygen therapy, and PaO2 on admission) were significantly associated with long-term mortality. Three factors (age, low Glasgow Coma Scale score, and pH) were significantly associated with increased risk of mortality in ICU-admitted study subjects.

CONCLUSION

Different factors correlate with mortality from COPD exacerbation in the short term, long term, and after ICU admission. These parameters may be useful to develop tools for prediction of outcome in clinical practice.

Chronic obstructive pulmonary disease and cardiovascular disease

Chronic obstructive pulmonary disease (COPD) is an inflammatory disease of the lung associated with progressive airflow limitation and punctuated by episodes of acute exacerbation. There is growing recognition that the inflammatory state associated with COPD is not confined to the lungs but also involves the systemic circulation and can impact nonpulmonary organs. Epidemiologic and mechanistic studies indicate that COPD is associated with a high frequency of coronary artery disease, congestive heart failure and cardiac arrhythmias, independent of shared risk factors. Possible pathways include complex interrelationships between chronic low-grade systemic inflammation and oxidative stress as well as shared risk factors such as age, cigarette smoking, and environmental pollutants. In this review, we provide an overview of the epidemiologic data linking COPD with cardiovascular disease, comment on the interrelationships among COPD, inflammation, and cardiovascular disease, and highlight diagnostic and therapeutic challenges.

Development, validation, and results of a risk-standardized measure of hospital 30-day mortality for patients with exacerbation of chronic obstructive pulmonary disease

BACKGROUND

Despite its large clinical and economic significance, measuring and improving the outcomes of patients hospitalized for chronic obstructive pulmonary disease (COPD) is only beginning to emerge as a national priority for policy makers and payers.

OBJECTIVE

To facilitate the public reporting of hospital outcomes, we developed a risk-standardized measure of hospital 30-day mortality for patients admitted with exacerbation of COPD.

DESIGN

Hierarchical logistic regression model.

SETTING/PATIENTS

Medicare Part A and Part B claims in a random sample of half of all admissions for patients admitted to acute care hospitals in 2008 (development cohort) and remaining 2008 admissions (validation cohort). We also assessed model performance and predictive ability in 2007 and 2009 data.

MEASUREMENTS

Hospital risk-standardized 30-day mortality rates.

RESULTS

The model development sample consisted of 150,035 admissions at 4537 nonfederal acute care US hospitals, with a mean unadjusted hospital 30-day mortality rate of 8.6%. The mean risk-standardized mortality rate was 8.6% and ranged from 5.9% to 13.5%. The development and validation models had good discrimination (areas under the receiver operating characteristic curve 0.72 and 0.72, respectively) and predictive ability (predicted mortality at the 1st and 10th deciles 1.5%, 23.7%, and 1.6%, 23.8%, respectively) and showed no evidence of over-fitting.

CONCLUSIONS

A 30-day mortality model based on administrative claims had similar discrimination to other public reporting models and can be used to compare risk-adjusted outcomes for patients with exacerbations of COPD and to track changes in outcomes over time. The high mortality and variation in rates across institutions suggest opportunities to improve quality of care.

Heart failure and chronic obstructive pulmonary disease: the challenges facing physicians and health services

Pulmonary disease is common in patients with heart failure, through shared risk factors and pathophysiological mechanisms. Adverse pulmonary vascular remodelling and chronic systemic inflammation characterize both diseases. Concurrent chronic obstructive pulmonary disease presents diagnostic and therapeutic challenges, and is associated with increased morbidity and mortality. The cornerstones of therapy are beta-blockers and beta-agonists, whose pharmacological properties are diametrically opposed. Each disease is implicated in exacerbations of the other condition, greatly increasing hospitalizations and associated health care costs. Such multimorbidity is a key challenge for health-care systems oriented towards the treatment of individual diseases. Early identification and treatment of cardiopulmonary disease may alleviate this burden. However, diagnostic and therapeutic strategies require further validation in patients with both conditions.

Hospitalization with acute exacerbation of chronic obstructive pulmonary disease and associated health resource utilization: a population-based Danish cohort study

OBJECTIVE

Health resource utilization (HRU) and outcomes associated with acute exacerbation of chronic obstructive pulmonary disease (AECOPD) are not well described. Therefore, a population-based cohort study was conducted to characterize patients hospitalized with AECOPD with regard to HRU, mortality, recurrence, and predictors of readmission with AECOPD.

METHODS

Using Danish healthcare databases, this study identified COPD patients with at least one AECOPD hospitalization between 2005-2009 in Northern Denmark. Hospitalized AECOPD patients' HRU, in-hospital mortality, 30-day, 60-day, 90-day, and 180-day post-discharge mortality and recurrence risk, and predictors of readmission with AECOPD in the year following study inclusion were characterized.

RESULTS

This study observed 6612 AECOPD hospitalizations among 3176 prevalent COPD patients. Among all AECOPD hospitalizations, median length of stay was 6 days (interquartile range [IQR] 3-9 days); 5 days (IQR 3-9) among those without ICU stay and 11 days (IQR 7-20) among the 8.6% admitted to the ICU. Mechanical ventilation was provided to 193 (2.9%) and non-invasive ventilation to 479 (7.2%) admitted patients. In-hospital mortality was 5.6%. Post-discharge mortality was 4.2%, 7.8%, 10.5%, and 17.4% at 30, 60, 90, and 180 days, respectively. Mortality and readmission risk increased with each AECOPD hospitalization experienced in the first year of follow-up. Readmission at least twice in the first year of follow-up was observed among 286 (9.0%) COPD patients and was related to increasing age, male gender, obesity, asthma, osteoporosis, depression, myocardial infarction, diabetes I and II, any malignancy, and hospitalization with AECOPD or COPD in the prior year.

LIMITATIONS

The study included only hospitalized AECOPD patients among prevalent COPD patients. Furthermore, information was lacking on clinical variables.

CONCLUSION

These findings indicate that AECOPD hospitalizations are associated with substantial mortality and risk of recurrence.

β-Blockers and All-Cause Mortality in Adults with Episodes of Acute Bronchitis: An Observational Study

BACKGROUND

Recent observational studies suggest that β-blockers may improve long-term prognosis in patients with chronic obstructive pulmonary disease (COPD). We assessed whether β-blocker use improves all-cause mortality in patients with episodes of acute bronchitis.

METHODS

An observational cohort study using data from the electronic medical records of 23 general practices in the Netherlands. The data included standardized information about daily patient contacts, diagnoses, and drug prescriptions. Cox regression was applied with time-varying treatment and covariates.

RESULTS

The study included 4,493 patients aged 45 years and older, with at least one episode of acute bronchitis between 1996 and 2006. The mean (SD) age of the patients was 66.9 (11.7) years, and 41.9% were male. During a mean (SD) follow up period of 7.7 (2.5) years, 20.4% developed COPD. In total, 22.7% had cardiovascular comorbidities, resulting in significant higher mortality rates than those without (51.7% vs. 12.0%, p<0.001). The adjusted hazard ratio of cardioselective β-blocker use for mortality was 0.62 (95% confidence interval [CI], 0.50-0.77), and 1.01 (95% CI 0.75-1.36) for non-selective ones. Some other cardiovascular drugs also reduced the risk of mortality, with adjusted HRs of 0.60 (95% CI 0.46-0.79) for calcium channel blockers, 0.88 (95% CI 0.73-1.06) for ACE inhibitors/angiotensin receptor blockers, and 0.42 (95% CI 0.31-0.57) for statins, respectively.

CONCLUSION

Cardiovascular comorbidities are common and increase the risk of mortality in adults with episodes of acute bronchitis. Cardioselective β-blockers, but also calcium channel blockers and statins may reduce mortality, possibly as a result of cardiovascular protective properties.

β-Blocker Use and Incidence of Chronic Obstructive Pulmonary Disease Exacerbations

BACKGROUND

β-Adrenergic antagonist (β-blocker) use in patients with chronic obstructive pulmonary disease (COPD) has been avoided as a result of potential risk of pulmonary adverse effects. However, recent studies indicate that β-blocker use in patients with COPD can decrease outpatient visits and either decrease or have no effect on the number of hospitalizations. Long-term treatment with β-blockers has been shown to increase survival and decrease exacerbations in patients with COPD.

OBJECTIVE

To assess the impact of β-blocker use on the incidence of exacerbations in patients with COPD.

METHODS

In a retrospective cohort study of patients with COPD from 2 academic primary care practice sites who were seen in 2010, patients were identified using International Classification of Diseases, 9th revision, Clinical Modification codes for COPD and reviewing active medication lists for COPD-specific medications (tiotropium). Patients were classified as either a β-blocker user or a nonuser. Primary outcomes were incidence and severity of COPD exacerbations. Secondary outcomes included COPD exacerbations distinguished by β-blocker cardioselectivity and all-cause hospitalizations.

RESULTS

The study enrolled 412 patients. Of those, 166 patients were β-blocker users and 246 were β-blocker nonusers. β-Blocker users were less likely to have a COPD exacerbation (OR 0.61, 95% CI 0.40–0.93) and had fewer mild exacerbations (OR 0.56; 95% CI 0.34–0.89). There was no significant difference in COPD exacerbations based on β-blocker cardioselectivity (OR 0.84, 95% CI 0.38–1.83). When controlled for, using a backwards stepwise logistic regression, β-blocker use was a variable in the model that predicted exacerbations but alone was not statistically significant (adjusted OR 0.62, 95% CI 0.39–1.01).

CONCLUSIONS

Patients with COPD prescribed a β-blocker were significantly less likely to have a COPD exacerbation and had fewer mild COPD exacerbations.

Chronic Obstructive Pulmonary Disease: Inpatient Management

This article outlines the management of patients with acute exacerbations of chronic obstructive pulmonary disease (COPD), which are common in the course of chronic COPD and are associated with substantial morbidity. There are numerous guidelines, but literature suggests that there is substantial variation in care in patients with acute exacerbations of COPD. Key components of acute therapy for most patients include oral steroids, antibiotics, nebulizers, oxygen, and early consideration of noninvasive ventilation. Adjuvant components of care include venous thromboembolism prophylaxis, appropriate immunizations, counseling for smoking cessation, and consideration of pulmonary rehabilitation.

Association of beta-blocker use and selectivity with outcomes in patients with heart failure and chronic obstructive pulmonary disease (from OPTIMIZE-HF)

In patients with heart failure (HF) with chronic obstructive pulmonary disease (COPD), concerns exist regarding β blockers, particularly noncardioselective β blockers, precipitating bronchospasm or attenuating the benefit of inhaled β(2) agonists. The aim of this study was to test the hypothesis that noncardioselective β blockers would not be associated with worse outcomes compared with cardioselective β blockers in patients with concomitant COPD in a large HF registry. A retrospective analysis of patients from the Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients With Heart Failure (OPTIMIZE-HF) who had systolic dysfunction, documentation of β-blocker status, and follow-up information available after index hospitalization (n = 2,670) was performed. The associations between cardioselective and noncardioselective β blockers and the end points of 60- to 90-day mortality and mortality or rehospitalization in patients with (n = 722) and without (n = 1,948) COPD were analyzed using regression modeling. The models were adjusted for covariate predictors of β-blocker use at discharge and clinical predictors of outcomes. Noncardioselective and cardioselective β blockers were associated with lower risk-adjusted mortality in patients with and without COPD. There was no evidence that β-blocker selectivity was associated with a difference in outcomes between patients with and those without COPD (p for interaction >0.10 for both outcomes). In conclusion, despite concerns regarding β blockers in patients with HF with COPD, there was no evidence that β-blocker selectivity was associated with differences in outcomes for patients with HF with COPD versus those without.

Association between β-blocker therapy and outcomes in patients hospitalised with acute exacerbations of chronic obstructive lung disease with underlying ischaemic heart disease, heart failure or hypertension

BACKGROUND

β-Blocker therapy has been shown to improve survival among patients with ischaemic heart disease (IHD) and congestive heart failure (CHF) and is underused among patients with chronic obstructive pulmonary disease (COPD). Evidence regarding the optimal use of β-blocker therapy during an acute exacerbation of COPD is particularly weak.

METHODS

We conducted a retrospective cohort study of patients aged ≥40 years with IHD, CHF or hypertension who were hospitalised for an acute exacerbation of COPD from 1 January 2006 to 1 December 2007 at 404 acute care hospitals throughout the USA. We examined the association between β-blocker therapy and in-hospital mortality, initiation of mechanical ventilation after day 2 of hospitalisation, 30-day all-cause readmission and length of stay.

RESULTS

Of 35 082 patients who met the inclusion criteria, 29% were treated with β blockers in the first two hospital days, including 22% with β1-selective and 7% with non-selective β blockers. In a propensity-matched analysis, there was no association between β-blocker therapy and in-hospital mortality (OR 0.88, 95% CI 0.71 to 1.09), 30-day readmission (OR 0.96, 95% CI 0.89 to 1.03) or late mechanical ventilation (OR 0.98, 95% CI 0.77 to 1.24). However, when compared with β1 selective β blockers, receipt of non-selective β blockers was associated with an increased risk of 30-day readmission (OR 1.25, 95% CI 1.08 to 1.44).

CONCLUSIONS

Among patients with IHD, CHF or hypertension, continuing β1-selective β blockers during hospitalisation for COPD appears to be safe. Until additional evidence becomes available, β1-selective β blockers may be superior to treatment with a non-selective β blocker.

Heart rate-lowering efficacy and respiratory safety of ivabradine in patients with obstructive airway disease: a randomized, double-blind, placebo-controlled, crossover study

BACKGROUND

There is substantial evidence that heart rate (HR) is a powerful predictor of mortality in both normal individuals and in patients with cardiovascular disease. The use of β-adrenoceptor antagonists (β-blockers) has confirmed the importance of lowering elevated HR in a patient's prognosis. However, these agents can have undesirable adverse effects (AEs) and due to the risk of bronchoconstriction are contraindicated in patients with obstructive airway disease. A selective bradycardic agent, without such undesirable effects, could be of therapeutic interest. Ivabradine, a new I(f) inhibitor that acts specifically on the sino-atrial node, is a pure HR-lowering agent.

OBJECTIVE

The objective of this study was to assess HR-lowering efficacy and respiratory safety of ivabradine in patients with asthma and chronic obstructive pulmonary disease (COPD).

METHODS

This was a randomized, single-center, double-blind, placebo-controlled, crossover trial. Enrolment began in May 2009, and the last patient completed the study in January 2011. The study was conducted in an ambulatory setting. A total of 40 patients completed the study (20 asthmatic patients and 20 COPD patients). Inclusion criteria were: documented diagnosis of asthma or COPD according to international guidelines, age 18-75 years, and mean HR on Holter ECG recording of ≥60 beats/min. Exclusion criteria included disease exacerbation in a previous month or inability to understand instructions on the study procedures. All patients received ivabradine 7.5 mg twice daily for 5 days and placebo twice daily for 5 days in a crossover manner, in one of the two arms of the study, with at least 2 days of washout between treatments. The main outcome measures included the difference in HR between ivabradine and placebo treatment and change in HR in comparison with baseline. Other evaluated outcomes were differences in the peak expiratory flow rate (PEFR), the daily symptom score, rescue medication consumption, and AEs.

RESULTS

Ivabradine produced significantly lower mean HR than placebo in both groups of patients: asthma 67.4 ± 8.38 versus 82.85 ± 11.19 beats/min (p < 0.001) and COPD 69.75 ± 8.9 versus 81.05 ± 9.75 beats/min (p < 0.001). Similar results were observed for the minimal HR as well as for the maximal noted HR. In comparision with baseline, ivabradine significantly reduced HR in both groups of studied patients (all p < 0.05), whereas placebo did not have such an effect. No significant difference, in either the asthma or the COPD group, was found between ivabradine and placebo in morning and evening peak expiratory flow rate, peak expiratory flow diurnal variability, daily symptom scores, and rescue medication usage (all p > 0.05). Both treatments were well tolerated. The incidence of AEs was low and generally similar in both periods of treatment, except for visual symptoms during treatment with ivabradine, which was reported by 5% of the patients.

CONCLUSION

Our study demonstrated that selective HR reduction with ivabradine is effective in patients with asthma and COPD, with no alteration in respiratory function or symptoms over the duration of the study. Ivabradine offers an interesting alternative, as an HR-lowering agent, in patients with respiratory disease and contraindications to β-blockers.

CLINICAL TRIAL REGISTRATION

Registered at www.clinicaltrials.gov (NCT01365286).