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

Do beta-blockers alter dyspnea and fatigue in advanced lung cancer? A retrospective analysis

INTRODUCTION

Dyspnea is common in lung cancer and may be partially attributable to increased ventilatory drive due to muscle weakness. The sympathetic component of this pathway might be mitigated by β-blockers.

METHODS

A retrospective review of new patients with stage III-IV non-small lung cancer or any small cell lung cancer was undertaken to assess the impact of β-blocker use on dyspnea and fatigue. Data were abstracted for clinical characteristics, β-blocker use, and pre-treatment Edmonton Symptom Assessment System dyspnea and fatigue scores.

RESULTS

Of 348 patients assessed, 202 met eligibility criteria. The median age was 67, 55.4% were female, 18.8% had chronic obstructive pulmonary disease (COPD), and 5.9% had active coronary artery disease. Over 60% of patients scored 4/10 or higher on their dyspnea and fatigue scores. While dyspnea and fatigue were moderately associated, no association was found between β-blocker use and either symptom. Recorded dosages of β-blockers were low. COPD was associated with dyspnea and fatigue, while anemia was associated with fatigue.

CONCLUSIONS

Dyspnea and fatigue are prevalent and increased in the presence of COPD and anemia. No association between β-blocker use and dyspnea or fatigue scores was observed. This may be attributable to inadequate dosing or to retrospective bias.

Update in diagnosis and therapy of coexistent chronic obstructive pulmonary disease and chronic heart failure

Chronic obstructive pulmonary disease (COPD) and chronic heart failure (CHF) frequently coexist in clinical practice as they share the same risk factors. The manifestations of COPD and CHF are similar. Exertional dyspnoea, easy fatigability and reduced exercise tolerance are common to COPD and CHF and required careful interpretation. Pulmonary function tests, plasma natriuretic peptides, echocardiography and cardiovascular magnetic resonance imaging should be carried out to acquire the objective evidence of pulmonary and cardiac function when necessary. Robust studies indicate that patients with COPD tolerate the cardioselective β-blockers well, so it should not be denied to CHF patients with concomitant COPD. Low-dose initiation and gradual uptitration of cardioselective β-blockers is currently recommended. However, β(2)-agonists should be used with cautions in COPD patients with CHF, especially in acute exacerbations. Statins, angiotensin-converting enzyme inhibitors, and angiotensin-receptor blockers may reduce the morbidity and mortality of the patients with COPD.

[Prevention of COPD exacerbation: a fundamental challenge]

INTRODUCTION

Acute exacerbations of chronic obstructive pulmonary disease (AECOPD) are a cause of suffering for patients and a burden for healthcare systems and society. Their prevention represents individual and collective challenge. The present article is based on the work of a group of experts who met on 5th and 6th May 2011 and seeks to highlight the importance of AECOPD.

STATE OF THE ART

In the absence of easily quantifiable criteria, the definition of AECOPD varies in the literature, making identification difficult and affecting interpretation of study results. Exacerbations increase mortality and risk of cardiovascular disease. They also increase the risk of developing further exacerbations, accelerate the decline in lung function and contribute to reduction in muscle mass. By limiting physical activity and affecting mental state (anxiety, depression), AECOPD are disabling and impair quality of life. They increase work absenteeism and are responsible for about 60% of the global cost of COPD.

PERSPECTIVES

Earlier identification with simple criteria, possibly associated to patient phenotyping, could be helpful in preventing hospitalization.

CONCLUSIONS

Given their immediate and delayed impact, AECOPD should not be trivialized or neglected. Their prevention is a fundamental issue.

A systematic review of validated methods for identifying acute respiratory failure using administrative and claims data

PURPOSE

The Food and Drug Administration's (FDA) Mini-Sentinel pilot program initially aims to conduct active surveillance to refine safety signals that emerge for marketed medical products. A key facet of this surveillance is to develop and understand the validity of algorithms for identifying health outcomes of interest (HOIs) from administrative and claims data. This paper summarizes the process and findings of the algorithm review of acute respiratory failure (ARF).

METHODS

PubMed and Iowa Drug Information Service searches were conducted to identify citations applicable to the anaphylaxis HOI. Level 1 abstract reviews and Level 2 full-text reviews were conducted to find articles using administrative and claims data to identify ARF, including validation estimates of the coding algorithms.

RESULTS

Our search revealed a deficiency of literature focusing on ARF algorithms and validation estimates. Only two studies provided codes for ARF, each using related yet different ICD-9 codes (i.e., ICD-9 codes 518.8, "other diseases of lung," and 518.81, "acute respiratory failure"). Neither study provided validation estimates.

CONCLUSIONS

Research needs to be conducted on designing validation studies to test ARF algorithms and estimating their predictive power, sensitivity, and specificity.

Impact of chronic obstructive pulmonary disease severity on symptoms and prognosis in patients with systolic heart failure

BACKGROUND

Systolic heart failure (SHF) and chronic obstructive pulmonary disease (COPD) are frequently associated. The purpose of our study was to explore the impact of COPD severity on symptoms and prognosis in patients with SHF.

METHODS AND RESULTS

Chronic obstructive pulmonary disease was systematically screened by spirometry in 348 patients admitted for SHF from April 2002 to December 2006. Severity of COPD was defined according to the GOLD classification. Prevalence of COPD was 37.9 %. Patients' distribution according to GOLD stages I, II, II and IV were, respectively, 51.5, 37.9, 7.6 and 3.0 %. Severity of dyspnoea increases with GOLD stage. There was a significant correlation between NYHA stage and left ventricular ejection fraction in patients without COPD (R (2) = 0.03; P = 0.01) but not in patients with COPD. Mean follow-up was of 54.9 ± 27.4 months. Mortality was 46.6 % and was highest in the COPD group (53.8 vs. 42.3 %; P = 0.049). Kaplan-Meier survival curves showed that patients with GOLD stage I had the same prognosis than patients without COPD and mortality increased from GOLD stage II to stage IV. After multivariate analysis, GOLD stage and diuretics' dose were independently associated with mortality.

CONCLUSIONS

Chronic obstructive pulmonary disease is frequent in patients with SHF and increases mortality. Since dyspnoea is poorly specific of COPD in chronic heart failure patients, COPD remains underdiagnosed thus leading to inappropriate increase of diuretics' dose. COPD should be systematically screened in patients with SHF to adapt prescription of selective β1-blockers, and diuretics' dose and reduce the exposition to risk factors.

Controversies in treatment of chronic obstructive pulmonary disease

Chronic obstructive pulmonary disease (COPD) is a chronic disorder with substantial comorbidity and major effects attributable to the high morbidity and mortality rates. Despite an increasing evidence base, some important controversies in COPD management still exist. The classic way to define COPD has been based on spirometric criteria, but more relevant diagnostic methods are needed that can be used to describe COPD severity and comorbidity. Initiation of interventions earlier in the natural history of the disease to slow disease progression is debatable, there are many controversies about the role of inhaled corticosteroids in the management of COPD, and long-term antibiotics for prevention of exacerbation have had a resurgence in interest. Novel therapeutic drugs are urgently needed for optimum management of the acute COPD exacerbation. COPD is a complex disease and consists of several clinically relevant phenotypes that in future will guide its management.

Adherence to treatment guidelines and long-term survival in hospitalized patients with chronic obstructive pulmonary disease

RATIONALE AND AIMS

Adherence to treatment guidelines in chronic obstructive pulmonary disease (COPD) has been shown to be less than optimal over the COPD continuum. This retrospective study aimed to assess the implementation of COPD guidelines and potential association with long-term mortality in patients with COPD.

METHODS

All consecutive patient discharges in the period of February 2002-June 2007 from the University Clinic of Pulmonary and Allergic Diseases Golnik, Slovenia, were screened for a primary discharge diagnosis of COPD.

RESULTS

Data on 1185 patients (mean age 70 ± 9 years, 72% men, 64% GOLD stage III/IV) were analysed. In the discharge letters 62% of patients had three or more drugs prescribed; 3% had no regular prescription. Most patients were discharged with short-acting (91%) and long-acting β2-agonists (LABAs, 65%) and inhaled corticosteroids (61%), and 23% received long-term oxygen therapy. Prescription rates of LABAs, tiotropium and inhaled corticosteroids increased over the disease continuum (P < 0.001). In total, 48% of patients died during a median follow-up of 1149 days. Deceased patients had been less often treated with LABAs, inhaled corticosteroids and tiotropium. In multivariate Cox proportional-hazards analysis, advanced age, current smoking status, lower body mass index, longer hospital stay and cancer were associated with higher mortality (P < 0.05 for all), and inhaled corticosteroids predicted lower mortality (hazard ratio 0.72, 95% confidence interval 0.55-0.94).

CONCLUSION

Implementation of guideline-recommended therapy was not optimal, particularly in patients who died during follow-up. The high long-term mortality calls for careful risk assessment and appropriate adherence to treatment guidelines.

Body mass index and prognosis in patients hospitalized with acute exacerbation of chronic obstructive pulmonary disease

BACKGROUND: Nutritional status, weight loss and cachexia have important prognostic implications in patients with chronic obstructive pulmonary disease (COPD). Body mass index (BMI) has been implicated in COPD risk assessment, but information is mostly limited to composite scores or to patients with stable disease. We aimed to analyse the association between BMI and mortality in acute exacerbation of COPD. METHODS: This retrospective survey included 968 patients hospitalized due to acute exacerbation of COPD at the University Clinic Golnik from February 2002 to June 2007. Vital status was ascertained with Central Population Registry, and database was censored on November 1, 2008. RESULTS: Median BMI was 25.08 kg/m(2) (interquartile range, 21.55-29.05 kg/m(2)) and 210 patients (22%) had BMI < 21 kg/m(2). During median follow-up of 3.26 years (1.79-4.76 years), 430 patients (44%) died. Lowest mortality was found for BMI 25.09-29.05 kg/m(2). When divided per BMI decile, mortality was lowest for BMI 25.09-26.56 kg/m(2) (33%). In univariate analysis, BMI per quartile and BMI per unit increase were predictive for all-cause mortality. In an adjusted model, BMI per 1 kg/m(2) unit increase was associated with 5% less chance of death (hazard ratio 0.95, 95% confidence interval 0.93-0.97). CONCLUSIONS: Low BMI < 21 kg/m(2) is frequent in patients hospitalized due to acute exacerbation of COPD. Higher BMI was independently predictive of better long-term survival. A better outcome in obese patients compared to normal weight is in contrast to primary prevention data but concurs with observations of an obesity paradox in other cardiovascular diseases.

Routine laboratory tests can predict in-hospital mortality in acute exacerbations of COPD

Chronic obstructive pulmonary disease (COPD) has a rising global incidence and acute exacerbation of COPD (AECOPD) carries a high health-care economic burden. Classification and regression tree (CART) analysis is able to create decision trees to classify risk groups. We analysed routinely collected laboratory data to identify prognostic factors for inpatient mortality with AECOPD from our large district hospital. Data from 5,985 patients with 9,915 admissions for AECOPD over a 7-year period were examined. Randomly allocated training (n = 4,986) or validation (n = 4,929) data sets were developed and CART analysis was used to model the risk of all-cause death during admission. Inpatient mortality was 15.5%, mean age was 71.5 (±11.5) years, 56.2% were male, and mean length of stay was 9.2 (±12.2) days. Of 29 variables used, CART analysis identified three (serum albumin, urea, and arterial pCO(2)) to predict in-hospital mortality in five risk groups, with mortality ranging from 3.0 to 23.4%. C statistic indices were 0.734 and 0.701 on the training and validation sets, respectively, indicating good model performance. The highest-risk group (23.4% mortality) had serum urea >7.35 mmol/l, arterial pCO(2) >6.45 kPa, and normal serum albumin (>36.5 g/l). It is possible to develop clinically useful risk prediction models for mortality using laboratory data from the first 24 h of admission in AECOPD.

High blood pressure, antihypertensive medication and lung function in a general adult population

Background

Several studies showed that blood pressure and lung function are associated. Additionally, a potential effect of antihypertensive medication, especially beta-blockers, on lung function has been discussed. However, side effects of beta-blockers have been investigated mainly in patients with already reduced lung function. Thus, aim of this analysis is to determine whether hypertension and antihypertensive medication have an adverse effect on lung function in a general adult population.

Methods

Within the population-based KORA F4 study 1319 adults aged 40-65 years performed lung function tests and blood pressure measurements. Additionally, information on anthropometric measurements, medical history and use of antihypertensive medication was available. Multivariable regression models were applied to study the association between blood pressure, antihypertensive medication and lung function.

Results

High blood pressure as well as antihypertensive medication were associated with lower forced expiratory volume in one second (p = 0.02 respectively p = 0.05; R²: 0.65) and forced vital capacity values (p = 0.01 respectively p = 0.05, R²: 0.73). Furthermore, a detailed analysis of antihypertensive medication pointed out that only the use of beta-blockers was associated with reduced lung function, whereas other antihypertensive medication had no effect on lung function. The adverse effect of beta-blockers was significant for forced vital capacity (p = 0.04; R²: 0.65), while the association with forced expiratory volume in one second showed a trend toward significance (p = 0.07; R²: 0.73). In the same model high blood pressure was associated with reduced forced vital capacity (p = 0.01) and forced expiratory volume in one second (p = 0.03) values, too.

Conclusion

Our analysis indicates that both high blood pressure and the use of beta-blockers, but not the use of other antihypertensive medication, are associated with reduced lung function in a general adult population.

[Cardiovascular comorbidity in COPD]

The presence of cardiovascular alterations in patients with chronic obstructive pulmonary disease (COPD) is no coincidence. Smoking, a risk factor for both entities, could partly explain the strength of the association; however, there are data that suggest that other determining factors such as systemic inflammation, oxidative stress, hypoxemia, endothelial dysfunction and even aging could also be involved. Prognosis is worse in patients with both entities. Cardiovascular disease (CVD) contributes to hospitalization in patients with COPD and to mortality. Approximately one out of every four patients with COPD dies from cardiovascular causes. Equally, COPD exacerbation also leads to a greater number of cardiovascular events and an increase in mortality has even been found among patients with CVD and COPD compared with controls without COPD. These determining factors underline the need to develop a comprehensive view for the early detection of at-risk individuals and use of appropriate therapeutic measures. Vasodilators, statins and beta-blockers may improve morbidity and mortality in patients with COPD, possibly because these drugs maximize control of the underlying CVD. Nevertheless, the antiinflammatory potential of statins could be of interest. Inhaled corticosteroids and even some bronchodilators could also decrease cardiovascular morbidity. These data are from observational studies and should be interpreted with caution but are nevertheless sufficiently interesting to warrant the enormous interest aroused by the interaction between the two most prevalent chronic diseases in the western world, COPD and CVD.

Effect of oral β-blocker on short and long-term mortality in patients with acute respiratory failure: results from the BASEL-II-ICU study

INTRODUCTION

Acute respiratory failure (ARF) is responsible for about one-third of intensive care unit (ICU) admissions and is associated with adverse outcomes. Predictors of short- and long-term outcomes in unselected ICU-patients with ARF are ill-defined. The purpose of this analysis was to determine predictors of in-hospital and one-year mortality and assess the effects of oral beta-blockers in unselected ICU patients with ARF included in the BASEL-II-ICU study.

METHODS

The BASEL II-ICU study was a prospective, multicenter, randomized, single-blinded, controlled trial of 314 (mean age 70 (62 to 79) years) ICU patients with ARF evaluating impact of a B-type natriuretic peptide- (BNP) guided management strategy on short-term outcomes.

RESULTS

In-hospital mortality was 16% (51 patients) and one-year mortality 41% (128 patients). Multivariate analysis assessed that oral beta-blockers at admission were associated with a lower risk of both in-hospital (HR 0.33 (0.14 to 0.74) P = 0.007) and one-year mortality (HR 0.29 (0.16 to 0.51) P = 0.0003). Kaplan-Meier analysis confirmed the lower mortality in ARF patients when admitted with oral beta-blocker and further shows that the beneficial effect of oral beta-blockers at admission holds true in the two subgroups of patients with ARF related to cardiac or non-cardiac causes. Kaplan-Meier analysis also shows that administration of oral beta-blockers before hospital discharge gives striking additional beneficial effects on one-year mortality.

CONCLUSIONS

Established beta-blocker therapy appears to be associated with a reduced mortality in ICU patients with acute respiratory failure. Cessation of established therapy appears to be hazardous. Initiation of therapy prior to discharge appears to confer benefit. This finding was seen regardless of the cardiac or non-cardiac etiology of respiratory failure.

TRIAL REGISTRATION

clinicalTrials.gov Identifier: NCT00130559.

Predicting outcomes following hospitalization for acute exacerbations of COPD

Acute exacerbations of chronic obstructive pulmonary disease (AECOPD) are a frequent cause of hospital admission and are associated with significant morbidity, mortality, high readmission rates and high resource utilization. More accurate prediction of survival and readmission in patients hospitalized with AECOPD should help to optimize clinical management and allocation of resources, including targeting of palliative care and strategies to reduce readmissions. We have reviewed the published retrospective and prospective studies in this field to identify the factors most likely to be of value in predicting in-hospital and post-discharge mortality, and readmission of patients hospitalized for AECOPD. The prognostic factors which appear most important vary with the particular outcome under consideration. In-hospital mortality is related most clearly to the patient's acute physiological state and to the development of acute comorbidity, while post-discharge mortality particularly reflects the severity of the underlying COPD, as well as specific comorbidities, especially cardiac disease. Important factors influencing the frequency of readmission include functional limitation and poor health-related quality of life. Large prospective studies which incorporate all the potentially relevant variables are required to refine prediction of the important outcomes of AECOPD and thus to inform clinical decision making, for example on escalation of care, facilitated discharge and provision of palliative care.

Chronic obstructive pulmonary disease exacerbations in emergency departments: predictors of outcome

PURPOSE OF REVIEW

Exacerbations have a major short-term and long-term impact on patients with chronic obstructive pulmonary disease (COPD). Risk stratification of patients presenting to the emergency department for an exacerbation of COPD is of utmost importance to help in deciding patients' orientation and treatment and in improving outcomes.

RECENT FINDINGS

Studies on predictors of outcomes of COPD exacerbations are markedly heterogeneous in terms of assessed variables, outcomes of interest and timeframe (short-term vs. long-term outcomes). Age, severity of underlying disease, clinical signs of immediate severity, and comorbidities are among the most frequently identified prognostic factors of in-hospital outcome. In the most severe patients, ICU scores such as the Acute Physiology and Chronic Health Evaluation II (APACHE II) also have a prognostic value. Several biomarkers have also been studied, but their additional value for risk stratification is not clarified.

SUMMARY

Scores predicting the risk of poor outcome could prove useful in the management of COPD exacerbations. Some have been suggested but remain to be further validated before their use can be generalized.

Comorbidity in the elderly with diabetes: Identification of areas of potential treatment conflicts

AIMS

To investigate the prevalence of comorbid conditions in the elderly with diabetes and the prescribing of potentially inappropriate medicines or treatment conflicts.

METHODS

A cross-sectional study of diabetics aged >or=65 years, using prescription dispensing data from the Australian Department of Veterans' Affairs. Comorbidities were determined using the comorbidity index Rx-Risk-V. Potentially inappropriate prescribing or treatment conflicts specific for the elderly were determined from guidelines or reference compendia, in addition to the 2003 updated Beers criteria.

RESULTS

Of 18,968 diabetics, the median number of comorbidities was 5 (IQR 3-8). Diabetes and associated cardiovascular medicines accounted for 41.9% of all medicine use. Associated cardiovascular diseases were highly prevalent comorbidities. 46% had gastro-oesophageal reflux disease, 25% depression, 20% chronic airways disease or chronic pain and 15% also had heart failure or inflammation-pain. At least 16% were dispensed a medicine associated with adverse effects in patients with diabetes and 22.7% were dispensed at least one potentially inappropriate medicine.

CONCLUSION

Significant comorbid conditions in elderly diabetic patients with potential for inappropriate prescribing or treatment conflicts include arthritis, heart failure, chronic airways diseases and diseases treatable with systemic corticosteroids. Appropriate management of comorbidity should be included in guidelines for the elderly with diabetes.

Racial differences in mortality among veterans hospitalized for exacerbation of chronic obstructive pulmonary disease

This study compared mortality in African American and white patients admitted to veterans affairs (VA) hospitals for chronic obstructive pulmonary disease (COPD) exacerbation and determined the potential impact of differences in intensive care unit (ICU) admission and mechanical ventilation. Administrative data from 2003-2006 identified African American (n = 7159) and white (n = 43820) patients admitted to VA hospitals with COPD exacerbation. Hierarchical logistic regression was used to compare risk-adjusted 30-day or inhospital mortality in African American and white patients. African Americans were more likely than whites to be admitted to ICUs (19.1% vs 17.2%, respectively; p < .001) and to receive mechanical ventilation (4.8% vs 4.1%, p < .001). African Americans had lower unadjusted mortality than white patients overall (7.1% vs 9.2%, p < .001), and among patients admitted to ICUs (16.9% vs 20.3%, p < .01) and non-ICU wards (4.8% vs 6.9%, p < .001). Mortality was similar for African Americans and whites receiving mechanical ventilation (28.8% vs 31.4%, p = .34). The risk-adjusted odds of death were lower for African Americans relative to white patients (OR, 0.71; p < .001) and in analyses that further adjusted for ICU admission and ventilation use (OR, 0.69; p <.001). Mortality was lower in African Americans than white veterans admitted for COPD exacerbation, even after adjusting for differences in ICU admission rates and ventilatory support. The lower risk-adjusted mortality in African Americans was not explained by more aggressive care.

A postmortem analysis of major causes of early death in patients hospitalized with COPD exacerbation

BACKGROUND

Mortality from COPD is increasing worldwide, but detailed causes of death are rarely assessed, particularly in low-income countries.

METHODS

In a retrospective study, we reviewed the autopsy reports and medical records of deceased patients admitted to the hospital for severe exacerbation of COPD, from January 2005 to December 2007, at the Institute for Pulmonary Diseases of Vojvodina, Serbia.

RESULTS

Forty-three patients with a hospital admission diagnosis of COPD exacerbation underwent autopsy; all had died within 24 h of admission to the hospital. Twenty-three patients (54%) had a long COPD history (> 10 years), and 19 patients (44%) had more than one hospitalization in the last year of life. The median age at death was 70 years (interquartile range, 65 to 75 years), and male sex was predominant (n = 31; 72%). The main (primary) causes of death were reported as cardiac failure (n = 16; 37.2%), pneumonia (n = 12; 27.9%), and pulmonary thromboembolism (PTE) (n = 9; 20.9%). Respiratory failure due to a progression of COPD was the primary cause of death in six patients (14%). Most patients had more then one comorbid disease (n = 33; 77%), and the most frequent comorbid disease was chronic heart failure (n = 25; 58%).

CONCLUSIONS

Autopsy results suggest that common contributing causes of early death in patients hospitalized with severe COPD exacerbation are concomitant complications, as follows: cardiac failure, pneumonia, and PTE. Quality improvement interventions should focus on recognizing and treating these conditions at the time of hospital admission.

Cardio-selective and non-selective beta-blockers in chronic obstructive pulmonary disease: effects on bronchodilator response and exercise

BACKGROUND

Patients with chronic obstructive pulmonary disease (COPD) often have co-existing cardiovascular disease and may require beta-blocker treatment. There are limited data on the effects of beta-blockers on the response to inhaled beta2-agonists and exercise capacity in patients with COPD.

OBJECTIVE

To determine the effects of different doses of cardio-selective and non-selective beta-blockers on the acute bronchodilator response to beta-agonists in COPD, and to assess their effects on exercise capacity.

METHODS

A double-blind, randomized, three-way cross-over (metoprolol 95 mg, propranolol 80 mg, placebo) study with a final open-label high-dose arm (metoprolol 190 mg). After 1 week of each treatment, the bronchodilator response to salbutamol was measured after first inducing bronchoconstriction using methacholine. Exercise capacity was assessed using the incremental shuttle walk test.

RESULTS

Eleven patients with moderate COPD were recruited. Treatments were well-tolerated although two did not participate in the high-dose metoprolol phase. The area under the salbutamol-response curve was lower after propranolol compared with placebo (P=0.0006). The area under the curve also tended to be lower after high-dose metoprolol (P=0.076). The per cent recovery of the methacholine-induced fall was also lower after high-dose metoprolol (P=0.0018). Low-dose metoprolol did not alter the bronchodilator response. Oxygen saturation at peak exercise was lower with all beta-blocker treatments (P=0.046).

CONCLUSION

Non-selective beta-blockers and high doses of cardio-selective beta-blockers may inhibit the bronchodilator response to beta2-agonists in patients with COPD. Beta-blockers were also associated with lower oxygen saturation during exercise. The clinical significance of these adverse effects is uncertain in view of the benefits of beta-blocker treatment for cardiovascular disease.

Cardiovascular injury and repair in chronic obstructive pulmonary disease

Cardiovascular disease represents a considerable burden in terms of both morbidity and mortality in patients with chronic obstructive pulmonary disease (COPD). For 20 years, forced expiratory volume in 1 second (FEV(1)) has been an established predictor of cardiovascular mortality among smokers, never-smokers, and patients with COPD. We review evidence for increased cardiovascular risk in COPD. In addition, we assess the emerging evidence which suggests that hypoxia, systemic inflammation, and oxidative stress in patients with COPD may cause cardiovascular disease. We also discuss alternative hypotheses that the endothelium and connective tissues in the arteries and lungs of patients with COPD and cardiovascular disease have a shared susceptibility to these factors.

Impact of cardioselective beta-blockers on mortality in patients with chronic obstructive pulmonary disease and atherosclerosis

RATIONALE

beta-Blocker use is associated with improved health outcomes in patients with cardiovascular disease. There is a general reluctance to prescribe beta-blockers in patients with chronic obstructive pulmonary disease (COPD) because they may worsen symptoms.

OBJECTIVES

We investigated the relationship between cardioselective beta-blockers and mortality in patients with COPD undergoing major vascular surgery.

METHODS

We evaluated 3,371 consecutive patients who underwent major vascular surgery at one academic institution between 1990 and 2006. The patients were divided into those with and without COPD on the basis of symptoms and spirometry. The major endpoints were 30-day and long-term mortality after vascular surgery. Patients were defined as receiving low-dose therapy if the dosage was less than 25% of the maximum recommended therapeutic dose; dosages higher than this were defined as intensified dose.

MEASUREMENTS AND MAIN RESULTS

There were 1,205 (39%) patients with COPD of whom 462 (37%) received cardioselective beta-blocking agents. beta-Blocker use was associated independently with lower 30-day (odds ratio, 0.37; 95% confidence interval, 0.19-0.72) and long-term mortality in patients with COPD (hazards ratio, 0.73; 95% confidence interval, 0.60-0.88). Intensified dose was associated with both reduced 30-day and long-term mortality in patients with COPD, whereas low dose was not.

CONCLUSIONS

Cardioselective beta-blockers were associated with reduced mortality in patients with COPD undergoing vascular surgery. In carefully selected patients with COPD, the use of cardioselective beta-blockers appears to be safe and associated with reduced mortality.

Cardioselective beta-blockers for chronic obstructive pulmonary disease

BACKGROUND

Beta-blocker therapy has a proven mortality benefit in patients with hypertension, heart failure and coronary artery disease, as well as during the perioperative period. These drugs have traditionally been considered contraindicated in patients with chronic obstructive pulmonary disease (COPD).

OBJECTIVES

To assess the effect of cardioselective beta-blockers on respiratory function of patients with COPD.

SEARCH STRATEGY

A comprehensive search of the Cochrane Airways Group Specialised Register (derived from systematic searches of CENTRAL, MEDLINE, EMBASE and CINAHL) was carried out to identify randomised blinded controlled trials from 1966 to May 2005. We did not exclude trials on the basis of language.

SELECTION CRITERIA

Randomised, blinded, controlled trials of single dose or longer duration that studied the effects of cardioselective beta-blockers on the forced expiratory volume in 1 second (FEV1) or symptoms in patients with COPD.

DATA COLLECTION AND ANALYSIS

Two independent reviewers extracted data from the selected articles, reconciling differences by consensus. Two interventions studied were the administration of beta-blocker, given either as a single dose or for longer duration, and the use of beta2-agonist given after the study drug.

MAIN RESULTS

Eleven studies of single-dose treatment and 9 of treatment for longer durations, ranging from 2 days to 12 weeks, met selection criteria. Cardioselective beta-blockers, given as a single dose or for longer duration, produced no change in FEV1 or respiratory symptoms compared to placebo, and did not affect the FEV1 treatment response to beta2-agonists. A subgroup analysis revealed no change in results for those participants with severe chronic airways obstruction or for those with a reversible obstructive component.

AUTHORS' CONCLUSIONS

Cardioselective beta-blockers, given to patients with COPD in the identified studies did not produce adverse respiratory effects. Given their demonstrated benefit in conditions such as heart failure, coronary artery disease and hypertension, cardioselective beta-blockers should not be routinely withheld from patients with COPD.